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September 2017-March 2018 JGMDS

Journal of Gandhara Medical and Dental Sciences is published on controlled circulation basis and distribution among the faculty of all medical and dental departments of Gandhara University of Peshawar. The Journal shall be published and circulated to libraries and private clinics throughout Pakistan and abroad in due course of time. All rights of Journal of Gandhara Medical and Dental Sciences are reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photocopying (except for internal or personal use) without the prior permission of the publisher. The publication and the members of the editorial board cannot be held responsible for errors or for any consequences arising from the use of the information contained in this journal. Journal of Gandhara Medical and Dental Sciences is published semiannual, composed and printed at Vision Printers and general order suppliers, Peshawar Publication Cell: Managing Editor, Gandhara University, Canal Road, University Town, Peshawar, Pakistan Land Line: +92 (0)91 5844429-32 Fax: +92 (0)91 5844428 Visit Us: www.gandhara.edu.pk Face book: Gandhara University Email: [email protected] [email protected]

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September 2017-March 2018 JGMDS

CHIEF PATRON PATRON

Roeeda Kabir Abdus Salam

Chancellor Vice Chancellor Gandhara University, Peshawar Gandhara University, Peshawar

EDITOR IN CHIEF EXECUTIVE EDITORS

Brig.Rtd Ahmad Hussain Shaheed Iqbal

Farida Naseer Masood-ur-Rehman

MANAGING EDITOR

Sofia Shehzad

ASSOCIATE EDITORS

Syed Nasir Shah

Shafaq Naz

Shakeel-ru-Rehman Khattak

Jawad Ahmad Kundi Saira Afridi

EDITORIAL BOARD

Muhammad Ahmad Nuzhat Huma Akhtar Shakeel-Ur-Rehman Iftikhar-Ud-Din Niazi Fida Muhammad Almas Begum Afridi Zafar-ul-Islam Anwar Taj

M. Ismail Qamar

Zahid Hussain Khalil Amjad Naeem

Ghulam Gillani Khan Aneela Ambreen

Imran Tajik Tahir Ali Khan

Saima Naz Baber Ahad

ADVISORY BOARD

Ahmad Iqbal Muhammad Hafeezullah Azmat Talaat Muzafar-ud-Din Khaliq-uz-Zaman Zahir Shah Mumtaz Marwat Qiam-ud-Din Sultan Mahmood

Zafar Durrani Zafar Hayat Ejaz Hassan

Mah Muneer Khan Sheraz Jamal

Aziz-ul-Hassan Amir Shehzad Akbar Khan

Zaineb Kabir Samir Khan Kabir

STATISTICIAN BIBLOGRAPHER Hamid Hussain Sher Bahadur

Gandhara University, Canal Road, University Town, Peshawar, Pakistan

EDITORIAL Dengue Outbreak- Is the Panic Justified? Sofia Shehzad 1

ORIGINAL ARTICLE Outcome Of Hemorrhoidectomy With The Ligasure In Comparison With The Traditional Open Method

Faiz-Ur-Rehman Arshad Amin Shahid Nisar

Musarat Hussain

2

Pattern Of Surgical Cases And Its Management In Bacha Khan Medical Complex Shahmansoor Swabi

Arshad Amin Faiz-Ur-Rehman

Fazli Junaid Shahid Nisar

6

Predictors Of Success Of Vaginal Birth After Previous Cesarean Section – An Analysis Of 100 Cases

Maimoona Qadir Sohail Amir

12

To Determine The Frequency Of Dural Tear In Patients Presenting With Depressed Skull Fracture: An Experience Of 96 Cases In A Tertiary Care Hospital

Sohail Amir Syed Amir Shah

Khaleeq-Uz-Zaman

18

Correlation of Mandibular Second Molar Caries With Patterns Of Mandibular Third Molar Impaction: A Retrospective Study

Muhammad Ilyas Jawad Ahmad Kundi

Irtifaq Ahmad Noor Obaid Zeb

Salman Khan

24

Different Types Of Complications In Patients Suffering From B-Thalassemia (Thalassemia Major)

Riaz Gul Jasim Dil Wazir

Shandana Rehman

30

INSTRUCTION TO AUTHORS 43

AUTHORS AGREEMENT 46

EDITORIAL JGMDS

September 2017-March 2018 1

DENGUE OUTBREAK - IS THE PANIC JUSTIFIED ?

Dr. Sofia Shehzad Outbreaks, defined as excess cases of a particular disease or illness which outweighs the response

capabilities, have the capacity to overwhelm health care facilities and need timely response and attention

to details in order to avoid potentially disastrous sequelae . In this day and age when improvement in public

health practices have significantly curtailed outbreak of various diseases, certain viral illnesses continue to

make headlines. One of the notable vector borne infectious disease affecting significant portions of south

east Asia in the early part of twenty first century is 'Dengue fever'. Dreaded as it is by those suffering from

the illness, a lot of the hysteria created is secondary to a lack of education and understanding of the nature

of the disease and at times a result of disinformation campaign for vested interests by certain political and

media sections.

'Dengue' in fact is a Spanish word, assumed to have originated from the Swahili phrase - ka dinga peppo -

which describes the disease as being caused by evil spirit. 1 Over the course of time it has been called

'breakbone fever', 'bilious vomiting fever', 'break heart fever', 'dandy fever', 'la dengue' and 'Phillipine, Thai

and Singapore hemorrhagic fever' Whilst the first reported case referring to dengue fever as a water poison

spread by flying insects, exists in the Chinese medical encyclopedia from Jin Dynasty (265-420 AD), the

disease is believed to have disseminated from Africa with the spread of the primary vector, aedes egypti, in

the 15th to 19th century as a result of globalisation of slave trade 45

In 80% of the patients affected by this condition the presentation is rather insidious and at best

characterized by mild fever. The classical 'Dengue fever' present in about 5% of the cases is characterized

by high temperature, body aches, vomiting and at times a skin rash. The disease may regresses in two to

seven days. However in rare instances (<5%) it may develop into more serious conditions such as Dengue

hemorrhagic fever whereby the platelet count is significantly reduced leading to bleeding tendencies and

may even culminate in a more life threatening presentation i.e Dengue shock syndrome.6

To understand the actual dynamics of Dengue epidemic it is important to understand the mode of its spread

in affected areas. Aedes mosquito (significantly Aedes Egypti) acts a vector for this disease. Early morning

and evening times7 are favoured by these mosquitos to feed on their prey. There is some evidence that the

disease may be transmitted via blood products and organ donation. 8 Moreover vertical transmission

(mother to child) has also been reported 9

Diagnostic investigations include blood antigen detection through NS-I or nucleic acid detection via PCR. IO

Cell cultures and specific serology may also be used for confirming the underlying disease. Whilst sporadic

and endemic cases are part of routine medical practice and may not raise any alarm bells, outbreaks

certainly need mobilization of appropriate resources for effective control. Needless to say 'prevention is

better than cure' and should be the primary target of the health authorities in devising strategies for

disease control.

The WHO recommended 'Integrated Vector control programme', lays stress on social mobilisation and strengthening of public health bodies, coherent response of health and related departments and effective capacity building of relevant personnel and organisations as well as the community at risk. For Aedes Egypti the primary control revolves around eliminating its habitats such as open sources of water. In a local perspective in our city Peshawar, venue of the recent dengue epidemic, it may be seen in the form of incidental reservoirs such

EDITORIAL JGMDS


as receptacles and tyres dumped in open areas such as roof tops with rain water accumulating in them and provtdjng excellent breeding habitats, Larvicidal and insecticides may be added to more permanent sources such as water tanks and farm lands. There is not much of a role for spraying with organophosphorous agents which is at times resorted to for public consumption. Public education is the key to any effective strategy which must highlight the need for wearing clothing that fully covers the skin, avoiding unnecessary early morning and evening exposure to vector agents, application of insect repellents and use of mosquito nets. It is also important not to panic if affliction with the disease is suspected as in a vast majority of instances it is a self limiting illness without any long term harmful effects and needs simple conservative management like antipyretics and analgesics.

An important consideration for responsible authorities in a dengue epidemic is to ensure that

maximum management facilities for simple cases are provided at the community level through primary

and secondary health care facilities and that the tertiary care hospitals are not inundated with

all sort of patients demanding consultation. These later facilities should be reserved for those patients who

end up with any complications or more severe manifestation of the disease.

Research is underway to develop an ideal vaccine for Dengue fever. In 2016, a vaccine by the name

'Dengvaxia' was marketed in Phillipines and Indonesia. However with development of new serotypes of the

virus, its efficacy has been somewhat compromised.

As for treatment , there are no specific antiviral drugs. Management is symptomatic revolving mainly around

oral and intravenous hydration. Paracetamol (Acetaminophen) is used for fever as compared to NSAIDS such

as Ibuprophen infusion as well as blood and platelet transfusion.

Data to date shows that slightly more than twenty three thousand people have been diagnosed with dengue

over the past three months ie August to October there is a lower risk of bleeding with the former. Those

with more severe form of the disease may need Dextran 2017, in Peshawar, Pakistan with around fourteen

thousand needing admission and about sixty nine recorded deaths. The mortality is well within the

acceptable international standards of less than 1% for the disease. In the backdrop of all the debate

surrounding the current epidemic, one can infer that such outbreaks are best addressed with effective

planning well ahead of the time before the disease threatens to spiral out of control. Simple measures such

as covering water storage facilities, using larvicidals where practical, use of insect repellents, mosquito nets

and avoiding unnecessary exposure can offer the best protection. Public health messages via print and

electronic media can help educate people in affected areas and allay any anxiety building up from a fear of

developing life threatening complications. Health department must mobilise all its resources to ensure local

management of diagnosed patients with simple dengue fever and facilitate hospital admission only for those

suffering from more severe form of the disease. Moreover the media hype into such situations needs to be

addressed through constant updates and discouraging any negative politicking on the issue. To sum up

Dengue fever is not really an affliction to be dreaded provided it is viewed and managed in the right

perspective.

EDITORIAL JGMDS


REFERENCES:

1) Anonymous (2006). “Etymolgoia: dengue”. Emerg. Infec. Dis. 12 (6): 893.

2) Halstead SB (2008). Dengue (Tropical Medicine: Science and Praactice). River Edge, N,J: Imperial

College Press. Pp. 1 – 10.

3) Barrett AD, Standberry LR (2009). Vaccines for biodefense and emerging and neglected diseases.

4) Gubler DJ (July 1998). "Dengue and dengue hemorrhagic fever". Clin. Microbiol. Rev. 11 (3): 480-

96,

5) Simmons CP; Farrar JJ; Nguyen vV; Wills B (April 2012). "Dengue". N Engl J Med. 366 (15): 1423-32.

6) Kularatne, SA (September 2015). "Dengue fever.". BMJ (Clinical research ed.). 351: h4661

7) Global Strategy For Dengue Prevention And Control (PDF). World Health Organization. 2012 pp. 16-

17.

8) Wilder-Smith A, Chen LH, Massad E, Wilson ME (January 2009). "Threat of dengue to blood dengue

to blood safety in-Dengue endemic countries". Emerge Infect. Dis. 15 (1): 8—11.

9) Wiwanitkit V (January 2010). "Unusual mode of transmission of dengue". Journal of Infection in

Developing Countries. 4 (1): 51—4

10) Kassim FM Izati MN TgRogayah TA, Apandi YM, Saat Z. Use of dengue NSI antigen for early

diagnosis of dengue virus infection. Southeast Asian J Trop Med Public Health. 2011

ORIGINAL ARTICLE JGMDS


OUTCOME OF HEMORRHOIDECTOMY WITH THE LIGASURE IN COMPARISON WITH THE TRADITIONAL OPEN METHOD

Faiz-Ur-Rahman1, Arshad Amin1, Shahid Nisar1, Musarat Hussain1 1. Town Teaching Hospital

OBJECTIVE To compare the operative time and outcomes of Ligasure hemorrhoidectomy with that of the traditional open hemorrhoidectomy.

METHODOLOGY

A total of 49 patients were included in this study. Out of which 24 were in the Ligasure group and 25 in the open group. The main objective or the primary variable was to assess the operative time for the excision of a single hemorrhoidal lesion, the need for morphine, for post operative pain relief and any other complications such as preoperative bleeding and the time to return to work. The data like age, sex, type of Haemorrhoidectomy, type of complicating etc. were recorded in already prepared proforma. The data was analysed through computer program SPSS10.

RESULTS The demographic data were comparable between the two groups. The time spent in excision of a solitary hemorrhoidal lesion was significantly shorter in the Ligasure group compared to the open group (8.25 min Vs 16.75 min ) and this difference was found to be statistically significant (p<0.001). Operative bleeding was also significantly lower than the open method of Haemorrhoidectony. Other parameters like post operative pain, opioid requirement, urinary retention and chronic complications like anal stenosis and gas incontinence were not significant. There was no difference in the period of convalescence and return to work between the two groups.

CONCLUSION

Hemorrhoidectomy with the Ligasure entails a shorter surgical time and could be associated with a lesser pain besides being safer.

