Editorial

Preeclampsia is a multisystem disorder unique to human pregnancy.This syndrome is characterized by new onset hypertension and proteinuria after 20 weeks of gestation.It effects about 7-10% of all pregnancies and together with eclampsia(seizure due to preeclampsia) is a leading cause of fetomaternal mortality and morbidity especially in underresourced settings and is recognized as a contributer of future cardiovascular and metabolic dysfunction. Preeclampsia(PE) and eclampsia is accounting for more than 75000 deaths per year.1 It is a systemic disorder of endothelial dysfunction which is considered to be central to the multiple organ pathophysiology of PE/eclampsia,but the pathogenesis involved in the initiation and progression of the disease process is still unknown. The definitive cure of PE/eclampsia is delivery of placenta. As patients with molar pregnancy can develop PE rather at early gestation so it is reasonable to ascertain that placenta play a major role in the pathogenesis of this disorder. Risk factors for PE/Eclampsia are first pregnancy, teenage pregnancy, age >35 years, low socioeconomic status, family history of PE/Eclampsia, past history of PE/Eclampsia, multifetal gestation, poor outcome in previous pregnancy including IUGR, abruption, fetal death, preexisting obesity, chronic hypertension, renal disease, gestational diabetes, vascular and connective tissue disorders, various inflammatory diseases like urinary tract and periodental infections. Numerous genetic, immunologic and environmental factors interact complex mechanism involving lipid, protein oxidation, altered nitric oxide production and placental glycoprotein playing role in the trophoblastic dysfunction. The main at placental level is inadequate trophoblastic invasion in the spiral arteriols resulting in the failure of conversion of spiral arteriols into low resistance vessels. What cause this defective placentation and ultimately this multisystem disorder remain unknown.

The poorly perfused placenta releases increased amount of vasoactive factors in maternal circulation. Among the most well characterized factors in this disease are anti angiogenic protein soluble Fms like tyrosine kinase-I, inflammatory cytokines and agonistic angiotensin-II type I receptor autoantibodies2. Elevation in these factors are proposed to result in endothelial dysfunction by decrease in bioavailable nitric oxide and increase in reactive oxygen and endothelion. These endothelial abnormalities in turn leads to increase in blood pressure by impairing normal pressure natriuresis and increase in total peripheral resistance and other manifestation of the disease.

Larger multicenter trials are undergoing to find out the exact etiology of this dreadful condition. Determining the underlying pathogenesis of PE/Eclampsia will be significant medical advance. Better understanding of this condition will allow us to screen high risk group which will ultimately help in reducing the adverse fetomaternal outcome.

Prof. Dr. Nuzhat Khawaja Obstetrics & Gynecology Department Sheikh Zayed Medical College/Hospital, Rahim Yar Khan

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189 JSZMC Vol.2 No.3 Original Article

CHRONIC HEPATITIS C AND EFFICACY OF á INTERFERON CHEMOTHERAPY Aamir Abbas11, Javed Iqbal , Muhammad Ashraf2

ABSTRACT Background: Chemotherapy with various drugs is in practice for the management of chronic hepatitis C. One of these drugs is á- interferon. Objectives: To study the efficacy of á-interferon therapy in male hepatitis C patients of Faisalabad region of . Period: Jan. to June 2000. Setting: Clinical laboratory Nawaz Medicare Hospital, Model Town, Faisalabad. Material and Methods: This international study was conducted on 20 male hepatitis C patients of 24 to 51 years of age, receiving injection of á-interferon thrice a week were selected and their sera were analyzed after the completion of 6 months chemotherapy. Results: After six month of treatment with á interferon, (18)90% of the patients became negative for HCV. The levels of serum total bilirubin before (0.939± 0.07mg/dl) and after treatment (0.924± 0.09mg/dl) with á-interferon remained almost normal. Similar results were observed for serum direct and indirect bilirubin.The levels of alkaline phosphatase (ALP) in our study subjects were within normal limits before and after treatment with á-interferon. The levels of Serum Glutamate Pyruvate Transaminsae (SGPT) were highly raised (337.40 ± 75.38 U/l) prior to treatment and became normal (26.8±7.42U/l) after treatment with á-interferon. Conclusion: á-interferon therapy in chronic hepatitis C patients for a period of 6 months gives sustained virological as well as biochemical responses and is useful for maintenance of SGPT values within normal limits in hepatitis C patients like other countries of the world.

Key Words: Chronic hepatitis 'C', á-Interferon, Liver function tests. INTRODUCTION designed to evaluate the effect of á-interferon on the Liver is a complex organ, uniquely placed for levels of serum bilirubin, SGPT and Alkaline handling dietary compounds. It is responsible for phosphatase in chronic hepatitis 'C' patients under the synthesis of many metabolically important local conditions. compounds and also for excretion and metabolism of toxic compounds.1 Chronic hepatitis 'C' caused MATERIALS AND METHOD by hepatitis 'C' virus (HCV) results in This international study was conducted on twenty inflammation of liver followed by necrosis, chronic hepatitis C male patients between 24-51 fibrosis and cirrhosis of the liver.2 High incidence years of age receiving injection á-interferon thrice a of liver cancer in patients having chronic hepatitis week for 6 months as treatment from Nawaz C and cirrhosis has also been reported.3 Medicare Hospital were registered for project Bilirubin, Serum Glutamic Pyruvate studies. Levels of serum total, direct and indirect Transaminase (SGPT) and Alkaline Phosphatase bilirubin, ALP and SGPT were determined for all (ALP) have been widely used as liver function patients before and after chemotherapy with á- tests (LFTS) in hepatitis. SGPT is the cytoplasmic interferon for 6 months. enzyme and its increased level is the specific indicator of liver damage. A greatly increased Analytical Methods plasma ALP activity is the main indicator of Serum total bilirubin (STB) was determined biliary obstruction, though it provides no following the kit method of Merk diagnostica6 and information about the site of that obstruction4. serum direct bilirubin (SDB) level was determined Interferon alpha has been found to be quite by the method of Schellong and Wende.7 SGPT was beneficial for hepatitis 'C' patients and might also assayed by optimized UV test8 and serum alkaline prove effective in treatment of membrane phosphatase level was determined by kinetic proliferative glomerulonephritis, thus minimizing calorimetric method using the kit prepared by Merk the chances of end stage renal disease with major diagnostic á-interferon. economic implications for individuals as well as society at larges.5 The present project was RESULTS 1. Biochemistry Department, Sheikh Zayed Medical After six months of treatment with á-interferon, 18 College, Rahim Yar Khan out of 20 patients became negative for HCV. 2. Punjab Medical College, Faisalabad. Biochemical findings including the levels of Serum

Correspondence: Dr. Aamir Abbas, Assistant Professor total bilirubin (STB), Serum Direct bilirubin (SDB), Biochemistry, Sheikh Zayed Medical College, Rahim Yar Khan Serum indirect bilirubin (SIB), Alkaline Phosphatase

Cell: 0333-4839227 (ALP) and Serum Glutamic Pyruvate Transaminase

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(SGPT) were recorded in all the 20 chronic revealed non-significant (P>0.05) difference hepatitis 'C' patients before and after between SIB values before and after chemotherapy. chemotherapy with á-interferon for 6 months and the results are described as under: 4. Alkaline phosphatase (ALP) Results showed very small differences in case of only Table : I a few patients in comparison of individual values The individual and average values of serum total, direct (Table:II). The average ALP values of patients before and indirect bilirubin in hepatitis C patients before and after treatment with á Interferon and after chemotherapy were found to be 211.10± 65.194 and 211.55± 64.075 U/l respectively. Non

significant (P>0.05) difference was observed Serum Direct Serum Indirect Bilirubin Serum Total Bilirubin (STB) (m g/dl) Bilirubin (SDB) ( STB) (mg/dl) between the levels of ALP before and after (mg/d l) chemotherapy. Before A fter Before After Treatment Treatment Before After Treatment Treatment Treatment Treatment 5. Serum Glutamate Pyruvate Transaminase 0.9359+0.76 0.7925+0.89 0.503+0.117 0.494+1.28 0.436+0.08 0.422+0.073 The range of the elevated SGPT levels (262-422U/l) Table II: Values of SGPT and ALP in hepatitis C patients in chronic hepatitis 'C' patients before chemotherapy before and after treatment with á Interferon gave indication of the extent of liver cells (hepatocytes) damage. But after treatment with á- SGPT (U/L) ALP (U/L) interferon the level of SGPT in these patients Before After Before After declined and became normal in range (16-47U/l) at Treatment Treatment Treatment Treatment the end of 6 months chemotherapy (Table:II) 337.40+75.38 26.8+7.42 211.10+65.194 211.55+64.075 The average values of SGPT, before and after treatment with á-interferon were found to be 337.40± 1. Serum Total Bilirubin 75.38 and 26.8± 7.42 U/l respectively. Comparison The results indicated minor differences in the of SGPT levels by t-test revealed highly significant individual levels of STB, with range before (0.73- (p<0.001) difference. 1.38mg/dl) and range after treatment (0.78- 1.12mg/dl) with á-interferon (Table:I). The DISCUSSION average values of STB before and after treatment In the initial stages of chronic hepatitis there is no with á-interferon were found to be 0.939± 0.076 widespread liver damage, necrosis or fibrosis. So the and 0.924±0.089 mg/dl respectively. Statistical excretory functions of the liver remain normal.2 In analysis by t-test revealed non significant our study subjects, the levels of serum total bilirubin (p>0.05) difference. before and after treatment with á-interferon remained normal. Similar trend was observed in case of serum 2. Serum Direct Bilirubin direct bilirubin and serum indirect bilirubin. The The range of individual values of SDB showed levels of ALP in chronic hepatitis C patients were minor differences which were found to vary from found to be almost normal before and after treatment 0.33 to 0.76mg/dl in patients before treatment and with á-interferon. ALP is present in hepatocytes, from 0.35 to 0.77 mg/dl after chemotherapy for 6 bound to hepatocyte membrane. In chronic hepatitis months (Table 1). The average SDB values were 'C' prior to the development of cirrhosis of liver found to be 0.503±.117 and 0.494±1.28 mg/dl cancer the pressure in the biliary canaliculi remains respectively before and after treatment with á- almost normal. The ALP in liver disease is raised interferon. Comparison of SDB values by t-test only when there is obstruction in the biliary passage.3 indicated non significant (P>0.05) difference. In our study individuals, the chronic hepatitis was in initial stages and there was no obstructive element. 3. Serum Indirect Bilirubin So, level of ALP remained almost normal before and The average values of SIB were found to be after treatment with á-interferon. The most important 0.436±0.08 and 0.422±0.073 mg/dl respectively and diret indicator of liver cells damage is SGPT.10 In before and after treatment with á-interferon which healthy state, hepatocytes are broken down and showed very small difference of range at regenerated. In healthy people, the level of SGPT individual levels (Table:I). Results of t-test remains within normal limits (9-40 U/l) but in

191 JSZMC Vol.2 No.3 Original Article chronic hepatitis 'C' the incidence of hepatocytes 6. Jendrassik L. Grof R. Photometric determination of break down is increased due to viral infection. total bilirubin in serum or plasma. Biol. Chem. 1938. 2. More break down of hepatocytes result in 297, 8. increased entry of SGPT into serum. SGPT level 7. Schellong G, Wende U. Photometric determination of was therefore, increased in chronic hepatitis 'C' direct bilirubin in serum or plasma. Arch. Kinderneilk. patients and after treatment with á-interferon it's 1960; 162, 126. level decreased to normal level. In earlier studies, 8. Lorentz K. Libeek G. Rochce G. Siekman L. patients were given higher doses of IFN (5MU, Determination GPT activity in serum or plasma by VV thrice weekly). Further more, a sustained response test according to IFCC. DG KG Kcinischi chemic was predicted on maintenance of normal ALT mittei 1993; 24:101-105. 11 values. When IFN were used at a dose level of 3 9. Tietz N.W. Determination of alkaline phosphatase by million units, 3 times weekly for a period of 6 kinetic of IFCC.Textbook of clinical chemistry, 2nd months, the biochemical End of Therapy edition, W.B Saunders company, Philadelphia 1994; Response (ETR) rates ranged from 35-50% and 2202. SR (Sustained response) rates ranged from 8- 21%. The virolgical ETR rates varied from 27 to 10. Ulrich PP, Romeo J.M Lane P.K., Keely l., Daniel L.T. 12 Vyas G.N. Determination Semi-quantitation and 35% and SR rates from 8 to 12%. Hoofnagle et variation in HCV sequence amplified from plasma of al,13 describe that interferon alpha, when given to blood donors with elevated ALT.J.Clin. Invest 1990; patients with non A, Non B hepatitis was able to 86:1609-1614. normalize liver enzyme levels in a substantial 11. Nousbaum J. Spol B. Nalpas B. Landais P. Berthelot P. number of patients. They also noted that relapses Brechot. Hepatitis 'C' virus type 16 (ll) infection in might occur if treatment was discontinued. France and Italy. Ann. Intern med. 1995; 122: 161-168.

