ISSN (2312-9433) J Gandhara Med Dent Sci ISSNe (2618-1452) March-September 2019 Vol. 05 No. 02
JOURNAL OF GANDHARA MEDICAL AND DENTAL SCIENCES JGMDS
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www.jgmds.org.pk ISSN (2312-9433) J Gandhara Med Dent Sci ISSNe (2618-1452) March-September 2019 Vol. 05 No. 02
JOURNAL OF GANDHARA MEDICAL AND DENTAL SCIENCES JGMDS
BIANNUAL
www.jgmds.org.pk
JGMDS
ISSN (2312-9433) J Gandhara Med Dent Sci ISSNe (2618-1452) March-September 2019 Vol. 05, No. 02
biannual
JGMDS
J Gandhara Med Dent Sci ISSN (2312-9433) March-September 2019 ISSNe (2618-1452) Vol. 05, No. 02 www.jgmds.org.pk
JOURNAL OF GANDHARA MEDICAL AND DENTAL SCIENCES
Roeeda Kabir Ejaz Hassan Khan
Zafar Hayat
Sofia Shehzad
Shafaq Naz Um-E-Laila Syed Imran Ali Shah Gilani Sofia Haider Durrani
Aneela Ambareen Rifaqat Ullah Syed Nasir Shah Tahir Ali Khan Shakeel ur Rehman Sofia Haider Durrani Arif Ullah Imran Gillani Muhammad Ali Chughtai Muhammad Ilyas Syed Murad Ali Shah
Qiam-ud-Din Azhar Zahir Shah Ejaz Hassan Farhan S. Imran (Int.) Shehzad Akber Khan Sajad Ahmad (Int.) Riaz Gul (Late) Zainab Kabir Arshad Muneer Noor Durrani Malik Naqi (Int.) Jibran Umar Ayub
Hamid Hussain Sher Bahadur JGMDS
ISSN (2312-9433) J Gandhara Med Dent Sci ISSNe (2618-1452) March-September2021 Vol. 05, No. 02 www.jgmds.org.pk CONTENTS
EDITORIAL
Tobacco Cessation: Do Smokers Need Professional Help to Quit? Baber Ahad 1-2
ORIGINAL ARTICLES
Correlation Between the Maturation Stages of Mandibular Third Molars Muhammad Ilyas 3-7 and Chronological Age in Patients Visiting Sardar Begum Dental Asma Khan College, Peshawar. Syed Murad Ali Shah Salman Khan Junaid Nadeem Malik
Community Pharmacy Practices in Timergara City Dir, Khyber Siraj Ul Haq Ayaz Ayub M. 8-15 Pakhtunkhwa, Pakistan. Hamayun Khan Hamid Hussain
Medicolegal Significance of Torture Under Police Custody on Prisoners’ Sayed M. Yadain 16-20 Health and Recommendations for Prevention of Violence Against Aftab Alam Tanoli Torture. Riffat Masood Shagufta Shafi Rizwan Zafar Ansari Zahid Hussain Khalil Qurat Ul Ain Aftab
Correlation Between Glycosylated Haemoglobin and Thyroid Function Ayesha Qaisar 21-26 Tests in Patients With Type-2 Diabetes Mellitus Riffat Sultana Jibran Umar Ayub Khan
Prevalence of Refractive Errors Among the Children of Special Bismah Saleem 27-31 Education Complex, Peshawar. Naeem Ullah Hamid Hussain Ayaz Ayub M. Hamayun Khan
INSTRUCTIONS TO AUTHORS
AUTHOR AGREEMENT
EDITORIAL JGMDS
TOBACCO CESSATION: DO SMOKERS NEED PROFESSIONAL HELP TO QUIT?
Baber Ahad Department of Community Dentistry Sardar Begum Dental College, Peshawar
Tobacco use is considered a risk factor for 6 of the 8 leading causes of death worldwide and is known to cause diseases affecting the heart and lungs1. Tobacco has a definite role in the etiology of a number of dental morbidities, and is an established risk factor for Oral Cancer and periodontitis. World health organization reported more than a billion smokers worldwide. The number of smokers is increasing and a shift of increased number of smokers in developing world is noticed. Tobacco is a big killer as more than 10% of adult deaths annually, from all causes are attributed to it. Moreover, tobacco kills almost five and a half million annually and on the average 10 persons per minute2. Considering gravity of the situation, a global and local tobacco control strategy becomes very important. The Government of Pakistan has increased taxes on tobacco products, banned its use in public places to discourage its use. This strategy would help reduce the number of tobacco products used by individuals. But what’s missing is to focus on regular smokers, and assess whether they need professional help to quit tobacco. Most of the smokers find it difficult to quit on their own, while some successful quitters consider motivation, will power and commitment important factors. How can a regular smoker be motivated is still not clear and needs more research3. The self-quit proportion for regular smokers is 3-5%4, which is quite low and most of the tobacco users find it difficult to quit, even after feeling the effects after years of smoking. The reason could be addiction to daily dose of nicotine to the brain. A good number of smokers want to quit at some time, but it is also noted that only a limited number of theses smokers have ever tried5. The clinical practice guidelines for treatment of Tobacco use and dependence, recommends the use “Five A’s” for tobacco cessation6. The first step of this smoking cessation protocol is to “ASK” an individual about current smoking status and any previous attempt to quit smoking. The next step is to “ADVISE”, through a clear and strong personalized message and help identify a quitting date. This is followed by “ASSESS”, whether the smoker is ready to quit. This is followed by the step “ASSIST”, in which literature is provided to help the smoker understand the benefits of quitting. The last step is called “ARRANGE”, which means arranging a follow up visit, usually after 1 to 2 weeks of quitting date. Health professionals are considered as a credible source of information. Family physicians can play a very important part in helping their patients who are regular smokers. By bringing “Five A’s” model into practice, a physician can give a better opportunity to a smoker to understand the health hazards of tobacco use, and know the benefits of quitting periodically. This can lead to a higher percentage of successful tobacco quitters. Other healthcare professionals, who can play an important role in helping smokers quit, are the dental professionals. A patient would spend more time in a dental office and routine dental advice should also include quit tobacco, along with oral hygiene instructions and dietary advice. Dental associations should encourage their members to advise patients about oral and systemic hazards of tobacco products.
REFERENCES: 1. World Health Organization. WHO report on the global tobacco epidemic, 2017: monitoring tobacco use and prevention policies [Internet]. Geneva: World Health Organization; 2017 [cited 2019 Feb 25]. 135 p. Available from: https://apps.who.int/iris/bitstream/handle/10665/255874/9789241512824-eng.pdf?sequence=1 2. World Health Organization. Tobacco facts [Internet]. Geneva: World Health Organization; 2009 [cited 2019 Feb 25]. Available from: http://.who.int//tobacco/mpower/tobacco_facts. 3. Smith AL, Carter SM, Dunlop SM, Freeman B, Chapman S. The views and experiences of smokers who quit smoking unassisted: a systematic review of the qualitative evidence. PLoS One. 2015;10(5):e0127144. doi: 10.1371/ journal.pone.0127144.
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EDITORIAL
4. Anderson JE, Jorenby DE, Scott WJ, Fiore MC. Treating tobacco use and dependence: an evidence-based clinical practice guideline for tobacco cessation. Chest. 2002;121(3):932-41. 5. Jiménez-Ruiz CA, Masa F, Miravitlles M, Gabriel R, Viejo JL, Villasante C, et al. Smoking characteristics: differences in attitudes and dependence between healthy smokers and smokers with COPD. Chest. 2001;119(5):1365-70. 6. Fiore MC, Bailey WC, Cohen SJ, Dorfman SF, Goldstein MG, Gritz ER, et al. Treating tobacco use and dependence: clinical practice guideline. Rockville (MD): U.S. Department of Health and Human Services; 2000.
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JGMDS
CORRELATION BETWEEN THE MATURATION STAGES OF MANDIBULAR THIRD MOLARS AND CHRONOLOGICAL AGE IN PATIENTS VISITING SARDAR BEGUM DENTAL COLLEGE, PESHAWAR
Muhammad Ilyas1, Asma Khan1, Syed Murad Ali Shah1, Salman Khan1, Junaid Nadeem Malik1, 1. Sardar Begum Dental College Peshawar
ABSTRACT: OBJECTIVES: The objective of this study was to determine the correlation of chronological age with the maturation stages of mandibular third molar.
METHODOLOGY: This descriptive, cross-sectional study was conducted at Sardar Begum Dental College, Gandhara University Peshawar on 384 patients from January 2018 to June 2018 and included patients having age 11-26 years with good quality Orthopantomogram showing mandibular third molar tooth germs bilaterally. Data were analyzed using SPSS version 22 p-value ≤ 0.05 was considered as statistically significant.
RESULTS: Females 286 (74.5%) were predominant than males 98 (25.5%) with mean age presentation of 18.12±3.03 years. The most frequent stage of Demirjian’s stages of mandibular third molar was stage F (24.7%). Pearson correlation showed that maturation stages of mandibular third molars were significantly related to the chronological age (r=0.446, p value=0.00).
CONCLUSION: A correlation between maturation stages of mandibular third molars and chronological age existed.
KEYWORDS: Age Estimation, Dental Age, Forensic Medicine, Tooth Development, Mandibular Third Molars
epiphysis-diaphysis fusion of long bones, medial INTRODUCTION: extremity of the clavicle, epiphyseal head of the Forensic age estimation is used to facilitate the first rib, anterior iliac crest at the epiphyseal authorities in detecting unidentified victims, union and fusion of the sphenoid bone with differentiation of cluster victims, establishing the basilar part of the occipital bone. However, the age of the drawback of bone maturation method is that Correspondence dead, these processes are completed roughly around Muhammad Ilyas deciding the age of eighteen years which is quite early as Department of Oral and Maxillofacial Surgery entitlement compared to the third molar development and Sardar Begum Dental College, for social maturation, which continues until the early Peshawar Email: twenties3,5. Therefore, stages of calcification of [email protected] benefits Phone: 0302-8809637 and third molar is one of the tools that can be used 3,6,7 https://doi.org/10.37762/jgmds.5-2.79 helping the as predictor of the chronological age . immigration authorities in dealing out A variety of classifications mainly based on undocumented refugees1,2. A number of methods numerical values and grading systems have are used to determine the chronological age of 3 been put forward by different authors but they children and adults . These methods are mainly were difficult to distinguish from one another2,8,9. divided into two main groups: (a) bone 10 Demirjian et al. proposed a classification that maturation and (b) tooth development4. involves, identifying only four stages for The bone maturation method is primarily based development of crown (stages A-D) and four root on radiographs of specific structures such as developmental stages (E-H) thus avoids numeric
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JGMDS identification of stages and minimizing the N=Z2(P) {1-P}/d2 possibility of suggesting more than one stage Z=Z statistic for level of confidence (95%)=1.96, representing the processes of the same duration. P=Prevalence / frequency, D = Precision=5%,
Third molars have large variation in the P is taken 50% as the population statistic could development, calcification and eruption timings. not be found. This study included patients having Calcification of third molar starts at about seven age 11-26 years with good quality years, formation of enamel ranges from 12-18 Orthopantomogram showing mandibular third years and completion of root formation between molar tooth germs bilaterally. Hypodontia / 18-25 years. Development and eruption of oligodontia / amelogenesis imperfecta / mandibular third molar varies with the ethnicity of dentinogenesis imperfecta, history of trauma / fracture in third molar region and patients with individuals. In Western countries, eruption of any systemic disease were excluded from this third molars range 17 to 21 years, in Africans 15 study. After the approval of Ethical Review to 19 years and in Asian 21.49 to 23.34 years of Committee of Gandhara University, a well- ages8,11. However, there is scarcity of research in documented proforma was used in which Pakistan in which correlation of the maturation patient’s bio-data and informed consent was stages of mandibular third molar with the taken. OPG radiograph was examined over the chronological age was demonstrated. Therefore, radiograph illuminator and stage of maturation of mandibular third molar tooth germ was a research may require correlating maturation determined and charted down on a proforma. stages of mandibular third molar with The stages of maturation according to chronological age that will help in the Demirjian's method10 is given in Figure 1. Data assessment of age in our population for were analyzed using SPSS version 22. forensics and medico-legal purposes. The aim of Descriptive statistics were applied for gender, this study was to determine the correlation of the age and Demirjian's stages. Pearson correlation was used for the correlation between the maturation stages of mandibular third molar with chronological age and stages of maturation of the chronological age. mandibular third molars. The level of significance METHODOLOGY: was kept at p ≤5. 0.05. A descriptive cross-sectional study was carried RESULTS: out in the Department of Orthodontics, Sardar The mean age presentation was 18.12±3.03 Begum Dental College and Hospital, Peshawar years. Out of total of 384 patients, 286 (74.5%) from January 2018 to June 2018. A total of 384 were females and 98 (25.5%) were males with patients were selected through convenience ratio of 2.9:1. The percentage of Demirjian's sampling technique using WHO formula for stages of mandibular third molar development is sample selection.