KEYWORDS

Open hemorrhoidectomy. Ligasure Hemorrhoidectomy. Surgic time. INTRODUCTION Hemorrhoids appear as engorged veins in the anorectal region. Etiology is Uncertain but constipation of long durat ion, pregnancy and straining during defecation could

be the factors in the causation of hemorrhoids (1). It is a fairly common disease and is commonly associated with itching, and bleeding in the form of fresh sprouts of blood following evacuation of stools. They could be assoc iated wi th severe pa in i f the hemorrho ids are thrombosed. Different

surgical approaches such as the open method of Milligan- Morgan, the closed hemorrhoiedectomy proposed by Ferguson, hemorrhoiedectomy using stapler and the recently introduced Ligasure hemorrhoidectomy. It seems that the commonly employed surgical approach of hemorrhoiedectomy is the Milligan- Morgan approach (2). As this approach causes pain which could be intense, the Ligasure method has been forwarded

Correspondence: Dr. Faiz-Ur-Rahman

Town Teaching Hospital Contact: 0333-9176048

Email: [email protected]

OUTCOME OF HEMORRHOIDECTOMY WITH THE LIGASURE IN COMPARISON WITH THE TRADITIONAL OPEN METHOD JGMDS


recently which in fact is a kind of coagulation and hemostasis. It is assumed that this method provides abloodless field in addition to ensuring total removal of the hemorrhoid lesion andimparts a lesser degree of heat to the hemorrhoids being excised. All these put together cause less post-operat ive pain (3). There are reports in the l i terature where in i t has been s tated and proved tha t the L igasure hemorrhoidectomy approach does in fact curtail the postoperative pain (4-7), but some reports fai l to document a reduct ion in the postoperat ive pain with the Ligasure method (8-10).Some of the publications point to a reduction in bleeding with the Ligasure method (8-9). A meta-analysis revealed that the Ligasure method did cause a significant r educ t ion in t he su rg ica l t im e and opera t i ve b leed in g bu t as f a r as postoperative pain, hospital stay and return to job were concerned, there wereno differences compared with the open method (11). This study aimed to see whether the L igasure method helped in reduc ing the surgical t ime or not

METHODOLOGY

In th is randomized cl in ica l tr ia l , a tota l of 49 pat ients scheduled for hemorrhoideetomy were inc luded. They were randomly a l located to the open h e m o r r h o i e d e c t o m y a n d t h e L i g a s u r e h e m o r r h o i e d e c t o m y g r o u p . Randomization was performed through a sealed envelope. Exclusion criteria i n c l u d e d p a t i e n t s w i t h p r i o r a n o -r e c t a l s u r g e r y , i n f e c t i o n a t t h e anorectal region or any suspicion of malignancy.

After having fasted for 10 hours, the pat ients were ass igned to general anesthesia or spinal anesthesia depending upon the patient's consent and choice. Both the methods were performanced by the surgeons involved and surgical t ime noted down. Ligasure TM (U.S.A) was util ized in this study. Patients were give I /V morphines if they were complaining of severe pain. Patients were discharged the next day if there was no bleeding or any other complication. Patients were prescribed Ibuprufen and to take the drug if there was pain. They were asked to report 10 days after surgery. Data were analyzed with SPSS 10. RESULTS

A total of 49 patients were recruited in the study (24 in Ligasure group & 25 in the open group). The average age of the patients was 37±7.8 years (26 -64 years). The age and the demographic data were comparable between the 2 groups. Duration of operat ion, postoperat ive pain and hospital stay are depicted between the two groups (Table 1).

Table 1: Comparison of indicators between two groups

Indicator LigaShure group

Open group

P-value

Intermediate Maximum Minimum Intermediate

Maximum Minimum

Morphine doses 1.23 2 1 1.71 3.4 1 0.58 A packof hemorrhoid excise time (min)

8.25 11 4.9 16.75 20 10 <0.001

Bedridden days 1.043 2 1 1.71 2 1 0.61

Ibuprofen dose 5.58 18 2 5.61 18 2 0.63



Visual Analogue Scale (VAS)

The mean average surgical time was 23.54 min in the open method and 15.25 min in the Ligasure method . The mean average t ime in excis ing a Single hemorrhoidal lesion was 16.94±2.84 min in the open method and 9.2±1.25 in the Ligasure method which was found to be statistically significant (P<0.001).

The consumption of morphine for postoperative pain (POP) was lower in the Ligasure group compared to the open group but it was not statistically significant. The hospital stay was also the same in both the groups (Table 1). Bleeding was not severe in both groups and urinary retention was not significant in both the groups. A t home for POP, the use of NSAID was the same in both the groups. At one month follow up no complications such as difficult defecation or gas incontinence were observed in both the groups. Likewise return to job after surgery was the same in both groups. DISCUSSION

This study showed that the surgical time was significantly less with the Ligasure method. This is because dissection and layer by layer separation of the sphincter is not needed during the Ligasure method. Secondly, it could be due to the blood—less field that is encountered when the Ligasure method is employed. Although blood loss was not calculated in this study but it appeared that the blood loss was less in the Ligasure method compared to the open method. Postoperative pain was found to be not statistically signif icant between the two groups. This could possibly be attributed to a small sample size used in this study (3).

A meta- analysis also corroborates with our findings and reveals that there was a significant difference in the surgical time between the two methods but there was no difference in pain following surgery (11). Secondly, in both groups, patients were discharged the next day and not on the same day of operation, thus discharge criteria were the same in both groups of patients. In some centers, patients are discharged on the day of operation as these operations are conducted as outpatient surgeries. In such situations, additional research is needed to get a clear and exact time of discharge from the hospital. Likewise, different surgeons employing these techniques could possibly get different results as such results depend on the expertise and experience of the surgeons as well. Less surgical time would obviously decrease the post-operative pain and other complications that are associated with surgery. Future studies can also calculate blood loss in such types of surgeries. Moreover, if the anesthetic technique is also the same, that would also have an obvious impact on the duration of surgery, the postoperative pain and the blood loss during surgery. As such there were no big limitations in our study except a slight denying behavior for the new technique which was usually easily addressed after counseling. The second problem was at times the unavailability of ligasure.

CONCLUSION The Ligasure method appears safe and the surgical time is meaningfully less than in

the open method.



REFERENCE

1. Brunicardi FC, Andersen DK, Billiar TR, Dunn DL, Hunter JG, Matthews JB, et al, editors. Schwartz's Principles of Surgery. 9th ed. New York: McGraw-Hill; 2010. p. 1057-8.

2. Jayaraman S, Colquhoun PH, Malthaner RA. Stapled versus conventional surgery for hemorrhoids. Cochrane Database Syst Rev 2006;(4):CD005393.

3. Altomare DF, Milito G, Andreoli R, Arcana F, Tricomi N, Salafia C, et al. Ligasure Precise vs. conventional diathermy forMilligan-Morgan hemorrhoidectomy: randomized, multicenter trial. Dis colon rectum.2008;51(5):514-19.

4. Khanna R, Khanna S, Bhadani S, Singh S, Khanna AK. Comparison of LigasureHemorrhoidectomy with Conventional Ferguson's Hemorrhoidectomy. Indian J Surg 2010;72(4):294-7.

5. Sakr MF. LigaSure versus Milligan-Morgan hemorrhoidectomy: a prospective randomized clinical trial. Tech Coloproctol .2010;14(1):13-7.

6. Fareed M, El-Awady S, Abd-El monaem H, Aly A. Randomized trial comparing LigaSure to closed Ferguson hemorrhoidectomy. Tech Coloproctol 2009;13(3):243-6.

7. Chung YC, Wu HJ. Clinical experience of sutureless closed hemorrhoidectomy with LigaSure. Dis Colon Rectum 2003;46(1):87- .92

8. Tan KY, Zin T, Sim HL, Poon PL, Cheng A, Mak K. Randomized clinical trial comparing LigaSure haemorrhoidectomy with open diathermy haemorrhoidectomy. Tech Coloproctol 2008;12(2):93-7.

9. lelpo B, Martin P, Vazquez R, Corripio R, Roman JS, Acedo F, et al. Long term results of diathermy Milligan-Morgan, stapled, harmonic scalpel and Ligasurehemorrhoidectomy. Colorectal Dis 2010;12 (Suppl 3):49.

10. Palazzo FF, Francis DL, Clifton MA. Randomized clinical trial of Ligasure versus open haemorrhoidectomy. Br J Surg .2002;89(2):154-7

11. Tan EK, Cornish J, Darzi AW, Papagrigoriadis S, Tekkis PP. Meta- analysis of short-term outcomes of randomized controlled trials of LigaSure vs conventional hemorrhoidectomy. Arch Surg 2007;142(141209-18; discussion 1218.

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PATTERN OF SURGICAL CASES AND ITS MANAGEMENT IN BACHA KHAN MEDICAL COMPLEX SHAHMANSOOR SWABI

Arshad Amin1, Faiz-Ur-Rahman1, Fazli Junaid1, Shahid Nisar1

1. Town Teaching Hospital

ABSTRACT

OBJECTIVE To study the pattern of general surgery cases and their management in Bacha Khan Medical Complex Shahmansoor Swabi.

METHODS This descriptive cases-series study was conducted prospectively in general surgery department Bacha Khan Medical Complex Shahmansoor Swabi form jan, 2013 to Dec, 2015. There were 1200 patients in the series who were managed either conservatively or operated upon. All patients with symptoms suggesting a surgical disease and managed as a surgical case were included, while cases that were referred to other departments and those that left against medical advice were excluded.

RESULTS Most of the patients had alimentary tract diseases 361(30%) followed by urinary tract diseases 264 (22%),superficial lumps 142 (11.8%), hernia 140 (11.7%), hepato-biliary-pancreatic diseases 116 (9.7%), breast diseases 55 (4.6%), scrotal diseases 41 (3.4%), thyroid diseases 28 (2.3%),salivary gland diseases 15 (1.3%), vascular diseases 8 (0.7%), thoracic diseases 2 (0.2%) and miscellaneous 28 (2.3%). A total of 604 (64.5%) patients were treated as elective cases and333 (35.5%). were treated as emergency cases. As many as 937 (74.08%) patient were treated by operations and 263 (21.92%) patients by conservative treatment, while 41 (3.41%) patients were referred. Seven patients expired, giving a mortality rate of 0.58%.

CONCLUSION The commonest cause of seeking surgical care was alimentary tract diseases, followed by urinary tract diseases, superficial lumps, hernias, hepato-biliary-pancreatic diseases, breast diseases, scrotal diseases and thyroid diseases. Bacha Khan Medical Complex Shahmansoor Swabi is a newly established hospital catering to the needs of population of district Swabi and adjoining districts and areas.

KEYWORDS

Surgical cases acute appendicitis, Urinary tract diseases, alimentary tract diseases, haemorrhoid. INTRODUCTION

Pakistan has an estimated population of 200 million (July, 2016), which is growing at a rate of 2.05% per annum and has a rural vs. urban distribution of64% vs. 36%1. Total registered medical practitioners in Pakistan till May 31, 2015 are 152792 making doctor to population ratio of 1:12150.2. District Swabi is

currently having population of 16 lakh making it the fourth populous district of Khyber Pakhtun Khwa after district Peshawar, Mardan & Swat. It is becoming very difficult to expand urban services and facilities adequately to cope with the growing pressure of the increasing population. Furthermore the increasing burden of Afghan refugees make the problem even more complicated. Bacha

Khan Medical Complex Shahmansoor Swabi is a 500 bed newly established hospital attached to Gajju Khan Medical College Swabi. Department of surgery comprises of 2 surgical units besides

Correspondence: Dr. Faiz-Ur-Rahman

Town Teaching Hospital Contact: 0333-9176048


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the specialties of urology, orthopaedic and neurosurgery. The two surgical unit have 50 bed, each with equal distribution of OPD. operation and emergency days. Bacha khan medical complex shahmansoor swabi mainly attracts peoples from district swabi. As this is the only hospital equipped with professional staff General surgeon, medical specialist, cardiologist, gynecologist, neurosurgeon, orthpaerdic surgeon and urologist in government setup so it attracts peoples from low income areas of Gadoon Amazai, Bunir, attock, Mardan and Haripur districts. Beside this alot number of Afghan Refugees avail the services of this hospital. The pattern of diseases varies with the geographical areas, in different races, age groups, social classes and in people with different occupation. Very few local studies are available on the epidemiology pattern of diseases and incidence of a particular disease prevalent in the district, province and the country. This study was carried out to find out the pattern of cases managed in a surgical department Bacha khan Medical Complex Shahmansoor Swabi. METHODOLOGY

This descriptive case-series study is a prospective analysis of all patients treated in surgical department Bacha Khan medical Complex Shahmansoor Swabi. The data was retrieved each month using record from patient’s file, admission register and operation theater register. Those patients who were having symptoms suggesting a surgical diseases and treated as a surgical case were included in the study. These patients were either admitted through out-patient department (OPD) Or emergency department or shifted to surgery department from other departments, or operated upon as a day cases. The variables noted and analysed were patient’s age, sex, diagnosis, mode of presentation, mode of admission, mode of treatment, nature of operation, complication and final outcome. All the data was analysed using computer program SPSS version-10. RESULTS

The patient were enrolled from jan, 2013 to dec, 2015.During the 3-year period 1200 patients were managed either conservatively or operated upon. The gender distribution was: 763 (63.58%) male, 437 (36.41%) female. The mean age of the patient was 39.14+16.6 year with the range of 2 year to 80 years. The Alimentary tract and urinary tract diseases formed the main bulk of the casestogether accounting for 52% cases (Table.1) Alimentary tract diseases comprises of non specific abdominal pain, haemorrhoid, Acute appendicitis, anal fissure, anal fistula, intestinal obstruction, ileal perforation, duodenal unlcer perforation, appendicular abscess and carcinoma of gut. Urinary tract diseases comprises of acute UTI renal stone diseases, BPH vesical calculus, non-funcational kidney, urethal stricture, and carcinoma of urinary tract, Superficial lumps(11.8%)hernias (11.7%) (12%) and hepato-biliary-pancreatic diseases (9.7%) were the other major diseases. Diseases related to breast (4.6%) scrotum (3.4%) thyroid (2.3%). salivary gland (1.3%) vascular (0.4%) thoracic (0.2%) and of miscellaneous nature. (2.3%) accounted for the minority of cases. Out of 937 operations 604 (64.5%) patients were categorized as elective cases while 333 (35.5%) patients as emergency cases (64.5%) patients were categorized as elective cases while 426 (35.5%) as emergency cases.

As for the ways of management, 937 (78.08%) patients were managed by operations and 263 (21.92%) patients by conservative treatment, while 41 (3.41%) patients were referred. In terms of operations performed in this series appendicectomy was the most common surgery. Uncomplicated hernia surgery (15%) was the 2nd most common procedure and included herniotomy, herniorrhaphy, and hernioplasty. The 3rd most common procedure was excision of various subcutaneous lumps (13%) including carbuncle. Fourth on the lest was haemorrhoidectomy, other common operations were cholecystectomy, urinary trach surgery and incision and drainage procedures.