12. Farrel, GC Therapy of hepatitis 'C' á-interferon-nl-trials. CONCLUSION Hematology. 1997; 26 (965-1005). From the findings of present study it was concluded that á-interferon improves liver 13. Hoofnagle, JH, Mullen K.D Jones D.B. Treatment of function and is an effective drug for the treatment chronic Non-A, Non-B hepatitis with recombinant human alpha interferon N. Engl. J. Med. 1986; 315: 1575-1578. of chronic Hepatitis 'C' under Pakistani conditions. Chemotherapy should not be discontinued and doses of á-interferon should be taken regularly to avoid any chances of relapses

REFERENCES

1. Baron DV, Wicher JT, Lee KE. A new short book of chemical pathology, 5th ed. Butter and Tanner Ltd., London. 1993 Pp. 174-175.

2. Finlayson NDC, Hayes PC, Simpson KJ. Disease of the liver and biliary system. In divisions principles and practice of medicine. 18th ed. Urchin living stone. 1999. P.683-736.

3. William F., Balistreri MO Robert R. Liver. functions: In Fundamentals of clinical chemistry, 4th ed. W.B. Sounders Company 1996; P 563.

4. Edwards CRW Bouchier lAD. Principles and practice of Medicine 16th ed. Funded by British Government, printed in Hongkong 1991. 1SBN 0443 04482 1.

5. Tufail Muhammad, Shoukat A, Chaudhry A Anwar PM. Amin K. Hepatitis B and C virus and Nephrotic syndrome. The professional 2000; 07 (02) 210-211.

JSZMC Vol.2 No.3 192 Original Article

GAMUT OF HEPATOCELLULAR CARCINOMA AT ONCOLOGY DEPARTMENT, SHEIKH ZAYED HOSPITAL, RAHIMYAR KHAN Khalid Shabbir11, Nadeem Zia , Sajid Ghafoor1, Faiz Rasool1

ABSTRACT Background: Hepatocellular carcinoma is ranked as third most cause of death from cancer in world. Objective: The objective of this study was to review predisposing factors among patients with Hepatocellular carcinoma (HCC) at a tertiary care centre in past two years. Material & Methods: This Descriptive study was conducted on patients who had proven HCC by histopathology or tumor marker were reviewed retrospectively and data for January 2009 to December 2010 was included. Demographic features were noted and positivity for hepatitis serology, presence of cirrhosis, level of alpha-fetoprotein, tumour size and distribution of liver lesions were noted. Results: A total of 192 patients were found to have histopathology and tumor marker proven HCC. Males were 149 (77.6%) vs females 43 (22.4%). Hepatitis B surface antigen was noted to be positive in 27(14%) patients, and HCV was found to be positive in 138 (72%) patients. Patients with dual hepatitis (HBV+HCV) were 16 (08%) & in remaining 11 (06%) patients the etiology was unknown. Alpha fetoprotein level was highly elevated in 154 (84%) & Cirrhosis was noted in 134 (70%) patients. 117 (61%) patients had multicentric distribution. Conclusion: Hepatocellular carcinoma in this area, is related to hepatitis C virus infection in majority of the patients. A large number have underlying cirrhosis, multicentric and advanced disease at presentation. The disease is seen in the 5th and 6th decade & predominantly among males.

Key words: Hepatocellular carcinoma, Hepatitis C, Hepatitis B, Alpha fetoprotein, Cirrhosis INTRODUCTION Aetiology, clinical features, and survival of hepato- Hepatocellular carcinoma (HCC) is the fifth most cellular carcinoma differ among the different common malignancy and the third most common countries.7 The objective of this study was to review cause of death from the cancer in the world).1 predisposing factors among patients with Chronic hepatitis C virus (HCV) infection a cause Hepatocellular carcinoma (HCC) at a tertiary care of the chronic liver disease and HCC has been on hospital. the rise worldwide.1 In developing countries, HCC is a leading cause of death and accounts for MATERIAL AND METHODS between 60% and 90% of all primary liver This descriptive study was conducted on case malignancies.2 records of all the patients who were diagnosed HCC Approximately, 160 million people are estimated histologically, radiologically and with elevated to be infected with HCV as figured out by the tumor marker at Clinical Oncology Department, World Health Organization, majority of them Sheikh Zayed Hospital, Rahimyar khan in past 2 reside in the developing countries of the world. years were reviewed. Demographic features were Even in developed countries, the burden of HCV- noted. Presence of hepatitis B surface antigen, anti related liver disease is increasing so that HCV has HCV antigen or other features were noted. become the single most important reason for Radiological features were noted for patients who cirrhosis and Hepatocellular carcinoma.3 had ultrasonography or CT scans. In Pakistan, many reports of HCC have been published in the last 10 years, viral hepatitis and 4 RESULTS aflatoxins have been documented in its etiology. Out of the one hundred and ninety two points, 149 In earlier studies HBsAg positivity was nearly 5 (77.6%) patients were male and 43 (22.4%) patients 60% in cases of Hepatocellular carcinoma. were female. One hundred and twenty one (63%) However, in latest studies the positivity for 6 patients were above the age of 60 years. hepatitis C virus infection has been up to 80%. Positive HCV serology was present in 138 (72%) of our patients, 27 (14%) patients were HBsAg positive, 1. Department of Clinical Oncology, Sheikh Zayed and in 16 (8%) patients were both HCV & HBV Hospital, Rahim Yar Khan. positive. No predisposing cause was found in Correspondence: Prof. Dr. Khalid Shabbir remaining 11 (6%) patients. Alpha fetoprotein was Head of Oncology Deptt. S.Z.M.C, Rahim Yar Khan elevated in 154 (84%) patients. The disease was multicentric in 117 patients (61%)

193 JSZMC Vol.2 No.3 Original Article

These data are shown in detail in Table I. are synergism of alcohol with viral hepatitis and diabetes mellitus.12 Presence of HBsAg in lower Table I: Clinicopathological features of HCC socio-economic class has been associated with HCC. Patients (n=192) Our study showed that alpha fetoprotein was elevated in 84% of patients. In different studies from Features Values Pakistan there is lack of correlation between alpha Age ran ge 30 - 80 years fetoprotein and size of the tumour as compared to similar study in Germany.13 The mulicentric tumors 149 ( 77.6% ) Males were presented in 61%. All the patients in our series were diagnosed on FNAC, Liver Biopsy, Females 43 (22.4%) radiological findings and elevated tumour marker. Cirrhosis was present in 70% of our patients. This has HBsAg 27 ( 14% ) been associated with significant number of patients HCV Ab 138 ( 72%) with chronic hepatitis C and has ranged from 76% in 14 13 Both HBV & India to 90% Germany. Along with hepatitis B and 16 ( 08% ) C, alcoholism has also contributed to the HCV development of cirrhosis which eventually leads to 15 Unknown HCC. A survey of blood donors in the large urban 1 1 ( 06% ) aetiology and rural centers of the country shows that only about 25% of blood and blood product donations AFP elevation 154 ( 84 % ) were tested for HCV infection. The major reason for Cirrhosis 134 ( 70 % ) not testing Hepatitis C was the higher cost of a test. It can be safely assumed that testing for HCV in rural multicentric 117 ( 61 % ) areas of southern Punjab is less frequent, making blood transfusions still the major cause of HCV transmission in this area. DISCUSSION A number of studies also show the relationship The studies from various parts of Pakistan showed between use of parenteral drug administration by the age ranges from 17-84 years. This study shows sharing the syringes between patients and that the Hepatocellular carcinoma is seen mostly transmission of HCV. There is enormous dependence in the 5th and 6th decade, predominantly in males in on parenteral therapy for treatment, both in the form rural areas of southern Punjab. It was noted that of injections and infusion of drips, driven by cultural 89% were male in one study. In earlier studies, beliefs in the power of parenteral therapy. Additional hepatitis B surface antigen was positive in 69% of risk factors that are peculiar to a developing country patients & Anti HCV was present in 87% of the and may be important modes of transmission are patients in one study.8 In addition to hepatitis C excessive use of barbers for shaving, ear piercing and and hepatitis B virus infection, aflatoxin non-sterile surgical and dental practices of contamination has also been noted in Pakistan and unqualified health care workers (quacks). However in many other under developed countries of Asia studies are needed in these areas to confirm this fact. and Africa.4 Alpha fetoprotein was found to be elevated in 84% of patients, which was the highest CONCLUSION number of the patients with elevated AFP. Eighty Our experience indicates that in HCC patients six percent of the patients were noted to have 9 majority are male and develop this in late age. Anti- cirrhosis present in one study. Hepatitis C virus HCV has been present in majority of the patients and infection leads to chronic hepatitis and cirrhosis alpha-fetoprotein elevation in more than 80% of and eventually to HCC and it takes a long interval patients. Seventy percent have underlying cirrhosis between the HCV infection and hepatocellular 10 and 61% had multilocular presentation. carcinoma to develop. Hepatitis B has been very Hepatocellular carcinoma is a frequent malignancy much a cause of hepatic carcinogenesis and 11 in Rahimyar Khan, and HCV is usual underlying presence of HBsAg increases the risk manifold. cause, however it presents with advanced stage. Other risk factors noted for hepatocarcinogenesis

