JDUHS

Volume 4, Issue 1 January - April, 2010

EDITORIAL BOARD

Editor-in-Chief Editor Associate Editors Assistant Editor Masood Hameed Khan Nazeer Khan Mohammad Rafiq Khanani M. Abdul Wahid Usmani Rana Qamar Masood

Managing Editor Members Bibliographer Zahid Mirza Nazli Hossain Shahbaz Ahmed S. M. Zahid Azam

ADVISORY BOARD National International Abdul Gaffar Billoo Adeel A. Butt (USA) Adnan Ahmed Khan IIyas Kamboh (USA) Aisha Mehnaz Mansour Mohammad Al-Nozha (Saudi Arabia) Dure-Samin Akram Muhammad Sameer Qureshi (UK) Fazal Ghani Nizam Damani (USA) Mohammad Nawaz Anjum Osman Mohammed Ahmed Taha (Sudan) Muhammad Saeed Shafi Sultan Ahmed (USA) Saeed Farooq Sina Aziz Syed Ali Anwar Naqvi Syed M. Wasim Jafri Talat Mirza Waris Qidwai

Recognized by the Pakistan Medical and Dental Council. Registration No. IP/036 Indexed in IMEMR, PakMediNet and Global Health The JDUHS is published 4 monthly by the Dow University of Health Sciences Editorial correspondence should be addressed to : The Editor-in-Chief, JDUHS, Dow University of Health Sciences, Baba-e-Urdu Road Karachi-74200, Pakistan. Tel : 9215754-57 Fax : 9215763 E-mail : [email protected], Website : www.duhs.edu.pk Annual subscribtion rates: In Pakistan : Rs. 450, Bangladesh & India: Rs. 600, UK : £ 15, U.S.A and other countries: US$ 15 Published by : The Registrar, Dow University of Health Sciences (DUHS), Karachi-74200, Pakistan i JDUHS

Volume 4, Issue 1 January - April, 2010

EDITORIAL Page No.

Diarrheal Disease: Major killer of Children, New Development Abdul Gaffar Billoo 1

ORIGINAL ARTICLE

Perception of Medical Students on Structured Viva Examination Anila Jaleel and Noreen Jaffrey 4 In an Integrated Undergraduate Curriculum at Ziauddin University

Detection of Peripheral Arterial Disease (PAD) in Diabetics using Khatoon Akhtar Bano, Naheed Hashmat , 8 Ankle Brachial Index (ABI) Asia Batool and Shameem Ahmad Siddiqui

Phenomena of Physical Activity in with Myocardial Infarction Shazia Azeem and Nazeer Khan 13 Patients of Karachi, Pakistan

Morbidity, Co-Morbidity Profile and Disability Status Among Yasmin Mumtaz, Hira Riaz, Muhammad Arsalan, 19 Elderly in Civil Hospital Karachi Sana Akhtar, Hareem Haider and Wajiha Manzoor

Current Pattern of Bloodstream Infections in a Tertiary Care Farhan Essa Abdullah, Yasmeen Taj 25 Hospital of Karachi and Clinical Significance of Positive Blood and Shaheen Sharafat Cultures

Contusion Index: Its Importance In Management of Traumatic Atiq Ahmed Khan, Muhammad Aslam, 31 Brain Contusions Muhammad Imran, Muhammad Muzaffaruddin, Irfanullah Shah and Junaid Ashraf.

CASE REPORT

Knotting of Urethral Catheters: a Preventable Complication Muhammad Shahab Athar, Muhammad Sajjad Ashraf, 38 Muhammad Talat Mehmood and Shero Moti

Pulmonary Alveolar Microlithiasis Nisar Ahmed Rao and Arsalan Ahmed 40

SHORT COMMUNICATION

Frequency of Smoking Among Employees at a Tertiary Care Ashfaq Ahmed Memon, Muhammad Ayaz Mustufa and 43 Children Hospital, Karachi Muhammad Ashfaq

ACKNOWLEDGEMENT OF REVIEWERS iii

INSTRUCTIONS TO AUTHORS vi

ii EDITORIAL Diarrheal Disease: Major killer of Children, New Development Abdul Gaffar Billoo

Disease Burden

Diarrheal disease is one of the biggest causes of childhood To alleviate the state of child health in resource poor mortality and morbidity in developing countries of the settings in developing countries, the World Health world. Organization (WHO) and the United Nations International Children’s Emergency Fund (UNICEF) presented the Diarrhea accounts for about 1.5 million deaths annually, Integrated Management of Childhood Illness (IMCI) 1 making up about 15 to18% of global under-5 mortality. algorithm in 1995 which is a comprehensive strategy to In the Eastern Mediterranean region, diarrhea accounts treat and prevent childhood illnesses and institute referrals for 17% of under-5 deaths.2 According to the Pakistan on detection of specific danger sings5. Diarrheal disease Demographic and Health Survey 2006-2007, diarrhea is also covered in IMCI,which provides simple guide accounts for 10.9% of deaths under the age of 5.3 Concurrent factors such as malnutrition and poor access lines for assessment and management of diarrhea to to rehydration are responsible for the majority of these improve the effectiveness of community health workers 5 deaths. Malnutrition is concurrently present in 54% of all and primary physicians. diarrhea-related deaths 4 (see Fig. 1). A detailed history and complete physical examination remain vital. The most important aspect of the management This emphasizes the great importance of nutritional status of a patient with diarrhea is to assess and classify the in determining the outcome of illness, particularly in a degree of dehydration. The emphasis is on replacement diarrheal episode. of fluid loss with ORS and homemade fluids with continued feeding. Fluid replacement guidelines are simplified based on whether the patient has NO 18% 25% dehydration, SOME dehydration or SEVERE dehydration, requiring treatment PLAN-A, PLAN-B or PLAN-C respectively.5 These guidelines have resulted in huge reduction in diarrhea related global mortality, from 4.5 deaths associated million to 1.5 million deaths annually, in last two decades. with mainutrition 15% 54% New Developments 1:- Improved Low osmolarity ORS 23% 10% Evidence suggests that efficacy of ORS solution for 4% 5% treating children with acute non-cholera diarrhea is Major causes of death among children under five in developing countries, 2002 improved by reducing its sodium concentration to 75mEq/L from 90 mEq/L, glucose concentration to

Acute respiratory infections HIV/AIDS 75mmol/L from 111 mEq/L and total osmolarity to Diarrhoca Perinatal 245 mosm/L from 311 mosm/L. (See Table no. 1).The Malaria Other Measles 245 mosm/L solution also appeared to be as safe and at least as effective as standard ORS for use in children with diarrhea. A systematic review of 15 randomized controlled Correspondence: Dr. Abdul Gaffar Billoo, Professor and Chairman of Paediatrics, trials concluded that in children admitted to hospital with Aga Khan University Hospital, Karachi, Pakistan. dehydration associated with diarrhea, reduced osmolarity E-mail: [email protected] Received: February 26, 2010: accepted: April 15, 2010. rehydration solution is associated with reduced need for

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 1-3 1 Abdul Gaffar Billoo fluids, lower stool volume, and less vomiting compared perspective, use of zinc as adjunct therapy has been shown with standard WHO rehydration solution.6 to have significantly improved the cost-effectiveness of standard management of diarrhea with particular benefitsin 14 With reduced osmolarity ORS having established its role mortality rates in non-dysenteric diarrhea. Zinc has been in improving outcomes in children with diarrhea, the latest demonstrated to be equally useful in the Pakistani WHO guidelines now recommend that countries use the population. A triple-blinded randomized trial conducted in following formulation in place of previously recommended an urban slum in Karachi concluded that daily provision ORS solution (See Table No. 1).Previous formulations of of micronutrients (including zinc) reduced the longitudinal ORS are now to be replaced by the new ones, and to avoid prevalence of diarrhea and thus reduced diarrhea related confusion, the new formulation is now to be simply referred mortality in young children.15 7, 8 to as ‘ORS’ Based on these findings, WHO and UNICEF(2004) issued a joint statement on the clinical management of 2:- Zinc in treatment of diarrhea diarrhea which recommends that, along with increased fluids, Low Osmolarity ORS , and continued feeding, Most children dying of diarrhea are also malnourished and all diarrheic children be given 20 mg per day of zinc have associated micronutrient deficiency. Children with supplementation for 10-14 days (10 mg per day for marginal nutritional status are at significant risk of infants below six months of age).16 aggravating zinc depletion with diarrheal episodes. 9 Daily losses of zinc in the intestinal fluid during acute diarrhea are as high as 159ug/kg/day compared with 47ug in control CONCLUSION AND group.10 Zinc deficiency also impairs cellular and humoral RECOMMENDATION immune function with zinc supplementation improving immunity. Zinc deficiency also has direct effects on the Diarrhea continues to be a significant cause of morbidity gastrointestinal tract such as impaired intestinal brush border, and mortality in Pakistani children, and reducing incidence increased secretion in response to bacterial enterotoxins 11 of diarrhea would have a significant impact in helping and a breakdown in intestinal permeability reduce child mortality, and in turn, achieving MDG-4. Low osmolarity ORS should replace existing With this biological basis, zinc has been studied in numerous formulations, AS SOON AS POSSIBLE and should be trials and a meeting held in New Delhi in May 2001, which widely distributed in the community. reviewed all studies conducted on effectiveness of zinc concluded that zinc supplementation given during an episode All children with diarrhea should be given ZINK of acute diarrhea significantly reduced the duration and SUPPLEMENTATION along with increased fluid and severity of the episode.12 In six of nine trials that evaluated continued feeding. prevention of diarrhea significantly, analysis demonstrated 18% less diarrhea.13 From a program implementation PREVENTION OF DIARRHEA TO REDUCE THE BURDEN OF THE DISEASE. COMPOSITION OF REDUCED OSMOLARITY ORS Advocacy for BREAST FEEDING, especially exclusive Reduced osmolarity ORS grams/litre breast feeding for 6 months, should be continued and sodium chloride 2.6 strengthened. Glucose, anhydrous 13.5 Potassium chloride 1.5 HAND WASHING has proved to be the most cost effective Trisodium citrate, dihydrate 2.9 intervention for prevention of diarrheal diseases. Total weight 20.5 Reduced osmolarity ORS mmol/litre Rotavirus vaccination should be seriously considered for Sodium 75 introduction as part of universal EPI coverage. Chloride 65 Glucose, anhydrous 75 Putting these recommendations in place would have a Potassium 20 significant impact in improving the health status of Pakistani Citrate 10 children. Further research is required to devise strategies Total osmolarity 245 and programs that would lower mortality even further.

2 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 1-3 Diarrheal disease: major killer of children, new development

REFERENCES 9. Golden BE, Golden MH. Plasma zinc and the clinical features of malnutrition. Am J Clin Nutr 1979; 32:2490-4. 1. Black RE, Morris SS, Bryce J. Where and why are 10 million children dying every year? Lancet 2003; 361:222-34. 10. Castillo-Duran C, Vial P, Uauy R. Trace mineral balance during acute diarrhea in infants. J Pediatr 1988; 113:452-7. 2. Bryce J, Boschi-Pinto C, Shibuya K, Black RE. WHO estimates of the causes of death in children. Lancet 2005; 11. Sempertegui F, Estrella B, Correa E, Aguirre L, Saa B, 365:1147-52. Torres M, et al. Effects of short-term zinc supplementation on cellular immunity, respiratory symptoms, and growth of 3. Pakistan Demographic and Health Survey 2006-07. malnourished Equadorian children. Eur J Clin Nutr National Institute of Population Studies and Macro 1996; 50:42-6. International Inc.; 2008.