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DISCUSSION The spectrum of diseases is generally considered a reflection of disease prevalence in a region. In

this series, alimentary tract diseases (30.08) were the most prominent cause of admission, followed by urinary tract diseases (22%),superficial lumps (11.8%) hernia (11.7%), hepate-biliary-pancreatic diseases (9.7%), breast diseases (4.6%), scrotal diseases (3.4%), thyroid diseases (2.3%), salivary gland diseases (1.3%) vascular diseases (0.7% ) thoracic diseases (0.2%), and miscellaneous (2.3%). In a report form the American Board of Surgery, the average number of procedures performed by general surgeons were: abdomen (hepato-biliary-pancreatic + hernia) 26%, alimentary tract 16%, breast 14% endoscopy 13% skin/soft tissue 12% and vascular 10% however, genitourinary tract, thoracic and endocrine procedures accounted for 1% each.4

Appendicectomy (17.6%) was the most common operation in our study. It usually runs in families and is common in those peoples who consume lessfibre in their diet. Since in Bacha Khan Medical Complex Shahmansoor Swabi the patients usually come from far flung areas so in ordered to avoid complication of acute appendicitis eg the risk of rupture these patient are usually preferred to be operated upon rather than sent back home without operation.Interestingly a case of suspected appendicitis was opened but the appendix was found absent after thorough search of retrocacecal and ileal regions. Three more senior surgeons were called upon to confirm the absence of appendix was declared as congenital absence of appendix in that particular patient. Such cases are rarely reported from other part of the world. The incidence is estimated to be one in 1,00,000 laparotomies for suspected appendicitis.A cute appendicitis is among the most frequent causes of surgical abdominal diseases worldwide 13,14 Another study from Ghana also reported appendicitis as the most common cause of acute abdomen (23.5%), followed by non-specific abdominal pain (21.4%), acute intestinal obstruction (10.8%), gynaecological causes (9.5%) and peptic ulcer (9.2%). 15 Caterino from Rome reported appendicitis as the most frequent diagnosis (16.4%) followed by non-specific abdominal pain (15.5%), Cholelithiasis (12.5%) abdominal malignancy (10.3%). 16Hernia surgery (15%) turned out to be the 2nd most common surgical operation in this series, which was in line with several other international studies 4-7. Excision of superficial lumps is also a common operation performed in over setup the spectrim ranges from lipoma to soft tissue sarcoma and infections of superficial tissue .The next most common disease requiring a surgical procedure was haemorrhoids (7.7%), a finding which is not reported earlier in any rural international series. The estimated prevalence rate of symptomatic haemorrhiods in the United States is (4.4%) of the adult population.8The othert common surgical disease in this series was gallstone disease (6.4%). Abu-Eshy et al reported the overall prevalence of gallstone disease in Saudi Arabia as 11.7%9Gallstone disease remains one of the most common medical problems leading to surgical intervention. Cholelithiasis affects approximately 10% of the adult population in the United states.10. In this series the most common cause of acute abdominal admission was acute urinary tract infection (UTI) 9.4%, followed by non-specific abdominal pain 7.2%, acute appendicitis 4.8%, acute urinary retention 2.4%, acute intestinal abstruction 2%, ileal perforation 0.6%, and duodenal perforation 0.4%. Ohene-Yeboah in an study from Ghana reported the following 7 conditions as the most common causes of acute abdominal pain requiring admission: acute intestinal obstruction (12.6%), gastroduodenal perforations (11.0%) non-specific abdominal pain (9.8%) abdominal injures (8.3%) and acute cholecystitis (3.2%).11 Chianakwana et al in an study from Nigeria reported appendicectomy as the most common emergency operation in 139 patients, followed by road traffic accidents (RTAs) involving 137 patients, gunshot injuries mainly from armed robbery attacks 127 cases, acute intestinal obstruction 92 cases.12.In over study RTA patients or not included because they are not entertained due to lack of infrastructure like ICU, blood bank, trauma center and professional trauma team these patients are referred to tertiary care hospital .The frequency of renal stone disease in patients with urinary tract infection was earlier reported from charsadda, Pakistan, as 18.98%.17 Acute pyelonephritis is a frequent condition responsible for more than 100,000 hospitalisations per year in the United States.18 Skin and soft tissue infections are common diseases, as noted in this series. The spectrum ranges from mild boil to severe necrotising soft tissue infection, as reported in other international studies,19,20 Similarly, gram-positive bacteria accounted for more than 80% of the cases.19 Diseases of the breast are common and include

JGMDS


problems, related to pregnancy and lactation, inflammatory conditions, non-neoplastic proliferative and benign neoplastic disorders 59.5% and malignant neoplasms.. An earlier study from several district (non-teaching) hospitals from rural areas of Pakistan showed the following spectrum: hernia surgery (8.7%), urinary calculus removal (6.2%), appendicectomy (5%), haemorrhoid or perianal surgery (4%), prostatectomy (4%), abscess drainage (3.5%), gastrointestinal operations (3.1%), excision of skin and subcutaneous lesions (2.9%), hydrocele operation (0.9%), gallbladder/biliary operation (0.6%), breast surgery (0.6%) and scrotal/testicular operation (0.6%).7. In this series 41 patients were referred to urban tertiary care institutions. The referred cases included mostly malignancies (oesophagus, stomach, rectum, kidney, bladder, prostate and thyroid), as well as cases of acute pancreatitis and choledocholithiasis. REFERENCES

1. Annual plan 2010-11, planning commission, Govt. of Pakistan: chapter 9, population & development. (Online) 2010 (Cited 2010 july 24). Available from URL: http://www.planningcommission.gov.pk/annual%20plans/2010-11/population%20and%20Development.pdf.

2. Statistics: Pakistan medical & dental council. (Online) 2005 (cited 2010 july 24). Available from URL: http://www.pmc.org.pk/statistics/tabid/103/default.aspx.

3. Final report: Karachi mega cities preparation project. (Online) 2005 (cited 2010 july 25). Available from URL: http://www.adb.org/Documents/Produced-Under-TA/38405/38405-PAK-DPTA.pdf.

4. Ritchie WP jr, Rhodes RS, Biester TW. Workloads and practice patterns of general surgeons in the United States, 1995-1997: a report from the American Board of surgery. Ann Surg 1999; 230: 533-42.

5. Humber N, Frecker T. Rural surgery in British Columbia: is there anybody out there? Can j surg 2008; 51: 179-84.

6. Awojobi OA. Principle of rural surgical practice. Dokita 1998; 25: 161-2.

7. Blanchard RJ, Blanchard ME, Toussignant P, ahmed M, Smythe CM. the epidemiology and spectrum

of surgical care in district hospitals of Pakistan. Am J Public Health 1987; 77: 143-45.

8. Schubert MC, Sridhar S, schade RR, wexner SD. What every gastroenterologist needs to know about common anorectal disorders. World J Gastroenterol 1009; 15:3201-9.

9. Abu-Eshy SA, Mahfouza AA, Badr A, El Gamal MN, Al-Shehri MY, Salati MI, et al. Prevalence and

risk factors of gallstone disease in a high altitude. Saudi population. East mediterr health 2007; J 13: 794-802.

10. Schirmer BD, winters KL, Edlich RF. Cholelithiasis and cholecystitis. J Long term Eff med implants

2005; 15: 329-38.

11. Ohene-Yeboah M Acute surgical admissions for abdominal pain in adults in Kumasi, Ghana. ANZ J Surg 2006; 76: 898-903.

12. Chianakwana GU, ihegihu CC, okafor PI, anyanwu SN, Mbonu OO. Adult surgical emergencies in a

developing country: the experience of Nnamdi Azikiwe University Teaching Hospital, Nnewi, Anambra state, Nigeria. World J surg 2005; 29: 804-7.

http://www.planningcommission.gov.pk/annual%20plans/2010-11/population%20and%20Development.pdf

http://www.planningcommission.gov.pk/annual%20plans/2010-11/population%20and%20Development.pdf

http://www.pmc.org.pk/statistics/tabid/103/default.aspx

http://www.adb.org/Documents/Produced-Under-TA/38405/38405-PAK-DPTA.pdf

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13. Noudeh YJ, Sadigh N, Ahmadnia AY. Epidemiologic features, seasonal variations and false positive

rate of acute appendicitis in shahr-e-Rey, Tehran. Int J surg 2007; 5: 95-8.

14. Davies GM, Dasbach EJ, Teutsch S. The burden of appendicitis-related hospitalizations in the United States in 1997. Surg infect (Larchmt) 2004; 5:160-5.

15. Naaeder SB, Archampong EQ. Clinical spectrum of acute abdominal pain in Accra, Ghana. West Afr

J Med 1999; 18:13-6.

16. Caterino S, Cavallini M, Mali C, Murante G, Schiffino L, Lotito S, Toncher F. Acute abdominal pain in emergency surgery: clinical epidemiologic study of 450 patients. Ann ital Chir 1997; 68:807-17.

17. Jan H, Akbar I, Kamran H, Khan J. Frequency of renal stone disease in patients with uinary tract

infection. J Ayub Med Coll Abbottabed 2008; 20: 60-2.

18. Rollino C. Acute pyelonephritis in adults. G Ital Nefrol 2007; 24: 121-31.

19. Kujath P, Eckmann C, Bouchard R, Esnaasheri H. Complicated skin and soft tissue infections. Zentraibl chir 2007; 132 411-8.

20. Gabillot-Carre M, Roujeau JC. Acute bacterial skin infections and cellulitis. Curr opin infect Dis 2007; 20: 118-23.

21. Mayun AA, Pindiga UH, Babayo UD. Pattern of histopathological diagnosis of breast lesions in Gombe, Nigeria. Niger J Med 2008; 17:159-62.

22. Agarwal G, Pradeep PV, Aggarwal V, Yip CH, Cheung PS. Spectrum of breast cancer in Asian women. World J Surg 2007; 31: 1031-40.

23. Hays RB, Evans RJ, Veitch C. The quality of procedural rural medical practice in Australia. Rural Remote Health 2005; 5: 474.

Corrigendum

In the issue Vol. 03 No.02 (March 2017-September 2017) of JGMDS in the article titled “Effectiveness of disk in the treatment of herniated lumbar intervertebral disc.”, the name of the authors were aberrantly printed by omitting two authors. Henceforth the author list for the said article should be read as under=

Sohail Amir1, Maimoona Qadir2, Muhammad Usman3

1. Naseer Teaching Hospital, Peshawar. 2. Khyber Teaching Hopital, Peshawar. 3. Naseerullah Babar Memorial Hospital, Peshawar.

JGMDS


PREDICTORS OF SUCCESS OF VAGINAL BIRTH AFTER PREVIOUS CESAREAN SECTION – AN ANALYSIS OF 100 CASES

Maimoona Qadir1, Sohail Amir2

1. Khyber Teaching Hospital 2. Naseer Teaching Hospital

ABSTRACT BACKGROUND Women eligible for vaginal birth after cesarean section (VBAC) have lower morbidity rates than women who undergo subsequent elective cesarean sections. Objective: To identify the obstetric parameters those influence the success of vaginal delivery in women with previous cesarean section. METHODOLOGY This descriptive cross sectional study was conducted at Gynaecology and Obstetrics Department of Khyber Teaching Hospital, Peshawar from 1st May 2015 to 31st April 2016.Inclusion criteria was all women of any age or parity presenting at >36weeks gestational age, with singleton pregnancy, vertex presentation, estimated fetal weight of 2.5 -3.5kg and documented previous lower uterine segment cesarean section for a non recurrent cause. Five predictors of success of vaginal birth after previous cesarean including maternal age, gestational age, and history of vaginal delivery, onset of labor and bishop score were evaluated in each patient. RESULTS Out of 100 women, 64 had VBAC and 36 had cesarean section. Fifty five were booked and 45 were non booked. Total women with history of VBAC were 24, out of these 16(66%) had VBAC and 8(33%) had repeat cesarean section. Ninety three had spontaneous onset of labor whereas 7 were induced,88 patients had Bishop score >5,out of these 61(69%) ended in VBAC and 27(30.6%) had cesarean section. The most common age group where VBAC occurred in majority was 25- 35 years. Thirty nine (61%) women had period of gestation between 38weeks to 39weeks+6days. Mean maternal age was 29.42 + 3.54 years CONCLUSION History of vaginal delivery, spontaneous sonset of labor and Bishop score >5 are the factors which are associated with more chances of vaginal delivery after cesarean section. KEY WORDS Bishop Score, Elective Cesarean Section, Gestational Age, Induced Labor, Vaginal Birth After Cesarean. INTRODUCTION Cesarean section is the commonest obstetrical procedure performed worldwide. When used appropriately, it can improve maternal/fetal outcomes. However, when used inappropriately, the potential

harm may exceed the potential benefits of cesarean section1.Its rate remained stable worldwide at under 10% until 1980s when they started to rise, reaching 30% of births in many developing countries in last decade. It is predicted that by 2020 the rate could be higher than 50%.2,3. Once a woman is delivered by cesarean, her option in subsequent pregnancy is either planned trial of labor or planned repeat cesarean

section4.Women eligible for VBAC have lower morbidity rates than those who undergo elective repeat cesarean section5A trial of labor can save them from risk of repeat cesarean6. In the long run, serious maternal morbidity increases as the number of previous cesareans increase7

Correspondence: Dr. Maimoona Qadir

Khyber Teaching Hospital Contact: 0346-9196731


PREDICTORS OF SUCCESS OF VAGINAL BIRTH AFTER PREVIOUS CESAREAN SECTION – AN ANALYSIS OF 100 CASES JGMDS


Understanding of prenatal determinants, timely intervention and proper monitoring of labor can promote VBAC8 Overall; the VBAC success rate is 60-82% in published studies9 In comparison to cesarean section, VBAC is associated with shorter stay in hospital 10,11,12,low rates of deep venous thrombosis, enhanced mother infant bonding and lower maternal morbidity due to escape from complications of operative delivery 13.On the other hand,the potential harms of VBAC include uterine rupture, risk of emergency cesarean section, perinatal mortality, hysterectomy, maternal infection and blood transfusions 14,15. A planned VBAC which leads to vaginal birth is associated with less number of complications than elective repeat cesarean section but a planned VBAC which results in an emergency cesarean section is associated with more complications than an elective repeat cesarean section 14.In order to assess suitability in patients with previous caesarian for successful VBAC, the current study looked at antenatal determinants like maternal age, gestational age, VBAC history, Bishop score. Assessing factors associated with successful VBAC is very important for counseling mother while offering VBAC. MATERIAL AND METHODS This cross sectional study was carried out on women attending antenatal clinic of Gynae Department, Khyber Teaching Hospital, Peshawar from 1st May 2015 to 31st April 2016.It included 100 patients picked by consecutive sampling technique, who had history of previous one cesarean section. The inclusion criteria entailed all women of any age or parity with gestational age >36 weeks, singleton pregnancy, vertex presentation, documented lower uterine segment scar for a non recurrent cause and estimated fetal weight 2.5-3.5kg.The exclusion criteria consisted of dead fetus, more than one caesarean section, surgery on uterus other than caesarean, previous vertical uterine scar, cephalopelvic disproportion, malpreentation in present pregnancy, medical disorder, placenta previa and non reassuring fetal heart rate patterns. A detailed structured proforma was used as study instrument and data was collected.