JSZMC Vol.2 No.3 194 Original Article

REFERENCES 9. Shah GG, Qureshi IA, Hakim T, Tarin BA, Farooq MA, Qureshi PS. Radiological aspects of hepatocellular 1. Yoshizawa H. Hepatocellular carcinoma associated carcinoma: A hospital based study. Pak Armed Forces with hepatitis C virus infection in Japan: Projection to Med J. 1999; 49: 54-7. other countries in the foreseeable future. Oncol 2002; 10. Castells L, Vargas V, Gonzalez A, Esteban L, Esteba R, 62(Suppl): 8-17. Guardia J. Long interval between HCV infection and 2. Tanaka Y, Hanada K, Mizokami M, Yeo AE, Shih JW, development of hepatocellular carcinoma. Liver 1995; 15: Gojobori T, et al. Inaugural article: A comparison of the 159-63. molecular clock of hepatitis C virus in the United States 11. Yang HI, Lu SN, Liaw YF, You SL, Sun CA, Wang LY, et and Japan predicts that hepatocellular carcinoma al. Hepatitis Be antigen and risk of hepatocellular incidence in the United States will increase over the carcinoma. N Eng J Med 2002; 347: 168-74. next two decades. Proc Natl Acad Sci.. 2002; 99: 15584- 12. Wang BE, Ma WM, Sulaiman A, Noer S, Sumoharjo S, 9. Sumarsidi D, et al. Demographic, clinical and virological 3. El-Serag HB. Hepatocellular carcinoma and hepatitis C characteristics of hepatocellular carcinoma is Asia: Survey in the United States. Hepatol 2002; 36 (5) 74-83. of 414 patients from four countries. J Med Virol 2002; 67: 4. Taseer JH, Malik IH, Mustafa G, Arshad M, Zafar MH, 394-400. Shabbir I, et al. Association of primary hepatocellular 13. Petry W, Heintges T, Hensel F, Erhardt A, Wenning M, carcinoma with hepatitis B virus. Bio Medica 1996; 12: Niederau C, et al. Hepatocellular carcinoma in Germany. 79-81. Epidemiology, etiology, clinical aspects and prognosis in 5. Butt A, Khan A, Alam A, Ahmad S, Shah S, Shafqat F, et 100 consecutive patients of a university clinic. J al. Hepatocellular carcinoma: analysis of 76 cases. J Gastroenterol 1997; 35: 1059-67. Pak Med Assoc 1998; 48: 197-201. 14. Sarin SK, Thakur V, Guptan RC, Saigal S, Malhotra V, 6. Qureshi H, Zuberi SJ, Jafarey NA, Zaidi SH. Thyagarajan SP, et al. Profile of hepatocellular carcinoma Hepatocellular carcinoma in Karachi. J Gastroenterol in India: An insight into possible etiologic associations. J Hepatol 1990; 5: 1-6. Gastroenterol Hepatol 2001; 16: 666-673. 7. Omata M, Dan Y, Daniele B, Plentz R, Rudolph KL, 15. Hwang SJ, Tong MJ, Lai PP, Ko ES, CO RL, Chien D, et al. Manna M, et al. Clinical features, etiology and survival Evaluation of hepatitis B and C viral markers: Clinical of hepatocellular carcinoma among different countries. significance in Asian and Caucasian patients with J Gastroenterol Hepatol 2002; 17 (Suppl): 540-9. hepatocellular carcinoma in the United States of America:. 8. Chohan AR, Umar M, Khar B, Khurram M, Zahid M, J Gastroenterol Hepatol. Oct.1996, 11(10) 949-54 Shah SF, et al. Demographic features of hepatocellular carcinoma: A study of 30 cases. J Rawalpindi Med Coll 2001; 5: 81-83.

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PATTERN OF INDICATIONS OF FLEXIBLE BRONCHOSCOPY AMONG ADULT PATIENTS IN A TERTIARY CARE HOSPITAL Fazli Maula, Arshad Javed11, Anila Basit , Safeer Zaman1, Muhammad Yousaf1, Ziaullah, Zafar Iqbal1, Syed Salman Shah1

ABSTRACT

Background: Flexible fiber optic bronchoscopy is frequently performed procedure in pulmonary medicine. Objective: To determine the Clinico-radiological indications of flexible bronchoscopy in a tertiary care hospital. Materials and Methods: This descriptive study was conducted in the bronchoscopy suit of department post graduate medical institute(PGMI), Lady Reading Hospital, Peshawar from Jan 2008 to Dec 2010. This was a retrospective analysis of the well maintained records of patients in whom bronchoscopy was done in the above mentioned duration. All the patients above 15 years were included. All the bronchoscopies were done by expert brochoscopists under local aneasthesia. Data was analyzed by SPSS 13 to find the frequencies and percentages. Results: Total number of patients were 423, with a male to female ratio of 1.6:1, in which 191 had haemoptysis , 115 presented with chronic cough, 42 had shortness of breath (SOB) , 11 presented as superior venacaval (SVC) obstruction, 25 had lobar or full lung collapse on chest x rays and 9 patients had solitary or multiple nodules, 8 were scoped for removal of foreign bodies, 4 for medical fitness and 2 for persisted fever. After analysis of x-rays of proven malignancies out of 60 patients, 20 (33.33%) had right side non-resolving consolidation, 18 (30%) Left side consolidation,08 (13.4%) presented with hilar mass, 03 (5%) with multiple nodules, 04 (6.66%) with mediastinal widening , 03 (5%), with left sided lobar collapse, 02 (3.33%) with right lobar Collapse and 02 (3.33%) had either side full lung collapse. Conclusion: Bronchoscopy is an important tool for the diagnosis of the cause of radiological/clinical findings like haemoptysis, chronic cough, SOB, SVC obstruction, hoarseness of voice and persistent x-ray opacity, or lobar or lung collapse. Heamoptysis and chronic cough are the main indications in our setting. Bronchoscopy is minimally invasive procedure with high diagnostic yield for bronchogenic tumours especially central.

Key words. Bronchoscopy, Bronchogenic Carcinoma, Radiological INTRODUCTION lesions <2 cm in diameter.2 Walid and colleagues Flexible fiber optic bronchoscopy (FOB), the found that the diagnostic accuracy of FOB was 64% most frequently performed invasive procedure in and 35%, for malignant and benign lesions practice of pulmonary medicine has largely respectively and it was directly related to the lesion replaced rigid bronchoscopy in the diagnosis and size.3 In one study by Laurent et al chest x-ray was management of inflammatory, infectious and compared with FOB and was found that chest malignant diseases of the lungs and air ways. This radiograph localized 20% and FOB 40% bleeding has been possible due to the comfort of the patient, sites and bronchogenic carcinoma was confirmed in greater maneuverability of the bronchoscope, 03% cases in which x-ray was normal.4 improved diagnostic accuracy and safety of FOB In another study, FOB was successful in removing as an out patient procedure. FOB is a useful in foreign bodies from 14 out 23 patients and now it can localization and biopsy of airway tumors, be used for thermoplasty in asthmatic patients and evaluation of interstitial lung disease, non- florescence bronchoscopy is even able to localize resolving pneumonia, unexplained haemoptysis and diagnose in situ lesions.7,8 Bronchoscopy is and assessment of response to treatment, indicated for chronic cough and about 2% cases of placement of catheters and stents for tumors and lung cancer present with chronic cough.5 The stricture management.1 principal goals of any diagnostic procedure is to The sensitivity of bronchoscopy is high for identify , diagnose and stage the disease for the endobronchial lesions and poor for peripheral purpose of management, and in pulmonary medicine bronchoscopy is the safest , least invasive and least 6 1. Bannu KPK, Pakistan. costly test for many diseases. Our study was planned to determine the pattern of Correspondence: Dr. Fazli Maula, Assistant Professor indications of flexible fiber optic bronchoscopy in a Pulmonology, Bannu Medical College, Bannu KPK. tertiary care hospital because we don't have studies Email: [email protected] on this topic in Pakistan.

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MATERIALS AND METHODS Table I: Indication of Bronchoscopies (423) No. of This descriptive study was conducted in the Indications of bronchoscopy %age bronchoscopy suit of pulmonology department, Patients Haemoptysis + x-ray findings Post Graduate Medical Institute (PGMI) Lady 112 26.5% Reading Hospital, Peshawar from Jan 2008 to Dec (fibrosis/cavity/) Haemoptysis with Normal x- 2010. This was a retrospective analysis of the well 78 18.5% maintained records of patients in whom ray Chronic cough with persistent bronchoscopy was done. All the patients above 15 82 19.4% shadow years were included. All the bronscopies were Chronic cough with normal 33 7.8% conducted by expert brochoscopists under local x-ray aneasthesia. Data was analyzed by SPSS Version Chest pain fever with opacity 17 4.01% 13 to find the frequencies and percentages. or effusion SOB + cough with or without 42 9.92% RESULTS x-ray findings A total of 423 bronchoscopies were conducted Lobar/lung collapse on x-ray 25 5.9% with a male to female ratio of 1.6:1. Out of these Foreign body 8 1.9% 112 (26.5%) patients had haemoptysis with Solitary/multiple nodules 9 2.12% fibrosis/cavity or consolidation on x-rays and 78 SVC obstruction with hilar (18.5%) had haemoptysis with normal x-rays, 82 mass or raised hemi 11 2.6% (19.4%) cases presented with chronic cough with diaphragm Normal people for medical opacity on x-rays and 33 (7.8%) having chronic 4 0.9% cough with normal x-rays, 42 (9.92%) were fitness patients with cough, fever, chest pain with or Persistent fever with normal without x-ray findings, while 17 (4.01%) patients x-rays and no response to 2 04.7% had chest pain, fever with opacity or effusion. treatment

Table II: Radiological (x-rays) presentations of In 25 (5.9 %) patients had lobar or lung collapse on histologically proven bronchogenic carcinoma x-rays. Among the remaining cases 08 (1.9%) had (No. of patients=60) foreign bodies, 09 (2.12%) had solitary or multiple nodules, 11 (2.6 %) SVC obstruction with hilar mass or raised hemi diaphragm, 04(0.9%) had X-ray Presentation No. of %age normal people for medical fitness and 02 ( 04.7%) Patients Right sided persistent patients were scoped for persistent fever having 20 33.33% consolidation normal x- rays and no response to treatment. Left sided persistent (Table I) 18 30% consolidation After analysis of x-rays of proven malignancies Hilar mass (any side) 8 13.4% Single or Multiple out of 60 patients, 20 (33.33%) had right side non- 3 5% resolving consolidation,18 (30%) Left side nodules(any side) consolidation, 08(13.4%) presented with hilar Mediastinal widening 4 6.66% mass, 03 (5%) multiple nodules, 04 (6.66%) mediastinal widening, 03 (5%), Lt. sided lobar lobar collapse(any lobe) 5 8.33% collapse, 02 (3.33%) Rt. Lobar Collapse and 02 full lung collapse(any side) 2 3.33% (3.33%) had either side full lung collapse. Some patients had only clinical findings but majority of patients had both radiological and DISCUSSION clinical indications. FOB is used for a number of diagnostic and therapeutic indications mainly haemoptysis, chronic cough, persistent radiological opacities, interstitial

197 JSZMC Vol.2 No.3 Original Article lung disease, removal of foreign bodies (if radiographic guidelines for FOB which recommends possible), biopsy and recently thermoplasty and that lobar collapse, hilar abnormality, pericardial florescence bronchoscopy for in situ effusion, pleural effusion and mass with >4cm malignancies.9 In our study the main indications should be bronchoscoped.14 Kvale etal showed that of FOB were haemoptysis and chronic cough with cough was a presenting feature in more than 65% of some shadows on chest x-rays but a large number patients with any form of lung cancer.5 of patients had normal radiographs. In the series In our series bronchoscopy was done for foreign by sakerl and colleagues, 5-15% of patients bodies in small number of patients but the percentage presented with massive haemoptysis for is more in international research. In one study FOB bronchoscopy and in the same study FOB was was successful in 60% of cases of adults for FB used as the special tool for haemoptysis.10 r e m o v a l while rigid bronchoscopy had success rate In a series by Tak S et al, out of 50 patients having of 97%. It shows that foreign body patients mostly haemoptysis with normal x rays bronchoscopy present to rigid bronchoscopy units as compared to diagnosed only 10% of cases and the remaining FOB. In our study a good percentage of patients were were diagnosed by HRCT(high resolution CT) but scoped for medical fitness, which is not done still haemoptysis is considered as the most internationally. These patients had bronchoscopy as im po rt an t in di ca ti on of br on sc ho sc op y a requirements for visa to some countries, otherwise diagnostically and therapeutically.11 In they were normal young adults. The number of comparison to this series we had high percentage patients scoped for multiple nodules were similar to of haemoptysis cases, which correlates with other other studies. The radiological presentations of studies. Chronic Cough defined as > 8 weeks bronchogenic carcinoma were mainly right or left duration remains an important clinical problem sided persistent consolidation and in the study by for primary care physicians and pulmonologists Fensilver SH and colleagues, they diagnosed 86% of specially when x-rays are normal, and non resolving consolidations via bronchoscopy.15 bronchoscopy is indicated with the suspicion of Hilar mass and collapse of lobe or lung are endobronchial lesions like malignancy or TB etc.12 considered important radiological markers of tumors Chronic Cough and haemoptysis are the major and in our series a good number of patients had these indications in the international research with or findings. In a local study hilar mass was present in without abnormal and for massive 62% of cases diagnosed as bronchogenic carcinoma. haemoptysis rigid bronchoscopy is the choice, and The radiographic findings can help the physician in these were also the findings of our study.13 Our better suspicion and diagnosis of lung tumor.16 series differs from other studies by having a good number of patients with fever, chest pain, and CONCLUSION acute cough and normal chest x-rays. These were Bronchoscopy is an important tool for the diagnosis the patients who had repeated normal radiology of of the cause of radiological/clinical findings like chest and sinuses, used repeated courses of haemoptysis, chronic cough, SOB, SVC obstruction, antibiotics with no response and had persistent hoarseness of voice and persistent x-ray opacity, or symptoms. In one study FOB was used for non lobar or lung collapse. Heamoptysis and chronic productive cough in 39 patients in which 16 had cough are the main indications in our setting. normal chest x-rays with endobronchial Tuberculosis. This study also recommends that REFERENCES before bronchoscopy, proper history, 1. Bale mugesh T,Agarwal A.N Guptha D Behera D J i n d a l examinations, x-ray chest and sputum evaluation S.K. Profile of replant FOB. Indian J chest Dis Allied should be done for these symptoms, otherwise Sci 2005; 47:181-185. early bronchoscopy is not indicated.14 We had 2. Schrebier G, Douglas Sc, Crory MC. The sensitivity of FOB in lung lesions. Chest 2003,123:1155-1289. many patients with lobar or lung collapse, hilar 3. Walid A, Baakini, Mauricio A, Remiso, Arnold B, Gurin, mass on chest x-rays with either shortness of Kanesh AS, Manian P. FOB in localization of lung lesions. breath, SVC obstruction or hoarseness of voice or CHEST 2000; 117: 1049-1054. raised hemi diaphragm and these findings 4. Laurent F, Martins M, Santy A. Hemoptysis Methods of correlate with the international studies. The study localization. Rev Med Suisse 2005 Nov 16; 41: 2659-63. 5. Kvale PA: Chronic cough due to tumor; ACCP evidence by SU WJ and colleagues made the chest based clinical practice guidelines. Chest 2006