4. Caulfield LE, de Onis M, Blossner M, Black RE. 12. Castillo-Duran C, Heresi G, Fishberg M, Uauy R. Controlled trial of zinc supplementation during recovery from Undernutrition as an underlying cause of child deaths malnutrition: effects on growth and immune function. Am assocated with diarrhea,, pneumonia, malaria, and measles. J Clinc Nutr 1987; 45:602-8. Am J Clin Nutr 2004; 80:193-8.

5. Integrated management of the sick child. Bull World Health 13. Fontaine O. effect of zinc supplementation on clinical Organ 1995; 73:735-40. course of acute diarrhoea. J Health Popul Nutr 2001; 19:339-46. 6. Department of Child and Adolescent Health and Development WH, Organization. Reduced osmolarity oral rehydration 14. Robberstad B, Strand T, Black RE, Sommerfelt H. Cost- salts (ORS) formulation – report from a meeting of experts effectiveness of zinc as adjunct therapy for acute childhood jointly organized by UNICEF and WHO diarrhoea in developing countries. Bull World Health Organ (WHO/FCH/CAH01.22). New York 2001. 2004: 82:523-31.

7. Hahn S, Kim Y, Garner P. Reduced osmolarity oral 15. Sharieff W, Bhutta Z, Schauer C, Tomlinson G, Z;ptlom S. rehydration solution for treating dehydration due to diarrhea Micronutrients (including zinc) reduce diarrhoea in children: in children: systematic review. BMJ 2001; 323:81-5. the Pakistan Sprinkles diarrhoea Study. Arch Dis Child. 2006; 91:573-9. 8. Duggan C, Fontaine O, Pierce NF, Glass RI, Mahalanabis D, Alam NH, et al. Scientific rationale for a change in the 16. WHO-UNICEF. Joint Statement on the Clinical Management composition of oral rehydration solution. JAMA 2004; of Diarrhoea. Geneva-New York; 2004. 291:2628-31.

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 1-3 3 ORIGINAL ARTICLE Perception of Medical Students on Structured Viva Examination in an Integrated Undergraduate Curriculum at Ziauddin University Anila Jaleel1 and Noreen Jaffrey2

ABSTRACT Introduction: Exponential growth of knowledge in the biomedical field has forced the medical educators for a change from traditional to integrated curriculum and conventional assessment techniques to newer structured techniques. Objective: Survey of medical students' views about the Structured Viva Examination (SVE) in an integrated curriculum. Methods: Feedback forms of Structured Viva Examination (SVE) were given to 144 students of first and second year MBBS (2008), after they completed their professional examination. SVE feedback form was categorized in the domains of agree, disagree and neutral with five different statements. Results: Out of 144 students 140 responded. One hundred and thirteen out of hundred and forty (80.71%) students agreed that the language of the cases was simple and easy to understand. One hundred and ten (78.57%) stated that the reading time of cases was adequate. One hundred and seven (76.42%) agreed that the time was adequately spaced between SVE stations. Hundred and one (72.14%) agreed that the examination was relevant with course content, while one hundred and two (72.85%) agreed that PBL in modules helped in interpreting such cases in their annual examinations. Conclusion: Educators need to explore newer assessment methods for better understanding of the health sciences with relevance to common disease.

Key words: Knowledge, conventional, professional examination, Structured Viva Examination.

INTRODUCTION Educational assessment is process of documenting, questioning which may have more than one correct answers usually in measurable terms, knowledge, skills, attitudes (or more than one way of expressing the correct answer) and beliefs. 1- 3 Assessment can focus on the individual Vivas have been used to assess such programs as doctoral learner, the learning community (class, workshop, or other degrees,5,6 clinical dentistry7 medical studies8 and various organized group of learners), the institution, or the educational system as a whole. 4 university degrees including natural sciences, engineering and the social sciences.9 Assessment (either summative or formative) is often In fact, all assessments are created with inherent biases categorized as either objective or subjective. Objective built into decisions about relevant subject matter and assessment is a form of questioning which has a single content, as well as cultural (class, ethnic, and gender) correct answer. Subjective assessment is a form of biases. 10,11 1. Department of Biochemistry, Ziauddin University, St-4/B-Block 6 Shahrah-I Ghalib Clifton, Karachi, Pakistan. The Objective Structured Viva Examination (OSVE) is a 2. Department of Psychology, Ziauddin University, St-4/B-Block 6 Shahrah-I Ghalib new concept in the assessment of basic health sciences Clifton, Karachi, Pakistan. in our country, used for evaluation of preclinical subjects. Correspondence: Dr. Anila Jaleel, Department of Biochemistry, Ziauddin University, Conventional techniques for assessing the knowledge of St-4/B-Block 6 Shahrah-I Ghalib Clifton, Karachi, Pakistan. E-mail: [email protected] undergraduate medical students are widely acknowledged Received: August 26, 2009: accepted: April 15, 2010 as being unsatisfactory. Viva examination is subjective, 4 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 4-7 Perception of medical students on structured viva examination in an integrated undergraduate curriculum at ziauddin university un structured and non valid in most of the medical schools Table1 : in Pakistan. Ziauddin Medical college introduced (OSVE) for undergraduate MBBS students of years one and two Statements Agree Neutral Disagree (2008), to maintain the objectivity and validity of the viva 1)Reading time of problems was adequate 110 (78.57%) 20 (14.28%) 10 ( 7.14%) examination .The examination comprised of nine scenarios 2)Examination was relevant with course 101 (72.14%) 29 (20.71%) 10 (7.14%) from three different modules. Each scenario was integrated objectives and accompanied by nine structured questions for viva 3)PBL helped in interpreting the cases 102 (72.85%) 26 (18.57%) 12 (8.57%) along with keys. The viva was conducted by anatomy, 4)Time adequately spaced between SVE 107 (76.42%) 24 (17.14%) 9 (6.42%) physiology and biochemistry departments in an integrated stations manner. The Objective of the present study is to survey 5)Language of the cases was simple and 113 (80.71%) 20 (14.28%) 7 (5.00%) medical students regarding Structured Viva Examination. easy to understand

METHOD 80

70

Recruitment and Procedure 60

50 Agree Neutral Percentage 40 Disagree Feedback forms were given to 144 first and second year (%) (2008) MBBS students of Ziauddin Medical College after 30 they completed their professional examination 20 Feedback form consisted of five items and student’s 10 0 feedbacks were categorized in the domain of Agree, Neutral 1 2 3 4 5 No of Question and Disagree. Figure – 1 : Feed back by Students (First Year) The questionnaire was developed by a team of an educationist and biostatistician. The questions were based on general surveys routinely used for evaluating courses 90 and assessment techniques. The questionnaire underwent 80 reviews for relevance and clarity. (A copy of a questionnaire 70 60 is available on request). Agree Percentage 50 Neutral (%) Disagree 40 30 RESULTS 20 10 0 Table 1 shows the response of 140 out of 144 students. No of Question One hundred and thirteen out of hundred and forty (80.71%) students agreed that the language of the cases Figure – 2 : Feed back by Students (Second Year) was simple and easy to understand. One hundred and ten (78.57%) stated that the reading time of problems was adequate. One hundred and seven (76.42%) agreed that DISCUSSION the time was adequately spaced between SVE stations. Hundred and one (72.14%) agreed that the examination Whilst students' views about the specific assessment tools was relevant with course content, while one hundred and may sometimes be at variance but overall they welcome two (72.85%) agreed that PBL in modules helped in the introduction of methods that provide meaningful interpreting the cases in their annual examinations. The assessment feedback. An OSVE may be an acceptable results of first and second years are shown in Figures 1 alternative to traditional methods of examination and is and 2 respectively which also comply with the combined superior in certain aspects in an integrated PBL based results of the two. curriculum.

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 4-7 5 Anila Jaleel and Noreen Jaffrey

Constructivism has provided a completely new view on REFERENCES how students learn best and the change from trait-oriented to competency- or role-oriented thinking has given rise to 1. Entwistle, N. J. Approaches to learning and perceptions of a whole range of new approaches in assessment. Certain the learning environment. Introduction to the special issue. methods of learning, such as problem-based learning (PBL), Higher Education 1991; 22:201-204. and assessment, however, are often seen as almost 2. Marton, F, & Säljö, R. Approaches to learning. In Marton, synonymous with the underlying concepts. It is generally F, Hounsell, D, & Entwistle N, editors. The experience of acknowledged that assessment drives learning; however, learning; implications for teaching and studying in higher students study more thoughtfully when they anticipate education 2nd ed. Edinburg: Scottish Academic Press; 1997, 12 certain examination formats. Any change in the format p.39-59. can shift their focus to clinical rather than theoretical issues. 13 3. Ramsden, P. The context of learning in academic departments. In: Marton F, Hounsell D, Entwistle N, editors. The All methods of assessment have strengths and intrinsic experience of learning: implications for teaching and studying flaws . The use of multiple observations and several different in higher education. 2nd ed. Edinburg: Scottish Academic assessment methods over time can partially compensate Press; 1997. p. 198-217. for flaws in any one method.14 Van der Vleuten describes five criteria for determining the usefulness of a particular 4. Paul B, Wiliam D. "Inside the Black Box: Raising Standards method of assessment: reliability (the degree to which the through Classroom Assessment.” Phi Delta Kappan 1998; measurement is accurate and reproducible), validity (whether 80:139 – 148. the assessment measures what it claims to measure), impact 5. Jackson, C., Back to Basics: a consideration of the purposes on future learning and practice, acceptability to learners of the PhD viva. Assessment & Evaluation in Higher and faculty, and costs (to the individual trainee, the Education 2001; 26:355-366. institution, and society at large). 15 6. Morely L., Leonard D., David, M. Variations in vivas: quality Various domains of competence should be assessed in an and equality in British PhD assessment. Studies in Higher integrated, coherent, and longitudinal fashion using multiple Education 2002; 27:263-73. methods and provision of frequent and constructive feedback.16 Educators should be mindful of the impact of 7. Yip H.K., Smales R.J., Newsome PRh., Chu FCS., Chow assessment on learning,17 the potential unintended effects T.W. Competency-based education in a clinical course in of assessment, the limitations of each method (including conservative dentistry. Br Dent J 2001; 191:517-22. cost),18-20 and the prevailing culture of the program or 8. Bashook, P. Assessing clinical judgment using standardized institution in which the assessment is occurring. oral examinations. The Annual Meeting of the American Educational Research Association, New Orleans, LA, 2000. CONCLUSION 24-28. Integrated curriculum has led to better understanding of the health sciences. Educators need to explore newer 9. Kehm BM. Oral Examinations at German Universities. Assessment in Education: Principles, Policy and Practice assessment methods for better understanding of the health 2001; 8:25-31. sciences with relevance to common disease. 10. Epstein RM, Hundert EM,. Defining and assessing ACKNOWLEDGMENT professional competence. JAMA 2002; 287:226-35

We would like to thank Dr. N. A. Jaffarey for motivating 11. Epstein RM, Assessment in medical education. N Engl J us in planning the study. We owe thanks to Ms Nighat Med. 2007; 356:387-96. Huda (Medical Educationist) for her efforts in conducting the examination and data collection. We would also like 12. Hakstian AR. The effects of type of examination anticipated to express sincere appreciation to students who participated on test preparation and performance. J Educ Res 1971; in the study voluntarily. 64:319-24.