Written informed consent was taken from the patients after explaining to them the purpose of study. The study was approved by institutional ethical review board. All women were admitted in the hospital on their due dates or earlier if they went into spontaneous labors. At time of admission, complete history including age, prepregnancy BMI, indication of previous caesarean section, intra or postoperative complications of previous caesarean in addition to all other details were recorded. Thorough general, per abdominal and cervical examination was done .Those failing to labor at 40 weeks were induced with only one tablet prostaglandin E2 as per unit protocol. Progress of labor was monitored by maintainance of partogram and strict fetal monitoring and the mode of delivery was seen .Five predictors of success were evaluated which included maternal age, previous successful VBAC, spontaneous onset of labor, bishop score and gestational age. All data was entered and analyzed using SPSS 20.0, and interpreted in the form of tables. Mean and standard deviation were calculated for numerical and frequency and percentages were calculated for categorical variables. RESULTS A total of 100 patients were included in the study. Among the 100 women,64 had VBAC and 36 had caesarean sections. Out of these 100,fifty five were booked patients who were already assessed antenatally, while 45 were non booked, self referrals or referrals from periphery. Amongst the 55 booked patients,39(71%) had VBAC and 16(29%) had cesarean section. Of the unbooked patients,25(55%) had VBAC and 20(44%) ended in caesarean section. Total women with history of VBAC were 24,out of these 24,16(66%) had VBAC and 8(33%) had repeat cesarean section. p-value was 0.001 and this was statistically significant(Table no.I)

Table II shows that out of 100 patients studied,12 had bishop score of less than 5,out of which 3(25%) had VBAC and 9(75%) ended in cesarean section.88 patients had bishop score more than 5,out of which 61(69%) ended in VBAC and 27(30.6%) in LSCS. This suggests association between bishop score and mode of delivery(p-value <0.001) Of 100 patients,93 had spontaneous onset of labor and 7 were induced. Of those spontaneously labored,61(65.5%) ended in VBAC and 32(34.4%) in LSCS.7 patients were induced,3(42.8%) had VBAC and 4(57%) ended in caesarean section.(Tabble no.III)



Regarding maternal age, the patients in our study were divided into three age groups. In patients less than 25 years, VBAC was seen in18(18%) and 7(7%)ended in cesarean delivery,38 successfully ended in VBAC in age group 25-35 years and 8 had VBAC in more than 35 years of age. Mean age was 29.42 + 3.54 years. The gestational age was found to be 38 weeks to 39weeks +6 days in 39(61%) patients who experienced VBAC. The mean gestational age was 39.2 + 0.9 weeks.

Table No. I.Distribution Of Patients By History Of Vbac And Mode Of Delivery.(N=100) History Of VBAC

Mode of Delivery p-value VBAC LSCS Total

0.001 Yes 16(66.6%) 8(33%) 24 No 28(36.8%) 48(63.4%) 76 Total 64(64%) 36(36%) 100

Table No. II.Distribution Of Patients On Basis Of Bishop Score.(N=100) Bishop Score

Mode of delivery p-value VBAC LSCS Total

<0.001 <5 3(25%) 9(75%) 12

>5 61(69.3%) 27(30.6%) 88 Total 64% 36% 100

Table No. III.Distribution Of Patients By Onset Of Labor And Mode Of Delivery.(N=100) Mode of Delivery p-value Onset of Labor

VBAC LSCS Total 0.001 Spontaneous 61(65.5%) 32(34.4% 93

Induction 3(42.8%) 4(57%) 7 Total 64(64%) 36(36%) 100

DISCUSSION Planned VBAC is indeed a better decision for women having previous cesarean due to a non recurrent cause .Large systematic review conducted in 2010 concluded that VBAC is reasonable and safe choice for most women; however, there are specific considerations which may increase the potential harms associated with VBAC10. We observed through our study that 64% of our study population delivered through VBAC. Of those women who had history of vaginal delivery prior to current pregnancy,66.66% ended in successful VBAC. Macones GA et al in their study observed that those women who had no history of vaginal birth are five to seven times at risk of having cesarean section in comparison to those having previous vaginal birth 16.Likewise,Maternal Fetal Medicine Unit report suggested that women with previous vaginal delivery have a success rate of 86.6% in delivering the next baby vaginally 17.This finding is supported by few other international studies 18,19.

Regarding the gestational age, the most prevalent gestational age group according to our study was 38weeks to 39weeks+6days.Landon MB et al observed that chances of VBAC are high at 37weeks to 40 weeks 20.Another case control study found that the chances of success of VBAC increases with each increasing week after the gestational age of 37 weeks21.A retrospective cohort study of 2,755 women showed that gestational age more than 40weeks is a risk factor for repeat cesarean section for women with previous cesarean opting for VBAC 22. In our study, the most common age group where successful VBAC was seen was 25-35 years with least success seen in more than 35years age .Increasing maternal age is a risk factor for repeat cesarean section, this was observed by Smith GC et al in their study 23.Bujold E et al and Srinivas SK et al also concluded that for women more than 35 years of age, there is more likelihood of unsuccessful trial of labor 24,25.



Bishop score was a strong indicator of successful trial of labor in our study where 75% of those women with bishop score >5 ended ultimately in successful VBAC. Nighat S et al and Raja FJ et al in their studies done at Pakistan also concluded the same findings 26,27.Macones GA et al reported that the success rate of VBAC increased with each centimeter increase in cervical dilatation 16.McNally OM et al found that effacement of 100% had fivefold increase in likelihood of VBAC 28. There were several limitations in our study. First the sample size was small. Secondly, as it was a hospital based survey so the results cannot be generalized. Thirdly, the educational status of majority of our patients and lack of awareness about the details of previous cesarean and records made it difficult for us to know about the details of previous cesarean section and its complications. CONCLUSION:

Previous vaginal birth, Bishop score > 5 and spontaneous onset of labor are factors associated with increased chance of successful VBAC. Increasing maternal age of >35 years and advancing gestational age of >40 weeks are risk factors for repeat cesarean section. RECOMMENDATIONS Decision to perform cesarean section or trial of labor in a woman with history of previous cesarean should be based on clear, compelling and well supported justifications. The decision should be consultant laden and should be discussed with the women as facilitated decision making will enable woman to make informed decisions about their birth options. REFERENCES

1. Abebe FE, Gebeyehu AW, Kidane AN, Eyassu GA. Factors leading to caesarian section delivery at Felegehiwot referral hospital,NorthwestEthiopia:a retrospective record view. Reprod Health 2016;13:6

2. SolheimJ.Preventing the first cesarean. J Matern Fetal Neonatal Med 2011; 24:1341-6

3. Betran AP, YE J, Moller AB, Zhang J, Gulmezoglu AM, Torloni MR. The increasing trend in caesarean section rates:global,regional and national estimates: 1990-2014. PLoS One. 2016; 11(2): e0148343

4. Scott JR. Vaginal birth after caesarean delivery: a common sense approach. J ObstetGynecol 2011;

11(2): 342-50 5. Senturk MB, Cakmak Y, Atac H, Budak MS. Factors associated with successful vaginal birth after

caesarean section and outcomes in rural areas of Anatolia. Int J Womens Health 2015; 7: 693-7

6. Bangal VB, Giri PA, Shinde KK, Gavhane SP. Vaginal birth after caesarean section. J Med Sci 2013; 5(2): 140-4

7. Marshall Ne, Fu R, Guise JM. Impact of multiple caesarean deliveries on maternal morbidity: a

systematic review. Am J ObstetGynecol 2011; 205(3): 262

8. Catling PC, Johnston R, Ryan C, Foureur MJ, Homer CS. Clinical interventions that increase the uptake and success of vaginal birth after caesarean section: a systematic review. J AdvNurs 2011; 67: 1646-61

9. Mansoor M, Kashif S, Tariq R. To evaluate factors for successful outcome in VBAC. Pak J Med Health

Sci 2010; 4: 322-5.

10. Guise JM, Eden K, Emeis C. Vaginal birth after cesarean: new insights.Evid Rep Technol Assess 2010; 191: 1- 397.



11. National Institute of Health and Clinical Excellence. Cesarean Section. NICE guidelines 132. National Institute of Health and Clinical Excellence 2011.

12. Cunningham FG, Bangdiwala SI, Brown SS. NIH consensus development conference draft statement

on vaginal birth after cesarean; new insights. NIH Consens State Sci Statements 2010; 27(3): 1- 42.

13. Maternity and Neonatal Clinical Guideline. Queensland Clinical Guideline 2015.

14. American College of Obstetricians and Gynecologists. Vaginal Birth after previous cesarean delivery. Practise Bulletin no.115. Clinical management guidelines for obstetricians-gynaecologists. Obstet Gynecol 2010; 116: 450- 63.

15. Tahseen S, Griffiths M. Vaginal birth after two cesarean sections-a systematic review with meta

analysis of success rate and adverse outcomes of VBAC-2 versus VBAC-1 and repeat cesarean sections. BJOG 2010; 117(1): 5- 19.

16. Macones GA, Hausman N. Predicting outcomes of labor in women attempting vaginal birth after

cesarean section: a comparison of multivariate methods with neural networks. Am J Obstet Gynecol 2001; 184: 409- 13.

17. The MFMU Cesarean Registry. Factors affecting the success of trial of labor after previous cesarean

section.Am J Obstet Gynecol 2005; 193(3): 1016- 23.

18. Hendler I, Bujold E. Effect of prior vaginal delivery or prior vaginal birth after cesarean delivery on obstetric outcomes in women undergoing trial of labor. Obstet Gynecol 2004; 104(2): 273- 7.

19. Madaan M, Agarwal S, Nigam A, Aggarwal R. Trial of labor after previous cesarean section; The

predictive factors affecting outcome. J Obstet Gynecol 2011; 31(3): 224- 8. 20. . Landon M, Hauth J, Leveno K, Spong C. Maternal and perinatal outcomes associated with trial of

labor after prior cesarean delivery. N Engl J Med 2004; 351: 2581- 9.

21. Pickhardt MG, Martin JN, Meydrech EF. Vaginal birth after cesarean delivery; are there useful and valid predictors of success or failure?. Am JObstet Gynecol 1992; 166: 1811- 9.

22. Zelop CM, Shipp TD, Cohen A. Trial of labor after 40 weeks gestation in women with previous

cesarean. Obstet Gynecol 2001; 97: 391- 3.

23. Smith GC, Pell JP, Cameron AD. Risk of perinatal death associated with labor after previous cesarean delivery in uncomplicated term pregnancies. JAMA 2002; 287: 2684- 90.

24. Bujold E, Hammoud AO, Hendler I. Trial of labor in patients with a previous cesarean section: does

maternal age influence the outcome?. Am J Obstet Gynecol 2004; 190: 1113- 8.

25. Srinivas SK, Stamilio DM, Sammel MD. Vaginal birth after cesarean delivery: does maternal age affect safety and success?. Paediatr Perinatal Epidemiol 2007; 21(2): 114- 20.

26. Nighat S, Safia KH. Predictors of successful trial of labor in patients with a previous cesarean section.

JPMA 2014; 64: 542.

27. Raja FJ, Bangash KT, Mahmud G. VBAC scoring: successful vaginal delivery in previous one cesarean section in induced labor. JPMA 2013; 63: 1147.

28. McNally OM, Turner MJ. Induction of labor after previous one cesarean section. Aust NZ J Obstet

Gynaecol 1999; 39: 425- 9.

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TO DETERMINE THE FREQUENCY OF DURAL TEAR IN PATIENTS PRESENTING WITH DEPRESSED SKULL FRACTURE: AN EXPERIENCE OF 96 CASES IN A TERTIARY CARE HOSPITAL

Sohail Amir1, Syed Amir Shah2, Khaleeq-Uz-Zaman2

1. Naseer Teaching Hospital. 2. Pakistan Institute of Medical Sciences, Islamabad.

ABSTRACT OBJECTIVE The objective of this study was to determine the frequency of dural tear in patients with depressed skull fractures. MATERIAL and Method This cross-sectional study was conducted in department of Neurosurgery Pakistan institute of Medical Sciences Islamabad from January 2010 to December 2011. All patients of either gender with depressed skull fracture above one year of age were included in the study. CT brain with bone window done in all patients. Per-operative dura in the region of depressed skull fracture was closely observed for any dural tear. The data collected on pre designed proforma. and analyzed using SPSS version 20.0 RESULTS A total of 96 patients were recruited in the study out of which 58(60.4%) were male and 38(39.5%) were female. Male to female ratio was 1.5:1. And mean age was 19.23 + 2.54 years. The most common location of depressed skull fracture was parietal 37(38.5%), followed by frontal in 27(28.1%), 15(15.6%)in temporal region,13(13.5%) in occipital region and only 4(4.1%) located in posterior fossa. Dural tear was present in 33(34.3%) while in 63(65.6%) it was absent. Other finding associated with depressed skull fracture per operatively were extradural hematoma in 16(16%), subdural hematoma in 11(11.4%), contusion in 16(16.6%) and pneumoencephalus was observed in 20(20.8%) cases. CONCLUSION The frequency of dural tear in DFS is quite high, so one should be vigilant to identify the defect and repair it properly to minimize post operative complications. Key WORDS Depressed skull fracture, Dural tear, Frequency, Head trauma, Contusion. INTRODUCTION Traumatic brain injury (TBI) is an acquired insult to the scalp, skull and intracranial content which may be

accompanied by loss or alteration in sensorium, it is a leading cause of death and severe disability in young population world wide1,2. In United States, more than 2 million sustained TBI annually, of which almost 15% have temporary or permanent neurological deficit. In addition it poses a great impact on economic losses and in one series estimated loss of 30 billion dollars in developed countries are reported3.