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Jan;129:1475 - 1535. 12. Authour(unknown). Is there any role of bronchoscopy 6. Young RC. Tissue diagnosis of suspected lung in the workup of cough? J Respiratory diseases, 1st cancer. Respire care CLin NA 2003 Mar; 9:51-76. June 2008. 7. Bourkew, Meilstein D, Gura R, Dough M, Robin 13. Vishumu SM, Pradeed NP Anuparo N, Mithra PP. AN, Smith LJ et al. Lung cancer in adults chest Bronchoscopic evaluation and final diagnosis in 1992 Dec; 102: 1723-29. patients with Chronic non Productive cough with 8. Limper AH, Parkash UB. Tracheo bronchial normal x-rays. Journal of health and allied sciences, foreign bodies in adults, Am Intern Med 1990;112: 2010. 604. 14. SU WJ, LEE Py, Pering RB. Chest radiographic 9. Cox G, Miller JD, Mec Williams A, et al. Bronchial guidelines in the selection of patients for FOB. Chest thermoplasty for Asthma. Am J resp Crit care Med 1993 Apr; 103(4):1198-201. 2006;173:965. 15. Fensilver SH, Fevin AM, Neiderman MS et al. Utility 10. Sarkr l, Dutav H. Massive hemoptysis an update on of FOB in non-resolving Pneumonia chest the role of bronchoscopy in diagram and treatment. 1990;98:1322. Respiration 2010; 80(1): 38-58. 16. Suleman MI, Ali B, Majeed H. Qureshi F. Chest 11. Tak S, Ahuvalia G, Sluruva SK. Haemoptysis in radiological findings in Bronchogenic carcinoma in patients with normal chest radiograph. Astralus Pakistani population. Pak J Med Res Vol.47, no.4, Radiol.1999 Nov;43(4):451-5. 2008.

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MORPHOLOGICAL STUDY OF ANATOMICAL VARIATIONS IN THE BRANCHING PATTERN OF HUMAN AXILLARY ARTERIAL SYSTEM

Bashir Ahmad Junjua12, Khadija, Samina , Aftab Ahmad3 ABSTRACT Background: The arterial variations in the upper extremities are quite common and may occur at the level of axilla, arm, cubital fossa and the hand. Knowledge of anatomical variations in the branching pattern of axillary artery is very important in medical & surgical practices. Objectives: To determine the anatomical variations in the branching pattern of axillary arterial system in cadavers. Secondarily, to avoid the injuries by applying this knowledge during clinical practice. Material and Methods: A total of 82 upper limbs of 41 human embalmed cadavers of both sexes (36 Males & 5 Females,) ranging from (45-70 years old) were dissected and examined at the department of , Nishtar Medical College, Multan, , Rawalpindi and Sheikh Zayed Medical College, Rahim Yar Khan over a period of four years. Upper limbs were labeled from 1-82 with letters (R) and (L) corresponding to the right or left limbs respectively and letters (M) or (F) corresponding to male or female respectively. Axillary artery (AA) with its normal or variant branches along with brachial plexus with its cords and branches was exposed in each cadaver. The topographic detail of each AA and its branching pattern deviated from the normal pattern was identified and photographed in both upper limbs of each cadaver. Results: The anomalous topographic pattern of branches of axillary arterial system was revealed in 14.64 % of the cadavers. Among 41(82 limbs) cadavers, the total anomalous branching pattern of AA were found in 6 (14.64 %) dead bodies, out of which 4 (9.76%) male and 2 (4.88%) female cadavers were seen. The frequency of bilateral variation was found in 1 (2.44%) male and 1 (2.44%) female cadavers but the frequency of unilateral variation was in 3 (7.32%) male dead bodies and in 1 (2.44 %) female cadaver. The study showed that axillary artery of the various cadavers gave origin to anamolous common thoraco- subscapular-circumflex humeral trunk in 5 (6.09 %) limbs, common circumflex humeral trunk in two (2.44%) limbs directly from the third part of the AA, independent branches from the different parts of the axillary artery (AA) were found in 4 cadavers i.e. in 6 (7.32 %) limbs and common thoracic trunk got origin from the 1st part of the AA in one (1.22 %) case. Conclusion: Our study reports existence of anomalous branches of AA. Knowledge of variation is very important during surgical exploration of the regions like axilla, arm and during flap or reconstructive surgeries. The anomalous branching pattern of AA associated with anomalies of various nerves are of interest to anatomists, surgeons, angiographers and radiologists, so keeping in view such anomalies, it is suggested that before doing any flap or reconstructive surgeries, these anomalies must be evaluated pre-operatively.

Key Words: Axillary artery, variations, anomalies, superior thoracic, thoraco-acromial, lateral thoracic, subscapular, anterior circumflex humeral, posterior circumflex humeral, thoracodorsal.

INTRODUCTION (third part) is below the muscle, gives origin to the Variations have been observed commonly in the subscapular artery (SSA), anterior circumflex arterial anatomy of the upper extremities. The humeral (ACHA)and posterior circumflex humeral prevalence of major arterial variations in upper arteries (PCHA).3 Sub scapular artery (SSA) further limb ranges from 11% to 24%.1 Axillary artery divides into thoracodorsal artery (TDA) and (AA), a continuation of subclavian artery extends circumflex scapular artery (CSA). Although, six from the outer border of first rib to the lower branches arise from the AA but the number arising border of teres major where it ends to become the independently from it, is a subject to be discussed for brachial artery.2 Conventionally, the Anatomy text its considerable variations.4 Twenty three different books describe, six branches from the AA. It is types of axillary arteries have been reported by some divided into three parts, in relation to pectoralis researchers 5 since 1928. Greate tendency of this minor muscle. Proximal part (first part), is above variation was found among the Negroes than in the pectoralis minor, from which superior Whites. Sex differences in the branching pattern of (highest) thoracic artery arises and the part lying AA were also examined by Trottler and her under the muscle is posterior part (second part), associates 6 in 1930. which gives thoraco-acromial artery (TAA) and During developmental stages, AA arises from the lateral thoracic artery (LTA) and its distal part seventh cervical segmental artery, so any 1. Sahiwal Medical College, Sahiwal abnormality during development may results in the 2. Army Medical College, Rawalpindi form of an unusual branching pattern, as described by 3. Sheikh Zayed Medical College, Rahim Yar Khan 7 Wollard in 1922. Researchers have reported Correspondence: Dr. Bashir Ahmad Junjua, Associate Professor different anomalies in the arterial anatomy of the Anatomy Department , Sahiwal Medical College, Sahiwal. upper extremities most commonly seen in 3rd part of 8,9 E.Mail: [email protected] the AA. It is thought that AA variability results from

JSZMC Vol.2 No.3 200 Original Article abnormal embryonic development of the limb bud Observations and results: vascular plexuses, derived from the persistence of 10 Out of 82 upper limbs of 41 cadavers, anomalous more than one cervical intersegmental artery. The branching pattern of the AA was found only in 6 largest and the most variable branch of the AA is cases, four males and two females. The observations subscapular artery (SSA), which arises at the distal 11 were recorded and described by keeping the border of the subscapularis muscle. Two following parameters, in view regarding the important muscles, the serratus anterior and variations of branching pattern of AA, subscapularis muscles are supplied by the SSA. The serratus anterior is used for free flap for 1. Total number of the branches / trunks from reconstruction surgery by the plastic surgeons.12 AA whether normal or variant. So it is important for, anatomists, cardiovascular, 2. Site of origin of each normal or variant general, plastic and orthopedic surgeons and branch/ trunk. vascular radiologists to know the accurate 3. Number and site of origin of each branch knowledge of normal and variant arterial anatomy from the anomalous trunk. of the axillary region. Therefore, to get benefit from this vessel and muscle, the vascular 4. Unilateral or bilateral anomalies. variations of this region should be well 5. Associated anomalies. investigated by ultrasonography and contrast arteriography to know any anomalous pattern of AA before planning any surgery. For this purpose RESULTS proper evaluation of the axillary arterial system is Among 41 (82 limbs) cadavers the total anomalies needed in each individual who is undergoing such regarding the anomalous branching pattern of AA types of investigations, intervention and were found in six (14.64%) cases. Out of which 4 operations. That is why; the present study was (9.76%) male and 2 (4.88%) female dead bodies carried out to record and evaluate the frequency of were seen with anomalies while in rest of the anatomical variations in the branching patterns of cadavers (85.36%) standard configuration of the AA in dissecting room cadavers. branching pattern of the AA was found as described in the textbooks of anatomy. The frequency of MATERIAL & METHODS bilateral variation was found in 1 (2.44%) male and 1 (2.44%) female cadavers but frequency of unilateral AA with brachial plexuses (BP), from 82 upper variation was in 3 (7.32%) male bodies and in 1 (2.44 limbs of 41 human cadavers of both sexes (36 %) female cadaver. So among 82 limbs, anomalies males and 5 females, embalmed with an were in 8 (9.76%) limbs, out of which 5 (6.09%) embalming fluid) ranging from (45-70 years old) limbs were male and 3 (3.66%) limbs were female. were dissected and examined at the department of The overall anomalies were found in three (3.66%) Anatomy, Nishter Medical College, Multan, Army right limbs and five (6.09%) left limbs. Medical College, Rawalpindi and Sheikh Zayed Medical College, Rahim Yar Khan over a period 1. Two to eight branches were observed coming out of 4 years. These were labeled from 1-82 with of the AA of various cadavers in this study. letters (R) and (L) corresponding to the right or left A). Three branches from AA in body no. 12, left arm, limbs respectively and letters (M) or (F) (Fig.I.). 1. (HTA). 2. Delto-pectoro-acromio- corresponding to male or female respectively. clavicular trunk (DPACT).This trunk gave four Exposure of AA with its normal or variant branches, deltoid, Pectroal, acromial and clavicular. branches along with brachial pluxses (BP) with its 3.Anomalous common thoraco- subscapulo- cords & branches was achieved, as directed by circumflex humeral trunk, (ACTSCHT) from 2nd 13 Cunningham's Manual of Practical Anatomy part of AA, above the formation of the main trunk of with special emphasis on the origin of various the median nerve. Lateral thoracic, accessory lateral branches of AA whether normal or variant, from thoracic, common humeral trunk and subscapular its first, second and third parts. The topographic artery were its branches. Subscapular Trunk (SSA) detail of arteries was examined by proper gave Circumflex Scapularl Artery (CSA) and dissection and anomalies were observed, Thoracodorsa Artery (TDA), Circumflex Humoral recorded, photographed and described. Trunk (CHT) gave circumflex humeral artery