6 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 4-7 Perception of medical students on structured viva examination in an integrated undergraduate curriculum at ziauddin university

13. Newble DI, Jaeger K, The effect of assessments and 17. Segers, M., & Dochy, F. New assessment forms in examinations on the learning of medical students. Problem- based Learning: the value- added of the Med Educ 1983; 17:165-71. students' perspective. Studies in Higher Education 2001; 26:327-43

14. Schuwirth LW, van der Vleuten CP. Changing 18. Earl LM. Assessment as Learning: Using Classroom education, changing assessment, changing research? Assessment to Maximise Student Learning. Thousand Med Educ 2004; 38:805-12. Oak, Corwin Press 2003.

15. Van Der Vleuten CPM, The assessment of professional 19. Educational assessment". Academic Exchange Quarterly 2009. competence: developments, research and practical implications. Adv Health Sci Educ 1996; 1:41-67. 20. Joint Information Systems Committee (JISC). "What Do We Mean by e-Assessment?" JISC InfoNet, 16. Wass V, Van der Vleuten C, Shatzer J, Jones R, [Accessed on January 29, 2009]. Available from: Assessment of clinical competence. Lancet 2001; (http://www.jiscinfonet.ac.uk/InfoKits/effective-use- 357:945-49. of-VLEs/e-assessment/assess-overview).

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Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 4-7 7 ORIGINAL ARTICLE Detection of Peripheral Arterial Disease (PAD) in Diabetics using Ankle Brachial Index (ABI) Khatoon Akhtar Bano1, Naheed Hashmat2, Asia Batool1 and Shameem Ahmad Siddiqui1

ABSTRACT Objective: To evaluate the Ankle Brachial Index (ABI) in the detection of peripheral arterial disease (PAD) among diabetic patients. Setting: Diabetic clinic of PMRC Research Centre, Fatima Jinnah Medical College, Lahore. Study Design: Cross sectional descriptive. Subjects & Methods: This pilot study included 95 diabetic patients with ages 40 years or above and duration of the disease was more than 5 years. Detailed history including treatment was documented. During examination systolic blood pressure in the right and left arms (Brachial Pressure) was measured & documented. Systolic Blood Pressure in both ankles was measured using ultrasound Doppler probe (Huntleigh Super Doppler – II). Left and right ABI were obtained by dividing brachial systolic pressure with ankle systolic pressure. A ratio of 0.9 or above was taken as normal. Results: The study included 95 patients (15 males and 80 females) with mean age 51.90 ± 9.49 years and mean duration of diabetes 13.23 ± 5.83 years. Smoking was observed in 53.30%, hypertension in 57.89% and 71.57% had dyslipidemia. ABI ratio was mildly abnormal in 52.68%, moderately abnormal in 7.38% while it was normal in 38.94% cases. Duration of thedisease was negatively correlated (r = - 0.650 & 0.937) with ABI & correlation was highly significant (p < 0.047 & 0.008). Blood sugar and lipid levels were not significantly correlated with ABI. Conclusions: The results conclude the detection of high percentage (60.08) of abnormal ABI in this group of patients. Ankle brachial index, a non-invasive and simple technique, may be used to screen the detection of PAD and diabetic foot.

Key words: Ankle Brachial Index, peripheral arterial disease, cardiovascular complications, diabetic foot.

INTRODUCTION Peripheral arterial disease (PAD) is a chronic, lifestyle- of diabetes correlates with the incidence and extent of limiting disease. It is an independent predictor of PAD. In a prospective cohort study, Al-Delaimy et al3 cardiovascular and cerebrovascular ischemic events. The found a strong positive association between the duration risk of PAD is markedly increased among individuals with of diabetes and the risk of developing PAD. The association diabetes mellitus and ischemic event rates are higher in was particularly strong among men with hypertension or these individuals with PAD compared to non-diabetic who were cigarette smokers. The degree of diabetic control population.1 Peripheral arterial disease affects approximately is an independent risk factor for PAD; with every 1% 12 million people in the U.S; approximately 20% to 30% increase in glycosylated hemoglobin the risk of PAD has of these patients have diabetes.2 The duration and severity been shown to increase by 28%.4 The risk of PAD is associated with advancing age and the presence of peripheral 1. PMRC Research Centre, Fatima Jinnah Medical College, Lahore. Pakistan. neuropathy.5 2. Department of Medical Unit I, Sir Ganga Ram Hospital, Fatima Jinnah Medical College, Lahore. Pakistan. The disorder is characterized by occlusive arterial disease Correspondence: Shameem Ahmad Siddiqui, PMRC Research Centre, Fatima Jinnah of the lower extremities. Although many patients are asymptomatic or have atypical exertional symptoms, Medical College, Lahore. Pakistan. approximately one-third experience intermittent E-mail: [email protected] claudication, described as aching, cramping, or numbness Received: September 05, 2010: accepted: April 15, 2010 8 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 8-12 Detection of peripheral arterial disease (PAD) in diabetics using ankle brachial index (ABI) in the affected limb occurring with exercise and relieved arteries was measured by using mercury by rest.6 Peripheral arterial disease in patients with diabetes sphygnomanometer and systolic blood pressure in the 7 adversely affects quality of life and is associated with ankles was measured by using ultrasound Doppler probe substantial functional impairment and mortality.8,9 The (Huntilegh Super Doppler-11).20 Left and right ABI reduced walking speed and distance associated with intermittent claudication may result in progressive loss of measurements were obtained by dividing mean systolic function and long-term disability.3,10 With severity of the blood pressure in the left and right ankle by corresponding disease, critical limb ischemia (CLI) may develop, resulting mean systolic brachial blood pressures. PAD was defined in ischemic ulceration of the foot and risk of other as an ABI less than 0.90 in either leg. Abnormal ABI ratio cardiovascular events as well as amputation. was graded as (a) Mild: when ratio was between 0.89- 0.70 (b) Moderate: when ratio was 0.69-0.40 (c) Severe: Introduction of sonography has made it possible for general when ratio was <0.39.19 Total cholesterol was measured physicians to diagnose asymptomatic PAD by determining enzymatically. Hypercholesterolemia was defined as a the Ankle Brachial Index (ABI), which is a noninvasive total cholesterol level of 240 mg/dl or higher in fasting technique. However, ABI is underutilized in clinical practice; condition.21 thus PAD remains under diagnosed and awareness of importance of treating PAD as a coronary heart disease is low among physicians partly because determination is time STATISTICAL ANALYSIS consuming. Because many patients with diabetes also have PAD, the American Diabetes Association now recommends The data were computerized and SPSS Version “13” was regular screening of the Patients for PAD who are over the used for analysis. Mean ± SD was calculated for all age of 50. Diabetic Patients who are younger than 50 years quantitative measures. Percentage values were calculated should be screened if they are under-treated.5 for various categories of ABI ratio to diagnose PAD. Pearson’s correlation was used to find out any relation This pilot study was designed to evaluate the role of ABI between ABI & blood sugar levels, lipid levels & duration as a simple, non-invasive and cost effective technique in of the disease. the detection of PAD in diabetics. This test may be utilized for simple screening purposes to all the diabetic population Table1 : Demographic Chracteristics of the Study Patients of and may be a helpful tool in early detection and prevalence Type-2 Diabetes Mellitus of diabetic foot. Parameters No. of Patients (95) Percentage (%)

Mean Age (years) 51.96 ± 9.49 - METHODS Sex: Male 15 16% This cross sectional, descriptive study was done at the Female 80 84% diabetic clinic of PMRC Research Centre, FJMC & Ganga Duration of diabetes (yrs) 13.23 ± 5.83 - Ram Hospital Lahore. All patients included in this study Smoking 8 8.42% were taking treatment for diabetes and hypertension. In CAD 3 3.15% this pilot study, 95 patients suffering from Diabetes Mellitus, (Coronary Artery Disease) 57.89% 40 years or above of both sexes with any duration of Hypertension 55 57.89% diabetes were included. Each patient was interviewed and Dyslipidemia 60 71.57% the information was recorded on a performa regarding age, Symptoms: Numbness Tingling 80 84.21% sex, duration of diabetes, smoking habits and any other Leg pains 54 56.42% cardiovascular disease. Blood sample was collected after Foot ulcers 5 5.26% an overnight fast using antiseptic measures to estimate Laboratory Tests: blood sugar fasting & random (2 hours postprandial) as Blood Sugar Fasting 112.67 ± 40.15 - well as lipid profile. Blood Sugar Random (2 hrs P.P)* 185.53 ± 52.17 - S. Cholesterol 193.45 ± 35.18 - During examination, systolic blood pressure was measured S. Triglyceride 188.64 ± 86.11 - on both right and left arms (brachial artery) and both ankles S. HDL 41.32 ± 33.09 - (posterior tibial arteries). Systolic blood pressure in brachial S. LDL 116.63 ± 32.92 -

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 8-12 9 Khatoon Akhtar Bano, Naheed Hashmat , Asia Batool and Shameem Ahmad Siddiqui