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JGMDS shown in figure 2 while frequency is given in of third molar and chronologic age (r=0.446) Table 1. The Pearson correlation showed that which were statistically significant (p value= there was correlation between Demirijian’s stage 0.00).
Table 1: Frequency of Demirjian’s Stages of Mandibular Third Molar Stratified by Age
Demirjian's Stage of Mandibular Third Molar Age Total A B C D E F G H 11.00 0 0 4 0 0 0 0 0 4 13.00 0 0 0 0 0 4 0 0 4 14.00 0 0 0 0 0 4 0 0 4 15.00 0 12 19 16 0 11 4 0 62 16.00 3 4 25 32 12 8 0 0 84 17.00 0 3 8 12 8 12 0 0 43 18.00 0 0 0 11 7 7 0 3 28 19.00 0 0 8 7 0 16 3 8 42 20.00 0 0 0 3 0 8 0 0 11 21.00 0 4 0 0 6 10 3 16 39 22.00 0 0 0 7 0 11 7 0 25 23.00 0 0 0 0 0 4 11 0 15 24.00 0 0 4 0 4 0 4 0 12 25.00 0 0 0 4 4 0 0 0 8 26.00 0 0 0 0 0 0 3 0 3 Total 3 23 68 92 41 95 35 27 384
DISCUSSION: sample age range was limited to a younger age In the current study the age range was set at 11 less than 24 years. Thus, they suggested that to 26 years in order to do full estimation of each the upper age limit for population samples in mineralization stage. Ajmal et al12, conducted a future studies should not be greater than 22 14 study in which age estimation using third molar years. According to Robetti et al at 18 years of teeth on Southern Saudi population was used. age, all permanent teeth have completed their They took age range of 13 to 23 years in their root formation with closed apices, except the study which is consistent with this study. Solari third molars. Third molar teeth offer the only and Abramovitch13, reported that the mean age possibility for dental age estimation between 16 for “Stage H” was 20.5 years. However, the and 22 years of age. In the present study mean age could be lower if the population females were more in number than males. The
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JGMDS reasons may be religious, and males have a Western China. J Forensic Leg Med. higher education than females so they are more 2014;24:24-7. doi: cautious about their oral hygiene. In this study, 10.10160jftm.2014.03.004. 4. Priyadharshini KI, Idiculla JJ. consecutive sampling was done which can be 4 Sivapathasundaram B, Mohanbabu V. another reason. A study by Pnyadharshini et al , Augustine D. Pate S. Age estimation using reported a sample of 848 subjects, of which 471 development of third molars in South Indian (55.4%) were males and 377 (44.5%) were population: a radiological study. J Int Soc females in South Indian population in which age Prey Community Dent. 2015;5(Suppl 1): estimation using development of third molars S32-8. doi: 10.4103/2231-0762.156522. was used. These results contradict this study 5. Talla MV. Adamala SR. SurapaneN S. Chilakuru D. Mandibular third molar results. This study showed no specific age for germination: a ram anomaly. J Indian Mad particular tooth stages were present. In the Oral Med Radiol. 2015;27(2):241-4. dot present study, “Stages D & E” were in range 10.4103/0972-1363.170145. from 15 to 25 years. “Stage F” was extended 6. Abu Asab S. Noor SN. Khamls MF. The from 13 to 23 years of age. “Stage G” was accuracy of Dermirjian method in dental age extended from 15 to 26 years of age. “Stage H” estimation of Malay children. Singapore was from 18 to 21 years. Therefore, age is a Dent J. 2011;32(1):19-27. doi: 10.1016/S0377- 5291(12)70012-3. good indicator of biologic when assessed based 7. Olze A. Ishikawa T. Zhu BL. Schulz R. on Demirjian's method. This is in agreement with Heinecke A. Maeda H. et al. Studies of the 15-18 other studies . chronological Cane of wisdom tooth eruption in a Japanese population. Forensic Sci Int. CONCLUSION: 2008:174(2-3):203-6. The maturation stages of mandibular third molars 8. Priyadarshini C. Puranik MP. Urea SR. were significantly related to the chronological Dental age estimation methods: a review. Int age. J Adv Health Sd. 2015;1(12):19-25. 9. Jayaraman J, King NM. Roberts GJ, Wong LIMITATIONS: HM. Dental age assessment: are Demirjian’s standards appropriate for southern Chinese The limitation of this study was its sample size children? J Forensic Odontostomatol. with no equal gender proportions. The patients 2011;29(2):22-8. selected were from one department only and 10. Demirjian A, Goldstein H, Tanner JM. A new may not predict the sample size of the system of dental age assessment. Hum Biol. community. Moreover, the stages of the 1973;45(4211-27. Demirjian's method of mandibular third molar 11. TeMoananui R. Kieser JA, Herbison GP. maturation showed a range of chronological age. Liversidge HM. Estimating age in Maori, Apart from these, this study thoroughly Pacific Island and European children from demonstrated the stages of mandibular third New Zealand. J Forensic Sci. molar maturation, age range with maturation 2008:53(2):401-4. doi: 10.1111/j.1556 - stage and correlation of age with maturation 4029.2007.00643.x. stage is uniqueness to our study. 12. Ajmal M. Assin KI. Al-Ameer KY. Assid AM, Luqman M. Age estimation using third molar CONFLICT OF INTEREST: teeth: a study on southern Saudi population. Conflict of interest is declared with research topic J Forensic Dent Sci. 2012;4(2):63-5. doi: and not among authors. 10.4103/0975-1475.109886. 13. Solari AC, Abramovitch K. The accuracy and REFERENCES: precision of third molar development as an indicator of chronological age in Hispanic s. 1. Manjunatha BS, Soni NK. Estimation of age J Forensic Sci. 2002;47(3):531-5. from development and eruption of teeth. J 14. Robetti I, lorio M, Dalle Molle M. Forensic Dent Sci. 2014;6(2):73-6. doi: Orthopantomography and the determination 10.4103/0975-1475.132526. of majority age. Panminerva Med. 2. Panchbhai AS. Dental radiographic 1993;35(3):170-2. indicators, a key to age estimation. 15. Franklin D, Flavel A, Noble J, Swift L, Dentomaxillofac Radiol. 2011:40(4):199-212. Karkhanis S. Forensic age estimation in doi: 10.1259/dmfr/19478385. living individuals: methodological 3. Qing M. Qiu L. Gao Z. Bhandari K. The considerations in the context of medico-legal chronological age estimation of third molar practice. Res Rep Forensic Med Sci. mineralization of Han population in South- 6 | J Gandhara Med Dent Sci January-March 2021
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2015;5:53-66. doi: 10.2147/RRFMS.S75140. Harm, responsibility, age, and consent. New 16. Cattaneo C, Obertova Z, Ratnayake M, Criminal Law Rev: Int Interdisciplinary J. Marasciuolo L, Tutkuviene J, Poppa P, et al. 2014;17(1):23-54. doi: Can facial proportions taken from images be 10.1525/nclr.2014.17.1.23. of use for ageing in cases of suspected child 18. Jurca A, Lazar L, Pacurar M, Bica C, pornography? a pilot study. Int J Legal Med. Chibelean M, Bud E. Dental age 2012;126(1):139-44. doi: 10.1007/s00414- assessment using Demirjian's method: a 011-0564-7. radiographic study. Eur Sci J. 17. Carpenter B, O'Brien E, Hayes S, Death J. 2014;10(36):51-60.
CONTRIBUTORS 1. Muhammad Ilyas - Concept & Design; Data Acquisition; Drafting Manuscript; Critical Revision 2. Asma Khan - Concept & Design; Data Acquisition; Data Analysis/Interpretation 3. Syed Murad All Shah - Critical Revision; Supervision; Final Approval 4. Salman Khan - Data Acquisition 5. Junaid Nadeem Malik - Data Acquisition
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COMMUNITY PHARMACY PRACTICES IN TIMERGARA CITY DIR, KHYBER PAKHTUNKHWA, PAKISTAN
Siraj ul Haq1, Ayaz Ayub1, Muhammad Hamayun Khan1, Hamid Hussain1 1. Khyber Medical University, Peshawar ABSTRACT: OBJECTIVES: To assess the community pharmacy practices in Timergara City in view of the standards set by the Drug Regulatory Authorities of Pakistan (DRAP).
METHODOLOGY: A cross-sectional survey of community pharmacies, Timergara city, was conducted from 2nd October to 28th November 2016. Out of 155 community pharmacies, 149 community pharmacies participated in the study. The data was collected on structured questionnaire. Face to face interview technique was used for data collection.
RESULTS: Among these pharmacies only 02 (01%) dispensers were qualified pharmacist with a Pharm-D degree, 08 (05%) had 8-Pharm degree, 80 (54%) had diploma in pharmacy and 59 (40%) had passed the pharmacy examination. Majority of community pharmacies 141 (95%) were selling medicines without prescription. In 140 (94%) of pharmacies, there were no arrangements for the control of insects, rodents and birds to prevent and eliminate possible infestation. In 140 (94%) pharmacies the medicines were stored on the floor, stairs and passageways due to lack of space. Only one pharmacy had temperature monitoring device and 19 (13%) pharmacies had refrigerators. Majority of the pharmacies 113 (76%) were using register for keeping record of the sale and purchase medicines. In 128 (86%) pharmacies the entrance was not accessible to the peoples with physical disabilities.
CONCLUSION: The community pharmacy practices in Timergara City was ineffectual with inexperienced staff, lack of prescription and security, and medicines were not stored according to the Drug Regulatory Authorities of Pakistan.
KEYWORDS: Community Pharmacy, Medicines, Patient's Counseling, Pharmacists, Prescription
INTRODUCTION: must be stored under the required temperature to maintain their efficacy3. In developing The role of a pharmacist is very important to countries, almost any drug can be obtained reduce the pharmacotherapy-related problems, Over-The-Counter (OTC) without any such as drug overdose, under-dose, and to prescription. People can easily get antibiotics, 1 minimize the incident of adverse drug effects . antipsychotics, antidepressants and other drugs https://doi.org/10.37762/jgmds.5-2.81 Community without any prescription4. The drug regulatory pharmacies authority of Pakistan has established certain are conditions for the issuance of pharmacy licenses5. accessible places Specialty doctors are available in Timergara and where most people from Lower Dir, Upper Dir and Bajaur of people Agency, which is adjacent with Timergara report easily seek healthcare advice and drugs in to these consultants for their medical needs6. developing and developed countries2. Standard The list of registered community pharmacies was and good quality medicines are degraded if not provided by District Health Officer (DHO). There stored properly. Therefore, the storage of are 155 licensed community pharmacies in medicines need proper attention and medicine Timergara city. As there is no baseline data 8 | J Gandhara Med Dent Sci January-March 2021
JGMDS about community pharmacy practices and its Written consent was taken from the participants related key problems, hence this study will help of the survey after explaining to them the in determining the current level of community purpose of the study. The data were collected with the help of structured questionnaire pharmacy practices in Timergara City of District standardized in the local setup. The Lower Dir. questionnaire consisted of two portions, one contained question which were directly asked METHODOLOGY: from the respondent, while second portion was a This was a cross-sectional study conducted in checklist regarding community pharmacy and community pharmacies, medical stores, medicos the pharmacist. or Chemists practicing in Timergara City. Data Different variables were evaluated; demographic collection team, comprising of 04 data collectors, variables, year of establishment of pharmacy, was trained in the data collection tools made for ownership, gender of pharmacists, age and this study. They were then sent to Timergara for qualification or education of the pharmacists the data collection. were all included. The variables related to Interviews were taken from the most pharmacy e.g. (external premises of the experienced pharmacist in the targeted pharmacies, internal environment of pharmacy, pharmacies. After the approval of the Advance storage conditions of pharmacy) and other Studies and Research Board (ASRB) and variables like, information regarding pharmacy Ethical Board, Khyber Medical University (KMU- staff, information regarding health and safety, EB), data was collected, entered and analyzed security related information, facilities for the by using SPSS Version 20. A list of registered pharmacy staff, laws and regulation related community pharmacies was obtained from the information were also evaluated. District Health Officer (DHO) district Dir Lower Timergara. There were 155 registered RESULTS: community pharmacies at Timergara city. Six Results showed that all authorized persons who refused to participate in the study so data was participated in the study were males working in collected from 149 community pharmacies. these pharmacies. Majority of pharmacies were Before data collection, written permission was established in the year 2001-2015 which is 94 taken from the District Health Officer (DHO) of (63%). Most of the pharmacies were District Lower Dir and a letter of reference was proprietorship 134 (90%). also taken from the registrar of Khyber Medical University. Table 1: Demographic Information of the Participants and Pharmacies (n = 149)
Items Remarks Frequency Percentage Before 1975 15 10 Year of establishment of pharmacy 1976-2000 40 27 2001-2015 94 63 Status of pharmacy regarding ownership Sole Owner 134 90 Partnership 15 10 25 or Less 01 01 Age of authorized person (pharmacists) in years 25-35 116 78 36-45 30 20 More than 45 02 01 Registered pharmacist present at the time of visit Yes 115 77 No 34 23 Pharm-D 02 01 B-Pharmacy 08 05 Education of the pharmacist Diploma in 80 54 Pharmacy Pharmacy Assistant 59 40 No of pharmacists or diploma in pharmacy or 1 76 51 technicians 2 70 47 All staff wear a badge stating their name, position Yes 00 00 and license number No 149 100
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JGMDS LAWS AND REGULATIONS RELATED pharmacies 140(94%) had license for sale of INFORMATION: respondents 146(98%) replied that drug drugs. Results showed that most of the community Majority of the pharmacies were operating through Category-B i.e. 79(53%). Most of the inspectors are visiting pharmacies regularly.