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(ACHA) and (PCHA). AA 5

2 HTA D.br B).Three branches in body no. 18 right arm. 1. 3 6 CPTT Anomalous common thoraco- subscapular- 4 Acro.br Pect.br circumflex humeral trunk (ACTSCHT) which AA 3rd LTA gave LTA and circumflex humoral trunk Part (CSCHT). This trunk further divided into CHT CSCHT CSHT CCHT and SSA.SSA then divided into TDA and CSA. 2. TDA

Anomalous common delto-pectoro-acromio- TDA CSA CHT thoracic trunk (ADPATT) which gave further four CSA PCHA branches, i.e. deltoid, pectoral, acromial, and highest thoracic. 3. Anterior circumflex humeral artery (ACHA). Associated anomaly was the Fig. III: formation of the trunk of the median nerve by Right arm female body no 35. Five branches from AA. st three roots. Common thoracic trunk, from 1 part giving highest thoracic and lateral toracic arteries. 1.Deltiod 2. Pectoral 3. Acromial Fig. I: branches, from 2nd part. Subscapular artery and common rd Male dead body no 12, left arm. Three branches from AA. 1. circumflex humoral trunk from 3 part. HTA. 2. Delto-pectoro-acromio-clavicular trunk (DPACT) with four branches.3. Anomalous common thoraco- 1 2 AA HTA subscapulo-circumflex humeral trunk, (ACTSCHT) from 2 1 CTT 3 4 2nd part of AA, giving two branches i.e. LTA, CHT and SSA. A A SSA gave further CSA and TDA.CHT gave ACHA and LTA PCHA 5 3 LTA CTSCHT A A 3rd PCHA DPATT 3rd CHT part CSHCT part PCHA SSA LTA MNT TDA SSA TDA T AA PCHA ACHA CSA H C S T MN ROOTS 3 ACTSCHT C A C). Six branches from AA of right arm. Male body no SSA CHT CSCHT 29, right arm. 1. Highest throracic artery (HTA). 2. LTA TDA CHT Deltiod branch (D.Br). 3. Acromial branch (A.Br). CSA SSA 4.Thoracic branch (T.Br) Two anomalous trunk were ACHA TDA CSA rd PCHA found, arising from the 3 part of the AA. 5. Common thoraco- subscapular-circumflex humeral trunk (ACTSCHT) which gave LTA, PCHA and SSA. SSA Fig. IIa: then divided into CSA and TDA. 6. Common humeral trunk (CHT) which divided into ACHA and Male body no 29, right arm. Six branches from AA of right arm.1.Highest throracic artery (HTA). 2. Deltiod branch PCHA. Six branches of AA, male body no 29, left (D.Br).3.Acromial branch (A.Br).4.Thoracic branch (T.Br) arm. 1.Highest thoracic. 2.Deltiod branch. 3 Two anomalus trunk were found, arising from the 3rd part of Acromial 4.Thoraco-pectoral trunk was found, the AA. 5. Common thoraco-subscapular-circumflex coming out from the medial side of the 2nd part, humeral trunk (CTSCHT) which gave LTA, PCHA and giving a).pectoral branch and b) lateral thoracic SSA. SSAthen divided into CSA and TDA. 6. Common humeral trunk (CHT) which divided into ACHA and PCHA. branch 5. Common scapulo-humoral trunk from its IIb Six branches of AA .1 Highest thoracic (HT). 2.Deltiod 3rd part giving circumflex scapular, thoracodorsal branch (Dbr). 3 Acromial branch(ABr).4.Thoraco-pectoral arteries and accessory muscular branches. 6 . trunk(TPT) was found, coming out from the medial side of Anterior circumflex humoral branch. the 2nd part of the AA 5. Common scapulo-humoral trunk (CSHT) from its 3rd part giving circumflex scapular, thoracodorsal arteries. 6. Anterior circumflex humoral branch (ACHA) Fig. IV: Male left arm, body no. 39 Anamolous common thoraco scaplo humeral trunk(ACTSCHT) from 2nd part of the axillary artery. This divided into TDA and

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CSCHT. CSCHT divided into TDA and CCHT F). Male left arm, body no. 39. Anomalous common which further dsivided into CSA and PCHT. Two thoraco- scaplo- humeral trunk (ACTSCHT) from 2nd independent branches ACHA and PCHA from 3nd part of the axillary artery. This divided into TDA and part CSCHT. CSCHT divided into TDA and CCHT which

ACHA further divided into CSA and PCHT. Two AA 2nd 3rd part part independent branches ACHA and PCHA came out nd CSCHT from 3 part. PCHA CTSCHT CCHT

CCHT 2. Anomalous common thoraco- subscapular- LTA CSA circumflex humeral trunk (ACTSCHT) got origin TDA from the AA in five (6.09 %) limbs among 82 limbs. From its 2nd part it was found in three (3.66 %) male limbs above the formation of the main trunk of the median nerve while from its 3rd part, it was present in one male (1.22 %) limb and one female(1.22 %) limb below the formation of the main trunk of the median nerve. 3. Common circumflex humeral trunk (CCHT) got D). Eight branches of the AA female body no 30. origin from the AA in six (7.32 %) limbs. In two 1.Highest thoracic, 2. Deltoid 3. Pectoral limbs (2.44%) it was getting direct origin from the 4.Acromial 5.Clavicular 6. Lateral thoracic third part of the AA, while in four (4.88%) limbs it nd arteries arising independently from 2nd part. 7. was arising indirectly from 2 part of the AA via the Anomalous common subscapulo-humoral trunk CTSCHT. (ACSHT) from 3rd part which divided into 4. Independent branches from the different parts of thoracodorsal artery and common subscapolo- the AA were found in six (7.32 %) limbs. In two humoral trunk (CSHT). This trunk further divided cadavers it was bilateral i.e. in 4 (4.88 %) limbs and into circumflex humoral trunk (CHT) and unilateral in two (2.44 %) limbs. circumflex scapular (CSA) arteries.8.Anterior 5. Common thoracic trunk (CTT) got origin from the circumflex humeral artery (ACHA) st 1 part of the AA in one case and divided into highest E). Left arm female body no.35. Six branches from thoracic and lateral thoracic arteries. AA. 1. Highest thoracic artery, from 1st part. Three independent branches (2,3,4) from 2nd part. Two These above mentioned anomalies were branches from 3rd part. Anomalous common accompanied by anomalous formation of median thoraco- subscapulo-humoral trunk (ATCSHT) nerve by 3 roots, 5 roots, pectoral nerve loop, a from 3rd part which divided into lateral thoracic communicating nerve between the medial and lateral and common subscapolo- circumflex- humoral cords, arching over the second part of the AA. trunk (CSCHT). This trunk gave posterior circumflex humeral and subscapular branches. Subscapular gave circumflex scapular and DISCUSSION thoracodorsal arteries. Anterior circomflex The arterial variations are quite common in the upper humeral artery (ACHA). Right arm female body extremities. These anomalies may occur at different no 35, Fig. III. Five branches from AA. Common st levels of the arm. Clinically relevant anomalies may thoracic trunk, from 1 part giving highest thoracic occur due to defective development of the vascular and lateral toracic arteries.1 Deltiod 2. Pectoral 3. 14 nd system at any embryological stage. It is important Acromial branches, from 2 part. for the anatomists, radiologists, vascular, Subscapulohumoral trunk which divided into cardiovascular, and orthopedic surgeons to know the PCHA and SSA which divided into CSA and TDA different variations in the origin, course and artery and common circumflex humoral trunk rd distribution of the principal arteries of the upper which divided into PCHA and ACHA from 3 limbs. During developmental stages, it is the 7th part.

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intersegmental artery from which the developing 21 who described the number of branches ranged from upper limb bud gets the main artery i.e. axis 2-9 in their study. Our findings are also in favor and artery.15 The proximal part of this axial artery is Syed at el who has described eight branches in their developed into AA, followed by the brachial and study.22 interosseus arteries.16 The anomalies of subclavian-axillary arterial system may occur due Common thoraco- subscapular-circumflex humeral to the persistence of channels that normally trunk got origin from the AA in five (6.09 %) limbs obliterate. Some times the primitive vascular among 82 limbs. From its 2nd part it was found in three plexuses may grow at unusual routes resulting in (3.66 %) male limbs (Fig.1) above the formation of occurrence of various anomalous pattern of AA the main trunk of the median nerve while from its 3rd system as observed in current study. Anatomists, part, it was present in one male (1.22 %) limb and vascular radiologists and cardiovascular surgeons one female (1.22 %) limb below the formation of the have shown keen attention about the variations in main trunk of the median nerve.The common the origin, course and branching pattern of the thoraco- subscapular-circumflex humeral trunk gave principal arteries of the upper limbs.17 The origin to LT, accessory LT, subscapular trunk (SST) thoracodorsal (TDA) anastomoses with the dividing into CHT and SSA which then subsequently branches of the subclavian and axillary arteries terminated into ACH and PCH arteries from CHT and those of the thoracic aorta.12 This important and CSA and TDA from SSA. This finding is in anastomoses gives collateral channel in patients accordance with the results of Durgun et al23 who with coarctation of aorta, and post-radiation reported a variation where the SSA arose from the occlusion of the axillary artery for arterial second part of the AA as a common trunk and circulation. produced the TDA, CSA, and PCHA. The frequency It is usually described that AA gives off six of aberrant branching observed by them was in 12% branches, but this number is not always constant, of cases. In another study where Lee and Kim 24 have however it may vary because of origin of two or reported a large common trunk originated from the more arteries together instead of their separate second part of the AA and gave origin to the LTA, origin, or two branches of an artery arise TDA, CSA, and PCHA. It has been described by separately instead of, the usual common trunk.18 DeGaris & Swartley25, that the SS, both CH and Both unilateral and bilateral variations of the profunda brachii arteries arose frequently from the branching pattern of the AA have been observed in AA as a common trunk in combination of any of two current study (Fig.3,5), which are in consonance or more which again favours our study results. The with the results of Saralaya et al19, and Daniela et results of study of Swapna et al26 also favours the al.20 Saeed et al14, have reported a bilateral results of this current study who found bilateral ACSCHT (3.8%) coming from the 3rd part of the variation, where a common stem was arising from the AA (branching into the circumflex humeral (CH) second part of right AA which gave off SS and LT and TD and a bilateral thoraco-humoral trunk arteries and independent branches namely LTA, HT. emerging from the 2nd part of the AA (1.9%) which While LTA and SSA .from its 2nd part and ACH and gave Lateral Thoracic Artery (LT), Common PCH arteries were arising from its third part. The Humeral (CH), SSA and TDA arteries. The study frequency of the common trunk in their study was showed that axillary artery of the various cadavers observed in 2.4% of cases from which the CSA and gave origin to three branches in body no 12, left TDA with the additional presence of a PCHA in 1.2% arm, three branches in body no 18 right arm, six of cases. In our study results, a common trunk arising branches right arm and six branches left arm in from third part of the AA gave origin to LTA and SST. body no 29, 8 branches left arm of a female dead This SST gave further SSA and PCHA. This result is body no 2, six branches from left arm and five similar to the study results of Samuel et al27 who from right arm in a female body no. 35 and three found an abnormal trunk from the third part of the AA branches in body no.39. Regarding every branch which gave to ACH, PCH, and SS arteries. getting origin directly from the axillary artery, Common circumflex humeral trunk (CCHT) got whether named, unnamed, or common trunk, the origin from the AA in six (7.32 %) cases. In two limbs number of branches ranged from 3 to 8 in our study (2.44%) it was getting direct origin from the third which is comparable to the works of Patnaik et al part of the AA, while in four (4.88%) limbs it was