Table2 : Demographic Chracteristics of the Study Patients of (0.69 – 0.40) were observed in 7.38% diabetic patients. Type-2 Diabetes Mellitus None of the diabetic patients was found to have severe PAD disease. Overall 61.06 % diabetics with variable ABI Ratio No. of Cases Percentage n =95 (%) duration of disease had abnormal ABI ratio and of these Normal 4 patients foot ulcer was present. In all the disease was ( > 0.90 ) 37 38.94 % mild and unilateral or bilateral. Two of the patients also Mild abnormality had associated hyperlipidaemia. One patient with foot (0.89 – 0.70) Total: 51 53.68 % ulcer had normal ABI with a dominant element of Bilateral involvement 12(23.53%) neuropathy. Unilateral involvement 39(76.47%) Moderate abnormality Correlation of ABI to the duration of diabetes, blood sugar (0.69 – 0.40) 7 7.38% & various lipids are shown in table 3. Duration of diabetes Severe < 0.39 - - has negative and highly significant (P = 0.047 & 0.008) correlation (r = - 0.650 & 0.937) with ABI ratio i.e the Table3 : Correlation of ABI with Blood Sugar Fasting, Random, & Serum lipids higher the duration the lower will be the ratio. However, blood sugar levels and lipids were not significantly Right ABI Left ABI Parameters Correlation P. Value Correlation P. Value correlated with ABI. Duration of Diabetes 0.650 0.047* 0.937 0.008 Blood Sugar Fasting 0.142 0.283 0.27 0.841 DISCUSSION Blood Sugar Random 0.069 0.661 0.272 0.76 (2hrs P.P) Peripheral Arterial Disease (PAD), an atherothrombotic Serum Cholesterol 0.037 0.737 0.171 0.121 syndrome associated with enhanced risk of cardio-vascular Serum Triglyceride 0.013 0.904 0.087 0.429 and cerebrovascular events remain under treated. Ankle- HDL 0.006 0.956 0.027 0.810 brachial index (ABI), a non-invasive and simple to apply LDL 0.014 0.901 0.126 0.254 technique provides reliable test for diagnosing PAD in *P Significant at 0.05. ** P.P Postprandial practice. However, its use in clinical practice is still limited & the condition is mostly diagnosed symptomatically. In RESULTS this pilot study, 95 patients suffering from diabetes mellitus with variable duration of disease were tested for ABI ratios. Ratio was abnormal (less than 0.9) in 61.06% Table 1 shows demographic & general features of the study diabetics. Abnormality was mild (ratio 0.89 – 0.70) in patients which included 15 (16%) males & 80 (84%) 53.68% and moderate (ratio 0.69 – 0.40) in 7.38% diabetic females with mean age 51.90 ±9.46 years. Duration of cases. In a cross sectional prevalence study of peripheral diabetes was 13.23± 5.83 years. History of smoking was arterial disease (PAD) using ABI in general population, present in 8 (8.42%) male patients. Of the total diabetics, much higher prevalence (57% - 75%) was observed among 55 (57.89%) had associated hypertension & 60 (71.57%) symptomatic and high risk groups.11The results of this had hyperlipidemia. Symptoms included tingling and pilot study in diabetics also show a high prevalence (61%) numbness (84.21%), leg pains (56.42%) and foot ulcers of PAD. (5.26%). Mean values of blood sugar fasting (112.67± 40.15), blood sugar random (185.53 ± 52.17), serum Other risk factors for PAD among the study group were cholesterol (193.45 ± 35.18), serum triglyceride (188.64 hypertension (57.89%), smoking (8.42%), coronary artery ± 86.11) and HDL cholesterol, LDL cholesterol are also disease (3.15%),dyslipidaemia (71.57%) and symptoms shown in table 1. of PAD i.e. leg pain (56.42%) and foot ulcers (5.26%). Higher prevalence rates of PAD have been documented Table-2 shows the results of ABI ratios in study patients in patients with CAD, past symptoms of PAD and Grading of ABI ratios show normal values (0.90 – 1.30) smoking.11-13 Cigarette smoking is the single most only in 38.94% cases. The ratio was mildly abnormal (0.89 important modifiable risk factor for the development & to 0.70) in 52.68 % and moderately abnormal ratios exacerbation of PAD12; however, in this study 8.42%

10 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 8-12 Detection of peripheral arterial disease (PAD) in diabetics using ankle brachial index (ABI) males were smokers. Hypertension is associated with the REFERENCES development of atherosclerosis and with a two to three 13 folds increased risk of claudication. 1. Marso SP, Hiatt WR. Peripheral Arterial Disease in patients The duration and severity of diabetes correlates with the with diabetes. J Am Coll Cardiol 2006: 47:921–9. incidence and extent of PAD3,14Adler et al15 estimated the prevalence of PAD up to 18 years after the diagnosis of 2. American Diabetes Association. Peripheral arterial disease diabetes in 4987 subjects (United Kingdom Prospective in people with diabetes. Diabetes Care 2003; 26:3333–41. Diabetes Study UKPDS). The results showed a high prevalence of PAD in those with longer duration of diabetes. 3. Al-Delaimy WK, Merchant AT, Rimm EB, Willett WC, In our study the mean duration of disease was 13.23 ± 5.83 Stamperfer MJ, Hu FB. Effect of type 2 diabetes and its years and there was a significant negative correlation (Rt. duration on the risk of peripheral arterial disease among ABI: r = -0.65, P 0.047 & Lt. ABI: r = - 0.937 & #P value < 0.008) of ABI ratio with duration of diabetes i.e the men. Am J Med 2004; 116:236–40. longer the duration the lesser is the ABI ratio and therefore, the higher incidence of PAD and cardiovascular events. 4. Selvin E, Marinopoulos S, Berkenblit G, Rami T, Brancati However, correlation of ABI with other biochemical FL, Powe NR, et al. Meta-analysis: glycosylated hemoglobin parameters like blood sugar, cholesterol, triglyceride & and cardiovascular disease in diabetes mellitus. Ann Intern HDL levels was statistically insignificant. Med 2004; 141:421-31.

ABI is a simple non-invasive and rapid technique which 5. American Diabetes Association: Peripheral arterial disease provides reliable data for the diagnosis of PAD. The overall in people with diabetes. Clinical Diabetes 2004; 22:181–9. accuracy of ABI in the diagnosis of PAD has been well established against contrast angiography and Doppler ultrasound and is considered to have good 6. Schainfeld RM. Management of peripheral arterial disease reproducibility.16-18 Therefore the implementation of ABI and intermittent claudication. J Am Board Fam Pract 2001; for detecting PAD would assist in early identification and 14:443–50. treatment of the condition especially in diabetics which will also lower the risk of subsequent cardiovascular events 7. Khaira HS, Hanger R, Shearman CP. Quality of life in in them. The American Diabetic Association (ADA) has, patients with intermittent claudication Eur J Vasc Endovasc therefore, recommended regular ABI screening of diabetic Surg 1996; 11:65–9. patients of long duration of disease particularly if disease is under treated.5 8. Diehm C, Lange S, Darius H, Pittrow D, von Stritzky B, The study concludes a high frequency of abnormal ABI Tepohl G, et al. Association of low ankle brachial index (<0.90) indicative of high PAD among diabetics with older with high mortality in primary care. Eur Heart J. 2006; age, longer duration of disease & other associated risk 27:1743-9. factors. Therefore, it is recommended that ABI screening should be a routine procedure for diabetic patients with 9. Vogt MT, Cauley JA, Kuller LH, Nevitt MC. Functional longer duration & specially for a poorly treated disease. status and mobility among elderly women with lower extremity arterial disease: the study of osteoporotic fractures. ACKNOWLEDGMENT J Am Geriatr Soc 1994; 42:923–29.

Thanks are due to the Messer’s Matrix Pharma (Pvt) Ltd., 10. McDermott MM, Liu K, Greenland P, Guralnik JM, Criqui for their help in providing us with the facilities to perform ankle Brachial Index i.e. the ultrasound Doppler probe. We MH, Chan C, et al. Functional decline in peripheral arterial are also obliged to Mr. Liaqat Ali Butt for the disease: associations with the ankle brachial index and leg computerization of data & typing of the manuscript. symptoms. JAMA 2004; 292:453-61.

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11. Cacoub P, Cambou JP, Kownator S, Belliard JP, 16. Lijmer JG, Hunink MG, van den Dungen JJ, Loonstra J, Beregi JP, Branchereau A, et al. Prevalence of Smit AJ. ROC analysis of noninvasive tests for peripheral peripheral arterial disease in high-risk patients using arterial disease. Ultrasound Med Biol 1996; 22:391-8. ankle-brachial index in general practice: a cross- sectional study. Int J Clin Pract 2009; 63:63-70. 17. Feigelson HS, Criqui MH, Fronek A, Langer RD, Molgaard CA. Screening for peripheral arterial disease: the sensitivity, 12. Lassila R, Lepantalo ML. Cigarette smoking and specificity, and predictive value of noninvasive tests in a the outcome after lower limb arterial surgery. Acta defined population. Am J Epidemiol 1994; 140:526 – 34. Chir scand 1988; 154:635–40. 18. Baker JD, Dix DE. Variability of Doppler ankle pressures 13. Stokes J, Kannel WB, Wolf PA, Cupples LA, with arterial occlusive disease: an evaluation of ankle Dagostino RB. The relative importance of selected index and brachial-ankle pressure gradient. Surgery 1981; risk factors for various manifestations of 89:134–7. cardiovascular disease among men and women from 35 to 64 years old: 30 years of follow-up in 19. Parks R. Ankle-brachial index test. Web Med. Last the Framingham Study. Circulation 1987; 75:65–73. updated October 16, 2009. Available from: (http://www.webmd.com/heart-disease/ankle-brachial- 14. Jude EB, Oyibo SO, Chalmers N, Boulton AJ. index-test). Peripheral arterial disease in diabetic and non- 20. Bilquis A, Saulat S, Rafiq A K, Sibgha Z Detection of diabetic patients a comparison of severity and atheriosclerosis by ankle brackial Index: evaluation of outcome. Diabetes Care 2001; 24:1433–7. palpatory method versus ultrasound Doppler technique. J Ayub Med Coll Abbottabad 2009; 21:11–16. 15. Adler Al, Stevens RJ, Neil A, Stratton IM, Boulton AJ, Holman RR. UKPDS 59, hyperglycemia and 21. Expert panel on detection evaluation and treatment of other potentially modifiable risk factors for high cholesterol in adults; Summry of the third report of peripheral vascular disease in type 2 diabetes. NCEP (Adult Treatment Panel III). JAMA 2001; 285:2486- Diabetes Care 2002; 25:894–9. 97.

12 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 8-12 ORIGINAL ARTICLE Phenomena of Physical Activity in with Myocardial Infarction Patients of Karachi, Pakistan Shazia Azeem1 and Nazeer Khan2

ABSTRACT Objectives: To assess the physical activity level among MI patients and to examine the relationship of physical activity with some MI risk factors such as age, gender, body mass index(BMI), waist circumference(WC), obesity, and occupation. Methods: The data of the present study were collected from different cardiac hospitals (Civil Hospital, Liaquat National Hopsital and National Institute of Cardiovescular Diseases) of Karachi. 235 patients of ages 30-70 years were interviewed through a questionnaire. The questionnaire included basic demographic and some socio-economic information and risk factors associated with MI patients. The questionnaire also included questions on the type, frequency and duration of physical activity of the patients. Activities were classified into five intensity categories and assigned metabolic equivalents (MET) according to the compendium of physical activity. Subjects were classified into physically active or inactive categories. Results: Activity prevalence (10.2%) was very low among MI patients. There were more active male patients (10.8%) than female patients (7.8%). Activity prevalence decreases with age and increases with increasing educational level. In the risk assessment model, age group (P<0.0001), occupation categories [(skilled vs. semi skilled) (p=0.028)] and [(skilled vs. house wife) (p=0.003)] were significant. Highly educated patients were significantly (p=0.022) more active than others. Furthermore, active patients had lower values of body mass index and waist circumference. Conclusion: The finding of the study revealed that most of the MI patients have sedentary life style and due to increasing age and low level of education they are inactive.

Key words: Myocardial Infarction, Coronary Artery Disease, Physical Activity, Karachi, Pakistan.