Table 2: Premises Appearance of Pharmacies (n=149) Questions Remarks Frequency Percentage Entrance of pharmacy is Yes 21 14 accessible to people with physical No 128 86 disabilities Prescription medicines are Yes 48 32 included in pharmacy-window displays or advertised to the public No 101 68
About 1 km away from the Government 33 22 Health Care Facility About 2 km away from the Government 12 08 Location of pharmacy Health Care Facility About walking distance from the 85 57 Government Health Care Facility In a super market 19 13 Physical arrangement of shelves Shelves are logically arranged 60 40 Not logically arranged 89 60 Design and layout permit Yes 31 21 effective communication and No 118 79 supervision by pharmacist Presence of patient counseling Yes 00 00 area No 149 100 Cleaning condition Visible dust exists 147 99 No visible dust 02 01
Table 3: Storage Conditions of Pharmacy (n=149) Questions Remarks Frequency Percentage In alphabetical order 08 05 Company name wise 84 56 Distribution of medicines in shelf In generic order 07 05 No order at all 50 34 Presence of quarantine area Yes 115 77 No 34 23 Presence of air condition Yes 18 12 No 131 88 Presence of humidity monitoring device Yes 00 00 No 149 100 Presence of temperature - monitoring Yes 01 01 device No 148 99 Presence of alternate power supply for the Yes 00 00 refrigerator No 149 100 Sell vaccines and other medicines that Yes 19 13 required refrigeration No 130 87
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Table 3: Storage Conditions of Pharmacy (n=149) (Continued) Questions Remarks Frequency Percentage Yes 19 13 Presence of refrigerator No 130 87 Using computer 08 05 Record keeping of sale and purchase Using registers 113 76 medicines Keeps no record 28 19 Availability of storage space so that no Yes 09 06 goods are stored on floors, stairs and No 140 94 passageways Presence of expired medicines in general Yes 06 04 stock No 143 96 Floors, walls and ceiling of pharmacy in a Yes 30 20 good repair No 119 80 Any arrangement for control of insects, Yes 09 06 animals (especially rodents) or birds to prevent and eliminate infestations No 140 94
Table 4: Information Regarding Health and Safety (n=149) Questions Remarks Frequency Percentage Sell medicines without prescription Yes 141 95 No 08 05 Medicines accessible by self-service Yes 120 81 No 29 19 Health and safety at work poster are clearly displayed Yes 15 10 No 134 90 The electrical wire presents a danger for staff or customers, Yes 08 5.36 which should not trail across the floor No 141 94.6
Table 5: Information Related to Security/Facilities of Pharmacy (n=149) Questions Remarks Frequency Percentage Presence of fire prevention and firefighting Yes 01 0.68 equipment No 148 99.32 Fire prevention and firefighting equipment Yes 01 0.68 are in working condition No 148 99.32 Properly locked 10 07 Management of controlled medicines Have separate shelves 31 21 Have no separate shelves 108 72 Presence of appropriate range of Yes 19 13 reference books No 130 87 Presence of internet Yes 26 17 No 123 83 Presence of telephone Yes 31 21 No 118 79 District Headquarter Hospital 51 34 From where most of prescription come to Community Health Center 13 09 the pharmacy Private doctor 85 57
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Questions Remarks Frequency Percentag 20 or Less 06 e 04
21 - 35 83 56 Number of prescriptions receive daily 36 - 45 53 35 More than 45 07 05
DISCUSSION: studied were 220. The result of this study revealed that there was no post graduate M- This study showed a tremendous increase in Pharm or Graduate B-Pharm pharmacists in their the number of community pharmacies from 10 pharmacies . Another study regarding pharmacy 2001 onwards, which indicates the interest of practice was conducted in the Upper West people in the profitable business of medicine. 11 Region of Ghana . On the other hand, the Similar trend regarding increase in the number pharmacists working in the community of pharmacies has been observed in United pharmacies of the developed countries were in Arab Emirates (UAE) since 2000 onwards. possession of pharm-D degrees. The reasons given for the growth of pharmacies were increased in population and In the present study, it was observed that there demand of health services in UAE7. was no proper storage arrangement of controlled medicines in these pharmacies. As per standard Regarding the ownership of pharmacies criteria or law the controlled drugs must be 134(90%) had a single owner and the properly locked and have separate shelves remaining 15(10%) were operating on because there is a great chance of abuse of partnership basis. A similar study conducted 12 these medicines . Only 10(07%) pharmacies in Karachi showed that 99.4% of pharmacies had proper lock system for the controlled 8 were owned by sole proprietors . In medicines in the separate shelves. The reason Pakistan, especially in Khyber for this is lack of professionally qualified Pakhtunkhwa, the major requirement for pharmacist. Majority of them did not know about opening of a retail or whole sale pharmacy is the controlled medicines. The results show that to get a two-year pharmacy diploma or to the regulatory drug inspector is regularly visiting get a certificate by passing an examination. these pharmacies. However, there are still a lot Lack of proper implementation of regulatory of gaps in spite of their regular visits to these laws may be the main reason inciting many pharmacies which poses a question mark on the people to open pharmacies. performance of the regulatory authorities. Lack Most of the pharmacies were in possession of of implementation of the laws and rules, and the drug sale license 140(94%). In 07(05%) of enforcement forces are the main reasons for the pharmacies, the authorized person or such performance. For District Lower Dir there is pharmacist responded that they have applied only one drug inspector. It is very difficult to for renewal of the license. Only 02(01%) manage a huge number of pharmacies by a pharmacies were found having expired drug single drug inspector. Our study results showed sale licenses and they had not yet applied for only 115 (77%) pharmacies have a Quarantine the renewal. This finding reflected that in area for rejected and expired stock and the Timergara city, the local drug inspectors have remaining pharmacies have no Quarantine area ensured that almost every community which is about 34 (23%). This shows that the pharmacy must have proper legal documents pharmacist worked in these pharmacies were not to operate a pharmacy. According to American aware about the importance of the quarantine Society of Health-System Pharmacists, all area. This is a serious issue which can lead to pharmacists must possess a current state life threatening situation in case of dispensing license for the practice of pharmacy9. In our expire medicine to the patients. Regarding the study most of the dispensers working in the availability of air conditioning facility, only 18 pharmacies were those who had got a diploma (12%) pharmacies had air conditioning facilities. or passed the examination in pharmacy. The presence of a functional air conditioner is necessary for the quality of medicines in the The number of qualified pharmacists who had pharmacy to keep the temperature in a range a Pharm-D or B-pharm degree is only 6% which must be less or equal to 25°C at any which is an alarming situation in Timergara time13. A research study conducted in Karachi city. As the presence of a qualified pharmacist city in December 2013 showed that there were is necessary in these community pharmacies. 54 (5.4%) pharmacies having the air conditioning A similar study was conducted in Bangladesh facilities8. A study on community pharmacy in which the total number of dispensers storage condition was conducted in Saudi Arabia
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JGMDS in 2012, found deficiencies in the storage there were a lot of deficiencies in patient condition of community pharmacies in Riyadh counseling at community pharmacies in Saudi during hot seasons, where 13 % of pharmacies Arabia20. (n=181) there was no thermometer for The drug regulatory laws of most countries temperature measuring. In 09% pharmacies the suggest that medicine should not be stored on thermometer was not working properly and in floors, stairs and passageways. The results of 19% of pharmacies there was no spare air- our study showed that 09 (06%) of the conditioner. While 7% of refrigerators had no pharmacies, had adequate storage facilities for thermometer and in 33% of refrigerators the 14 the proper storage of medicines. In the thermometer was not working properly . remaining pharmacies, the storage facilities This study showed that there was no pharmacy were not proper and medicines were stored on with a humidity monitoring device. There was the ground. The results also show that there only one pharmacy which possessed a was presence of expired medicines in the temperature monitoring device. general stock. According to the rules, there must be a separate quarantine area for the Results showed that 19 (13%) of the pharmacies storage of the expired medicines in the were selling vaccines and other medicines had 21 pharmacy . In 06 (04%) pharmacies, there refrigerators for the storage of these medicines were expired medicines present in the general and vaccines. These pharmacies were mostly stock. There are chances that expired drugs situated near District Head-Quarter Hospital. may be dispensed to the patients. We Thus, the vaccines and medicines liable to high observed that 30 (20%) of the pharmacies, temperature were at risk to lose efficacy. A had a good repair of walls and ceiling, while similar study was conducted in Karachi in the remaining 119 (80%) were in bad October 1999 showed 167 (76%) pharmacies condition. There must be proper arrangement (n=219) were selling Tetanus toxoid and only for control of insects, animals (especially 15(8.9%) of these pharmacies had 15 rodents) or birds to prevent and eliminate refrigerators . Our results showed that majority 1 possible infestations in the pharmacy . 141 (95%) of pharmacists were selling medicines without any prescription. A survey-based study CONCLUSION: was conducted in various areas of Karachi and Most of the community pharmacies were run by reported that 17% pharmacies were dispensing 16 inexperienced persons in the absence of a medicines without any prescription . qualified pharmacist. Medicines were dispensed Display of Pharmacy license and the in-charge mostly without prescription. There was no proper pharmacist's license is compulsory in most of the arrangement of security of the pharmacies and developed and developing countries of the world. pharmacy staff. Medicines were not stored under It should be displayed in such a place where it is proper storage conditions as prescribed by the clearly visible to the public. Results showed that Drug Regulatory Authorities of Pakistan. in 130 (87%) of the pharmacies, the licenses LIMITATIONS: were displayed properly. A study on the quality of community pharmacies had been conducted in The main limitation of our study was that only the urban Rawalpindi showed that 6% pharmacies registered community pharmacies, in Timergara had displayed their license prominently to the were included in the study. So, we remained public properly17. A similar study in India showed unaware of the great number of community that ratio of visibility of license in urban pharmacies, which are not registered with the pharmacies, were more in hospital pharmacies Drug Regulator Authority. that is 76% as compared to that of urban and rural pharmacies, was 68% and 8% respectively. RECOMMENDATIONS: The reason being that in the hospital The Drug Regulatory Authority should give pharmacies, there are qualified pharmacists and license only to those people who fulfill the there is implementation of law as compared to requirement for opening a community pharmacy. 18 that of urban and rural pharmacies . To evaluate They should properly check the storage the community pharmacy practice, a similar condition and staffing before opening a study was conducted in Istanbul, Turkey pharmacy. There is dire need to improve the observing that 32% of the pharmacists were community pharmacy practices in light of the not present in their pharmacies, during the visit regulatory standards/laws of Drug Regulatory for interview. Majority of the patients got their Authorities of Pakistan. medications without any prescription, which indicated that the practice of community pharmacy is also very poor in Istanbul, Turkey19. Alaqeel and Abanmy highlighted that
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JGMDS CONFLICT OF INTEREST: Epplen KT, Marsden LM, et al. ASHP guidelines: minimum standard for There is no conflict of interest among the authors. ambulatory care pharmacy practice. Am J Health Syst Pharm. 2015;72(14):1221-36. REFERENCES: doi: 10.2146/sp150005.