JSZMC Vol.2 No.3 204 Original Article arising indirectly from 2nd part of the AA via the axilla, arm and flap or reconstructive surgeries. It is ACTSCHT. These findings are similar to the suggested that before doing any flap or findings of Lenjek et al28 who have described the reconstructive surgeries, these anomalies must be presence of bilateral CHT from 3rd part and THT evaluated. from 2nd part of AA but have not told about its frequency. Saeed et al 14 have reported the origin of REFERENCES bilateral ACSCHT from the 3rd part and a bilateral 1. Uglietta JP, Kadir S. Arteriographic study of variant arterial nd anatomy of the upper extremities. Cardiovasc Intervent THT arising from the 2 part of AA. Indirect Radiol. 1989; 12: 145-148. origin of the CCHT from AA have been reported 2. Last RJ. Upper limb. In: Sinnatamby CS, editor. Lasts by many authors, as also described in current study anatomy: Regional & applied. 10th ed. Edinburgh: Churchill but no one has reported direct origin of this trunk Livingstone; 1999; 48-50, 337. from the 3rd part of the AA. 3. Standring S, Johnson D, Ellis H, Collins R. Gray's Anatomy. 39 Ed. Churchill Livingstone, London, 2005; 856. People have commonly described six branches of 4. Hollinshead W H. Anatomy for surgeons in AA, but variable number and site of origin of of the upper limb. The back and limbs. New York, A Heber independently arising arterial branches from Harper Book, 1958. 3.290-300. various parts of the AA, found in our study is a 5. De Garis CF, Swartley WB. The axillary artery in White and matter to be discussed. It has been observed in Negro stocks. Am J Anat. 1928; 41:353. 6 .Trottler M, Henderson JL, Gass H, Brua RS, Weisman S, current study that two or more of usual branches Agrecs H, et al. The origins of branches of the axillary artery may arise by a common trunk or branch or in whites and in American Negroes Anat Rec 1930; 46:133. branches of a usually named artery may arise 7. Wollard HH. The development of the principal arterial stems which is in agreement to the study of Hollinshead29 in the forelimb of the pig. Contrib Embryol. 1922; 14:139 in 1958, and De Garis & Swartley, in 1928. TAA 8. Poynter CWM. Congenital anomalies of the arteries and veins of the human body with bibliography. University was absent bilaterally as such but two separate Studies, University of Nebraska. 1920; 22: 1-106. branches like deltoid and acromial, right arm and 9. Huelke DF. Variation in the origins of the branches of the three individual branches like deltoid, acromial axillary artery. Anat Rec . 1959; 35: 33-41. and clavicular, left arm in a male body no 29, were 10. Ciervo A, Kahn M, Pangilinan AJ, Dardik H. Absence of the nd brachial artery: Report of a rare human variation and review arising from the 2 part of AA. In a female of upper extremity arterial anomalies. J Vasc Surg. cadaver, TAA was absent while four independent 2001;33:19 -194. individual branches like deltoid, pectoral, 11. Hollinshead WH. Pectoral region, axilla and shoulder. In: acromial and clavicular were emerging from the Rosse C, Gaddum-Rosse P, editors. Hollinsheads textbook of posterior surface of the 2nd part of AA, while in Anatomy. 5th ed. Philadelphia (USA): Lippincott-Raven. 1997; 212-216. another female cadaver, only two independent 12. De-Fontaine S, Decker G, Goldschmidt D. Anomalous pectoral branches, left arm and three independent blood supply to the serratus anterior muscle flap. Br J Plast branches like deltoid, acromial and pectoral, right Surg. 1994; 47: 505-506. arm came out from lateral side of the 2nd part of 13. Romans G.J. Cunningham's manual of practical anatomy In: AA. Common thoracic trunk (CTT) got origin The upper limb; 15th Edn; Oxford University Press, New st York, Tokyo: 1999. from the 1 part of the AA in one case and divided 14.SaeedM, Amin AR, Salah EE, Muhammad SS. Variations into highest thoracic and lateral thoracic arteries. in the subclavian-axillary arterial system. Saudi Medical The frequency of CTT (from the 1st part of the AA) Journal. 2002; 22 (2): 206-212 was in (1.22%) limb which divided into HT and LT 15. Hamilton WJ, Mossman HW. Cardiovascular system. In: arteries. This finding of our study is in consonance Human embryology. 4th ed. Baltimore: Williams and 30 Wilkins, 1972; 271- 290. with the results of Pan who found LTA with HTA. 16. Moore KL, Persaud TVN. The cardiovascular system. In: The developing human, clinically oriented embryology. 6th ed. Philadelphia (PA):WB CONCLUSION Saunders; 1998; 335-341 Our study report the existence of anomalous 17. Collins P. Embryonic circulation. In: Bannister LH, branching pattern of AA. The knowledge of Berry MM, Collins P, Dyson M, Dussek JE, Ferguson MWJ, editors. Grays Anatomy. 38th ed. Edinburgh (UK): anomalous branching pattern of AA associated Churchill Livingstone; 1995; 318-319. with anomalies of various nerves are of interest to 18. Ramesh Rt, Shetty P, Suresh R. Abnormal branching anatomists for basic learning, to angiographers pattern of the axillary artery and its clinical significance. and radiologists for investigations and to surgeons Int J Morpho. 2008; 26(2):389-392. during surgical exploration of the regions like 19. Saralaya V, Joy T, Madhyastha S, Vadgaonkar R,

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Saralaya s. Abnormal branching of the axillary artery: 2 6 . S w a p n a B i j u r a j , K G o p i n a t h a n a n d K K subscapular common trunk. A case report. Int J Morphol. KrishnammaAIMS,Kochi, Kerala. Variation In The 2008; 26(4):963-966. Origin Of The Axillary Artery Branches Journal of t h e 20. Daniela S, Ana D, Julijana H, Iva T. Bilateral arterial Anatomical Society of India. 2007; 56: 1 and nervous variations in the human upper limb: A case 27.Samuel VijayaPaul, Vollala VenkataRamana, Nayak report Annals of Anatomy - Anatomischer Anzeiger. Satheesha, Rao Mohandas, Bolla Sreenivasa1928., 2007; 189; 3 , 290-294 Pammidi Narendra A rare variation in the branching 21. Patnaik VVG, Kalsey G, Singla K. Branching Pattern of pattern of the axillary artery Indian Journal of Plastic Axillary Artery - A Morphological Study J Anat Soc India. Surgery. 2006; 39: 2: 222-23 2000; 49(2) 127-132 28.Lenjec B, D hem A.Unusual variations of the 22. Syed RD, Abu US, Rajendra N W. Variations in the vasculonervous elements of human axilla. Arch Anat branching pattern of axillary artery with high origin of Histol Embryol. 1989;72:57-67 radial artery. International Journal of Anatomical Variations. 2010; 3; 7677 29. Hollinshead W.H.: Anatomy for surgeons. The back and 23. Durgun B, Yucel AH, Kizilkanat ED, Dere F.. Multiple limbs. In: Pectoral region, axilla and shoulder - The arterial variation of the human upper limb. Surg Radiol axilla Vol.3, Paul B.Hoebar, Inc. Med. Book Deptt. of Anat 2002; 24:125128. Harper & Brothers, 49 East, 33rd Street, New York. 24. Lee JH, Kim DK.. Bilateral variations in the origin and 1958; 16: 290-300 branches of the subscapular artery. Clin Anat. 2008; 30. Pan MT. The origin of branches of the axillary arteries in 21:783785. Chinese. American Journal of Physiology and 25. DeGaris CF, Swartley WB: The axillary artery in White Anthropology. 1940; 27: 269-279. and Negro stocks. Am J Anat. 1928; 4: 353-397,

JSZMC Vol.2 No.3 206 Original Article

INFLUENCE ON VISUAL DEFICIT AFTER TRANSSPHENOIDAL HYPOPHYSECTOMY FOR PITUITARY ADENOMAS

Shahid Ayub11, Mumtaz Ali , Fakhar Hayat1, Muhammad Usman1, Naeem ul Haq1, Muhammad Ishaq, Azam Khan1. ABSTRACT Background: Transsphenoidal surgical exision of pituitary tumor in widely used route. Objective: To determine the effects on visual symptoms after transsphenoidal hypophysectomy for pituitary adenomas. Patients & Methods: This retrospective study was conducted in the department of , Postgraduate Medical Institute, Lady Reading Hospital, Peshawar. All patients from January 2006 to January 2011, who underwent transsphenoidal surgery for pituitary adenomas, were included for visual deterioration. Results: During the five years time a total of 65 patients were operated for transsphenoidal adenomas. Four patients were excluded due to various reasons. There were 44 (72.13%) male and 17 (27.87%) female patients. The age ranged from 31 years to 62 years. The mean age was 44 years. There was improvement in visual symptoms in 39 (63.93%) patients immediately after surgery, 13 (21.31%) patients showed improvement in four weeks time, while there was no improvement in 9 (14.75%) patients. Conclusion: The improvement in visual symptoms occurs in majority of the patients after transsphenoidal hypophysectomy. There are several factors which influence the outcome, like duration and size of the lesion.

Key words: Transsphenoidal Hypophysectomy, PituitaryAdenoma, Visual Outcome. INTRODUCTION pituatry apoplexy) and leads to severe headache, Transsphenoidal route is widely considered for episode of acute blindness or visual deterioration and surgical excision of pituitary tumors which are other endocrinal symptoms like adrenal restricted to intrasellar area and sphenoid sinus or insufficiency. 4 slight suprasellar. It is a safe and effective route Different pituitary tumors with visual symptoms with extremely good outcome and procedure of present in this area, may be secretary (Functional) or choice for removal of intrasellar lesions.1,2,3 non-secretary (non-functioning).2 Growth hormone Mostly the presenting symptoms of these tumors secretary adenomas and prolactinomas are the are visual deterioration, neuroendocrine or raised commonest among the secretary tumors. Surgical intracranial pressure.2 Different visual symptoms treatment is required for most of these for the relief of are known, including deterioration of visual visual symptoms and prevention of further acuity, visual field defects, oculomotor deterioration.4 symptoms.1,3 Visual field defects are quite variable The objective of this study is to determine the ranging from complete blindness and no transsphenoidal surgery outcome in terms of visual perception of light to uniocular or binocular small symptoms improvement and the different factors scotoma, quadrantomas and bitemporal which may influence the visual outcome. hemianopia (very common to these tumors). Vision may be completely normal in small tumors PATIENTS AND METHODS which do not compress the visual apparatus.3 This retrospective study was conducted in the Complete blindness may be in one eye or both, department of neurosurgery, Postgraduate Medical may be acute or chronic. Blindness usually occurs Institute, Lady Reading Hospital, Peshawar. All due to optic nerve atrophy by progressive tumor patients from January 2006 to January 2011, who compression in chronic or delayed cases of underwent endonasal transsphenoidal surgery for blindness, these may be irreversible.5 Sometimes pituitary adenomas, were included for visual there may be sudden bleed inside the tumor (called deterioration. Four out of 65 patients were excluded due to redo transsphenoidal surgery and insufficient 1.Department of Neurosurgery, Postgraduate Medical pre or post operative ophthalmological data. All Institute, Lady Reading Hospital, Peshawar patients with primary ocular disease, previous ocular surgery and systemic disorders other than pituitary Correspondence: Dr. Shahid Ayub, Assistant Professor, Department of Neurosurgery PGMI adenoma that could affect visual function were Govt Lady Reading Hospital excluded. Peshawar KPK Pakistan Patient's record was addressed retrospectively and data regarding age, sex, visual symptoms, detailed Email: [email protected] visual assessment by ophthalmologist (perimetery, visual acuity, fundoscopy) other presenting