INTRODUCTION Coronary artery disease (CAD) is a major public health quality of life.5 The increased risk of coronary heart disease problem in the world. The prevalence of CAD in the and mortality is associated with overweight/obesity and subcontinents is now parallel to those in the industrialized decreased risk is associated with leisure-time physical 1 countries and people of Indo-Asian origin show one of activity.6 Manson et al7 indicated that both walking and the highest susceptibilities.2 It is now the leading cause of vigorous exercise were associated with substantial death in this region.3 In Pakistan CAD plays a preponderant reductions in the incidence of cardiovascular events among role in the mortality indicator (12%) as reported by National Health Survey of Pakistan 1990-1994.4 postmenopausal women, irrespective of race or ethnic group, age, and body-mass index. One of the studies

Interventions using physical activity can improve the showed that overweight subjects, even if they are regularly 1. Department of Statistics, Federal Urdu University of Arts, Sciences and Technology, engaged in vigorous sport activities during leisure time, Gulshan-e-Iqbal, Karachi, Pakistan. still have equal or lower heart rate variability at rest 2. Department of Research and PhD Program, Dow University of Health Sciences, compared with sedentary lean subjects.8 Physical fitness Karachi, Pakistan. showed beneficial effects on numerous mediators of CVD Correspondence: Shazia Azeem, A-142, Block no 11, Gulshan-e- Iqbal, risk including obesity.9 Consequently, weight loss can Karachi, Pakistan. improve multiple CVD risk factors.10, 11 Therefore, increased E-mail: [email protected] Received: November 06, 2009: accepted: April 15, 2010 physical activity appears to be an ideal therapy for CHD.

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 13-18 13 Shazia Azeem and Nazeer Khan

Most of the obesity related studies, however, have not into 2 categories, active and inactive, as described below. adequately measured physical activity and functional capacity, which are also known to predict risk of CHD.12- The physical activity was calculated as MET value 15 A study on CAD indicated that aerobic exercise was multiplied by the duration of activity in minutes, multiplied effective for increasing VO2 max in stable CAD patients.16 by the frequency of activity per week, i.e. Many risk factors are associated with Myocardial Infarction (MI) and lack of physical activity is one of them.5 These Activity = MET x (Duration of activity in minutes) x (Frequency of activity per week), studies clearly showed the importance of physical activity for MI & CAD patients. However, no significant amount If this value was more than 600, patient was considered of work is reported in the literature for Pakistan in this as active; otherwise inactive.21 The study was approved regard. Therefore, a study was conducted on MI patients by the Institutional Review Board (IRB) of Dow University regarding the risk factors of MI and other related of Health Sciences (DUHS). The second author (NK) information. In this study the effect of physical activity belongs to this university and there is no IRB in first on MI patients is reported. author’s (SA) institution. All the study hospitals accepted the IRB approval of DUHS and gave permission for the METHOD study. The study was explained to the patients and the consent was taken verbally. The author (SA) herself visited The data of the present study were collected from different all the selected hospitals and collected the information cardiac hospitals (Civil, National Institute of Cardiovascular regarding demographic, socio-economic, anthropometric Disease, Karachi Institute of Heart Disease, Liaquat variables and physical activity information. Lab reports National Hospital) of Karachi. The population of Karachi and other information were taken from their hospital files. for the year 2007 was an estimated 13.16 million. Using The data collection covered the period from August 2008 the information of 1998 census17 and assuming the burden to December 2008. of CAD in the selected population as 26.9%18, the sample Data were entered into computer using SPSS (ver. 15). size was calculated as 233 with 95% confidence interval Descriptive statistics were computed and multivariate and maximum error ±5.7%.19 The questionnaire included binary logistics regression was employed to determine basic demographic and socio-economic information in risk assessment model for physical activity. detail and risk factors associated with MI patients. The questionnaire also included information on the type, RESULTS frequency and duration of physical activity of the patients. Two hundred thirty five patients were included in this The types of physical activity were divided into 5 intensity study. Sixty seven percent of the patients were males with categories and each category was assigned Metabolic an average age of 52.31 years. Ninety percent of the Equivalent (MET) values according to the compendium subjects were from urban areas, 70% percent were married of physical activity.20 One MET equals to the energy and 33% were illiterate. Twenty nine percent were unskilled, expenditure at rest, or roughly 3.5 ml of oxygen consumed 33.6% were from the income group of PRs. 10,000— PRs per kilogram of body weight per minute.21 The type of 15,000. Seventy one percent had no previous history of physical activity categories included in the questionnaire chest pain and 34% had positive history of parental death were: 1. Vigorous intensity aerobic activity such as running, through CAD. vigorous swimming and cycling (MET = 7.5), 2. Vigorous- intensity intermittent sport activity such as basketball, The mean ± SD of age, weight and height of all patients tennis and racquet balls (MET=7), 3. Moderate-intensity were (52.79±9.96) years, (67.58±13.00) Kg and aerobic activity such as moderate intensity icycling and (161.89±10.95) cm, respectively. Age, body mass index light jogging (MET=6), 4. Moderate intensity activity such (BMI) and waist circumference were not statistically as brisk walking and recreational volleyball (MET=3.5), significant among males and females, while height and and 5. Light aerobic activity such as normal walking and weight were significant. Males were heavier (male: golfing (MET=2.5). Based on the intensity, duration and 67.32±13.15 kg, female: 61.51±13.22 kg, P=0.005) and frequency of physical activity, participants were classified taller (male: 164.50 ± 10.89 cm, female: 156.55±9.01 cm,

14 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 13-18 Phenomena of physical activity in with myocardial infarction patients of Karachi, Pakistan p<0.0001) than females. Only 10.8% (95% CI: 5.9-15.6) The proportion of male and female patients who were of males and 7.8% (95% CI: 1.8-13.8) of females were in active or inactive relative to BMI and waist circumference active group and this difference was insignificant (p=0.321). (WC) was discussed in Table 2. There were no significant Age group was significantly different for males (p=0.024) differences among active and inactive patients with respect and females (P=0.002). to BMI and WC (p > 0.05). Table 3 shows mean (± SD) values of age, BMI and waist circumference in male and The prevalence of active MI patients in the sample size female patients. Only mean age and mean BMI were was 10.2%. There was no significant difference in the statistically significant between active and inactive females proportion of activity between urban and rural residents with respective p-values of 0.031 and <0.0001. Inactive (p=0.455). There was a significant upward trend of females were older and heavier than active females. prevalence of activity with increase in educational level (p=0.022). University educated patients showed the highest Table 2 : The proportion of male and female patients who are prevalence of activity (25.9%, 95% CI: 9.3-42.4). Income active or inactive relative to body mass index (BMI) level was significantly different among active and inactive and waist circumference (WC) patients (p=0.004). The highest prevalence of activity was Active Inactive BMI/WC N P-value observed in highest paid (PRs. >30,000) patients (27.3%, N (%) 95%CI N (%) 95%CI 95% CI: 12.1-42.5). Occupation of the patients was also Male (BMI) <23 51 10(19.6) 8.7-30.5 41(80.4) 69.5-91.3 0.054 significant (p=0.001) with activity. Highest prevalence of 23.00-24.99 36 4(11.1) 0.8-21.4 32(88.9) 78.6-99.2 >25. 71 4(5.6) 0.3-10.9 67(94.4) 89.1-94.7 activity was observed in skilled workers (31.2%, 95%CI: Female (BMI) <23 23 2(8.7) 2.8-20.2 21(91.3) 79.8-102.8 0.651 15.1-47.2) (Table 1). 23.00-24.99 16 2(12.5) 3.7-28.7 14(87.5) 71.3-103.7 >25. 38 2(5.3) 1.8-12.4 36(94.7) 87.6-101.8 Table 1 : Proportion of patients who are active or inactive relative Female (WC) <85 28 1(3.6) 3.3-10.5 27(96.4) 89.5-103.3 0.659 to some demographic characteristics >85. 35 1(2.9) 2.6-8.4 34(97.1) 91.6-102.6 Male (WC) <90 72 8(11.1) 3.8-18.3 64(88.9) 81.7-96.1 0.588 Active Inactive Variable N P-value >90. 56 6(10.7) 2.6-18.8 50(89.3) 81.2-97.4 N (%) 95%CI N (%) 95%CI Gender Male 158 17(10.8) 5.9-15.6 141(89.2) 84.4-94.0 0.321 Table 3 : Mean and standard deviation of age, body mass index Female 77 6(7.8) 1.8-13.6 71(92.2) 86.2-98.2 (BMI) and waist circumference (WC) male and for Male 30-44 38 9(23.7) 10.2-37.2 29(76.3) 62.8-89.8 0.024 female patients who were active or inactive 45-59 68 5(7.4) 1.2-13.6 63(92.7) 86.4-98.8 >60 52 4(7.7) 0.5-14.9 48(92.3) 85.1-99.5 VariableActive Inactive P-value Female 30-44 12 4(33.3) 6.63-59.9 8(66.7) 40.1-93.3 0.002 45-59 39 1(2.6) 2.3-7.5 38(97.4) 92.5-102.3 Age 51±9.354 52.56±10.417 0.557 Male >60 26 1(3.8) 3.5-11.1 25(96.2) 88.9-103.5 BMI 23.39±4.75 25.38±4.11 0.06 Residence Urban 211 21(10.0) 6.0-14.0 190(90) 85.9-94 0.455 WC 92.93±8.616 93.53±13.96 0.864 Rural 24 3(12.5) 0.73-25.7 21(87.5) 74.27-100.7 Age 49.84±6.021 55.07±9.0726 0.031 Occupation Skilled 32 10(31.2) 15.1-47.2 22(68.8) 52.8-84.8 Female BMI 21.63±3.37 26.21±3.51 <0.0001 Intermediate 30 4(13.3) 10.7-25.5 26(87.7) 75.5-99.9 0.001 WC 88.23±10.23 92.49±10.16 0.118 Semi skilled 38 1(2.6) 2.4-7.7 37(97.4) 92.3-102.5 *T-test for mean differences Unskilled 69 5(7.2) 1.1-13.3 64(92.8) 86.7-98.9 House wife 58 3(5.2) 0.5-10.9 55(94.8) 89.1-100.5 Others 8 1(12.5) 10.4-35.4 7(87.5) 64.6-110.4 Table 4 illustrates the results of multivariate binary logistics Education Illiterate 77 4(5.2) 0.3-10.1 73(94.8) 89.9-99.9 0.022 regression for physical activity (active vs. inactive) on Read &write 15 1(6.7) 5.9-19.3 14(93.3) 80.7-105.9 significant risk factors obtained through univariate analysis. Primary 31 5(16.1) 3.2-29 26(83.9) 71.0-96.8 High school 36 1(2.8) 2.5-8.2 35(97.2) 91.8-102.6 Age-group [(30-44)yrs, (45-59)yrs, (>60)yrs],Sex (male, College 49 6(12.2) 3.0-21.4 43(87.8) 78.6-97.0 female), Occupation (skilled, intermediate, semiskilled, University 27 7(25.9) 9.3-42.4 20(74.1) 57.6-90.6 2 Income 6000-10,000 43 3(7.0) 0.6-14.6 40(93.0) 85.4-100.6 0.004 unskilled, housewives, others) and BMI [<23 kg/m ,(23- 10001-15,000 79 4(5.1) 0.3-9.9 75(94.9) 90.1-99.7 24.99) kg/m2, >25 kg/m2], Income (6,000-10,000, 10,001- 15001-30,000 80 8(10.0) 3.4-16.5 72(90.0) 83.5-96.5 15,000,15001-30,000, >30,000), Education (illiterate, read >30,000 33 9(27.3) 12.1-42.5 24(72.7) 57.5-89.9 Total 235 24(10.2) 211(89.8) & write, primary, high school, college, university) were *Chi-square for proportion differences included in multivariate binary logistic regression. Age