1. Wiedenmayer K, Summers RS, Mackie CA, 10. Shill MC, Das AK. Medication practices in Gous AGS, Everard M, Tromp D. Bangladesh: roles of pharmacists at Developing pharmacy practice: a focus on current circumstances. Int J Pharm Pharm patient care: handbook [Internet]. Geneva: Sci. 2011;3(4):5-8. World Health Organization; 2006 [cited 2019 Feb 27]. 97 p. Available from: 11. Khojah HM, Pallos H, Tsuboi H, Yoshida N, Abou-Auda HS, Kimura K. Adherence of https://www.who .int/medicines/publ community pharmacies in Riyadh, Saudi ications/ WHO_PSM_PAR_2006.5.pdf Arabia, to optimal conditions for keeping and selling good-quality medicines. 2. Naveed S, Zafar IN, Musharraf M,Yaqoob S, Pharmacology & Pharmacy. 2013;4(5):431- Zaman S, Naqvi SZJ, et al. Pharmacy 7. doi: 10.4236/pp.2013.45061. dispensing practice in various pharmacies of Karachi. Mintage J Pharm Med Sci. 12. Rayes IK, Hassali MA, Abdue lkarem AR. A 2014;3(2): 19-21. qualitative study exploring public perceptions on the role of community 3. Parthasarathi G, Nyfort-Hansen K, Nahata pharmacists in Dubai. Pharm Pract MC, editors. A text book of clinical pharmacy (Granada). 2014;12(1):363. practice: essential concepts and skills. Chennai: Orient Blackswan; 2004. 13. Ninomura P.E. P, Bartley J. New ventilation guidelines for health-care facilities. ASHRAE 4. World Health Organization. Joint FIP/WHO J. 2001;29-33. guidelines on good pharmacy practice: standards for quality of pharmacy services 14. Hussain A, Ibrahim Ml. Qualification, [Internet]. World Health Organ Tech Rep knowledge and experience of dispensers Ser. 2011;(961):1-13 [cited 2019 Feb 27]. working at community pharmacies in Available from: Pakistan. Pharm Pract (Granada). 2011;9(2):93-100. http://apps.who.int/medicinedocs/documents 15. Hussain A, Malik M, Toklu HZ. A literature /s18676en/s18676en.pdf review: pharmaceutical care an evolving 5. Nahata MC, Beck DE, Draugalis JR, Flynn role at community pharmacies in Pakistan. AA, Kerr RA, Wells BG. The academy's Pharmacology and Pharmacy. agenda for improving the safety of 2013;4(5):425-30 doi: medication use: report of the 2006-2007 10.4236/pp.2013.45060. Argus commission. Am J Pharm Education. Zafar SN, Syed R, Waqar S, Zubairi AJ, 2007;71(6):1-4, doi: 10.5688/aj7106S18. 16. Vaqar T, Shaikh M, et al. Self- 6. Hanafi S, Poormalek F, Torkamandi H, medication amongst university students Hajimiri M, Esmaeili M, Khooie S, et al. of Karachi: prevalence, knowledge and Evaluation of community pharmacists' attitudes. J Pak Med Assoc. knowledge, attitude and practice towards 2008;58(4):214-7. good pharmacy practice in Iran. J Pharm 17. Farris KB, Fernandez-Llimos F, Benrimoj SI. Care. 2013;1(1):19-24. Pharmaceutical care in community 7. Rayes IK, Hassali MA,Abduelkarem AR. pharmacies: practice and research from The role of pharmacists in developing around the world. Ann Pharmacother. countries: the current scenario in the United 2005;39(9): 1539-41. Arab Emirates. Saudi Pharm J. 18. Perce KH. Disaster recovery: lessons 2015;23(5):470-4 . doi: 10.1016/j .jsps .2014.02.004 . learned from an occupational health and human resources perspective. MOHN J. 8. Shah SS, Naqvi BS, Fatima M, Khaliq A, 2007;55(6):235-40. Sheikh AL, Baqar M. Quality of drug stores: storage practices & regulatory compliance in 19. Toklu HZ, Akici A, Oktay S, Cali S, Sezen Karachi, Pakistan. Pak J Med Sci. SF, Keyer-Uysal M. The pharmacy practice 2016 ;32(5):1071-6 . of community pharmacists in Turkey. Marmara Pharm J. 2010;14:53-60. doi: 9. Buxton JA, Babbitt R, Clegg CA, Durley SF, 14 | J Gandhara Med Dent Sci January-March 2021
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10.12991/201014464. 21. O'Leary K, Burke R, Kirsa S. SHPA standards of practice for the distribution 20. Alaqeel S, Abanmy NO. Counselling of medicines in Austra lian hospitals. J practices in community pharmacies in Pharm Pract Res. 2006;36(2):143-9. Riyadh, Saudi Arabia: a cross-sectional doi: 10.1002/j.2055-2335.2006.tb00592.x. study. BMC Health Serv Res. 2015;15:557. doi: 10.1186/s12913-015- 1220-6 .
CONTRIBUTORS 1. Siraj UI Haq - Concept & Design; Data Acquisition; Data Analysis/Interpretation; Drafting Manuscript; Final Approval 2. Ayaz Ayub - Concept & Design; Critical Revision; Supervision;Final Approval 3. Muhammad Hamayun Khan - Concept & Design; Data Analysis/Interpretat ion; Drafting Manuscript 4. Hamid Hussain - Concept & Design; Data Acquisition; Data Analysis/Interpretation; Drafting Manuscript; Supervision; Final Approval
March 2019 – September 2019 J Gandhara Med Dent Sci | 15
JGMDS MEDICOLEGAL SIGNIFICANCE OF TORTURE UNDER POLICE CUSTODY ON PRISONERS' HEALTH AND RECOMMENDATIONS FOR PREVENTION OF VIOLENCE AGAINST TORTURE
Sayed Mohammad Yadain1, Aftab Alam Tanoli2, Riffat Masood3, Shagufta Shafi1, Rizwan Zafar Ansari4, Zahid Hussain Khalil5, Qurat ul Ain Aftab6 1. Abbottabad International Medical College, Abbottabad 2. Women Medical College, Abbottabad 3. Foundation University Medical College, Islamabad 4. Northwest School of Medicine, Peshawar 5. Kabir Medical College, Peshawar 6. District Police Hospital, Peshawar ABSTRACT OBJECTIVES: The aim of the study was to determine (a) most common sites of torture, nature of injuries and their complications and (b) psychological and physical effects of torture on the prisoner's mental and physical health.
METHODOLOGY: It was a cross-sectional descriptive study. The study was conducted on 193 prisoners admitted at District Police Hospital Peshawar over a period of one year. These prisoners were the victim of torture under police captivity. Majority of the victims were prisoners. The data was collected on a Performa mentioning age, duration of captivity; nature of injuries (simple, grievous), weapon used for physical torture (blunt, sharp) and prisoners were interviewed and examined by the medical officers and co authors. SPSS 20 was used for data analysis.
RESULTS: One hundred and eighty (93.2%) of the 193 subjects were male. Average age was 27.4 ± 4 years. Hundred (51.8%) prisoners were physically tortured and 92 cases (47.6%) were due to physical assault among prisoners. Out of 92 cases 12 (13.04%) prisoners showed injuries due to strenuous physical work, mostly on palms and soles in the form of blisters. These injuries were carefully examined and correlated with history. Torture methods observed in this study were beating with hands on face (35.6%), whipping with rod (61.6%), kicking on buttock and abdomen (16.4%), forceful dragging (16.4%), burning with cigarettes (12.3%), hanging with hand cuffs (13. 7%) and whipping on palms and sole (6.9%). Majority of the cases (74%) were tortured in custody, (12.3%) in prisons, (9.6%) on the street and (4.1%) at home. The impact of physical and psychological torture was variable depending upon the duration of captivity and nature of torture. Patients kept for a longer period 42 (42%) had developed post captivity psychosocial stress syndrome. Physical torture has taken 07 (3%) lives and 24 (12.4%) victims were permanently disabled in this year.
CONCLUSION: A wide range of different types of injuries were observed on various parts of the body. Blunt trauma was most frequent. Violation of Istanbul Protocol for violence against torture under police custody was also clear.