A skull fracture can be classified in to linear, depressed and comminuted4. Depressed fracture is one

where in the fracture fragment is displaced inward at a distance equal or greater than the thickness of skull bone.5,6,7. Patient with depressed skull fracture (DFS) can present with sign and symptoms of raised intracranial pressure like headache, vomiting, papilledema. It can also present with decrease level of consciousness, seizure, and cerebrospinal fluid leak or in some cases oozing of brain matter through wound. Plain x-ray skull will clearly show the type, location and degree of depression. CT scan is the gold standard as it not only demonstrate the

Correspondence: Dr. Sohail Amir

Naseer Teaching Hospital Contact: [email protected]

Email: 0332-5723653

TO DETERMINE THE FREQUENCY OF DURAL TEAR IN PATIENTS PRESENTING JGMDS WITHDEPRESSED SKULL FRACTURE: AN EXPERIENCE OF 96 CASES IN A TERTIARY CARE HOSPITA


depressed fracture but also show intracranial lesion8,9. Depending upon the status of underlying skin DFS can be divided in to closed or open. In closed depressed skull fracture (DFS), the skin is intact and is usually treated conservatively until there is significant cosmetic deformity, underlying hematoma or venous sinus injury10. On the other hand open DFS in which the skin is breached are surgical candidates because of increased risk of infection due to contamination11 . Surgical treatment includes elevation of depressed fragment, evacuation of hematoma, wound debridement and repair of dura and dural venous sinuses. DFS should be treated properly and timely to prevent complications such as infection, seizures, progression of neurological deficit, and post traumatic Hydrocephalus.12 DFS are often associated with dural tear which significantly increases the risk of infection, seizure and neurological deficit. The incidence of dural tear in depressed skull fracture varies and reported to be 25% and 65% in different studies13. To view the integrity of dura is paramount importance as foreign debris and brain matter may be present in the wound which need proper debridement and water tight closure of dura either with fascia lata graft or pericranium to prevent complications like cerebral abscess, meningitis and pseudomeningocele formation14. The main objective of our study is to determine the frequency of dural tear in patient with depressed skull fracture. Our study will provide a data which will be shared with other Neurosurgeons to make suggestions regarding the management plan of depressed skull fracture. MATERIAL AND METHODS This descriptive (cross sectional) study was done at Neurosurgery Department of Pakistan Institute of Medical Sciences Islamabad, from 1st January 2010 to 31st December 2011. Sample size was 96 and sampling technique was consecutive (non probability) sampling. All patients of either gender with depressed skull fracture admitted via outpatient department or Emergency department were included in the study, while children below one year of age and those presenting 2 weeks after trauma were excluded. The study was conducted after approval from hospital ethical and research committee. Patient fulfilling the inclusion criteria were included in the study. Informed consent was taken from all the patients. After detailed history and clinical examination patients were sent to radiological investigation including X-ray skull( anterio-posterior, lateral view) and CT scan brain with bone window. Skull was said to be depressed when the fracture fragment is displaced inward at a distance equal or greater than the thickness of skull bone diagnoses on CT brain. Per operatively dura was closely observed for any tear and repair was done either with fascia lata graft or pericranium. The data were collected on predesigned proforma. Data was analyzed using SPSS version 20.0 and presented in form of tables. RESULTS Out of 96 patients 58(60.4%) were male and 38(39.5%) were female. Male to female ratio was 1.5:1. In our study the age of patient ranged from 1 to 50 years with mean age 19.23 + 2.54 years. The incidence of dural tear was 21(21.8%) in males and 12(12.5%) in females as shown in table no. I

The patients were divided in to five groups for the distribution of age. Out of 96 patients 44(45.8%) were in age range of 0-1 years, 25(26%) were in age range of 11 to 20 years, 16(16.6%) were in age group 21-30 years, 7(7.2%) in age group of 31-40 years and 2(2.08%) in age range from 41-50years. Regarding the age distribution in association with dural tears were 9(9.3%) in age range of 1-10 years, 10(10.4%) in 11-20 years, 8(8.3%) in 21-30 years, 4(4.1%) in 31-40 years and 2(2.08%) in 41-50 years, as shown in table. no.II

The most common location of depressed skull fracture is parietal 37(38.5%), followed by frontal 27(28.1%), and temporal 15(15.6%) region. Occipital depressed fracture were 13(13.5%) and only 4(4.1%) were located in posterior fossa. There is no significant differences found in dural tear when location of depressed fracture were taken in to consideration as shown in table no. III In our series we used pericranial graft in 18(18.7%) patient and fascial lata graft in 11(11.8%) patient, in 4(4.1%) we were unable to close the dura, however post operatively CSF leak was not observed in single case. Out of 96 patients, 33(34.3%) had dural tear while in 63(65.6%) there was no dural tear. Other findings associated with depressed skull fracture per operatively were extradural hematoma in 16(16%), subdural hematoma in 11(11.4%), contusion in 16(16.6%) and pneumoencephalus was observed in 20(20.8%) patients as shown in table. No .IV



Table. No. I Gender distribution with dural tear.(n=96) Gender Dural Tear

Present Absent Percentage Total Male 21 37 21.8% 58

Female 12 26 12.5% 38 Total 33 63 100% 96

Table. No II Age group with dural tear.(n=96)

Age group Dural Tear Total

Present Absent Percentages 1-10years 9 35 9.3% 44 11-20years 10 15 10.4% 25 21-30 years 8 8 8.3% 16 31-40 years 4 3 4.1% 7 41-50 years 2 2 2% 4

Total 33 63 100% 96

Table. No. III Location of depressed skull fracture and dural tear.(n=96)

Location Dural tear

Present Absent Total Parietal 14 23 37 Frontal 11 16 27

Temporal 4 11 15 Occipital 3 10 13

Posterior fossa 1 3 4 Total 33 63 96

Table No. IV Per operative findings.(n=96) Peroperative findings Frequency Percentages

Dural tear 33 34.3% Extradural hematoma 15 15.6% Subdural hematoma 11 11.4%

Contusion 16 16.6% Pneumoencephalus 21 22.5%

DISCUSSION

Depressed skull fracture (DFS) occurs as result of direct blow to a small surface area of the skull with a blunt object. Generally it is thought that DFS is a very serious head injury having very bad prognosis. But the reality is that, it become serious only when it directly or indirectly involve the brain.15 Compound depressed fractures are surgical emergencies and should be dealt with properly to prevent complications like meningitis, cerebrospinal fluid leak and post traumatic seizure. If there is Dural rent, the brain matter which may be present in the wound should be sucked out, and after proper homeostasis dural tear should be repaired water tight either use of fascial lata graft or pericranium14,16. In our study 96 patient were recruited of which 58(60.4%) were male and 38(39.5%) were female with male to female ratio 1.5:1. This male predominance coincides with other national and international studies17,18. In one study shows depressed skull fracture more common in male population because of exposure to traffic and daily outdoor activities19

In our study the most common region was the parietal 37(38.5%), followed by frontal in 27(28%). Temporal region was effected in 15(15.6%) and occipital in 13(13.5%) . This is in accordance with study done by Braakman R20 in Digkzikt hospital Netherland on 225 consecutive cases. The location of DFS depends upon the type of trauma and the region of skull which receives the blow.



We observed that dural tear was present in 33(34.3%) and it was absent in 63(65.6%) subjects. The frequency of dural tear in depressed skull fracture varies and reported to be 25% and 65% in different studies13. So dural tear is one of the common finding neurosurgeon can encounter during DFS surgery and one must be vigilant to identify the rent and repair water tight wit h fascia lata graft or pericranium to prevent complications. In current study the frequency of dural tear shows no significant differences in either gender with 21(36.2%) male and 12(31.5%) females patient having dural tear, similarly the frequency of dural tear in different age groups were shown in our study as 9(9.3%) in age group of 1-10 years, 10(10.4%) in 11-20 years, 8(8.3%) in 21-30 years,4(4.1%) in 31-40 years and 2(2.08%) in 41-50 years patients were having dural tears. Gul Muhammad et al. reported almost same results21 There are few limitation in our study. Firstly, the patients were not followed for the postoperative complications, after they were discharged from the hospital. Secondly, as it was a hospital based survey, so its results cannot be generalized to the whole population. Lastly, only Pakistan Institute of Medical Sciences was taken as the study place, inclusion of other hospitals from the same locality would have given better idea about the prevalence of condition in that area. CONCLUSION Depressed skull fracture is a very common neurosurgical emergency. The frequency of dural tears in DFS is quite high, so one should be vigilant to identify the defect and repair it properly to minimize post operative complications. REFERENCES

1. Parel PA.Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. Br. Med. J 2008;336:425-9.

2. Emejulu JKC, Shokunbi MT, Malomo AO, Adeleyo A. Causes of delay in the definitive treatment of compound depressed skull fracture: A five year study from Nigeria. East. Cent. Afr. J. Surg 2006;12:116-22.

3. Hoyt DB, Holcomb J, Abraham E, Atkins J, Sopko G.Working group on trauma research programe

summary report: National heart lung blood institute( NHLBI), National institute of genereal medical sciences ( NIGMS). And National institute of Neurological disorder and stroke ( NINDS) of the National institute of Health(NIH), and the Department of Defence(DOD). J Trauma 2004;57(2):410-5.

4. Rodrigurez ED, Stanwix MG, Nam AJ, et al. twenty six year experience treating frontal sinus fracture:

a novel algorithm based on anatomical fracture pattern and failure of conventional techniques, Plastic Reconstr Surg 2008;122(6):1850-66.

5. Khan AH. Depress skull fracture epidemiology and avoidance of its complication. Thesis, Punjab

university ,Lahore,2004

6. Ali M, Ali L. Roghani, IS. Surgical management of depress skull fracture. JPMI 2003;17: Record 23.

7. Rehman L, Ghani E, Hussain A, etal. Infection in compound depress fracture of skull. J Coll physicians surg Pak.2007;17(3):140-3.

8. Tseng WC, Shih HM, Su YC, Chen HW,Hsiao KY, Chen IC.The association between skull bone

fractures and outcome in patient with sever traumatic brain injury. J Trauma 2011;71(6):1611-4.

9. Mehdi SA, Ahmad B, Dogar IH, Shoukat A. Depressed skull fracture; interrelationship between ct evaluation of and its clinical findings. Prof. Med J 2010;17(4):616-22.

10. Manish J, MathewH, Nupur P, Amey R, Savardekar, Sarbesh T, Malla B. Midline depressed skull

fracture presenting with quadriplegia: A rare phenomenon. Pu Surg Neurol Int 2017;8:39-46



11. Al-Haddad SA, Kirollos R A 5 year study of the outcome of surgically treated depressed skull fracture: Ann R Coll Surg Engl.2002;84(3):196-200.

12. Fitzsimmons-Francis C, Morris P, Prehospital care: Triage and trauma scoring. Surg int 2001;52:25.

13. Nayak PK, Mahapatra AK. Primary reconstruction of depressed skull fracture-the changing scenioro.

Indian J Neurotrauma 2008;5(1):35-8.

14. Hussain R, Khan B, Azam F, et al. outcome of surgically managed Depress Skull Fracture in Tertiary Care Hospital.Pak J.Neurol.surg.2013;17(2):168-170

15. Nazer H Quresh. Skull fracture Department of Neurosurgery, university of Arkansas for Medical

sciences.2008.

16. Hossain MZ, Mondle MS, Hoque MM. Depress skull fracture of the skull: outcome of surgical treatment. TAJ 2008;21(2):140-6

17. Igum GO. Predictive indices in traumatic intracranial hematomas. East Afr Med J 2000;77(1):9-12.

18. Yavuz MS, Asirdizer M, Cetin G, Gunay Balci Y,Altinkok M. The co relation between skull fractures

and intracranial lesion due to traffic accidents. Am J Forensic Med Pathol 2003;24(4):339- 45.

19. Langolis JA, Rutland-Brown W, Wald MM. The epidemiology and impact of traumat brain injury: a brief overreview. J Head trauma Rehabil 2006;21(5):375-8.

20. Braakman R. Depressed skull fracture: data, treatment and follow-up in 225 consecutive cases J

Neurol Neurosurg Psychiatry 1972;35(3):395-402.

21. Muhammag G, Aurangzeb A, Khan S, Suhail R et al. dural tears in patients with depressed skull fractures. J Ayub Med Coll Abbottabad 2017;29(2):311-5.