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 13-18 15 Shazia Azeem and Nazeer Khan group and occupation showed significant effect in this risk that daily moderate physical activity (e.g., the equivalent assessment model. The patients of age group (30-44) years of brisk walking of 35-40 min per day) has lowered the were 4 times (p=0.001) more active than the patients having risk of CHD by 55%.24 The low prevalence of physical ages (45-59) years and 7 times (p<0.0001) more active activity is particularly important since it negatively impacts than the patients having ages (>60) years. The patients the health status and also increases the economic burden (senior professionals, managers, doctors, directors, etc) on the society.25 were 4 times (p=0.028) more active than the patients (junior clerk, mechanics, traders etc) and 9 times (p=0.003) more In the present study the prevalence of activity was higher active than house wives. in males than in females (10.8% male and 7.8% female). This result is consistent with another Middle East study Table 4 : Multivariate logistic regression of physical activity with respect to age groups, sex education, occupation, which showed that the majority of MI patients who exercised BMI & income categories (75%) were males.27However; this finding is inconsistent Variable in the with the result of a study conducted in Saudi Arabia which equation B SEWald df P-Value Odds showed that women were more or moderately active than Occupation 10.357 5 0.066 men.26 It is not in our culture that females involve in Skilled vs -1.16 0.69 2.830 1 0.093 3.19 physical activities, such as outdoor games or walking in intermediate Skilled vs -1.442 0.656 4.824 1 0.028 4.2 the parks. Furthermore, there are not enough physical semiskilled fitness facilities available, especially for lower or upper Skilled vs -0.951 0.532 3.191 1 0.074 2.59 middle classes. This result of low level of physical unskilled Skilled vs -2.15 0.731 8.652 1 0.003 8.6 activities among females is also consistent with Western 28, 29 house wives studies. But the reasons could be different. Since they Skilled vs -1.131 1.177 0.924 1 0.333 3.09 have dual responsibilities of family and profession, they others do not have enough time for physical fitness. This study Age in groups 15.520 2 <0.0001 (30-44)yrs vs -1.364 0.445 9.414 1 0.002 3.9 showed that there was no significant difference in the 45-59)yrs activity level of urban and rural population which is in (30-44)yrs vs -2.012 0.570 12.459 1 <0.0001 7.4 contrast with another study.23 Furthermore the findings of (=60)yrs Constant -1.759 0.271 43.839 1 <0.0001 6.02 the study showed that inactivity prevalence decreases with increase in education because education increases health DISSCUSSION awareness. This result is consistent with a previous study according to which an association exists between a low 30, 31 This study investigated the effect of physical activity of level of education and acute myocardial infarction. different risk factors of MI i.e. age, gender, BMI, WC, The prevalence of obesity was lowest among unmarried 32 obesity and occupation on the age group of 30 - 70 years. people, which is consistent with another study, which The data for this study were collected from four cardiac could be a proxy of low level of activity. The result of our hospitals (National Institute of Cardiovascular Diseases, study also showed that the skilled worker with higher pay Karachi Institute of Heart Diseases, Civil Hospital, and scales had the highest prevalence of activity. A cross- Liaquat National Hospital). The inclusion criteria for the sectional study (National Health and Nutrition Examination patients were definite MI patients, diagnosed by the hospital Survey III) reported that the likelihood of being obese consultants. The major findings of the study were low could be reduced by as much as one half with a physically prevalence of activity in MI patients (10.2%) which was active occupation.33 The present study also indicated that much lower as compared to other populations.22, 23 To physical activity decreases with advancing age. Age related improve the conditions of MI patients this percentage of decline in physical activity has been well described in the physical activity should be improved because the low level literature.27, 34 Waist circumferences of inactive MI patients of physical activity has been identified as a major modifiable for both genders was also higher in our study and this result risk factor for cardiovascular diseases.22 Busy life of this is consistent with another study according to which inactive metropolitan city could be one of the reasons for this low patients with elevated waist circumference have a high risk level of physical activity. In an Indian study, it was found of coronary heart disease.35

16 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 13-18 Phenomena of physical activity in with myocardial infarction patients of Karachi, Pakistan

CONCLUSION 11. Okura T, Tanaka K, Nakanishi T, Lee DJ, Nakata Y, Wee SW. et al. Effects of obesity phenotype on coronary heart In summary the findings of the study revealed that mostly disease risk factors in response to weight loss. Obes Res MI patients were physically inactive with higher values of 2002; 10:757-66. BMI and waist circumference. The patients having ages 12. Kanaya AM, Vittinghoff E, Shlipak MG, Resnick HE, Visser from 30 to 44 years were found more active than the other M, Grady D, et al. Association of total and central obesity age groups. Skilled and highly educated patients were more with mortality in postmenopausal women with coronary active than the patients belonging to other occupational heart disease. Am J Epidemiol 2003; 158:1161-70. categories. 13. Wolk R, Berger P, Lennon RJ, Brilakis ES, Somers VK. Body mass index: a risk factor for unstable angina and REFERENCES myocardial infarction in patients with angiographically confirmed coronary artery disease. Circulation 2003; 1. Yusuf S, Reddy S, Ounpuu S, Anand S. Global Burden of 108:2206-11. cardiovascular disease. Part II: variation in cardiovascular disease by specific ethnic groups and geographic region 14. Jonsson S, Hedblad B, Engstrom G, Nilsson P, Berglund and prevention strategies. Circulation 2001; 104: 2855- G, Janzon L. Influence of obesity on cardiovascular risk: 64. twenty-three-year follow-up of 22,025 men from an urban Swedish population. Int J Obes Relat Metab Disord 2002; 2. Joshi P, Islam S, Pais P, Reddy S, Dorairaj P, Kazmi K. 26:1046-53. et al. Risk factors for early myocardial infarction in South Asians compared with individuals in other countries. 15. Rea TD, Heckbert SR, Kaplan RC, Psaty BM, Smith NL, JAMA 2007; 297:286–94. Lemaitre RN, et al. Body mass index and the risk of recurrent coronary events following acute myocardial 3. Lopez AD, Mathers CD, Ezzati M, Jamison DT, Murray infarction. Am J Cardiol 2001; 88:467-72. CJ. Global and regional burden of disease and risk factors, 2001: systematic analysis of population health data. 16. Kalyani MJ, EbadI A, Mehri SN, Motamedi MHK. Survey Lancet 2006; 367:1747–57. the effect of aerobic exercise on aerobic capacity in patients with coronary artery disease (CAD). Pakistan J Med Sci 4. Pakistan Medical Research council; National Health 2007; 23:665-70. Survey of Pakistan 1990-1994, Health Profile of the people of Pakistan 1998. 18. Jafar TH, Jafary FH, Jessani S, Chaturvedi N. Heart disease epidemic in Pakistan: women and men at equal 5. Spirduso WW, Cronin DL. Exercise dose-response effects risk. Am Heart J 2005; 150:221-6. on quality of life and independent living in older adults. Med Sci Sports Exerc 2001; 33:598-608. 19. Chou YL. Statistical Analysis. New York: Holt, Rineheart 6. Meyer HE, Søgaard AJ, Tverdal A, Selmer RM: Body and Winston Inc 1969, pp 286. mass index and mortality: the influence of physical activity and smoking. Med Sci Sports Exerc 2002; 20. Ainsworth BE, Haskell WL, Whitt MC, Irwin ML, Swartz 34:1065-70. AM, Strath SJ, et al. Compendium of physical activity: an update of activity codes and MET intensities. Med Sci 7. Manson JE, Greenland P, LaCroix AZ, Stefanick ML, Sports Exerc 2000; 32:498-504. Mouton CP, Oberman A, et al. Walking compared with vigorous exercise for the prevention of cardiovascular 21. U.S Department of Health and Human Services. Physical events in women. N Engl J Med 2002; 347:716-25. Activity and Health:A Report of the Surgeon General.Atlanta GA:Centers for Disease Control and 8. Rennie KL, Hemingway H, Kumari M, Brunner E, Malik Prevention(CDC)National Centres for Chronic Disease M, Marmot M. Effects of moderate and vigorous physical Prevention and Health Promotion, 1996. activity on heart rate variability in a British study of civil servants. Am J Epidemiol 2003; 158:135-43. 22. Iqbal R, Held C, Islam S, Rangarajan S, Yusuf S. Work and Leisure Time Related Physical Activity and the Risk 9. Manson JE, Skerrett PJ, Greenland P, VanItallie TB. The of Myocardial Infarction: Results of the INTERHEART escalating pandemics of obesity and sedentary lifestyle: Study. American Heart Association 2007; 116:II-834 a call to action for clinicians. Arch Intern Med 2004; 164:249-58. 23. Prevalence of selected risk factors for chronic disease––Jordan, 2002. Morbidity and mortality weekly 10. Schunkert H. Obesity and target organ damage: The report Centers for Disease Control and Prevention 2003; heart. Int J Obes Relat Metab Disord 2002; 26:15-20. 52:1042–4.

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24. Rastogi T, Vaz M, Spiegelman D, Reddy KS, Bharathi 30. Bobák M, Hertzman C, Skodová Z, Marmot M. Own AV, Stampfer MJ, et al. Physical activity and risk of education current conditions, parental material coronary heart disease in India. Int J Epidemiol 2004; circumstances, and risk of myocardial infarction in a 33:759-67. former communist country. J Epidemiol Community Health 2000; 54:91-6. 25. Davis MA, Neuhaus JM, Moritz DJ, Lein D, Barclay JD, Murphy SP, et al. Health behaviors and survival 31. Mittleman MA, Maclure M, Nachnani M, Sherwood among middle-aged and older men and women in the JB, Muller JE. Educaional attainment, anger and the risk of triggering myocardial infarction onset.The NHANES I Epide-miologic Follow-up Study. Prev determinants of myocardial infarction onset study Med 1994; 23:369–76. investigators. Arch Intern Med 1997; 157:769-75.

26. Ai-Hazzaa HM. Health-enhancing physical activity 32. Vioque J, Torres A, Quiles J. Time spent watching among Saudi adults using International Physical television, sleep duration and obesity in adults living Activity Questionnaire (IPAQ). Public Health Nutr in Valencia, Spain. Int J Obes Relat Metab Disord 2007; 10:59-64. 2000; 24:1683-8.

27.Nsour M, Mahfoud Z, Kanaan MN, Balbeissi A. 33. King GA, Fitzhugh EC, Bassett DR Jr, McLaughlin Prevalence and predictors of non-fatal myocardial JE, Strath SJ, Swartz AM, et al. Relationship of leisure- infarction in Jordan. East Mediterr Health J 2008; time physical activity and occupational activity to the 14:818–830. prevalence of obesity. Int J Obes Relat Metab Disord 2001; 25:606–12. 28.Centers for Disease Control and Prevention (CDC).Prevelance of physical activity, including 34. Livingstone MB, Robson PJ, McCarthy S, Kiely M, lifestyle activites among adults United States, 2000- Harrington K, Browne P, et al. Physical activity patterns 2001.Morb Mortal Wkly Rep 2003; 52:764-69. in a nationally representative sample of adults in Ireland. Public Health Nutr 2001; 4:1107-16. 29. Pitsavos C, Panagiotakos D, Lentzas Y, Stefanadis C, 35. Rana JS, Arsenault BJ, Després JP, Côté M, Talmud Epidemiology of leisure-time physical activity in socio- PJ, Ninio E, et al. Inflammatory biomarkers, physical demographic, lifestyle and psychological characteristics activity, waist circumference, and risk of future coronary of men and women in Greece: the ATTICA study. heart disease in healthy men and women. Eur Heart J BMC Public Health 2005; 5:37. 2009; 18:1–9.