KEY WORDS: Police Torture, Bruise, Prisoner, Custody, Health person's human rights. It is the deliberate self- INTRODUCTION: Implication of severe pain or suffering by law enforcement personnel to obtain Information Torture is an act of Intentional Infliction of severe from the suspects under captivity2. The victims pain or greatly suffer with Irreversible psychological and suffering behavioral Issues about their worst experience which can and hesitant to lay complaints against this be either physical and abusive violence they suffered mental, while in police custody. Government has no physical definite rehabilitation and counseling programs or both, to for them to lead a normal life once again; they https://doi.org/10.37762/jgmds.5-2.82 a person 3 1 are left traumatized, ashamed and frightened . for obtaining Information or punishing him . This act of violence is against the guidelines of Torture is one of the most dreadful violations of a 16 | J Gandhara Med Dent Sci January-March 2021
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Istanbul protocol; a manual of guidelines jurisdictions, a prisoner could be examined on accepted internationally for protection of the order of Magistrate without obtaining consent prisoner's right while in custody4. There is an of victim of police torture. Mean and standard absolute prohibition on torture under deviation was calculated for age, sex, gender, international laws. Physical torture may cause injuries type, severity and age of injuries at the internal organ injuries, fracture of limbs and ribs. time of examination. Complete general Inhumane treatment, insult and disgraceful examination was also performed including vital treatment may lead to psychological damage signs, chest, heart, abdominal examination and such as insomnia, nightmares, stress, neurological examination. Local examination for restlessness and fear of torture even in a safe all the wounds was carefully described, environment 5. Torture victims may have difficulty documented and diagrammed. Radiograph was to resume a normal life they may experience obtained where fracture(s) was suspected. difficulty in getting to sleep or may wake early, Descriptive statistics were obtained as mean with sometimes shouting or with nightmares6. They standard deviation and proportion for quantitative may experience anxiety, persistent feeling of and qualitative data, respectively. For statistical fear, insecure and memory loss. The analysis: two-tail test was performed and Chi consequences of torture can be long-term Square test "X2" was used in statistical analysis causing permanent detrimental effects on the of some of the results where p-value < 0.05 is personality and horrendous effects on mental significant. health, physical disability or even death of the RESULTS: prisoners. Demographic data showed that among 193 Torture is prohibited under a number of cases, 179 (92.7%) were males while only 14 international and regional human right protection (7.2%) were females. The age of the cases laws. United Nations Convention against torture 8 ranged from 20 to 38 years (Mean 27.7± 4.2). prohibits any kind of violence on prisoners . The Out of the 193 cases of torture allegation 144 purpose of torturing is usually to obtain (75%) were in the third decade, while 48 cases information or forced confession, to get a 9 (25%) were in their fourth decade. Of the 193 testimony incriminating others . The increased cases of the study, 101 (51.8%) cases actually incidence of abduction and torture by police is 10 tortured as were evidenced by medico legal now spreading terror in the community . Torture examination after taking their full history, 92 is a worldwide, man made epidemic. Human cases (47.6%) were due to physical assault rights organizations report that over 120 among prisoners while 71 cases proved to be countries in the world today routinely use torture 11 alleged torture where no physical evidences to control their citizens . were found. After careful history and meticulous METHODOLOGY: medico-legal examination these injuries were declared as fabricated (self-inflected) wounds In this study, the results of the medico legal and were excluded from the study. Table 1 examinations of 193 cases of torture admitted at shows age of injuries at the time of discharge. District Police Hospital, Peshawar over a period The number of victims of torture admitted in a of 1-year (Jan-Dec 2018) were analyzed on week was significantly high i.e. ±2.09 per week. SPSS version 20. The study included cases of These victims also complain about ill treatment, torture due to police and other prisoners. Cases humiliation, insult and disgraceful attitude of the of self-inflected injuries were excluded. Written police officers. This resulted in agitation among permission from Medical Superintendent and them. They felt helpless and in constant fear of informed consent was obtained prior to medical being tortured. examination. In Pakistan Penal Code (PPC)
Table 1: Age of Wound at Time of Examination No of Victims Percentage Age of Injuries at Time Nature of Injuries ln=101) of Discharge 55 56.4 2-5 days Mixed nature 27 26.7 6-10 days Grievous bruises and fractures 11 10.8 11-40 days Dangerous head injuries 8 7.9 41 - 80 days Mental or physical disability
The hospital stay depends upon the nature of observa on for at least 48 hours (02 days). Pa ents injuries. Pa ents with simple injuries were with complex head injuries, fractures and mental or discharged within 24 hours while pa ents with physical disability stayed for a longer period while grievous and dangerous injuries were kept under simple bruises lacera ons and abrasions were March 2019 – September 2019 J Gandhara Med Dent Sci | 17
JGMDS discharged within a week. Medico-legally eight types concluded that bruises, abrasions and fractures were of lesions were detected in the studied cases. the most common injuries, whereas the back of the Table 2 also shows nature and pa ern of injuries trunk, palm of hand and sole are the most common according to hurt PPC 337 (medico-legal classifica on sites of torture. The most o en used instrument for of in Junes according to Qisas and Diyat act). It was also torture was a wooden s ck Table 2: Nature of Injuries on Body Nature of Injury Type of Weapon/Reason Nature of Injuries on Body Simple Grievous Dangerous Abrasion Dragging 22 2 - Laceration (tear) Heavy blunt weapon 11 8 3 Bruise (crush) Heavy blunt weapon 14 36 2 Fracture Heavy blunt weapon 9 7 1 Head injuries Heavy blunt weapon 9 11 1 Cuts Sharp edge weapon 17 7 2 Burns Cigarette burn, electrocution etc. 12 32 1 PTSD (Post Traumatic Stress Prolong captivity, mental torture - 12 8 Disorder)
As shown in Table 3, 41 victims were admitted In this study 58% of the victims were tortured with due to beating with heavy blunt weapon, 19 more than one method. The victims were tortured dues to beating with hands, 14 victims had with blunt weapon mostly on the back of the internal bruises and fracture of ribs due to trunk (n=37) 36.6% while 28.8% on abdomen kicking while 16 patients were admitted due to and face. 17 victims suffered fracture of limbs, burns. ribs and even skull fracture. Table 3 Methods and site of Injuries in Tortured Cases Methods Site of injuries in Tortured Cases n=101 Back of Face Head Abdomen Limbs Chest Trunk n=37 n=16 n=21 n=09 n=11 n=6 Beating with hands N=19 6 10 - 3 - 1 Beating with blunt weapon N=41 20 3 11 2 5 1 Dragging N=11 05 - 4 - - 2 Kicking N=14 3 - 2 3 5 1 Miscellaneous: Cigarette burn, cuts, head N=16 3 6 4 1 1 1 shave
Torture in Pakistan especially in district done in Faisalabad's. Anatomically the parts of Peshawar is a widespread and persistent the body most affected were the buttocks, soles phenomenon. Law enforcement agencies and of feet, back of chest, back and front of thighs, the police routinely torture suspects captivated palms of hands and wrists. The most common for interrogation leading to grievous injuries and agent allegedly used to inflict for torture were few may sustain fatal injuries or death in custody. cane stick and broad, flat leather slipper dipped In some cases, officials torture detainees to in oil to enhance the effect of pain15,16. In Egypt it punish, intimidate, or humiliate them. Police also was found that 48% of the prisoners suffered detains and tortures family members to obtain more than one method of torture. It was information or confessions from a relative, or to observed that 64% of the suspects have suffered force a wanted relative to surrender15. This is an beatings with blunt weapon resulting in blunt alarming situation as evidence of physical trauma, fracture or even death17. In Italy a group trauma is visible on the bodies of the victims and of doctors led the foundation of volunteer no such legislative body is there to take notice services for people who experienced torture in against this violation of human rights. UN their countries and found that most of the victims Convention Against Torture (CAT) has have beating marks on their bodies (64%). Of recommended sanctions against Uganda, the these 14% victims were tortured by hanging from Philippines and Bolivia for violating international sealing, detention into dark room for a longer laws. The common pattern of injuries ranging period causes psychological disturbances in from abrasions to bruises was found in a study 28%, bums/electric shock (21%), wet 18 | J Gandhara Med Dent Sci January-March 2021
JGMDS asphyxiation and water jets (11%), sexual necessary for identification of all forms of violence (15%), amputation/penetrating injuries human rights violations and submit (22%), dental torture and traumatic removal of suggestion for their rectification. nails was formed in (6%)18. As a result of violent application of force complications were also ABBREVIATIONS: noted and cases were referred to various OHCHR: Office of the High Commissioner for specialties. Radiological examination especially Human Rights (United Nations), UNCAT: United of hand and severity of various skeletal and soft Nation Convention against Torture, PPC: tissue injuries were identified. Expert dental, ENT and eye opinion were also required. In some Pakistan Penal Code, PTSD: Post Traumatic cases, referral was made for Neurosurgery Stress Disorders opinion to determine the paraplegia or loss of ACKNOWLEDGEMENT: tone in a group of muscle especially of shoulder and wrist joint due to prolonged upside-down The authors would like to thank the Dean, as hanging and dragging with hand cuffs. The well as the Head, Forensic Medicine situation in Pakistan about police torture cases is Department, Khyber Medical College, Medical increasing alarmingly. The violation of the human Superintendent, Police Hospital and Medical rights by law enforcing agencies is very clear in Officers, District Police Hospital Peshawar for the results of the study. Awareness by various their support and permission to do the study. sectors of the society and adoption of preventive measures is urgently required in this regarding. REFERENCES:
CONCLUSION: 1. Gautam S, Gautam A. Victim of torture in From this study it is concluded that law police custody: a case study. Int J Higher enforcement agencies are violating international Education Res. 2014;5(1) :1-8. guidelines against torture in captivity. A rd superficial graze abrasion due to dragging and 2. Raghupathi NM. 3 degree torture by blunt trauma were the most frequent types of doctors and police. S.O.S e-Voice for injuries. It was also concluded that bruises, Justice-e-news weekly. 2015;11(43):1-35. abrasions and contusions were the most Available from: common injuries, whereas the back of the trunk, https://evoiceofhumanrightswatch.wordpress palm of hand and sole are the common site of .com/2015/10/18/3rd-degree-torture- torture. The mostly used instrument for turture by doctors-police/ was a wooden stick. 3. Humayon AA, Raza S, Amir H, Hussain MS, Ansari NA. Assessment of work stress RECOMMENDATIONS: among police in Pakistan. J Appl Environ 1. It is suggested that steps to be taken for Biol Sci. 2018;8(2):68-73. implementation of legislation to refrain law enforcing agencies from using torture as a 4. Sharma B, Ommeren MV. Preventing torture method of investigation. and rehabilitating survivors in Nepal. 2. Suspects under police captivity must be Transcultural Psychiatry. 1998;35(1):85-97. examined by the doctor. doi: 10.1177/136346159803500104. 3. Doctors attending the medico-legal case must be certified in Medical Jurisprudence. 5. Terrill W, Ingram JR. Citizen complaints 4. Doctors must not use medical knowledge to against the police: an eight-city examination. use against the victims. Police Quarterly. 2016;19(2):150-79. doi: 5. Doctors working within the justice system 10.1177/1098611115613320. should be provided with the training. 6. Police officials should be provided training to 6. Rasmussen OV. Medical aspects of torture. use other means of interrogation. Dan Med Bull. 1990;37(Suppl 1):1-88. 7. Identify group of prisoners and police officers who are torturing prisoners due to mental 7. Saukko P, Knight B. Knight's Forensic fixation and take measures not allow them to Pathology. 4th ed. London: CRC Press; repeat torturing in future. 2015. 8. Isolate the sadist and ill-minded prisoners from other prisoners. 8. McColl H, Bhui K, Jones E. The role of 9. Accused officers should be put on trial and doctors in investigation, prevention and punished. treatment of torture. J R Soc Med. 10. Local government must provide resources 2012;105(11):464-71. doi: March 2019 – September 2019 J Gandhara Med Dent Sci | 19
JGMDS 10.1258/jrsm.2012.120100. Tibetan refugees: a systematic review. BMC Int Health Hum Rights. 2005;5:7. 9. Government of Pakistan. Pakistan's initial report on united nations convention against 14. Forrest DM. Examination for the late torture and other cruel, inhuman or physical after effects of torture. J Clin degrading treatment or punishment (CAT). Forensic Med. 1999;6(1):4-13. 2015. 15. REDRESS. Torture in Uganda: a baseline 10. lacopino V, Allden K, Keller A. Examining study on the situation of torture survivors in asylum seekers: a health professional's Uganda. London: The Redress Trust; 2007. guide to medical and psychological evaluations of torture. Boston: Physicians for 16. Raja KS, Arshad H, Manzur F. Pattern of Human Rights; 2001. injuries in police torture victims coming to District Standing Medical Board Faisalabad. 11. Chaudhry MA, Haider W, Nagi AH, Ud-Din Professional Med J. 2011;18(2):285-8. Z, Parveen Z. Pattern of police torture in Punjab, Pakistan. Am J Forensic Med 17. Khanal SP. Right against torture in Pathol. 2008;29(4):309-11. doi: international law: a case study of Nepal 10.1097/PAF.0b013e3181847d93. [dissertation on the internet]. Kathmandu (Nepal): Tribhuvan University; 2012. [cited 12. Asian Human Rights Commission (AHRC). 2019 Feb 21]. Available from: Pakistan: a chilling tale of police torture. Asia http://202.45.147.21:8080/jspui/bitstream/12 Pacific Solidarity Network; 2009. Available 3456789/350/1/72- from: https://www.asia- Shambhu%20PV020Khanal.pdf pacificsolidarity.net/southasia/pakistan/state ments/ahrc_achillingtaleolpolicetorture_2905 18. de C Williams AC, van der Merwe J. The 09.htm psychological impact of torture. Br J Pain. 2013;7(2):101-6. doi: 13. Mills EJ, Singh S, Holtz TH, Chase RM, 10.1177/2049463713483596. Dolma S, Santa-Barbara J, et al. Prevalence of mental disorders and torture among
CONTRIBUTORS
1. Sayed Muhammad Yadain - Concept & Design; Data Analysis/Interpretation; Drafting Manuscript 2. Aftab Alam Tanoli - Data Acquisition; Data Analysis/Interpretation; Drafting Manuscript 3. Riffat Masood - Data Acquisition; Drafting Manuscript 4. Shagufta Shafi - Data Acquisition; Data Analysis/Interpretation; Critical Revision 5. Rizwan Zafar Ansari - Concept & Design; Data Analysis/Interpretation; Supervision 6. Zahid Hussain Khalil - Critical Revision; Supervision 7. Qurat-Ulain Aftab - Data Acquisition Data collected was emailed to all the co-authors for analysis, interpretation, discussion and review.
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CORRELATION BETWEEN GLYCOSYLATED HAEMOGLOBIN AND THYROID FUNCTION TESTS IN PATIENTS WITH TYPE-2 DIABETES MELLITUS
Ayesha Qaisar1, Riffat Sultana2, Jibran Umar Ayub Khan3 1. Khyber Medical College 2. Khyber Girls Medical College 3. Kabir Medical College, Peshawar ABSTRACT OBJECTIVES: The aims of this study were to determine the frequency of undetected dysfunction of thyroid in patients with diabetes, determination of correlation between glycosylated Hb and thyroid hormones, and to find out the relationship between blood glucose control and function of thyroid in patients of type 2 diabetes mellitus in comparison to normal individuals.