CORRELATIONOF MANDIBULAR SECOND MOLAR CARIES WITH JGMDS PATTERNS OF MANDIBULAR THIRD MOLAR IMPACTION: A RETROSPECTIVE STUDY


CORRELATIONOF MANDIBULAR SECOND MOLAR CARIES WITH PATTERNS OF MANDIBULAR THIRD MOLAR IMPACTION: A RETROSPECTIVE STUDY

Muhammad Ilyas1, Jawad Ahmad Kundi1, Irtifaq Ahmad Noor1, Obaid Zeb1, Salman Khan1

1. Sardar Begum Dental College

ABSTRACT OBJECTIVES The aim of this study was to evaluate the relation of distal caries of second molar with patterns of impacted third molar. METHODOLOGY A retrospective study was carried out from January 2017 to June 2017.A total of 160 patients and 276 impacted teeth were selected with an age > 18 years. A single researcher assigned the diagnosis of caries and patterns of impacted teeth through clinical notes and orthopantomogram(OPG)which was reviewed by Head of Department. Winter’s and Pell and Gregory classification was used for impaction classification. The data was analyzed using SPSS 22.0 version. P ≤ 0.05 was considered as statistically significant. RESULTS Female (56.3%) were predominant than male (43.8%) with mean age presentation was 24.2 ± 4.7 years.271 mandibular second molars were present. Vertical (64.5%) impaction was found to be the most frequent followed by mesioangular (19.6%). Pearson correlation showed that vertical impaction was significantly related to distal caries of second molar(Right side, r=.262 p=.002 and Left side, r=.240 p=.006). CONCLUSION Vertical impaction was positively related with distal caries therefore prophylactic removal of lower impacted teeth is recommended. KEYWORDS Third molar, patterns, second molar, caries. INTRODUCTION Impactionis the inability of tooth to erupt in the dental arch within the specified time period and may be due to the obstruction in the path of eruption, inappropriate positioning of toothand absence of space or any other obstacles.1The most frequent impacted teeth are mandibular third molars which started at an age

of 16 years and could hamper until 18-20 years.2 Impacted mandibular third molars predominantly involved females than males.3 Various pathologies are associated with impacted lower third molar and this could be due to the disparate angulation and position.4-6Retained lower third molar is the risk factor for second molar and frequently initiate periodontal pockets or decay on lower second molar.7Impacted third molars does not

engage in mastication and provide more beneficial environment for bacterial accumulation.8However, a remarkable percentage of lower third molar with free of pathology for a prolong duration have shown in the studies.4-6

Correspondence: Dr. Muhammad Ilyas

Sardar Begum Dental College Contact: 0302-8809637





The most acceptable classification of impacted teeth was described by winters and Pell and Gregory. Winter’s illustrated the angulations of impacted tooth with longitudinal axis of adjacent tooth while Pell and Gregory classify the level of impaction of lower third molar in relation to the ramus and occlusal level of second molar.9,10 The objective of this study was to determine the incidence and correlation of caries in the lower second molar with different angulations and impaction’s level of lower third molar. METHODOLOGY A review on the patient’s record was carried out from January 2017 to June 2017 on all those who encounter extraction of lower third molar impaction. A total of 160 patients who came to the Department of Oral and Maxillofacial Surgery, Sardar Begum Dental College and Hospital, Peshawar were evaluated with an age above 18 years. The diagnosis of caries and angulation of lower third molar was carried out by a single researcher and reviewed by the head of department.The data were collected from the clinical notes and orthopantomogram(OPG). The age, gender, presence, location, depth, angle of impaction of third molars and caries of second molars were noted. All those patients who received any trauma or having pathosis to the jaw which results in occlusal disruption and patients with systemic diseases were excluded from this study. The angulation of impaction was classified according to Winter’s classification.9The angulation of impaction was measured using Quek et al’s classification system: mesioangular impaction at 11° to 79°; vertical impaction at 10° to −10°; distoangular impaction at −11° to −79°, and horizontal impaction at 80° to 100 °.11The level of impaction in relation to ramus (Class I,II and III) and occlusal level (Class A, B and C) respectively was determined using the Pell and Gregory classification.10The data was analyzed using SPSS 22.0 version.P ≤ 0.05 was considered as statistically significant. Pearson correlation was appliedto show a relation of second molar caries and patterns of third molar impaction.

Mesioangular Distoangular Horizontal

Vertical Transverse Inverse

Figure.1. Winter’s classification of lower third molar impaction.



Figure.2. Pell and Gregory’s classification of lower third molar impaction.

RESULTS The mean age presentation was 24.2 ± 4.7 years. Among 160 patients male were n=70(43.8%) and female were n=90(56.3%). The female to male ratio was 1.3:1. A total of 276 lower impacted molars and 271 second molars were included in this study. The most frequent pattern of impacted teeth in terms of angulation was vertical n=178(64.5%) followed by mesioangular n=54(19.6%). According to Pell Gregory classification the position of impacted tooth was n=194(70.3%) third molars in Class A, n= 64(23.2%) in Class B, and n=18(6.5%) in Class C relationship while n=185(67.0%) were Class I,n=69(25%) Class II and n=22(7.97%) in Class III as shown in table 1. Distal Caries were most frequently found in right side (44.4%) than left side (37.5%).A total of n=131(48.3%) distal caries were present with impacted teeth. Pearson correlation showed that distal caries were significantly related with vertical impaction (Right side, r=.262 p=.002 and Left side, r=.240 p=.006), depth (Right side, r= -.314 p=.001 and Left side, r= -.332 p=.001) in both sides. Distal caries of second molar with ramus were statistically found significant on right side (r= -.172, p=.043) while left side showed insignificant (r= -.160, p=.067). Pearson correlation demonstrated that as the ramal and depth of impaction increases the incidence of caries significantly decreases. DISCUSSION This study revealed that the most common impaction found was vertical 64.5% amongst all impactions. This can be supported by other studies which found vertical impaction to be the most frequent impaction.12,13Byahatti14, Kruger15 and Srivastava16 found that mesioangular impaction was most common type of impaction which is contrary to our study and the difference may be due to the different classification system used and geography.

The incidence of distal caries in second molar is influenced by occlusal angulation and depth of impacted third molar with second molar.17,18Ozec et al in their series found that the prevalence of distal caries of second molar was 20% with impacted teeth and suggested that caries formation in second molar was due to the contact point on cement-enamel junction and with increasing age.17 This study contradict



this study which showed 48.3% caries in the second molar. Falci et al in their study exhibit the prevlance rate of distal caries with impacted and found to be 13.4% which is in contrary to this study.19Syed et al revealed that distal caries in second molar was 39 % which almost support this study.20 Silva et al21 demonstrated that males were predominant than females which opposes this study however, they disclosed that distal caries was most frequently involved with vertical impaction which assist the present study.Syed20, Allen22 and Bruce23 reported that mesioangular impacted third molar was the utmost reason for causing caries on the distal surface of the second molar which does not support this study. The difference may be attributed due to a wide age range in the study populations. The limitation of this study was the use of orthopantomogram instead of intraoral radiograph which may be deficient in detecting inter proximal caries. Apart from this, the present study thoroughly revealed the age involved patterns of mandibular impaction and distal caries of second molar. The correlation of patterns of mandibular impaction with the distal caries of second molar is uniqueness to this study. For further appraisal it is advisable to carried out a prospective study with long term follow up on the role of impacted lower third molar with distal caries of second molar. CONCLUSIONS Vertical and class A and Class I impaction is the most common type of impaction which is related to distal caries of second molar and females is the predominant gender. RECOMMENDATIONS Prophylactic removal of impacted third molar is the legitimate reason due to incidence of distal caries. ACKNOWLEDGEMENT We are thankful to the Department of Radiology, Sardar Begum Dental College & Hospital, Peshawar for providing access to the data. CONFLICT OF INTEREST None to declare. REFERENCES

1. Hupp JR, Ellis E, 3rd, Tucker MR. Principles of Management of Impacted Teeth. 6th ed. Philadelphia: Elsevier Publishers; 2014. Contemporary Oral and Maxillofacial Surgery; pp. 143–67.

2. Sadeta Sesis SP, Komsic S, Vukovic A. Incidence of impacted mandibular third molars in population of Bosnia and Herzegovina: A retrospective radiographic study. J Health Sci. 2013;3:151–8.

3. Padhye MN, Dabir AV, Girotra CS, Pandhi VH. Pattern of mandibular third molar impaction in the

Indian population: A retrospective clinico-radiographic survey. Oral Surg Oral Med Oral Pathol Oral Radiol. 2013;116:e161–6.

4. Akarslan ZZ, Kocabay C. Assessment of the associated symptoms, pathologies, positions and

angulations of bilateral occurring mandibular third molars: Is there any similarity? Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2009;108:e26–32.

5. Al-Khateeb TH, Bataineh AB. Pathology Associated with impacted mandibular third molars in a group of Jordanians. J Oral Maxillofac Surg. 2006;64:1598–602.

6. Bouloux GF, Busaidy KF, Beirne OR, Chuang SK, Dodson TB. What is the risk of future extraction of asymptomatic third molars? A systematic review. J Oral Maxillofac Surg. 2015;73:806–11.

7. Marciani, R.D. Is there pathology associated with asymptomatic third molars?. J Oral Maxillofac Surg.

2012; 70: S15–S19.



8. Fejerskov O, Kidd E. Dental Caries: The Disease and Its Clinical Management. 2nd ed. Oxford: Blackwell Publishing Ltd.; 2008.

9. Winter GB. The principles of exodontia as applied to the impacted third molars: A complete treatise

on the operative technic with clinical diagnoses and radiographic interpretations. St Louis, Missouri: American Medical Book Co; 1926.

10. Pell GJ, Gregory GT. Report on a ten year study of a tooth division technique for the removal of

impacted teeth. Am J Orthod Oral Surg. 1942;28:B660–6.

11. Quek SL, Tay CK, Tay KH, Toh SL, Lim KC. Pattern of third molar impaction in a Singapore Chinese population: A retrospective radiographic survey. Int J Oral Maxillofac Surg. 2003;32:548–52.

12. Reddy KV, Prasad KV. Prevalence of third molar impactions in urban population of age 22–30 years

in South India: An epidemological study. J Indian Dent Assoc. 2011;5:609–11.

13. Haidar Z, Shalhoub SY. The incidence of impacted wisdom teeth in a Saudi community. Int J Oral Maxillofac Surg. 1986;15:569–71.

14. Byahatti S, Ingafou MS. Prevalence of eruption status of third molars in Libyan students. Dent Res J

(Isfahan) 2012;9:152–7.

15. Kruger E, Thomson WM, Konthasinghe P. Third molar outcomes from age 18 to 26: Findings from a population-based New Zealand longitudinal study. Oral Surg Oral Med Oral Pathol Oral Radiol Endod. 2001;92:150–5.

16. Srivastava N, Shetty A, Goswami RD, Apparaju V, Bagga V, Kale S. Incidence of distal caries in

mandibular second molars due to impacted third molars: Nonintervention strategy of asymptomatic third molars causes harm? A retrospective study.Int J Appl Basic Med Res. 2017 Jan-Mar; 7(1): 15–19.

17. Ozec I, Herguner Siso S, Tasdemir U, Eziganli S, Goktolga G. Prevalence and factors affecting the

formation of second molar distal caries in a Turkish population. Int J Oral Maxillofac Surg. 2009;38(12):1279–82.

18. Ahmed I, Gul e E, Kumar N. Mandibular third molar angulation in extraction and non-extraction

orthodontic cases. J Ayub Med Coll Abbottabad. 2011;23(3):32–35.

19. Falci SG, de Castro CR, Santos RC, de Souza Lima LD, Ramos-Jorge ML, Botelho AM, et al. Association between the presence of a partially erupted mandibular third molar and the existence of caries in the distal of the second molars. Int J Oral Maxillofac Surg. 2012;41(10):1270–74.

20. Syed KB,Alshahrani FS, Alabsi WS, Alqahtani ZA, Hameed MS, Mustafa AB et al.Prevalence of

Distal Caries in Mandibular Second Molar Due to Impacted Third Molar.J Clin Diagn Res. 2017 Mar; 11(3): ZC28–ZC30.

21. Silva HO, Pinto ASB, Pinto MC, Rego MRS, Gois JF, De Araújo TLC, et al. Dental caries on distal

surface of mandibular second molar. Braz Dent Sci. 2015;18(1):51–59.

22. Allen RT, Witherow H, Collyer J, Roper-Hall R, Nazir MA, Mathew G. The mesioangular third molar –to extract or not to extract? Nalysis of 776 consecutive third molars. Br Dent J. 2009;206(11):E23:586–87.

23. Bruce RA, Frederickson GC, Small GS. Age of patients and morbidity associated with mandibular

third molar surgery. J Am Dent Assoc. 1980;101(2):240–45

JGMDS


DIFFERENT TYPES OF COMPLICATIONS IN PATIENTS SUFFERING FROM B-THALASSEMIA (THALASSEMIA MAJOR)

Riaz Gul1, Jasim Dil Wazir1, Shandana Rehman1

1. Northwest School of Medicine, Peshawar.

ABSTRACT INTRODUCTION Thalassemia is a heterogeneous group of gene disorders caused byan inherited mutation or deletion of genes at chromosome 16 & 11 resulting in decreased synthesis of adult hemoglobin. Its incidence is higher in people/children having a positive family history of Thalassemia Among its various types Beta Thalassemia major is the one which requires regular blood transfusions. OBJECTIVES The main objective of the study was to determine the frequency of different types of complications in patients suffering from B-Thalassemia. METHODOLOGY The study was conducted in two private originations in Peshawar i.e. Fatimid Foundation and Hamza Foundation.150 patients) were studied, the study was Cross-Sectional, descriptive type and sampling type was Non-Probability, convenience type sampling. All necessary data were obtained by using semi structured questionnaire, having both closed and open ended questions. Pilot Study was conducted on 15 patients (10%of target questionnaires). After completing the pilot study necessary changes were made in questionnaire and a well-informed, well-designed and organized questionnaire was finalized. An informed consent was taken from respondents and the responses were obtained each from the parents & from children themselves (in case of older children). Data was collected and results were presented in the form of tables and charts. Manual analysis of the data was carried out. RESULTS According to the study, among 150 patients, Splenectomy was done in about 86% patients. Consanguinity among the parents of these patients was about 76%, while awareness only 72% of patients. About 64% patients were having psychological problem. Among neurological problems 57% of patients had headache. Among complications, majority of patients had palpitations about 54% joint pains about 32% & history of bones fractures about 21%. Socioeconomic condition of majority of them was poor about 52%. All of them were taking primary treatment i.e. Blood transfusion &Chelating Therapy to prevent iron overload. CONCLUSSIONS Thalassemia major is a life threatening disease causing morbidity and mortality among those who are not treated properly. The incidence of the disease is high among those with a family history of Thalassemia. KEY WORDS: Thalassemia major, inherited mutation, chelating therapy. Splenectomy INTRODUCTION Thalassemia is the commonest inherited disorder present throughout world affecting approximately 5% of the world population. Beta-Thalassemia Major affects a significant segment of population in certain

areas of the world. Alternation in migration patterns have changed the geographic distribution of this disease and have made it a worldwide disease health problem with a high frequency in Africa, India, Southeast Asia and Mediterranean area.1 Thalassemia is a heterogeneous group of genetically determined hemolyticanemias due to an impaired synthesis of globins’ chains which are an integral part of the hemoglobin molecule.2

There are two types of Thalassemia: Alpha-Thalassemia and Beta-Thalassemia. Alpha-Thalassemia is a disorder in

Correspondence: Dr. Riaz Gul

North West School of Medicine Contact: 0345-9386866



DIFFERENT TYPES OF COMPLICATIONS IN PATIENTS SUFFERING FROM B-THALASSEMIA (THALASSEMIA MAJOR) JGMDS


which there is defective synthesis of α-globins chains resulting in depressed production of hemoglobin that contain α-chains i.e. HbA1, HbA2 and HbF3. Beta-Thalassemia is a common autosomal recessive disorder generally caused by point mutations in β-globins gene that is located as a cluster on the short arm of chromosome 11.4,5. Beta-Thalassemia occurs worldwide, with a higher prevalence among Mediterranean population, in the Middle East, in parts of India, Pakistan, and South East Asia. It is also prevalent in southern parts of former USSR and People’s Republic of China. It is seen in all racial groups, even in the homozygous states, in persons of pure Anglo0Saxon stock. In Pakistan, the disease is seen in almost all parts of the country. The estimated carrier status is around 5-7% meaning thereby that there are about 9.8 million carriers in the total population. Although no documented registry of Thalassemia patients exists in Pakistan, the estimate is that approximately 9000 Beta Thalassemia children are born every year. The average life expectancy in Pakistan is 10 years and at present the disease load is of 90000 to 100000 patients throughout the country. 5