18 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 13-18 ORIGINAL ARTICLE Morbidity, Co-Morbidity Profile and Disability Status Among Elderly in Civil Hospital Karachi Yasmin Mumtaz1, Hira Riaz2, Muhammad Arsalan2, Sana Akhtar2, Hareem Haider2 and Wajiha Manzoor2 ABSTRACT Objective: To evaluate the Morbidity, Co-morbidity profile and Disability status among elderly in Civil Hospital Karachi. Study Design: A Descriptive cross sectional study. Subjects and Methods: The study was conducted at Civil Hospital Karachi from 15 June 2009 to 15 August 2009. Patients aged 60 years and above admitted to selected wards i.e. Medicine, Cardiac medicine, Surgery, Gynecology, E.N.T and Ophthalmology were included except those patients who had psychiatric illnesses, history of trauma and neurological deficits. A questionnaire was designed for assessment of morbidity, co morbidity and disability status of elderly patients. SPSS version 16 was used for data analysis Results: A total of 220 elderly subjects (60+) were included in the study. Most common morbidities were cerebrovascular accidents (13.6%), chronic liver diseases (7.7%) and hernias (7.7%). When classified according to organ systems most common disorders were of digestive system (28.6%), nervous system (15%) and malignancies (12.2%). Hypertension was the most frequent co-morbidity (28.63%), followed by diabetes mellitus (27.2%) and ischemic heart diseases (7.27%). 63.6% of elderly had minimal disability, 12.3% had moderate disability, 2.7% were severely disabled and 21.4% had no disability. Conclusion: Most of elderly patient admitted to CHK for C.V.A (13.6) Most common disorder were related to Digestive System 28.6%, among Co-Morbidities (Chronic) Hypertension was frequent 28.63%. A large number (78.6%) of elderly patient had some sort of disabilities.

Key words: Co-morbidity, Disability, Elderly, Morbidity.

INTRODUCTION Aging is a privilege and societal achievement. It is the The world's elderly population - people aged 60 years and accumulation of changes in an organism or object over older - is the fastest growing age group.4 The world has time. 1 Aging is an “Irreversible” process and refers to: experienced a gradual demographic transition from pattern of high fertility and high mortality rates to low fertility and “A multidimensional process of physical, psychological delayed mortality. Also epidemiological transition from infectious diseases to chronic diseases and degenerative and social changes”Sir James Sterling Ross commented: illnesses leads to an older population, resulting in lower You do not heal old age, you protect it, you promote it proportion of younger population and increase in proportion and you extend it” of elderly.

5 At the moment, there is no United Nations standard 11% of total population of world (mid year) is of elders. numerical criterion but, the UN agreed cut off is 60+ At present in developed countries 22% are already aged 60 or above and this proportion is projected to reach 33% years to refer to the Older or Elder population.3 In many in 2050.6 While in developing countries between 2009 and instances the age at which person becomes eligible for 2050 the population aged 60 or above is expected to increase statutory and occupational retirement pension, has become from 9% to 20%.6 Population (mid year 2009) of Pakistan the default definition.3 is 174,578,558 of which 6.1% are elders and they will be 8.4% and 16.78% in 2025 and 2050 respectively.5 Aging 1. Department of Community Medicine, Dow University of Health Sciences, Karachi, st Pakistan. is a challenge which has impact on all aspects of 21 century 2. 4Th Year MBBS Students, Dow University of Health Sciences, Karachi, Pakistan. society. Beside creating pressure, which may affect the Correspondences: Dr. Yasmin Mumtaz, Department of Community Medicine, Dow overall equilibrium of developmental and humanitarian University of Health Sciences, Karachi, Pakistan. resource management at country and regional level, aging E-mail: [email protected] Received: December10.2009: accept: April 15, 2010. has important implication at family and individual level.

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 19-24 19 Yasmin Mumtaz, Hira Riaz, Muhammad Arsalan, Sana Akhtar, Hareem Haider and Wajiha Manzoor Health status has an important impact on quality of life of MORBIDITY: “Morbidity is a diseased state or the index elderly population. The major elements of health status disease for which patient is admitted in hospital.” are perceived health, especially psychological well being, chronic illness and functional status. Many health problems CO MORBIDITY: “That disease other than index disease are known to increase with age, as individual is more prone whose duration is of 1year or more is considered as to have problems with various functions of body in late COMORBID condition (chronic) or Co-morbidity”. phase of his life. Of roughly 150,000 people who die each DISABILITY: “Disability is an umbrella term, covering day across the globe, about two-third 100,000 people die impairment, activity limitation and participation restriction.” of age related causes.7 By 2050, close to 80% of all deaths 8 are expected to occur in people older than 60 years. A Descriptive cross sectional study was carried out on The presence of disease is associated with a decline in people aged 60 year and above in selected wards; Medicine, many health outcomes, including quality of life, mobility, Cardiac medicine, Surgery, Gynecology , ENT and functional ability, increase in hospitalizations, psychological Ophthalmology wards of Civil Hospital Karachi from 15th distress, mortality and the use of health care resources. June 2009 to 15th August 2009. Using a purposive sampling The most common morbidities (diseases) of aging include technique a sample of 220 subjects was drawn. Patients Arthritis, Hypertension, Cataract, Anemia, Diabetes with psychiatric illness, history of neurological deficits mellitus, Cancer, GIT problems, Deafness, COPD.9-12 and trauma were excluded. A questionnaire has been Older people usually have several coexisting health designed for research purpose. problems. The types, numbers, duration and severity of Disability status was assessed by using ‘Rapid Disability these problems may have an impact on longevity and Rating Scale-II’. The collected data was analyzed through maintenance of independence.13 Another concern in this SPSS 16. connection is the prevalence of the disability among the elders, which represents the health related physical or Verbal consent was taken from patients and then interviewed medical functional limitation. at their respective wards. Socio-demographic data was WHO has produced an age-friendly PHC toolkit.14 WHO recorded i.e. Age, Gender, Educational status, occupation also developed a project entitled “Integrated Health Care and Family income. The brief history was taken the related Systems Response to Rapid Population Ageing in to his/her complaints including, chronic conditions patient Developing Countries INTRA” in 2001.15 was suffering from. A detailed review of patient file was done including symptomatology, general and systemic In Pakistan, no special health program is working for examinations findings, medical report findings, medications elderly except entitlement. Good health is essential for given to them, any chronic condition/s and diagnosis made older people to remain independent and to play a part in by the consultant. Our main emphasis was on patients’ file family and community life. So if there are effective as diagnosis given therein was considered as the morbid measures to prevent these morbidities, co-morbidities and condition of the patient and so as for co-morbidity. If patient to ameliorate the disease induced disability to a non-severe is not able to answer, illness was inquired from his/her degree, a significant proportion of economical burden and attendant. demand for infirmary service would also be eliminated. Rapid Disability Rating Scale-II consists of 18 items divided This data may be used to generate the pattern of health into two parts; part A deals with activities of daily living problems in elders. It may shed new light on the need for (ADL) and focuses on eight basic activities: walking, elders’ primary care, geriatric medical, nursing and social mobility, bathing, dressing, toileting, grooming, adaptive home support programs and rehabilitation centers. tasks, and eating, and part B assesses the degree of disability The objective of study was to evaluate morbidity, co- which occurs as a result of the natural process of ageing, morbidity and disability status among elderly patients basically in communication, hearing, sight, diet, locomotion, admitted to Civil Hospital Karachi. continence, physical health making a person dependent on medication, and mental efficiency. Patient are questioned about the Activities written in scale and then score is given SUBJECTS & METHODS to each activity. Note all these questions for disability status assessment correspond to their usual normal health status, OPERATIONAL DEFINITIONS two weeks before the onset of present disease symptoms, as we are not measuring the ill effect of disease on physical ELDERS: Elders are people 60years of age and older. activities of patient in our research.

20 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 19-24 Morbidity, co-morbidity profile and disability status among elderly in civil hospital Karachi

iv) Disability Status: Disability status of male and female patients was assessed with the help of Rapid Disability Rating Scale-II which revealed that 63.6% had minimal disability 21.4% had no disability, 12.3% were moderately disabled and 2.7% had severe disability. Disability status of elderly patients when related to age categories and socioeconomic groups showed that difference in age categories was found to be statistically significant (P<0.05) while differences in socioeconomic groups were not significant. (Table IV & Figure -1)

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 19-24 21 Yasmin Mumtaz, Hira Riaz, Muhammad Arsalan, Sana Akhtar, Hareem Haider and Wajiha Manzoor

TABLE -III Co-morbidity profile of elderly patients. DISCUSSION Characterstics Male(n=139) Female(n=81) Total(n=220) Co-morbidities Longer life expectancy has become commonplace and is Hypertension 38(27.3%) 25(30.9%) 63(28.6%) generally accompanied by presence of several simultaneous Diabetes Mellitus 43(30.9%) 17(21%) 60(27.3%) occurring costly acute(morbid) and chronic(co-morbid) IHD 9(6.5%) 7(8.6%) 16(7.3%) conditions.16 The present study done at Civil Hospital Hepatitis C 3(2.2%) 5(6.2%) 8(3.6%) Karachi provides a good opportunity to examine trends Joint pain 2(1.4%) 5(6.2%) 7(3.2%) of common multiple morbidities, co- morbidities and Asthma 1(0.7%) 1(1.2%) 2(0.9%) disabilities in elders. COPD 2(1.4%) 0(0%) 2(0.9%) Hepatitis B 1(0.7%) 1(1.2%) 2(0.9%) Cataract 0(0%) 1(1.2%) 1(0.5%) MORBIDITY PROFILE Paralysis 1(0.7%) 0(0%) 1(0.5%) Tuberculosis 1(0.7%) 0(0%) 1(0.5%) Morbidity profile of elderly patients in this study revealed No co-morbidity 38(17.2%) 19(8.6%) 57(25.8%) that most common morbidities in order of magnitude were TABLE - IV : Disability status of elderly patients cerebrovascular accidents (13.6%), chronic liver diseases in relation to Age catagories and Socioeconomic groups. (7.7%), hernias (7.7%), diabetic complications (7.7%), Relation with Age catagories acute coronary syndromes (5.5%) and gall bladder diseases Disability 60-69 yrs 70-79 yrs 80+ yrs Total Pearson Chi- (5.5%). It is evident from these findings that non- Status (n=220) square Test communicable diseases are more frequent. The increasing prevalence of non-communicable diseases is a serious No disability 34(23.3%) 10(17.5%) 3(17.6%) 47(21.4%) challenge, where the success in extending life expectancy Minimal 96(65.8%) 37(64.9%) 7(41.2%) 140(63.6%) is translated into a real threat to global health.17 Non- disability 0.013 communicable diseases are linked to a cluster of major Moderate 12(8.2%) 10(17.5%) 5(29.4%) 27(12.3%) risk factors that are measurable and largely modifiable so disability majority of non-communicable diseases are preventable.18 Severe 4(2.7%) 0(0%) 2(11.8%) 6(2.7%) disability Morbidities when grouped according to chapters given in International Classification of Diseases showed that most Relation with Socioeconomic groups. frequent disorders were of digestive system (28.6%) Disability <6000 Rs. >6000 Rs. Total(n=220) Pearson Chi- followed by nervous system disorders (15%), malignancies Status square Test (12.2%) and cardiovascular system disorders (11.3%). No disability 14(16.1%) 33(24.8%) 47(21.4%) Disorders of digestive system were most frequent (28.6%) Minimal 57(65.5%) 83(62.4%) 140(63.6%) and among digestive system disorders chronic liver diseases, disability 0.382 hernias and gall bladder diseases were most common. Moderate 13(14.9%) 14(10.5%) 27(12.3%) Similar frequency of digestive system disorders were 19 disability obtained in a study carried out by Corina et al. in Ireland. Severe 3(3.4%) 3(2.3%) 6(2.7%) Second most frequent disorders were of nervous system disability (15%) and among these cerebrovascular accidents and meningitis were most commonly reported. Malignancies accounted for 12.2% of all morbidities in our study Minimal Disability No Disability population which is comparable with the study by Bilquis et al. at Sir Ganga Ram Hospital Lahore where 10.5% of Moderate Disability Severe Disability elderly patients were diagnosed having malignancies.20 Cardiovascular disorders including acute coronary 21.4% syndromes, myocardial infarction and congestive cardiac failure were 11.4%. Similar result (11.4%) were reported in a study by Younis I Munshi et al. in Kashmir valley.21 63.3% 12.3% 2.7% The changes in economic, social and demographic determinants of health and adoption of unhealthy life styles are thought to be contributing to observed data of morbidity pattern in study population.