METHODOLOGY: This study was carried out at Department of Medicine, Hayatabad Medical Complex, Peshawar. It was a cross sectional study. A sample size of 358 subjects was taken using non-probability consecutive sampling in which 179 had type-2 diabetes and 179 were healthy normal subjects. Based on the results, they were classified into either hypothyroid or hyper thyroid categories, and then a comparison was done with HbA 1c to determine their correlation. The data was analyzed by using SPSS version 23.
RESULTS: The mean age of both the groups was 54.35 ± 9.38 years and 42.66 ± 9.20 years respectively on comparison of median (as data lacked normality) and mean ages of cases was much higher as while drawing comparison to control group with p-value less than 0.001. In these cases, the total number of male patients were 62 (34.64%) and females were 117 (65.36%) while in controls the males and females were 124 (69.27%) and 55 (30. 73%) respectively. In these cases, the number of hypothyroid patients were 13 (7.3%), hyperthyroid individuals were 26 (14.5%) and 11(6.1%) cases had subclinical hyperthyroidism. Normal thyroid function was found in all controls. In these cases, a weak positive correlation was found between HBA 1c and T3 (r = 0.239, p-value 0.001). Also, there was an insignificant correlation with T4 (r=-0.017, p-value=0.817) and correlation of insignificant nature found with TSH (r=-0.036, p-value=0.634). Among controls same (insignificant) correlation was found between Glycosylated Hb and T3 (r=0.070 p-value=0.352), a weak positive correlation with T4 (r=0.238, p value = 0.001) and a moderate negative relationship with thyroid stimulating hormone (r= -0.586, pvalue <0.001).
CONCLUSION: Early detection of thyroid dysfunction in diabetic patients can prevent complications and leads to optimum control of blood glucose level.
KEYWORDS: Type-2 Diabetes Mellitus, Glycemic Control, Glycosylated Hb, Thyroid Dysfunction, Thyroid Hormone
INTRODUCTION: developing complication of diabetic nephropathy1-3. It is characterized by disorders of Diabetes Mellitus (OM) is one of the commonest carbohydrate fat as well as protein metabolism1,2. endocrine disorders affecting major populations. Diabetes mellitus and thyroid disorders are both Diabetes mellitus is featured by absolute or important and are strongly associated with one partial another and have got profound and positive deficiency in clinical effects for insulin sensitivity and secretion subsequent treatment which will help in clinical of Insulin or care of patients with OM and thyroid disorders3,4. its Excess or deficiency of either insulin and thyroid resistance hormones lead to derangement of each other's https://doi.org/10.37762/jgmds.5-2.83 and has an functions as both of them are involved in cellular association with chronic increase in blood sugar metabolism. Patient with thyroid dysfunction, levels. One of the most vital organs to be deteriorates the thyroid disorders3-4. Excess or affected by diabetes is kidney with patient March 2019 – September 2019 J Gandhara Med Dent Sci | 21
JGMDS deficiency of either insulin and thyroid hormones surgery, patients with radiations to thyroid gland lead to derangement of each other's functions as were excluded from the study. After approval of both of them are involved in cellular metabolism. synopsis from Khyber Medical University and Patient with thyroid dysfunction, deteriorates the permission from Head of Department of glycemic controls3-5. The strong relationship Medicine, HMC, patients were selected from between both these endocrine diseases Medical Wards of Hayatabad Medical Complex persuaded the American Diabetes Association and diagnosed with T2DM on operational (ADA) to come up with proposition that people definition basis. A total of 358 individuals were with increased blood sugar levels must be selected through non-probability consecutive checked randomly for thyroid functions3. A study sampling. A written consent was taken from the reported that about 12% cases had thyroid patients for participation in the study. Their disorders and 28.5% of Saudi patients with height was measured by a measuring tape and diabetes were noted to have variations in their weighing in kg was calculated by weight machine thyroid hormones levels5. Alteration in thyroid followed by BMI calculation13. function has got a detrimental effect on blood The selected individuals were divided equally glucose control and is found mostly in patients 5 between type 2DM and non-diabetics normal with enhanced age . Thyroid dysfunction affects individuals (controls) and then a comparison was metabolism and also impedes the management done between these two groups to examine their of diabetes. Hypothyroidism is frequently found mutual correlation in virtue of thyroid (unction in patients with diabetes. DM influences function disturbance and glycemic control. For of thyroid at two destinations; one is at glycosylated hemoglobin determination, thyroid hypothalamus interfering with release of Thyroid profile (TSH, T3, T4), 5m1 of blood was obtained Stimulating Hormone and then at a site where 9 from antecubital vein while keeping infectious there is peripheral conversion of T4 to T3 . Rise control measures in check and was centrifuged in blood sugar level causes a reversible at 4000 rpm. Serum were separated into two reduction hepatic deiodinase (enzyme) level, batches (one meant for glycosylated hemoglobin reduced T3 levels, and enhanced level of 5,10,11 and second one for thyroid function tests). reverse T3 . Patients with thyroid dysfunction 12 HbA1c was determined via chromatography may go undetected in type 2 diabetes . There is technique. Serum thyroid functions were gradual non-enzymatic covalent addition of calculated by standard method. Based on the glucose to hemoglobin in diabetic patients. This results patients were grouped in hypo or raises the level of glycated Hb (HbA1c) to a hyperthyroidism categories and then they were considerable extent. The occurrence of thyroid correlated with glycosylated Hb to see mutual dysfunction in diabetes has not received due relationship. Diabetes mellitus type-2 was attention. Timely diagnosis of thyroid dysfunction defined as fasting glucose > 7.0 mmol / I (126 in such patients can have a profound effect on mg/dl) at two occasions at least and blood glycemic control and thereby reducing the glucose level > 11.1 mmol / I (200 mg/dl) when morbidity. checked randomly. TFTS were performed and METHODOLOGY: normal ranges were considered as T3 58- 159ng/ml. T 44.741.7 g/dl TSH 0.3-4.94mIU/ml This cross-sectional study was conducted at while, clinical Hypothyroidism was defined here Medical Units of Hayatabad Medical Complex TSH above 5.5mlU/ml and T3 as well as T4 Peshawar. After the approval from ethical lower than optimum level. Clinical committee, the duration was three months (from Hyperthyroidism was considered if the level of January to March 2017). Sample size of 358 was TSH was lower than normal and T3 as well as 14 calculated through usage of confidence level of higher than reference level. 95%, 5% error margin with expected percentage of thyroid dysfunction in type-2 diabetes mellitus Collected data was analyzed by SPSS version subjects as 28.5%, were included. Using non- 23. A p-value below 0.05 was given significance probability consecutive sampling, type-2 diabetic and the results were presented in form of tables. individuals who were having oral hypoglycemic medications or insulin regime or both at same RESULTS: time and a nearly matched control (healthy The age of both cases as well as controls while subjects) for each case of particular age group taking the mean was 54.35 9.38 years and (35-70 years) and gender were taken. Cases 42.66 9.20 years; on comparison of median (as with past medical background of thyroid disease, data did lack normality) and revealed that cases medications history like thyroxin, hydrocortisone. had greater median age while drawing a betablockers (anti thyroids), patients consuming comparison to controls, p-value of less than drugs known for modifying the thyroid functions 0.0001. In cases the total number of male e.g. lithium, patients with history of thyroid patients was 62 (34.64%) and females 117 22 | J Gandhara Med Dent Sci January-March 2021
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(65.36%) while in controls the males and females T4 was 9.24 ± 3.98 and 7.01 1.59, the mean of were 124 (69.27%) and 55 (30.73%) TSH in both of them was 1.24 ± 1.48 and 2.33 ± respectively. The difference of gender in both 1.02. The median T3 and T4 was found to be cases and controls was dissimilar with a p-value considerably greater in cases and TSH of less than 0.0001. Majority of patients found in significantly lower in cases while drawing a cases were house-wives while controls comparison to normal subjects meaning control comprised of employed subjects. There was ones, p-value less than 0.0001. The average difference of profession in both these groups HBA1c in both groups was 6.44 ± 2.81 and 5.28 with a p-value of 0.002. The average BMI ± 2.87 with essentially greater readings in together in both groups was 25.73 5.34 and patients with diabetes in comparison to normal 23.60 5 respectively. In cases the number of subjects, with a p-value of less than 0.0001. underweight patients were 6 (3.4%), normal Hypothyroidism was reported in 13 (7.3%) cases, weight patients were 90(50.3%), 51(28.5%) were 26 (14.5%) had hyperthyroidism and subclinical having weights above the appropriate level and hyperthyroidism was found in only 11 (6.1%) 32(17.9%) patients were in the obesity range. In patients. The controls had subjects with normal control subjects, there were 21(11.7%) thyroid function. In cases a weak positive individuals who were underweight, 102 (57%) correlation was established between HbA1c and had optimum weights, 39 (21.8%) were in T3 (r=0.239, p-value = 0.001), little significant overweight range and only 17(9.5%) were in relation with T4 (r= -0.017, p-value = 0.817) and obesity range. The mean BM did vary a lot in correlation of lithe significance with that of TSH both cases and controls with a p-value of less (r= -0.036, p-value = 0.634). In second group than 0.002. The mean value of T3 in both the with normal subjects there was groups was 2.32 ± 5.02 and 1.07 ± 0.44, while
Table 1: Comparison of Age, Weight, Height, Bl, T3, T4, TSH and Glycosylated Hb in Cases and Controls Study Group Mean S.D Median S.D p-valuea
Cases (n=179) 54.35 ± 9.38 55 ± 11 Age (years) Control (n=179) 42.66 ± 9.20 39 ± 12 <0.0001
Cases (n=179) 68.87 ± 12.60 68 ± 20 Weight (kg) Control (n=179) 71.36 ± 10.14 70 ± 13 0.038
Cases (n=179) 1.64 ± 0.12 1.64 ± 0.18 Height (m) Control (n=179) 1.76 ± 0.18 1.77 ± 0.21 <0.0001
Body mass index (BMI} Cases (n=179) 25.73 ± 5.34 24.73 ± 6.58 <0.0001 Cases (n=179) 2.32 ± 5.02 1.11 ± 0.49 T3 Control (n=179) 1.07 ± 0.44 1.01 ± 0.2 <0.0001
Cases (n=179) 9.24 ± 3.98 8.63 ± 3.94 T4 Control (n=179) 7.01 ± 1.59 6.8 ± 1.4 <0.0001
Cases (n=179) 1.24 ± 1.48 0.900 ± 1.19 TSH Control (n=179) 2.33 ± 1.02 2.3 ± 1.23 <0.0001
Cases (n=179) 6.44 ± 2.81 6 ± 3.7 Glycosylated Hb Control (n=179) 5.28 ± 2.87 4 ± 0.9 <0.0001 a: as data was not normal, so Mann Whitney U test was applied relationship of minor significance statistically both cases and controls, a positive correlation between HbA1C and T3 (r = 0.070 p-value = was found between HbA1c and thyroxine with a 0.352), weak significant correlation with T4 with a p-value of less than 0.001. p value of 0.001 and correlation with TSH with a p-value of less than 0.001. Combined result of
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JGMDS Table 2: Comparison of Thyroid Status in Both Study Groups Study Group Total p-value Cases Control 129 179 308 Normal 72.1% 100.0% 86.0%
13 0 13 < 0.0001
Hypothyroid 7.3% .0% 3.6% Thyroid status 26 0 26 Hyperthyroid 14.5% .0% 7.3% 11 0 11 Subclinical Hyperthyroid 6.1% .0% 3.1% 179 179 358 Total 100.0% 100.0% 100.0%