207 JSZMC Vol.2 No.3 Original Article symptoms, pituitary hormonal assays, duration of had no improvement. Whereas, 8 (13.11%) patients symptoms, CT/MR findings was collected. Visual and 15 eyes out of 122, presented with visual acuity acuity was measured during post operative between 6/24 and 6/60, 3 improved to normal and 5 hospital stay and follow up after 10 days and 3, 6, had partial improvement, 13.11% total improvement. and 12 months. Goldman perimetery, Snellen While 8 (13.11%) patients and 12 eyes of 122, chart, ophthalmoscopic fundoscopy and slit lamp presented with visual acuity from 6/60 and counting examination techniques was used for this purpose. finger (CF). Out of these, 3 patients had improved to Data analysis was performed through SPSS normal and 4 had partial improvement, total 11.47% version 10.0. Frequencies and percentages were had total improvement. A total of 5 patients computed for categorical variables like age, sex, presented between CF and hand movement (HM) MRI CT findings, preoperative findings, visual and had 4.91% improvement in visual acuity. Total 5 preoperative and postoperative findings and patients presented with no perception of light and improvement, and endocrinal assays. complete blindness, 2 (3.27%) of these had partial improvement over time. Thus there was total or RESULTS partial improvement in 52 (85.24%) patients in term A total of 61 patients, operated (Endonasal of visual acuity as shown in detail in table I. transsphenoidal surgery) for pituitary adenoma 33 (54.09%) out of the total 61 patients had during 5 years duration between January 2006 and bitemporal hemianopia, 10 (16.39%) had single January 2011 were included in this study. There quadrantopia in temporal fields, 7 (11.47%) had two were 44 male and 17 female patients. Male to quadrants temporal field defects and the same female ratio was 2.58:1. The ages ranged from 31 number had three quadrants visual field defects, to 62 years. 31 (50.08%) were in 3rd decade of their while 4 (6.55%) were totally blind. Visual field life. 18 (29.50%) in 4th, and 12 (19.67%) in 5th improved in 74% of cases with different pattern of decade of age. Only one patient was older than 60 defects. 64% improved partially while 10% had years. Redo transsphenoidal surgery was complete improvement, and 26% had no performed in 3 cases. Sellar packing was done in improvement in visual field as shown in table II. One 10 cases with fat ball taken from anterior blind patient had partial improvement in his field of abdominal wall to prevent CSF leak. Radical or vision. gross total resection was done in 45 (73.77) cases, Fundoscopy done pre operatively showed normal CSF diversion with VP shunt was required in 3 optic discs in 48 patients, papilledema in 4 patients cases. with pending hydrocephalus, and optic atrophy in 9 The main presenting symptoms were progressive patients. Those patients with neuroendocrine visual decline, endocrine dysfunctions and abnormality presented with complaints like weight symptoms of raised intracranial pressure. All of loss, stunned growth, hypothyroidism, Diabetes the 61 patients had visual decline variably. 35 of insipidus in 8 (13.11%) patients. Headache was these patients were referred from different present in 47 (77.04%) patients. units, 23 admitted through OPD, 3 33 (54.09%) of the tumors were non secretary. admitted through emergency with symptoms of Others were having increased amount of various severe headache and vomiting and sudden visual hormones secretion, Prolactin 18 (29.50%), Growth loss, diagnosed as pituitary apoplexy. Visual hormone 6 (9.83%), Corticotroph secreting acuity was measured by Snellen chart and post adenomas 3 (4.91%), and TSH secreting adenoma 1 operative visual acuity was noted after 2 days, (1.63%). and follow up 10 days, 6 months and 12 months in Factors affecting the visual outcome observed in our OPD and private clinics. 25 (40.98%) patients out study included age, sex, duration of visual decline, of 61, and 55 eyes out of 122, presented with duration of blindness, presence of hypothalamic visual acuity between 6/6 and 6/12, out of these symptoms, pituitary apoplexy, imaging 17 (27.86%) had partial improvement, 7 improved characteristics of sellar/suprasellar/parasellar to normal and one had no improvement. 10 extensions, operative findings regarding consistency (16.39%) patients and 25 eyes out of 122, of tumor, necrosis, hemorrhage in the tumor, extent presented with visual acuity between 6/12 and of surgical resection of the tumor, and 6/24. 8 (13.11%) had partial improvement and 2 histopathological results of the biopsy.

JSZMC Vol.2 No.3 208 Original Article

Younger age, male sex, short duration of nerves, CSF pathway and so on. Optic chiasma and s y m p t o m s , s m a l l t u m o r s w i t h o u t optic nerves and optic tract are in close proximity of suprasellar/parasellar extensions, pituitary the sella turcica and these tumors.2,3 Nasal fibers of apoplexy and hemorrhage findings during the optic nerves cross in the optic chiasma and join operation were some favorable variables noted in the temporal fibers of the opposite side to form the our study for better outcome and improvement of optic tract. Compression of the optic chiasma is visual defects. common and leads to bitemporal visual field defects/ hemianopia. Because of the irregular and variable Table: I growth of the tumors the visual compromise and Effects on visual acuity of transsphenoidal deficit is usually asymmetrical in both eyes. surgery Pituitary tumors present with progressive visual deficits as the tumor enlarges. Usually it causes Visual Eyes Improved Partial No Total Patien ts Acuity effected to normal improvement improvement improvemen t visual field defects, identified by different methods 6/6- 25 55 (45.08%) 7 17 1 24 (39.34%) 6/12 of perimetery. Commonly the temporal fields are 6/12- 10 25 (20.49%) 0 8 2 8 (13.11%) affected symmetrical or asymmetrically. It may also 6/24 6/24- 8 15 (12.29%) 3 5 0 8 (13.11%) cause color vision abnormality, diplopia, 6/60 rd th 6/60- ophthalmoplegia and 3 or 6 nerves palsies. Visual 8 12 (9.83%) 3 4 1 7 (11.47%) CF fields defect has been reported in up to 90% of the CF- HM 5 7 (5.73%) 0 3 2 3 (4.91%) patients before 1970.10 In most of the patients the NPL 5 8 (6.55%) 0 2 3 2 (3.27%) visual field defects are the presenting symptom. Total 61 122 (100%) 13 39 9 52 (85.24%) Optic atrophy is commonly found in chronic cases with chiasmal compression. This happens due to Table: II secondary retrograde degeneration of axons.2,3 It was Effects on visual field after transsphenoidal present in about 13% of patients in this group with surgery prolonged symptoms and visual acuity up to no

Visual No of Improved Partial No perception of light (PL) and hand movements (HM). %age field eyes to norma l improvemen t improvemen t This is the group of patients which will have poor BTH 33 54.09% 3 28 2 visual outcome depending upon the duration of onset Upper quadrant 10 16.39% 2 5 3 of visual field defects. The visual outcome after TFD Two transsphenoidal surgery is excellent. Even severe quadrant 7 11.47% 0 2 5 TFD visual defects due to optic apparatus compression Three 11,12 7 11.47% 1 3 3 quadrants can improve completely or partially. 70% of the

Blind 4 6.55% 0 1 3 severely affected eyes in our study had good visual

Total 61 100% 6 (9.83%) 39 (63.93%) 16 (26.22%) outcome, two of them were totally blind for a period of two to ten days. This is in comparison to the previous reports- 71% 13, 75% 14, and 79%.15 We had DISCUSSION improvement in majority of affected eyes (82%) Pituitary adenomas are frequently been treated by which is quite similar to the previous literature. Other transsphenoidal endonasal route.2,3,6 Gross total or larger surgical series employing the transsphenoidal near total resection of the lesion is the goal of approach, have reported post operative improvement surgery. There can be secondary visual in 74-95% of patients.16,17,18,19 deterioration after transsphenoidal surgery in rare Ocular motor palsies prevalence with pituitary occasion.7,8 But this rate must be less than 2% as adenoma ranges from 1% to 14% 20, it was present in compared to the 70-80% visual improvement over 5% of our patients and 3rd cranial nerve involvement variable duration of time.9 is most common.21 Hollenhorst and Younge reviewed Pituitary adenomas are benign slow growing 1000 cases of pituitary adenoma and found 59 (5.9%) tumors which arise from the anterior pituitary with cranial nerves palsies.16 Sixth nerve palsy can cells. They may be secretary or non secretary.2 be involved either because of direct tumor extension They can present with systemic endocrine and compression or because of raised ICP and symptoms or local compression of different obstructive hydrocephalus by significant large adjacent structures like visual apparatus, cranial tumors.22

209 JSZMC Vol.2 No.3 Original Article

CONCLUSION 1987. J Clin Neuroophthalmol. 1991;11:262-267. 9. Peter M, De Tribolet N. Visual outcome after A large number of patients with pituitary adenoma transsphenoidal surgery for adenomas. Br J Neurosurg and visual defects improved after transsphenoidal 1995;9:151-157. surgical procedure, showing that visual defects are 10. Anderson D, Faber P, Marcovitz S, Hardy J, Lorenzetti D. not irreversible. Visual improvement was Pituitary tumor ophthalmologist. Ophthalmology. observed in about 80% of the cases. There was 1983;90:1265-1270. 11. Agrawal D, Mahapatra AK. Visual outcome of blind eyes significant improvement in 40% of cases. in pituitary apoplexy transsphenoidal surgery: a series of Younger age, male sex, short duration of 14 eyes Surg Neurol. 2005;63:42-46. symptoms, small tumors without suprasellar/ 12. Powell M. Recovery of vision following trans-sphenoidal parasellar extensions, pituitary apoplexy and surgery for pituitary J Neurosurg.. 1995;9:367-373. hemorrhage findings during operation are good 13. Turner H E, Adams CB, Wass JA. Pituitary tumours in the elderly Eur J Endocrinol. 1999;140:383-389. prognostic factors for visual defects by these 14. Comtois R, Beauregard H, Somma M, Serri O, Aris-Jilwan tumors. N, Hardy J. The endocrine outcome to trans-sphenoidal Excellent visual improvement can be achieved in microsurgery of nonsecreting pituitary. Cancer. severely affected eyes with early intervention. 1991;68:860-866. Hence awareness regarding the reversibility of 15. Black PM, Zervas NT, Candia G. Management of large pituitary adenomas transsphenoidal surgery. Surgical vision in pituitary adenoma needs to be increased . 1988;29:443-447. among the ophthalmologists and medical 16. Hollenhorst RW, Younge BR. Ocular manifestations community so that early referral is made possible. produced by adenomas gland: analysis of 1000 cases. In: Kohler PO, Ross GT, editors. Diagnosis and pituitary tumours. Amsterdam: Excerpta Medica, 1973:53. REFERENCES International Congress. 303. 17. Laws ER, Trautmann JC, Hollenhorst RW. Trans- 1. Yoshifumi Okamoto, Fumiki Okamoto, Shozo Yamada, sphenoidal decompression nerve and chiasm. J Neurosurg. Maiko Honda,Takahiro Hiraoka, and Tetsuro 1977;46:717-22. Oshika;Vision-Related Quality of Life after 18. Mortini P, Losa M, Barzaghi R, Boari N, Giovanelli M. Transsphenoidal Surgery for Pituitary Adenoma IOVS Results of transsphenoidal a large series of patients with July 2010 51:3405-3410; pituitary adenoma. Neurosurgery. 2005;56:1222-1233. 2. Ashish Suri, Karanjit Singh Narang, Bhawani Shankar 19. Peter M, De Tribolet N. Visual outcome after Sharma, and Ashok Kumar Mahapatra;Visual outcome transsphenoidal surgery for adenomas. Br J Neurosurg. after surgery in patients with suprasellar tumors and 1995;9:151-157. preoperative blindness J Neurosurg. 108:19-25,2008. 20. Petermann SH, Newman NJ. Pituitary macroadenoma 3. Essam A. Elgamal, Essam A. Osman, Sherif M.F. El- manifesting as an nerve palsy. Am J Ophthalmol. Watidy, Zain B. Jamjoom, Nuha Al-Khawajah, Noha 1999;127:235-236. Jastaniyah, Molhem Al-Rayess: Pituitary Adenomas: 21. Wray SH. Neuro-ophthalmic manifestations of pituitary Visual Presentation And Outcome After and parasellar lesions. Neurosurg. 1976;24:86 -117. Transsphenoidal Surgery - An Institutional expense. 22. Levy A. Pituitary disease: Presentation, Diagnosis, and The Internet Journal of Ophthalmology and Visual management. Neurosurg . 2004;75 Suppl:47-52. Science. 2007. 4. Naoya Takeda, Katsuzo Fujita, Shigenori Katayama, Nobuyuki Akutu, Shigeto Hayashi and Eiji Kohmura; Effect of transsphenoidal surgery on decreased visual acuity caused by pituitary apoplexy, Medicine. 2007;13/2:154-9. 5. Jallu A, Kanaan I, Rahm B, Siqueira E: Suprasellar meningioma and blindness: a unique experience in Saudi Arabia. Surg Neurol. 45:320323, 1996. 6. G. Blaauw, R. Braakman, M. Cuhadar, L. J. Hoeve, S. W. J. Lamberts, R. M. L. Poublon, Influence of transsphenoidal hypophysectomy on visual deficit due to a pituitary tumor. Acta Neurochir. (Wien) 1986 83:79-82. 7. Cohen AR, Cooper PR, Kupersmith MJ, Flamm ES, Ransohoff J. Visual recovery transsphenoidal removal of pituitary adenomas. Neurosurgery 1985;17:446-452. 8. Sullivan LJ, O'Day J, McNeill P. Visual outcomes of pituitary adenoma surgery. Vincent's Hospital 1968-