In Pakistan it is the β-Thalassemia which is the most prevalent; other forms of Thalassemia are uncommon. Gene frequency of β-Thalassemia in Pakistan stands at 6% with a population of 140 million; there are over 8 million carriers of β-Thalassemia. Inter-marriages and first cousin marriages has resulted in high incidence of homozygous β-Thalassemia (β-Thalassemia major). It is estimated that in Pakistan at present there are about 121,000 patients of β-Thalassemia major.5 Over 5000 children are born with transfusion dependent Thalassemia annually in Pakistan and 65% of them belong to KPK.6 The major life threatening complications of B-Thalassemia are due to Iron overload, Infections, and Transfusion reactions.7 The management of Beta-Thalassemia includes: Conservative Management which includes Regular blood transfusion, Iron Chelating agents and Management of complications. In developing countries patients are not ideally managed on the conservative regiment due to a number of reasons. It is partially the unavailability of safe blood, lack of education and poverty. Curative Treatment: includes bone Marrow transplantation.8 The basic aim of management of the disease is to alleviate the anemia by blood transfusion therapy, maintaining a mean Hb level of at least 10g/dl at different weekly intervals. In order to prevent accumulation of iron, iron-chelating agents are used as chelating therapy to reduce the resulting hemosidrosis and organ failure.7 METHODOLOGY This study was conducted to determine frequency of various complications of Beta-Thalassemia Major and its management and was carried out in Fatimid Foundation and Hamza Foundation Peshawar. Our study population included all Thalassemia patients suffering with B- thalassemia visiting Fatimid Foundation and Hamza Foundation, irrespective of their age and sex. This study was carried out from 1st November 2016 to 29thApril 2017.The sampling technique for our study was Non-Probability, Convenience Sampling. Sample of 150 respondents were included in the study.. The study design was Observational Cross-Sectional Study. Patients suffering from beta thalassemia of all ages were included in the study sample. Patients suffering from other types of thalassemia and receiving treatment outside of Peshawar were excluded from the study. The questionnaire was designed to collect data from patients. Both open and close ended questions were included in questionnaire. The reason being to ensure objectivity as it was the only feasible method which could have help in getting the required information and to ensure statistical analysis. Firstly, Pilot Study was conducted on 15 patients (10% of target questionnaire). The purpose was to check the feasibility of questionnaire and to make necessary changes in required. In order to make it more informative and organized. After completing the pilot study necessary. To study the complications of β-Thalassemia major & its management in (150) patient’s changes were made in questionnaire and a well-informed, well-designed and organized questionnaire was finalized. An informed consent was taken from respondents and the responses were obtained each from the parents and from children themselves (in case of older children). Final data was collected and transferred to computer, compiled and processed and was presented on the master sheet, tables, bars and pie charts for analysis and statistical evaluation. RESULTS



TABLE NO. 01

AGE OF THE REPONDENTS S. No DIAGNOSTIC AGE OBSERVATION PERCENTAGE

1 BELOW 10 YEARS 77 51.33% 2 10 to 15 YEARS 54 36.00% 3 15 to 20 YEARS 14 9.33% 4 ABOVE 20 YEARS 05 3.34%

SS Total 150 100%

Table and fig no.1 shows different age groups of the respondents, showing that out of total150 respondents, most of the respondents are under the age of 10 years, i.e. 77( 51%), 54 (36%) are upto 15 years of age, 14(9.3%) respondents are upto 20 years while on 05 (3.3%) are above 20 years of age. Table No. 02

GENDER STATUS OF THE RESPONDENTS S. NO GENDER OBSERVATION PERCENTAGE

1 MALE 88 58.66% 2 FEMALE 62 41.33% TOTAL 150 100%

Majority of the respondents are male, i.e. 88 (59%) while the remaining 62(41%) are female respondents, depicted in table and fig no. 2. Table No. 03

FAMILY’S SOCIOECONOMIC CONDITION S. NO SOCIOECONOMIC

CONDITION OBSERVATION PERCENTAGE

1 POOR 78 52.00% 2 SATISFACTORY 56 37.34% 3 GOOD 16 10.66% TOTAL 150 100%

51.33%%

36%

9.33%3.3%

0% OBSERVATION

BELOW 10 YEARS

UPTO 15 YEARS

UPTO 20 YEARS

ABOVE 20 YEARS



Table and fig no. 3 is showing the socioeconomic condition of the patient’s family. In this result we found that majority of the respondents i.e.78 (52%), belongs to poor families, few of them i.e. 56(37%) had satisfactory socioeconomic condition while very few i.e. only 16 (11%) are in a good socioeconomic condition. During our survey, we found that 55% of respondent’s siblings were also having Thalassemia while the remaining 45% were free of this disease. These results are shown in table and fig no. 6 Table No. 04

FAMILY HISTORY OF THALASSEMIA S . NO FAMILY HISTORY OBSERVATION PERCENTAGE

1 YES 53 35.34% 2 NO 97 64.66%

TOTAL 150 100%

Table and fig no. 04 shows that majority of the respondents i.e. 97(65%) were not having any family history of Thalassemia while in 53 (35%) patients we saw that this disease was running in their families.

RELATED TO CARDIAC COMPLICATIONS

Table No. 05

POOR 52%SATISFACTORY

37%

GOOD11%

FAMILY’S SOCIOECONOMIC CONDITION

YES35%

NO65%

FAMILY HISTORY OF THALASSEMIA



CARDIAC PROBLEMS TO THE RESPONDENT S. No Cardiac problems Observation Percentage

1 Chest pain 47 31.34% 2 Palpitations 81 54.00% 3 Fainting 07 04.66% 4 Easily tired 111 74.00% 5 Any swelling around the ankles 23 15.34 6 Shortness of breath 63 42.00 7 Disturbed sleep while lying flat 33 22.00% 8 Persistent coughing or wheezing 54 36.00% 9 Polyuria 52 34.66%

About cardiac complications, about 47 (31%) patients complained of chest pain,81 (54%) responded to palpitations, 07 (5%) responded to fainting,111 (74%) were complaining of easily tiredness, 23 (15%) complained about swelling around the ankles, 63(42%) were facing problem of shortness of breath, disturbed sleep while lying flat was answered by 33 (22%) of the respondents, persistent cough and wheezing was the problem of 54 (36%) patients while 52 (35%) patients were having polyuria. Fig 5shows the doughnut chart that represents the different responses of the people. RELATED TO SPLENOMEGALY Table No. 06

SPLENOMEGALY S. NO SYMPTOMS OF SPLENOMEGALY OBSERVATION PERCENTAGE

1 Pain in left upper side of abdomen 55 36.66% 2 Pain in left shoulder 21 14.00% 3 Constant hiccups 34 22.66% 4 Anorexia & early fullness of stomach 57 38.00% 5 Frequent infections 64 42.66%

Total 150 100%

Table and fig06is showing the symptoms of splenomegaly. This shows that majority of the patients i.e. 64 (43%) are having frequent infections, anorexia and early fullness of stomach was seen 57 (38%) patients,

10%

17%

2%

24%5%

13%

7%

11%

11%

CARDIAC PROBLEMS

Chest pain

Palpitations

Fainting

Easily tired

Any swelling around theankles

Shortness of breath



55(37%) responded to pain in left upper side of abdomen, 34 (23%) answered to constant hiccups while pain in left shoulder was seen in 21 (14%) respondents.

RELATED TO GROWTH AND DEVELOPMENT

TABLE NO.07

GROWTH AND DEVELOPMENT OF RESPONDENT S. No Normal growth & development Observation Percentage 1 YES 116 77.34% 2 NO 34 22.66% Total 150 100%

Out of150 respondents, growth and development was Normal in 116 (77%) respondents, which is the majority while only 34 (23%) complained of abnormal growth and development. These values are given in table and fig no. 07. RELATED TO BONY DEFORMITIES TABLE NO. 08

BONY DEFORMITIES REGARDING THALASSEMIA S. NO ANY BONY DEFORMITY OBSERVATION PERCENTAGE 1 YES 63 42.00% 2 NO 87 58.00% Total 150 100%

YES77%

NO23%

GROWTH AND DEVELOPMENT



It was revealed by 42 % of the respondents that they were having bony deformities and 58% replied with no. (Table and fig. no 08).

RELATED TO NEUROLOGICAL PROBLEMS

TABLE NO. 09 NEUROLOGICAL PROBLEMS ASSOCIATED WITH THALASSEMIA

S. NO NEUROLOGICAL PROBLEMS OBSERVATION PERCENTAGE 1 HEADACHE 86 57.34% 2 DROWSINESS 35 23.34% 3 EPILEPTIC FITS 08 05.34% 4 NYSTAGMUS 10 06.66% 5 TWICHING OF HANDS, FEETS OR WHOLE

LIMBS 15 10.00%

6 VOMITING 38 25.34% TOTAL 150 100%

YES NO

126

174

42.00%

58.00%

ANY BONY DEFORMITY



Regarding Neurological Problems associated with Beta-thalaseemia major, we observed that headache was problem seen in 86 (57%) patients Drowsiness was problems of 35 (23%) respondents,08 (05%0 of patients were facing problem of epileptic fits, nytagmus was see in only 10 (07%) people, twitching of hands, feet of Whole limb was complain of about 15 (10%) respondents, while 38 (25%)patients were having vomit problem. (table and fig no.10)

RELATED TO PSYCHOLOGICAL PROBLEMS

Table No. 10 ANY PSYCHOLOGICAL PROBLEMS TO THE RESPONDENT

S. NO ANY PSYCHOLOGICAL PROBLEMS OBSERVATION PERCENTAGE 1 YES 97 64.66% 2 NO 53 35.34% Total 150 100%

57.34%

23.34%

05.34%

06.66%

10.00%

25.34%

NEUROLOGICAL PROBLEMS

HEADACHE

DROWSINESS

EPILEPTIC FITS

NYSTAGMUS

TWICHING OF HANDS, FEETS ORWHOLE LIMBS

VOMITING

65%

35%

Yes NO

Any psychological problems



Table and fig no 10 indicates the frequency of psychological problems in Beta-thalaseemia patients. Out of 150 respondents, 97 (65%) answered yes while only 53 (35%) patients replied with No.

RELATED TO IRON OVERLOAD Table No. 11

SYMPTOMS RELATED TO IRON OVERLOAD S. NO SYMPTOMS OBSERVATION PERCENTAGE 1 JOINT PAINS 67 44.66% 2 ABDOMINAL CRAMPS 53 35.34% 3 WEAKNESS & LETHARGY 56 37.34% 4 DIABETES 06 04.00% 5 HYPOTHYROIDISM 02 02.66% TOTAL 150 100%

During our study, while asking about symptoms of iron overload we came to know that joint pain were present 67 (45%) patients, abdominal cramps in 53 (35%) respondents, Weakness and lethargy was replied by 56 (37%) patients,06 (04%) patients were diabetic while 02(03%) respondents were observed to have hypothyroidism. (table and fig no.11)

RELATED TO TREATMENT Table No.12

TREATMENT FOR THALASSEMIA S. NO TREATMENT STARTED OBSERVATION PERCENTAGE 1 YES 150 100% 2 NO 00 00.00% TOTAL 300 100%

On asking about the treatment for their disease from the respondents, we got yes answer from al of the 150 respondents and there was not a single patient who was not taking any treatment for the disease. TABLE NO. 13

BLOOD TRANSFUSION PER MONTH S. NO NO. OF TRANSFUSION OBSERVATION PERCENTAGE 1 1-2 91 60.66% 2 3-5 55 36.66% 3 6-10 2 01.34% 4 MORE THAN 10 2 01.34% TOTAL 150 100%

61% patients revealed that they were taking about 1-2 transfusion per month, 37% respondents were taking 3-5 transfusion, only 1 % patients were taking 6-10 transitions per month and also only 1% respondents were taking more than 10 transfusions per month. Table and fig no. 15.