Table 3: Correlation of T3, T4 and TSH with GIycosyIated Hb
Controls (n=179) Overall (n=358) Cases (n=179)
Glycosylated Hb Glycosylated Hb Glycosylated Hb Pearson Pearson Pearson p-value p-value p-value Correlatio Correlatio Correlatio T3 n 0.239** 0.001 0.07n 0.352 n0.2 <0.001 T4 -0.017 0.817 0.238** 0.001 0.117 0.0127 TSH -0.036 0.634 -0.586** <0.001 -0.311 <0.001
DISCUSSION: A research was carried out to determine the occurrence of thyroid dysfunction in type-2 Thyroid dysfunction is divided into clinical and diabetics. The result showed a low level of T3 subclinical states, depending on the titre of and T4 and high level of TSH when it was hormones and clinical presentation having an compared with non-diabetic healthy subjects. impact on follow-up and treatment plans In the study there were fifty diabetic subsequently. In diabetics, thyroid disease is participants, 30% presented had abnormal more common when compared with the normal thyroid function tests. Therefore, it was proved population3. that there was a high incidence of thyroid dysfunction in diabetic population11. A study was done retrospectively in 2015 in Riyadh to find out (1) the serum levels of thyroid Swamy et al, did a research and found that out function tests as well as HbA1c in diabetics, (2) of 58 patients having type-2 diabetes, 7 (12.06%) correlation between thyroid function tests and of them presented with hypothyroidism while 18 glycosylated hemoglobin. It involved 100 diabetic (31.03%) patients had hypothyroidism sub patients in both genders. Biochemical analysis clinically. There was a reduction in levels of T3 was obtained from laboratory while patients' and T4 while TSH concentration was enhanced information was accessed from ward files. in type-2 diabetes mellitus pati ents when Statistical analysis followed according to drawing comparison to controls. A significant standard practice. The results revealed a high statistical difference was seen with T4 and TSH level of HbA1c (8.4%) and Thyroid stimulating only with pvalue less than 0.001 15. Another hormone (TSH) (4.5 mlU/L) and T4 (14.1 pmol/L) study done in year 2012, focused on the were reported as normal. The result also prevalence of thyroid disorder in DM type 2 in proved a weak correlation between HbA1c and Manipur, India. A sample size of 202 subjects TSH with p-value of 0.034 and insignificant having type-2 diabetes was taken and among relation with that of thyroxin T4 with p-value of those 139 (68.8%) were clinically euthyroid. In 0.855. Lastly, it also showed that increase in total 61 were males and 141 were females. 33 blood glucose level in serum could set off (16.3%) had hypothyroidism in subclinical state hypothalamus in pituitary to cause enhanced (10 males and 23 females), 23 (11.4%) were TSH secretion14. reported to have hypothyroidism (6 males and
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17 females), increased thyroid hormone levels Premchand, Devi IS, et al. Thyroid status in sub-clinically were found in 4 (2%) and only 3 diabetes mellitus. J Glycomics Lipidomics. (1.5%) case had full blown hyperthyroidism. 2013;3(1):1-4. doi: 10.4172/2153-0637.100010 Increased cases of hypothyroidism were noted in middle-aged group and in overweight individuals 6. Kadiyala R, Peter R, Okosieme OE. Thyroid with BMI above 2516. Another retrospective study dysfunction in patients with diabetes: clinical at Puducherry India showed a high percentage of implications and screening strategies. Int J thyroid dysfunction in patients with diabetes. Clin Pract. 2010;648:110)-9. doi: Among 200 patients, 57 (25.5%) had altered 10.1111/j.1742 241.2010 .02376.x. thyroid function, showing the interrelationship 17 between the two diseases . 7. Ghazali SM, Abbiyesuku FM. Thyroid Singh et al ascertained the occurrence of thyroid dysfunction in Type 2 diabetics seen at the disorder in type-2 diabetics and concluded that University College Hospital, Ibadan, Nigeria. out of total 80 diabetic patients, 30% had altered Niger J Physiol Sci. 2010;25(2): 173-9. thyroid hormones levels (23.75% had hypothyroidism and 6.25% with 8. Nagaraju K, Pirouz A, Sadeghi T, Esmaeili P. hyperthyroidism)18. Thus, it demonstrates that in Prevalence of thyroid dysfunction and its diabetic population there is a high prevalence of management in diabetic patients attending hypothyroidism warranting regular monitoring in outpatient clinic of KIMS hospital. Int Res J such patients. Apart from studies described Pharm. 2013;4(9):132-5. doi: 10.7897/2230- above, another study was done to ascertain the 8407.04928 . frequency of thyroid disorder in diabetics and found increased blood levels (46.5%) of 9. Taksali R, Bindu SM, Mulay S. Evaluation of deranged thyroid hormones in the Nigerian thyroid dysfunction in Type 2 diabetes mellitus: diabetic patients. Among females (16.8%) there a case control study. Int J Curr Med Appl Sci. was an enhanced occurrence of hypothyroidism 2013;1(1):16-20. as compared to men (9.9%)19. 10. Wang C. The relationship between Type 2 diabetes mellitus and related thyroid diseases. CONCLUSION: J Diabetes Res. 2013;390534. doi: From this study it is concluded that thyroid 10.1155/2013/390534 dysfunction is common in Diabetics and there is need for screening in such patients/cases. 11. Vikhe VB, Kanitkar SA, Tamakuwala KK, Gaikwad AN, Kalyan M,Agarwal RR. Thyroid
dysfunction in patients with Type 2 diabetes REFERENCES: mellitus at tertiary care centre. Natl J Med 1. Rai S,Ashok Kumar J, Prajna K,Shetty SK, Rai Res. 2013;3(4):377-80 . T, Shrinidhi, et al. Thyroid function in Type 2 diabetes mellitus and in diabetic nephropathy. 12. Begum HA, Islam KS, Hassen MR, J Clin Diagn Res. 2013;7(8):1583-5. doi: Monirujjaman M,Ahmed S. Co-occurrence of 10.7860/ JCDR /2013/6216.3299. Type 2 diabetes mellitus and thyroid metabolic disorders in Bangladeshi population. Sch J 2. Yadav S, Saldhana A, Majumdar B. Status of Appl Med Sci. 2014;2(2B) :605-12. thyroid profile in Type-2 diabetes mellitus. JoNMC [Internet). 2012 [cited 26 Jan 13. Raj PP, Palanivelu C. Guidelines for bariatric 2019);1(2):72-6. Available from: (metabolic) surgery for Indian population. In A https://www.nepjol.info/index.php/JoNMC/articl Muruganathan, editor. Medicine update e/view/7302 (Volume 23). 1st ed. JPB; 2013. p.750-52. http://www.apiindia.org/medicine_update_2013/c 3. Al-Geffari M, Ahmad NA, Al-Sharqawi AH, hap172.pdf (accessed on 5th December Youssef AM, Al-Naqeb D, Al-Rubeaan K. Risk 2014). factors for thyroid dysfunction among Type 2 diabetic patients in a highly diabetes mellitus 14. Karar T, Alhammad RI, Fattah MA, Alanazi A, prevalent society. Int J Endocrinology. Qureshi S. Relation between glycosylated 2013;417920. doi: 10.1155/2013/417920. hemoglobin and lipid and thyroid hormone among patients with Type 2 diabetes mellitus 4. Kalra S. Thyroid disorders and diabetes. J Pak at King Abdulaziz Medical City, Riyadh. J Nat Med Assoc. 2014;64(8):966-8. Sci Biol Med. 2015;6(Suppl 1): S75-S79. doi: 10.4103/0976-9668.166091. 5. Bharat, Hijam D, Gangte D, Lalnunpui, March 2019 – September 2019 J Gandhara Med Dent Sci | 25
JGMDS 15. Swamy RM, Kumar N, Srinivasa K, Manjunath J Adv Med. 2018;5(4):822-4. doi: GN, Prasad Byrav OS, Venkatesh G. 10.18203/2349-3933.ijam20182445. Evaluation of hypothyroidism as a complication in Type 2 diabetes mellitus. Biomed Res. 18. Singh G, Gupta V, Sharma AK, Gupta N. 2012;23(2):170-2. Evaluation of thyroid dysfunction among Type 2 diabetic Punjabi population. Adv 16. Demitrost L, Ranabir S. Thyroid dysfunction in Biores. 2011;2(2):3-9. Type 2 diabetes mellitus: a retrospective study. Indian J Endocrinol Metab. 19. Udiong CE, Udoh AE, Etukudoh ME. 2012;16(Suppl 2): S334-5. doi:10.4103/2230- Evaluation of thyroid function in diabetes 8210.104080. mellitus in Calabar, Nigeria. Indian J Clin Biochem. 2007;22(2):74-8. doi: 17. Hussain KSA. Thyroid dysfunction in 10.1007/BF02913318. patients with diabetes mellitus at Puducherry, India: a retrospective study. Int
CONTRIBUTORS
1. Ayesha Qaisar - Concept & Design; Data Acquisition ; Data Analysis/Interpretation; Drafting Manuscript 2. Riffat Sultana - Critical Revision; Supervision;Final Approval 3. Jibran Umar Ayub Khan - Data Acquisition; Drafting Manuscript; Critical Revision
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PREVALENCE OF REFRACTIVE ERRORS AMONG THE CHILDREN OF SPECIAL EDUCATION COMPLEX, PESHAWAR
Bismah Saleem1, Naeem Ullah2, Hamid Hussain1, Ayaz Ayub1, Muhammad Hamayun Khan1 1. Khyber Medical Un versity,Peshawar 2. Swat Med cal College, Swat
ABSTRACT: OBJECTIVES : The objective of our study was to determine the prevalence of refractive errors among children of special education complex.
METHODOLOGY: A cross-sectional study was conducted to determine refractive error among the children of special education complex Hayatabad, Peshawar. A total of 272 children were examined from age 5-19 years. Refractive errors were determined by doing retinoscopy, subjective and objective refraction, ophthalmoscope and, hand held auto refractors. Snellen's charts, lea symbol chart and kay pictures were used for assessing the visual acuity in children who could cooperate.
RESULTS: Among 272 children, 225 children were males (82.7%). 34(12.5%) were mentally retard, 182(66.9%) were hearing impaired and 56(20.6%) were physically handicapped. Children suffering from refractive errors were 47(17.3%). 11(4.0%) reported that they were using glasses. Squint was present in 5(1.8%). On examination status of right eye 5(1.8%) were with visual acuity 6/60 or less. For children who were unable to comprehend with Snellen visual acuity chart, they were be assessed by using other charts like Lea symbol chart or Kay pictures. 19(7.0%) were assessed by Lea symbol chart, 9(3.3%) by Kay pictures and maximum number of children easily understand Snellen visual acuity chart that was 244(89.7%).
CONCLUSION: This study concluded that refractive errors were common in special children.
KEYWORDS: Refractive Errors, Strabismus, Children, Snellen’s Chart, Visual Acuity
INTRODUCTION: Ocular and visual disorders such as refractive errors, strablsmus, nystagmus, cataract, reduced Visual Impairment is a major public health visual acuity and poor accommodation are found problem. Worldwide prevalence of myopia and 1 to be more common in children with Intellectual presbyopia has dramatically increased . Low 7 disabilities than in typically developing children . vision is the main cause of visual impairment and the second leading cause of Blindness2. Consanguineous marriages together with Worldwide 285 million people are visually environmental factors and maternal Infections impaire3. have high Incidence for developmental I According congenital abnormalities in children. Other to causes include trauma, nutritional factors of American childhood blindness, Vitamin A deficiency, Blindness, corneal scaring, trachoma and ophthalmia https://doi.org/10.37762/jgmds.5-2.84 one in four neonatorum and use of harmful traditional school age children have vision problems and if it practices8. is not treated than it will affect their personality, learning ability and adjustment in school4. A study was done by two optometrists in special Children with special educational needs are education schools in Wales, UK to identify the more likely to have refractive errors and visual visual status and ocular disorders. From this impairment than normal chlldren5. The main study, 05 out of 44 schools' children presented 5 function to provide proper education to special with refractive errors and low vision . children is important. Education is about to Another study was conducted in Nigeria, the develop cognitive, moral, spiritual, Imaginative, children with low income were more affected by mentally, social, emotional, aesthetic and ocular diseases. About 10% of students were physical aspects6. found with abnormal ocular findings9.