JSZMC Vol.2 No.3 210 Student Corner (Original Article)

FREQUENCY OF MAJOR RISK FACTORS FOR CORONARY HEART DISEASE IN PATIENTS OF SOUTHERN PUNJAB M Siddique Khan Qadri11, Tehseen Iqbal , Haroon Aziz Khan Babar2, Zafar Hussain Tanveer3, Aftab Ahmad3 ABSTRACT

Background: Coronary Heart Disease (CHD) in most common form of heart diseases and premature deaths. Objective: To determine the risk factors of coronary heart disease (CHD) in patients from Southern Punjab. Subjects & Methods: This retrospective study was carried out in the Community Medicine Department, Nishtar Medical College, Multan in collaboration with the CPE Institute of , Multan and Cardiology Ward, Nishtar Hospital, Multan. All patients presenting with acute coronary heart disease, from September to November, 2009, were included in this study. The diagnosis was made by a Cardiologist. Patients were interviewed for the presence or absence of Conventional Risk Factors for CHD. The risk factors studied were gender, smoking, hypertension, positive family history, diabetes mellitus, obesity, dyslipidemia, anxiety and depression. All information was entered into a pre designed proforma. Data was analyzed in SPSS version 10. Results: Among patients of CHD, 70% were males and 30% were females. Smoking habit was seen in about half of the patients (49.50%). Hypertension was present in 45%, positive family history in 32%, diabetes mellitus in 29.50% of patients 26% were obese, 23% have dyslipidemia while 15% reported to have anxiety and depression. Conclusion: We conclude that after male gender, smoking habit was the most prevalent risk factor seen in our study population. Other risk factors found, in the descending order, were hypertension, positive family history, diabetes mellitus, obesity, dyslipidemia, and anxiety and depression. Our study demonstrates the importance of modifiable risk factors which may be targetted in designing the preventive strategies for CHD.

Key Words: Coronary Heart Disease, Risk factors, Preventive measures. INTRODUCTION Coronary Heart Disease is most commonly due to Coronary Heart Disease is the most common form obstruction of the coronary arteries by atheromatous of heart diseases and the single most important plaque.4 Coronary Heart Disease is an atherosclerotic cause of premature death in Europe, the Baltic disease that is multi-factorial in origin, giving rise to States, Russia, North and South America, the concept of risk factors. Certain living habits Australia and New Zealand. By 2020, it is promote atherogenic traits in genetically susceptible estimated that it will be the major cause of death in persons. A number of risk factors are known to all regions of the world. In the United Kingdom 1 predispose to the condition. Some of these, such as in 3 men, and 1 in 4 women die from Coronary age, gender, race and family history can not be Heart Disease (CHD) and an estimated 33000 changed, whereas other major risk factors such as people have a myocardial infarct each year and serum cholesterol, smoking habits, Diabetes approximately 1.3 million people have Angina.1 Mellitus and hypertension can be changed.5 Previously considered a disease of the affluent and Since 1960, when the Framingham Heart Study first developed countries; CHD is now emerging as identified smoking, hypercholesterolemia and epidemic in the developing world in general and hypertension as risk factors for CHD,6 various South Asia in particular.2 In South Asian studies all over the world have validated the results of immigrants to United States, their longevity of the historical Framingham Study.7 Modifiable residence increases their risk many fold to develop behavioral risk factors (smoking, obesity, lipid CHD with a higher fatality rate compared to local disorders, Diabetes Mellitus and hypertension) lead reference population. Total variability in CHD risk to cardiovascular diseases that are leading causes of in South Asia has not been explained by traditional mortality. The prevalence of modifiable risk factors risk factors, indicating the presence of other for CHD such as tobacco use, inappropriate diet and important, yet unidentified risk factors.3 physical inactivity, are responsible for significant morbidity and mortality.8 There is evidence to 1. Nishtar Medical College, Multan. suggest that the control of cardiovascular risk 2. CPE Institute of Cardiology, Multan factors, particularly smoking, has resulted in a 3. Sheikh Zayed Medical College/Hospital, 9 Rahim Yar Khan decline in mortality due to CHD. Unfortunately in most countries, the response to CHD prevention and control is still based on the Correspondence: Muhammad Siddique Khan Qadri infectious disease paradigm. Consequently the Nishtar Medical College, Multan global and national capacity to respond to CHD

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Student Corner (Original Article) epidemic is woefully inadequate. The gap between Table I: Major Risk Factors for Coronary Heart the need for CHD prevention, control and capacity Disease seen in the Study Population to meet them will go even wider unless urgent 10 steps are taken. The objective of prevention is to Sr. Risk Factor % age reduce incidence of first or recurrent clinical event No due to CHD, Ischemic strokes and peripheral 1 Gender: 11 artery disease. In Pakistan, the National Action Males (n=140) 70% Plan for Non-Communicable Disease Prevention Females(n=60) 30% (NAPNCD) incorporates prevention and control of CVD as part of a comprehensive and integrated 2 Smoking (n=99) 49.50% 12 3 Hypertension (n=90) 45% non communicable diseases prevention effort. 4 Positive Family History 32% This study was planned to determine the risk (n=64) factors of coronary heart disease (CHD) in patients from southern Punjab. 5 Diabetes Mellitu s (n=59) 29.50% 6 Obesity (n=52) 26% PATIENTS AND METHODS 7 Dyslipidemia (n=46) 23% This descriptive study was carried out in the 8 Anxiety and Depression 15% Department of Community Medicine in (n=30) collaboration with the Cardiology Department, Nishtar Hospital Multan and CPE Institute of Cardiology Multan. This is important to mention DISCUSSION that patients were selected from the Tertiary Care This is documented that in the etiology of Coronary Health Facilities which cater mainly patients from Heart Disease some factors are modifiable risk Southern Punjab. The patients of Southern Punjab factors, while others are non-modifiable. Among the i.e., Multan, Bahawalpur, D.G. Khan and Rahim non-modifiable risk factors are the age, gender and Yar Khan were included in the study, and the genetics. Among modifiable risk factors are the patients of other provinces were excluded. A total factors which can be modified by life style such as of 200 consecutive patients with CHD admitted smoking, obesity, physical inactivity and anxiety and during September- November 2009, were selected depression. Some modifiable risk factors can be for this study. After taking informed verbal modified by pharmacotherapy and/or the life style consent patients were interviewed to collect changes. These are hypertension, diabetes mellitus information regarding their health profile and and lipid disorders.13 We found that there is a personal and family history. All the data were predisposition of male gender among patients of entered into a pre-tested questionnaire. Data was CHD (Male: Female ratio = 70:30). Many studies entered & analyzed to get frequencies of different from different areas of Pakistan showed the same risk factors among the study population. results.14,15,16 The second most important risk factor for CHD found in our study was smoking (49.5%). RESULTS Studies from Faisalabad, Lahore and Islamabad14,15,16 Important findings of the study are shown in table showed the similar results. Hypertension and I. In the study population of 200 patients, majority dyslipidemia were shown to be other risk factors for of patients were males (70%) and female patients CHD in our study like other studies from this area.17,18 were only 30%. After gender predisposition to There was a positive family history in our 32% males, smoking was found to be the greatest risk patients of CHD. About 30% patients were Diabetic, factor. Among patients of CHD, 99 (49.5%) were 26% were obese and 15% reported to have anxiety smokers. Hypertension was seen among 90 (45%) and depression. These findings are similar with the patients. Among 64 (32%) there was a positive findings of some other studies.18 Coronary Heart family history, 59 (29.5%) were having diabetes Disease is primarily a disease of the masses. The mellitus, 52 (26%) were obese, 46 (23%) were strategy should therefore be based on mass approach having dyslipidemia and 30 (15%) patients focusing mainly on the control of underlying causes reported anxiety and depression. i.e. Risk Factors, in the whole population, not merely in individuals. This approach is based on the

JSZMC Vol.2 No.3 212 Student Corner (Original Article) principle that small changes in risk factors level in Circulation 1998; 97; 596 601 total population can achieve the biggest reduction 3. Mooteri SN, Peterson F. Dagubati R, Pai RG. Duration of residence in the United States as a new risk factor for in mortality. The population strategy centers on coronary artery disease (The Konkani Heart Study). Am the following areas. Dietary modification is the J Cardiol 2004; 93; 359 61 principle preventive strategy in the prevention of 4. Maseri A: Ischemic Heart Disease. In: A Rational basis CHD. Our study has also shown that many for clinical Practice and Clinical Research. New York patients have risk factors based on dietary habits Churchill Livingstone 1995 5. Kumar PJ, Clark DM. Ischemic Heart Disease. In: such as 29% have DM, 26% have obesity and 23% Clinical Medicine 6th Edition, Elsevier Saunders, have dyslipidemia. As far as CHD is concerned, London 2005. 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In: The National important to encourage children to take up Action Plan for the prevention & control of non Communicable diseases and health promotion in physical activities that they can continue Pakistan. J Pak. Med Assoc, 2004; 54 (12 Supp3):14 25 throughout their lives. 26% of the patients had 13. Haslett C, Chilvers ER, Boon NA. Davidson's obesity in our study. Secondary prevention must Principles and Practice of Medicine. 19th edition, be seen as a continuation of a primary prevention. Elsevier Saunders, New Dehli 2004; P. 422 It forms an important part of an overall strategy. 14. Chaudhary AH, Muhammad D, Sharif MA, Ahmad N. Study of various risk factors in patient s with ischemic The aim of secondary prevention is to prevent the heart disease. Professional Med J April-June 1996; recurrence and progression of CHD. Secondary 3(2):151-9 prevention is a rapidly expanding field with much 15. Ahmed N, Mirza T, Malik N. 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