Table No. 14 TRANSFUSION TRANSMITTED INFECTIONS

S. NO AGE GROUP IN YEARS

NO. OF PATIENTS POSITIVE FOR TTIS HIV HBV HCV

1 1-10 YEARS ---- ---- 02 2 11-15 YEARS ---- 1 05 3 16-20 YEARS ---- 1 02 4 ABOVE 20 YEARS ---- ---- 02 TOTAL 00 02 11

Table and fig no. 17 tell us about the Transfusion Transmitted Infections in different age groups, which shows that in a age group below 10 years, no cases of HIV and HBV was reported, while there were 2 cases of HCV. In age group 11-15 years, no HIV were seen, there was only 1 case of HBV and about 5 cases of HCV. In 16-20 years of patients, again no case of HIV, 1 case of HBV and 2 cases of HCV were there. No HIV case was found in age group above 20 years, no HBV was seen in this age group, but 2 HCV cases were seen in this age group. So total of 2 HBV and 11 HCV were seen among our 150 respondents, whereas no case of HIV was seen. DISCUSSION Thalassemia has forced an unbearable burden on the healthcare systems in developing countries. Thalassemia patients require lifelong medical care based on standards approved in developed countries which is extremely costly mokhtar 2011.10 “β-Thalassemia major (β-TM) is an inherited Hb disorder characterized by chronic anemia and iron overload due to transfusion therapy and gastrointestinal absorption”(Mokhtar et al. 2011)10.Iron overload is mostly responsible for the associated morbidity and mortality in these patients, affecting the endocrine glands resulting in growth retardation, failure of sexual maturation, diabetes mellitus, and insufficiency of the parathyroid, thyroid, pituitary, and less commonly, adrenal glands (Mokhtar et al. 2011; Cunningham et al. 2009).10,11 Thalassemia major patients die during the first few years of life if remain untreated; patients may possibly survive until 4th-5th decades through regular transfusion programs, appropriate chelating therapy, and effective treatment of complications (Yaman et al. 2013)12. The appearance of complications in thalassemia patients are commonly observed after the first decade and rise with age (Olivieri and Brittenham 1997)13. In this study, the most common complications found in 97 respondents were psychological problems/psychiatric disorders (65%). According to a study conducted by Hoseini et al. (2007),14 psychiatric disorders were found in 14 to 24 patients with thalassemia. While in other studies, approximately 80 % of young β-TM patients suffered from serious psychiatric disorders such as depression especially major depression disorder (MDD), obsessive-compulsive disorder (OCT), tic disorders, oppositional defiant disorders (ODD), psychosis, nocturnal enuresis nocturnal (Aydin et al. 1997; Messina et al. 2008)15. Similarly, a high rate of psychological problems has been reported in children with possible mental health disorders in a study by Aydinok et al. (2005)16. According to some studies psychological disorders are more prevalent in female thalassemia patients; however no such finding was observed in this study (Naderi et al. 2012).17

Among cardiac problems, chest pain was reported by 47 patients and 63 patients faced shortness of breath. Palpitations were a chief complaint in 81 respondents. Yemen retrospectively analyzed patients with thalassemia in Turkey where 22.4% patients suffered from cardiac complications. Iron overload is largely found to be the main cause of heart disease and about 71% of β-TM patients die due to cardiac complications (Borgna-Pignatti 2005; Mokhtar 2011).10,18 The frequency and severity of iron overload-related complications is influenced by compliance with iron chelating therapy (Galanelloand Origa 2011).19 Symptoms of iron-load such as joint pain, abdominal cramps and lethargy were seen in 67, 53 and 56 respondents respectively. Though, hypothyroidism as a result of iron overload was present in 2.6% of patients which makes its appearance in the second decade in the ratio of 6-24% (Borgna-Pignatti 2005).18 Another study conducted by Adil et al. in Pakistan, 11.8% suffered from hypothyroidism. 20



Patients in the study showed symptoms of splenomegaly which is documented to be one of complications of beta-thalassemia leading to Splenectomy (Mokhtar 2011).10 Aessoposet al. (2004)21 summarized that splenomegaly is a regular finding in β-TM patients which is mainly due to the development of extramedullary haematopoiesis, splenic pooling and chronic passive congestion of the spleen due to portal hypertension and/or heart failure. Increased transfusions or cellular components of the blood are needed in case of hypersplenism which is often associated with gradual splenic enlargement and ultimately leading to splenectomy (Aessoposet al. 2007)22.On the other hand, splenectomy is an uncommon finding in β-TI patients and presented chiefly late in life(Mokhtar et al. 2011).10 Normal growth and development was present in 116 respondents (77.34%) which comprised of majority of the study sample. Growth retardation was found in 22.6 % similar to the studies conducted by yemen and Cario et al. 2000. Cario et al.23 (2000) reported growth retardation in one third of 203 patients with mean age of 13.8 years. While, Yaman et al. (2013) 24stated 19.4% of the patients in the study with growth retardation. Causes of growth retardation that usually becomes remarkable in puberty are chronic anemia-related chronic hypoxemia, increased calorie need due to increased erythropoietin, growth hormone deficiency that may develop as a result of toxicity on hypothalamo-hypophysial level caused by increased iron load, hypothyroidism, inability to make the growing spurt because of delayed puberty (Yaman et al. 2013).23 CONCLUSIONS

On the basis of results following conclusions are made:

1. 71% were diagnosed as Thalassemia at less than 6 months. 2. 45% of patients suffering from Thalassemia were under 10 years of age, more common in males. 3. 100% were complaining of cardiac problem and sign & symptoms of splenomegaly and iron overload. 4. 78% had retarded growth like short stature, delayed neck holding, late crawling, sitting and standing. 5. 100% of them are taking treatment for Thalassemia like blood transfusion & chelating therapy. 6. 77% patients had family history of Thalassemia.

RECOMMENDATION Based on results following are the recommendations:

1. Provision of screening and counseling services for those genetically prone, to reduce chance of transmission of thalassemia to their offspring.

2. Provision of appropriate health care services and management for Thalassemia patients. 3. Patients should avoid food rich in iron to reduce problems caused due to iron overload like cardiac

problem & hemosidrosis. 4. Always transfuse screened blood, never transfuse from addicts or person suffering from Hepatitis,

AIDS or any other disease. . 5. Reduction of marriages between relatives who are suffering from Thalassemia or having history of

familial Thalassemia. Make it possible to identify carriers of the disease and provide them with genetic counseling, marriage counseling sessions are appropriate information about Thalassemia.



REFERENCESs 1. Rahman M, Lodhi Y. Prospects and future of conservative management of Beta-Thalassemia Major

in a developing country, Pakistan Journal of Medical Science. 2004; Vol. 20; 106.

2. Pearon HA, cohen AR, Giardina PJ, Kazazian HH. The changing profile of homozygous β-Thalassemia: demography, ethnicity and age distribution of current North-American patients and changes in two decades. Paediatrics 1996; 97:352-6.

3. Weatherall DJ, Clagg JB, Higgs DR, Wood WG. The hemoglobinopathies. The metabolic and molecular Basis of inherited Disease. MC Graw-Hill, New York. 1989;3417-83.

4. Current medical diagnosis & treatment-39th edition chap 13 page 503-504 Lawrence M. Tierney, Tr Stephen J, McPhene Maxine A.Papadakis.

5. Oliveri NF. The Beta-thalassemias. New Eng J Med 1999; 341: 99-109.

6. Taher A, Abou-Mourad Y, Abchee A, Zallouaa P, Shamseddine A. Pulmonary thromboembolism in beta-thalassemia intermedia: are we aware of this complication? Hemoglobin 2002;26(2):107-112.

7. Bowden DK Vickers MA, Higgs DR. A PCR-based strategy to detect the common severe determinants of aplaha-thalassemia. Br J Haemetol 46:208-213, 1992.

8. Flint J, Harding RM, Boyce AJ, Clegg JB. The population genetics of the hemoglobinopathies. In The hemoglobinopathies, Bailliere’s clinical haematology, DR higgs, DJ Weatherall (eds0, pp. 2155-262, London: Baelliere Tindall and WB Saunders, 1993.

9. Karimi M, Darzi H, Yavarian M. Haematologic and clinical responses of thalassemia intermedia patients to hydroxyurea during 6 years of therapy in Iran. J PediatrHematolOncol 2005;27(7):380-385.

10. Mokhtar, G. M., Tantawy, A. A. G., Adly, A. A. M., & Ismail, E. A. R. (2011). Clinicopathological and radiological study of egyptian β-thalassemia intermedia and β-thalassemia major patients: Relation to complications and response to therapy. Hemoglobin, 35(4), 382-405. doi:10.3109/03630269.2011.598985

11. Cunningham MJ, Sankaran VG, Nathan DG, Orkin SH. The Thalassemias. In: Orkin SH, Nathan DG, Ginsburg D, Look AT. Nathan and Oski’sHematology of Infancy and Childhood, 7th ed. Philadelphia: Sounders Elsevier; 2009:1015-1109

12. Yaman, A. Pamir ISIK, Nese YARALI, Selmin KARADEMIR, Semra CETINKAYA, Ali BAY, Serdar OZKASAP, Abdurrahman KARA, Bahattin TUNC (2013). Common complications in beta-thalassemia patients. International Journal of Hematology and Oncology, 23(3), 193-199. doi:10.4999/uhod.12005

13. Olivieri NF, BrittenhamGM. Iron chelating therapy and the treatment of thalassemia. Blood 89: 739-761,1997.

14. .Hoseini SH, Khani H, Khalilian A, Vahidshahi K. [Comparison mental health of patients with beta thalassemia major that referred to Bou-Ali Sina hospital of Sari, Iran between 2003-2005 with control group]. Mazandaran Med SciencUnivers J, Iran 2007; 17: 51-60

15. Aydin B, Yaprak I, Akarsu D, Okten N, Ulgen M. Psychosocial aspects and psychiatric disorders in children

with thalassemia major. Acta PaediatrJpn 1997; 39: 354-357.



16. Messina G, Colombo E, Cassinerio E, Ferri F, Curti R, Altamura C, et al. Psychosocial aspects and psychiatric disorders in young adult with thalassemia major. Intern Emerg Med 2008; 3: 339-343

17. Adinok , Yaprak I, Akarsu D, Okten N, Ulgen M. Psychosocial aspects and psychiatric disorders in children with thalassemia major. Acta PaediatrJpn 2005; 39: 354-357

18. Borgna-Pignatti C, Cappellini MD, De Stefano P, Del Vecchio GC, Forni GL, Gamberini MR, Ghilardi R, Origa R, Piga A, Romeo MA, Zhao H, Cnaan A: Survival and complications in thalassemia. Ann N Y Acad Sci 2005, 1054:40-47.

19. Galanello, R., &Origa, R. (2010). Beta-thalassemia. Orphanet Journal of Rare Diseases, 5(1), 11-11. doi:10.1186/1750-1172-5-11

20. Adil, A., Sobani, Z. A., Jabbar, A., Adil, S. N., & Awan, S. (2012). Endocrine complications in patients of beta thalassemia major in a tertiary care hospital in pakistan. JPMA. the Journal of the Pakistan Medical Association, 62(3), 307.

21. Aessopos A, Farmakis D, Tsironi M, et al. Hemodynamic assessment of splenomegaly in β- thalassemia patients undergoing splenectomy. Ann Hematol. 2004;83(12):775–778.

22. Aessopos A, KatiM, Farmakis D.Heart disease in thalassemia intermedia: a review of the underlying pathophysiology. Haematologica. 2007;92(5):658–665.

23. Yaman, A. Pamir ISIK, Nese YARALI, Selmin KARADEMIR, Semra CETINKAYA, Ali BAY, Serdar OZKASAP, Abdurrahman KARA, Bahattin TUNC (2013). Common complications in beta-thalassemia patients. International Journal of Hematology and Oncology, 23(3), 193-199. doi:10.4999/uhod.120

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methods should be given, including statistical methods. References and brief descriptions for methods that have been published but are not well-known should be provided; only new or substantially modified methods should be described in detail, giving reasons for using them, and evaluating their limitations. All drugs and chemicals used should be identified precisely, including generic name (s), dose(s), and route(s) of administration. For statistical analysis, the specific test used should be named, preferably with reference for an uncommon test. RESULTS

These should be presented in a logical sequence in the text, tables, and illustrations. All the data in the tables or illustrations should not be repeated in the text; only important observations should be emphasized or summarized with due statement of demographic details. No opinion should be given in this part of the text. DISCUSSION

This section should include author’s comment on the results, supported with contemporary references, including arguments and analysis of identical work done by other workers. Study limitations should also be mentioned. A summary is not required. Any conflict of interest, however, must be mentioned at the end of discussion in a separate heading. CONCLUSION

Conclusion should be provided under separate heading and highlight new aspects arising from the study. It should be in accordance with the objectives. No recommendations are needed under this heading. PEER REVIEW

Every paper will be read by at least two staff editors of the Editorial Board. The papers selected will then be sent to two external reviewers. If statistical analysis is included, further examination by a staff statistician will be carried out. The staff Bibliographer also examines and authenticates the references.

Address for correspondence:

Dr. Sofia Kabir Managing Editor, Journal of Gandhara Medical and Dental Sciences

Gandhara University, Canal Road University Town,

Peshawar, Pakistan Land Line: +92 (0)91 5844429-32

Fax: +92 (0)91 5844428 Website: www.gandhara.edu.pk,


http://www.gandhara.edu.pk/

JGMDS

AUTHOR AGREEMENT

* All authors should read the following carefully. A completed copy of this form must be signed by each author and submitted along with the article * Name of Journal: __________________________________________________________________________________________ Title of the Article: __________________________________________________________________________________________ ________________________________________________________________________________________________________ The undersigned (after reviewing criteria for authorship as defined by International Committee of Medical Journal Editors [ICJME] found at `http: //www/icmje.org/` and have participated reasonably in the intellectual content, analysis of data and writing of the article) jointly and severally, hereby transfer and assign all rights, title, and interest therein, including any and all copyrights in all forms and media now or hereafter known, to the Journal of Gandhara Medical and Dental Sciences. The author(s) retain the nonexclusive right to use part or all of the article in future work of their work of their own, provided proper credit is given to the Journal of Gandhara Medical and Dental Sciences. In case, the submitted article is not published, the Editorial Board agrees to release its rights therein. I certify that 1) None of the material in the manuscript has been published previously/currently under consideration for publication elsewhere. 2) The article has not been accepted for publication elsewhere 3) I have not signed any right or interest in the article to any third party 4) I am willing to produce the data on which this article is based, should the Editorial Board of the Gandhara Journal of Medical and Dental Sciences request such data. 5) Animal Care Committee/Institutional Review Board approval was granted for this study.

I (including spouse and children), disclose financial interest at the level a) Nothing to disclose b) Financial interest to the amount of: ________________________.

6) I/We confirm to comply fully with the suggestions/critical views of the reviews/ editor, failing which my/our article may be rejected at the sole discretion of the editor. I/we further confirm that if our article is rejected (which is the sole discretion of the editor) I/we will have no right to complain against the journal/editor/representative of the journal/painter in any forum including the court of law.

7) I/we suggest the following to overseas reviewers to review our article. Name of authors in order in which they appear in the article Author’s Name Signature Phone/Email .............................................................................. .................................................................. ..................................................... .............................................................................. .................................................................. ..................................................... .............................................................................. .................................................................. ..................................................... Reviewer Name: .................................................. Phone/Email: .......................................................... Reviewer Address: ........................................................................................................................................................................... Author’s Checklist: i) Eliminate nonstandard abbreviation in the titles ii) Supply full name authors (including institutions) iii) Abstract: (maximum) 250 words, Article: (maximum) 2000 words (excluding references). iv) Supply references in Vancouver style, accurately cited in the text in numerical order.

v) Send 02 Hard copies and on a R/W CD (in MSWord), in a protective envelope, do not use clips vi) Cite tables in the next in numerical order vii) Cite figures in the text in numerical order viii) Author agreement is signed by all authors (principal author and co-authors).

Gandhara University, Canal Road, University Town, Peshawar, Pakistan

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