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JGMDS A study was carried out in Hualien, Taiwan Literature search showed no specific work on showed that 35.4% children suffered from prevalence of refractive errors in special refractive error and the prevalence of ocular education schools in Pakistan. Although disorder was more common in multiple disability literature is available regarding prevalence of than the simple intellectual disability group10. refractive errors in others schools. Due to lack of awareness these special children need extra In India, a study was conducted in children from need, attention and care if these children are not 11 special schools of learning disabilities. The observed at early age than they lead to severe eye examination was done by ophthalmologist. eye problems. In Khyber Pakhtunkhwa there are Half of the children suffer from refractive errors many special education schools but none has and one fourth had their vision improved with 11 focused on these schools. Our objectives were glasses . to determine the prevalence of refractive errors One study was done in Iran that compared and strabismus among students of special children with hearing impairment with different education complex. eye problems. In deaf children, vision is one of METHODOLOGY: the important senses used. This study simply demonstrated that the deaf children have A cross sectional study was carried out. A total number of 272 children were selected. The age significantly more eye problems as compare to group selected 5-19 years. Age was divided into normal children, and the possible relation found 3 groups i.e. 5-9 years age group, 10-14 years was between deafness and eye problems. If age group and 15-19 years age group. Data was proper treatment and attention is given to these collected from special education complex, children than these eye problems can easily be 12 Hayatabad, Peshawar through a convenience cured . simple. Many previous studies demonstrated that vision All the children registered in daily attendance impairment and hearing influence the activities of sheet of special education complex of Peshawar daily living (ADL). Hearing and visual impairment were selected. Children having hearing increase the risk of fear of falling, fall, feeling impairment, mentally retarded and physically unsafe, reduced social participation, dependency handicapped were included. Blind students were and also the main difficulty in daily life excluded from the study. activities8,13-15. Data was collected after approval by Graduate Aden the city of Yemen conducted a study on Committee, Advanced Scientific Research Board deaf and dumb students having ocular (ASRB) of Khyber Medical University and from abnormalities. The leading abnormality was social welfare department of Khyber refractive errors, Waardenburg syndrome and Pakhtunkhwa. An informed consent and history pigment epithelium patches were seen in this from the parents of children, children and 16 study . Ovenseri-Ogbomo G, Abraham C teachers was taken. Ocular examination was carried out a study of ocular findings and visual carried out with retinoscope, ophthalmoscope impairment among hearing and deaf children. and flash light. Snellen's E chart, Kay symbols Astigmatism is the commonest form of refractive were used for assessing the visual acuity in 17 error in this study . children who could read and cooperate. In Lahore, a cross sectional study was For descriptive statistics scale variables i.e. age conducted. High schools' children taken from (in years), mean and standard deviation were th th class 6 to 10 were targeted. The result shows calculated while for categorical variables i.e. that myopia and astigmatism was more common gender, frequencies and percentages were 18 in children than hypermetropia . calculated by SPSS Version 23. Prevalence of refractive errors and strabismus is a major public health issue in Pakistan.
RESULTS: Mean age presentation was 12 ± 5.9 years.
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Table 1: Demographics of the Students in Special School of Peshawar Age Groups Frequency Percentage 5 to 9 years 90 33.08 10 to 14 years 93 34.2 15 to 19 years 89 32.72 Gender Frequency Percentage Male 225 82.7 Female 47 17.3 Class Frequency Percentage Primary 129 47.4 Middle 61 22.4 Higher 82 30.1
Table 2: Children Presented with Abnormality Children Presented with Abnormality Frequency Percentage Mentally retard 34 12.5 Hearing impairment 182 66.9 Physically handicap 56 20.6
Table 3: Presence of Refractive Errors in the Special Children Presence of Refractive Errors Frequency Percentage Yes 47 17.3 No 225 82.7
Table 4: Distribution of Study Variables Children Using Glasses Frequency Percentage Yes 11 4.0 No 261 96.0 Squint Present Frequency Percentage Yes 5 1.8 No 267 98.2
This study was conducted to determine the Woodhouse JM et al. in their study in special refractive errors of the special children. schools of Wales documented that astigmatism Esotropia was more common type of squint but is more common than myopia and hyperopia a smaller number of children were affected by while myopia is common in our study. strabismus. Puri S et al7, in their study on ocular Esotropia is common in their study; other ocular and visual disorders among children with abnormalities were also present like cataract, intellectual disability studying in special schools hazy cornea, blepharitis, in their study which of Nepal, showed that females were more may not be documented in our study due to common than males. Maximum numbers of age factor. children were in the age group of 5 to 9 years Joshi RS and Somani AAK, in their study in and minimum number of children in age group children with mental disorder in India age 10 to 14 years. This study contradicts our study group was 6 to 16 years documented that in which N = 225(82.7%) were more than myopia was more common in mentally females N = 47(17 .3%) and a greater number of retarded children than myopic and children were in 10-14 years age group N = astigmatism. The children with increased 93(34.2%). March 2019 – September 2019 J Gandhara Med Dent Sci | 29
JGMDS mental level had more refractive errors and 6. NCSE. Children with special educational other ocular abnormalities. Strabismus was needs: information booklet for parents. also common in their study8. Trim County Meath: National Council for Another study which was carried by lsawumi M Special Education; 2014. and Akinsola F in special schools of Osun 7. Puri S, Bhattarai D,Adhikari P, Shrestha state of Nigeria. Refractive errors were more JB, Paudel N. Burden of ocular and common, but the cause of blindness and visual disorders among pupils in special visual impairment was due to corneal diseases schools in Nepal. Arch Dis Child. 9 while we excluded blind in our study . 2015;100(9):834-7. CONCLUSION: 8. Joshi RS, Somani AAK. Ocular disorder The study concluded that refractive errors in children with mental retardation. were common in special children. The children Indian J Psychiatry. 2013;55(2):170-2. with refractive errors were mainly boys. 9. lsawumi M, Akinsola F. Ocular health LIMITATIONS: status and causes of enrolment into special schools in Osun State, Nigeria. More children were taken from the primary Zahedan J Res Med Sci. class of the special education complex and 2016;18(12):e4960. doi: 10.17795/zjrms- male were in higher number in the sample 4960. size. Due to these limitations the results may not be anticipated globally. 10. Tsao WS, Hsieh HP, Chuang YT, Sheu MM. Ophthalmologic abnormalities among RECOMMENDATIONS: students with cognitive impairment in Arrangements need to be ensured to examine eastern Taiwan: the special group with the children for periodic yearly assessment undetected visual impairment. J Formos inclusive of ophthalmology. Special school Med Assoc. 2017;116(5):345-50. doi: need to take the cases for corrective 10.1016/j.jfma.2016.06.013. measures. 11. Gogate P, Soneji FR, Kharat J, Dulera REFERENCES: H, Deshpande M, Gilbert C. Ocular disorders in children with learning 1. Public Health Research [Internet].[cited disabilities in special education schools 2017 Jul 10]. Available from: of Pune, India. Indian J Ophthalmol. https://www.brienholdenvision.org/publich 2008;59(3):223-8. Available from: ealth/public-health-research.html http://www.pubmedcentral.nih.gov/articlere 2. Pearce MG, Pearce N. Addressing n refractive error visual impairment: der.fcgi?artid=3120244&tool=pmcentrez&r volunteer organisations' alignment with endertype=abstract Vision 2020 and public health principles. 12. Ostadimoghaddam H, Mirhajian H, Clin Exp Optom. 2012;95(6):583-9. doi: Yekta A, Sobhani Rad D, Heravian J, 10.1111/j.1444-0938.2012.00710.x . Malekifar A, et al. Eye problems in 3. World Health Organization. Visual children with hearing impairment. J Curr impairment and blindness [Internet]. Ophthalmol. 2016;27(1-2):56-9. doi: Geneva: World Health Organization; 2016 10.1016/j.joco.2015.10.001. [cited 2019 Feb 25]. 13. Dhungana AP. Ocular morbidity in hearing 4. Vision problems of school-age children impaired school children in Eastern Nepal. [Internet]. [cited 2017 Jul 12). Available J Kathmandu Med Coll. 2014;3(1):4-7. from: 14. Ahmed A,Abah E, Oladigbolu K. Hearing http://www.allaboutvision.com/parents/sch and audiometric estimates in a blind oolage.htm population in North-Western, Nigeria. 5. Woodhouse JM, Davies N, McAvinchey Sub-Saharan African J Med. 2016;3(1):8. A, Ryan B. Ocular and visual status Available from: among children in special schools in http://www.ssajm.org/text.asp?2016/3/1/8/17 Wales: the burden of unrecognised 6294. visual impairment. Arch Dis Child. 15. Chukwuka I, Adio A, Chinawa N. 2014;99(6):500-4. Screening for ophthalmic disorders among 30 | J Gandhara Med Dent Sci January-March 2021
JGMDS
deaf school children in Nigeria: a 17. Ovenseri-Ogbomo G, Abraham C, Kio F. neglected population. Ophthalmol Res Visual impairment and ocular findings An Int J. 2016;5(4):1-6. Available from: among deaf and hearing impaired school http://sciencedomain.org/abstrac/14388 children in Central Region, Ghana. J Med Biomed Sci. 2013;2(2):16-22. 16. Salem RA, Basaleh SS, Mohammed SF. Ocular abnormalities among deaf students in 18. Ali A, Ahmad I, Ayub S. Prevalence of Aden City, Yemen. Iraqi J Med Sci. undetected refractive errors among school 2014;12(3):144-7. children. Biomedica.2007;23:96-101.
Contributors 1. Bismah Saleem - Concept & Design; Data Acquisition; Data Analysis/Interpretation; Drafting Manuscript; Final Approval 2. Naeem Ullah - Data Analysis & Interpretation, Drafting Manuscript, Critical Revision 3. Hamid Hussain - Concept & Design; Data Acquisition; Data Analysis/Interpretation; Drafting Manuscript; Supervision; Final Approval 4. Ayaz Ayub - Concept & Design; Critical Revision; Supervision; Final Approval 5. Muhammad Hamayun Khan - Concept & Design; Data Analysis/Interpretation; Drafting Manuscript
Data collected was emailed to all the co-authors for analysis, interpretation, discussion and review.
Corrigendum In the issue of JGMDS, Volume: 05, No: 01; the name of the editor Aneela Ambreen in the "Editorial Board" was aberrantly printed by incorrect spellings.
Obituary The Editors, Editorial and Advisory Board members of JGMDS mourn the loss of the journal's Advisory Board Member, Dr. Riaz Gui, who passed away on the 12 of February, 2019.
March 2019 – September 2019 J Gandhara Med Dent Sci | 31
JGMDS
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32 | J Gandhara Med Dent Sci January-March 2021
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JGMDS 6-10 references. There should be relevant relevance, statistical methods, significance, documentary prove including pictures or adequacy of documentation, reader interest and investigations with the consent of the patients, composition. Every paper will be read by at least should be submitted along with the manuscript. two staff editors of the Editorial Board. The papers selected will then be sent to two external LETTER TO THE EDITOR reviewers. If statistical analysis is included, It should provide publication that does not further examination by a staff statistician will be contain material which has been submitted or carried out. The ultimate authority to accept or published elsewhere. The letter must be double reject the manuscript rests with the Editor. We space with no references and should not exceed use Open and Blind Review Policy. 200 words. If it is regarding recent journal article, PUBLICATION AND DISTRIBUTION the references should not exceed more than five and one figure or table. The letters regarding Journal of Gandhara Medical and Dental recent articles should be received within one Sciences is published based on controlled month of its publication. circulation and distributed among the faculty of Include your complete address, contact number, all medical and dental departments of Gandhara fax number and email address. University Peshawar. The journal will be published and circulated to libraries, institutes AUTHORS GUIDELINES and clinics throughout Pakistan and abroad. The guidelines should be followed which are available in the Agreement Form as "Authors All rights of Journal of Gandhara Medical and Checklist". Dental Sciences are reserved. No part of this publication may be reproduced, stored in a PLAGIARISM retrieval system, or transmitted in any form or by We endorse committee of publication ethics any means, electronic, mechanical, COPE (www.cope.org), ICMJE (www.icmje.org), photocopying (except for internal or personal Pakistan Association of Medical Editors (PAME), use) without the prior permission of the and Higher Education Commission (HEC) publisher. The publication and the members of (www.hec.gov.pk) policies regarding plagiarism. the editorial board cannot be held responsible for The author is responsible to ensure that the work errors or for any consequences arising from the submitted is original literary work, given due use of the information contained in this journal. credit by providing appropriate citations to the words and work of others. Plagiarism is Journal of Gandhara Medical and Dental deemed unethical publishing conduct and Sciences publication is biannual, and for every unacceptable. According to HEC policy, the published work, copies of the journal will be similarity index of more than 19% will be supplied free of cost to the principal author and rejected. co-author(s). Additional copies of the journal can PEER REVIEW be obtained from publication office JGMDS. There are no submission/processing/ Journal of Gandhara Medical and Dental subscription charges till date. Sciences is a peer reviewed journal. We use Open and Blind Review Policy. Submitted manuscripts are reviewed for originality,
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35 | J Gandhara Med Dent Sci January-March 2021
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