22 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 19-24 Morbidity, co-morbidity profile and disability status among elderly in civil hospital Karachi

CO-MORBIDITIES determinants of functional decline in elderly which is in accordance with the fact reported by S. Canbaz 23-25 55.5% of elderly patients were found to have co-morbid et al. and Taylor R. 21.4% of elderly patients did conditions. Hypertension was the most frequent co- not have any sort of disability. Elderly without any morbidity (28.63%). Our findings are consistent with disability and enjoying successful aging provide evidence study conducted by A.J. Purty et al. Tamil Nadu India, that much disability is avoidable by preventing disabling which showed 25.9% prevalence of hypertension 22 and diseases, adaptive behavior to illnesses, environmental with study carried out at Sir Ganga Ram Hospital Lahore20 changes and life style modifications to adjust with while study done by S.Canbaz et al. also revealed that process of aging and rehabilitation. Furthermore if most frequently reported chronic disease is hypertension disabilities not prevented, the degree of dependency in elderly people. 23 Diabetes Mellitus was found to be (disability) can be lessened by modification in environment to accommodate disabilities as reported the second most frequent co-morbid condition (27.2%). 26 Similar observation was reported by Younis.I Munshi et by N. K. Kutty. So, it is necessary to address the al. (28%)21 and by Bilquis et al. (31%).20 Study by N. E. disability avoidance agenda for elderly in parallel with Schoenberg et al. reported that most common all other issues. constellations of multiple morbidity are hypertension, heart disease and arthritis or hypertension, heart disease CONCLUSION and diabetes.16 The present study is comparable to the study. Major health problems and pattern of disease and disability have been identified. Among morbidities Increased frequency of hypertension, diabetes mellitus cerebrovascular accident (13.6%), chronic liver diseases and heart diseases can be explained on the basis of (7.7%) and hernia (7.7%) are common. Elders are not sedentary and modern life styles and stress especially in suffering from single disease, they have multiple morbid urban areas while due to their chronic course these conditions simultaneously. Among chronic condition diseases are becoming a major cause of morbidity and Hypertension was the most frequent one, followed by mortality in elderly in addition to other age groups. diabetes and ischemic heart diseases. Most of the patients Chronic diseases disturb the social life of people. have minimal disability. So besides dealing with only Functional disturbance, insufficiency and disability occur one geriatric health matter at a time, episodic care for as a result of physical and mental illnesses which disturb multiple chronic conditions should be provided, to the quality of life of the elderly.23 prevent premature death, and to eliminate economical burden and infirmary service demand. DISABILITY STATUS LIMITATIONS Disability with advancing age comes in degrees and a key threshold is the requirement for frequent help from Our study has several limitations, there is marked other people beyond what would be expected by virtue lack of surveys & studies in this field especially of family and social ties(i.e. dependency).24 in Pakistan to compare result. Language difference while dealing with the patients was a major Assessment of disability status showed that 78.6% of hindrance. Attendants were mostly biased while elderly patients had disability and when categorized rating the disability than patients’ own rating. 63.6% had minimal disability, 12.3% were moderately Heterogeneity of this population with regard to disabled and 2.7% had severe disability. Such high race/ethnicity, education and with acute presentation frequency of disability among elderly can be explained of disease may limit the generalization of the study on the basis of high prevalence of chronic conditions. findings. Although many chronic diseases are not fatal, chronic conditions are leading cause of disability among the ACKNOWLEDGEMENT elderly and result in many elderly people being limited in their daily activities of life.25 Disability status of We acknowledge the work of 4th year MBBS elderly patients when related to age was found to be students of Dow University of Health Science, statistically significant (p<0.05) which shows that Karachi. Shams Iqbal Jawahir, Shakeel, Abdul increasing age deteriorates functional ability of elderly Wahab and Maria Iqbal who helped in data persons causing more disability. Thus among socio- collection. demographic characteristics age is one of the main

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 19-24 23 Yasmin Mumtaz, Hira Riaz, Muhammad Arsalan, Sana Akhtar, Hareem Haider and Wajiha Manzoor

REFERENCES 14. World Health Organization. Older people and Primary Health Care(PHC). [Accessed August 28, 2009]. Available 1. Bowen RL, Atwood CS. Living and dying for sex. A from:(http://www.who.int/ageing/primary_health_care/en theory of aging based on the modulation of cell cycle /index.html) . signaling by reproductive hormones. Gerontology 2004; 50:265-90. 15. World Health Organization. INTRA: Integrated Response of Health Care Systems to Rapid Populations Ageing. 2. Vijaya K., Kiran ER. Profile of Geriatric in-Patient [Accessed September 10, 2009]. Available from: Admissions. Journal of the Academy of Hospital (http://www.who.int/ageing/projects/intra/en/index.html). Administration 2004; 16:87-12. 3. World Health Organization. Definition of an older or 16. Schoenberg NE, Kim H, Edwards W, Fleming ST. Burden elderly person. [Accessed August 23, 2009]. Available of common multiple-morbidity constellations on out-of- from:(http://www.who.int/healthinfo/survey/ageingdefn pocket medical expenditures among older adults. Gerontologist 2007; 47:423-37. older/en/index.html). 4. World Health Organization. 10 Facts on ageing and the 17. World Health Organization. Noncommunicable Diseases. life course. [Accessed August 23, 2009]. Available [Accessed September 14, 2009]. Available from: from:(http://www.who.int/features/factfiles/ageing/agei (http://www.emro.who.int/ncd/). ng_facts/en/index.html). 18. World Health Organization. Issues and challenges in the 5. U.S. Census Bureau. International data Base. Accessed prevention and control of noncommunicable diseases in August 20, 2009. the South-East Asia Region. [Accessed September 14, 2009]. Available from: 6. United Nations. Commission on population and (http://www.searo.who.int/en/section1174/section1459.htm). development to focus on population growth in least developed nations, impact on development, 30 March-3 19. Naughton C, Bennett K, Feely J. Prevalence of chronic April. [Accessed September 5, 2009]. Available from: disease in the elderly based on a national pharmacy claims (http://www.un.org/News/Press/docs/2009/pop970.doc. database. Age Ageing 2006; 35:633-6. htm). 20. Sohail B, Nazir A, Hussain S, Qaisera S. Pattern of diseases 7. Aubrey D.N.J de Grey. Life Span Extension Research in geriatric patients admitted at Sir Ganga Ram Hospital, and Public Debate: Societal Considerations. Studies in Lahore Ann King Edward Med Coll 2004; 10:26-9. Ethics, Law and Technology 2007; 1:1-15. 21. Munshi YI, Iqbal M, Rafique H, Ahmad Z. Geriatric 8. World Health Organization. 10th Facts on ageing and the morbidity pattern and depression in relation to family life course. [Accessed August 23, 2009]. Available at: support in aged population of Kashmir valley. The Internet (http://www.who.int/features/factfiles/ageing_facts/en/i Journal of Geriatrics and Gerontology 2008; 4(1). ndex4.html). 9. Swami HM, Bhatia V, Dutt R, Bhatia SPS. A community 22. Purty AJ, Bazroy J, Kar M, Vasudevan K, Veliath A, Panda based study of the morbidity profile among elderly in P. Morbidity pattern among the elderly population in the rural area of Tamil Nadu, India. Turk J Med Sci. 2006; Chandigarh, India. Bahrain Med Bull 2002; 24:13-16. 36:45-50. 10. Gaur DR, Goel MK, Goel M, Das A, Arora V. A study of morbidity profile of elderly in urban areas of North India. 23. Canbaz S, Sunter AT, Dabak S, Peksen Y. The prevalence Int J Epidemiol 2008; 5. of chronic diseases and quality of life in elderly people in Samsun. Turk J Med Sci 2003; 33:335–40. 11. Joshi K, Kumar R, Avasthi A. Morbidity profile and its relationship with disability and psychological distress 24. Harwood RH. Commentary: Disability amongst elderly among elderly people in Northern India. Int J Epidemiol people world-wide: the need for multi-dimensional health 2003; 32:978-87. assessment. Int J Epidemiol 2003; 32:988-9. 12. Munshi YI, Iqbal M, Rafique H, Ahmad Z. Geriatric 25. Measuring Healthy Days, Population Assessment of Health- morbidity pattern and depression in relation to family Related Quality of Life. Centers for Disease Control and support in aged population of Kashmir valley. The Internet Prevention, U.S. Department of Health And Human Services Journal of Geriatrics and Gerontology 2008; 4. 2000.

13. Cornoni-Huntley JC, Foley DJ, Guralnik JM. Co-morbidity 26. Kutty NK. Demand for home modifications: a household analysis: a strategy for understanding mortality, disability production function approach. Applied Economics 1999; and use of health care facilities of older people. Int J 31:1273–81. Epidemiol 1991; 20:8-17.

24 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 19-24 ORIGINAL ARTICLE Current Pattern of Bloodstream Infections in a Tertiary Care Hospital of Karachi and Clinical Significance of Positive Blood Cultures Farhan Essa Abdullah,Yasmeen Taj and Shaheen Sharafat ABSTRACT Objective: Blood stream infections (BSI) (septicemias) require prompt empirical therapy based on awareness of the drug susceptibility profiles of locally prevalent pathogens isolated. Place and Duration of Study: Department of Pathology Dow University of Health Sciences, Karachi, in collaboration with Dr Essa’s Diagnostic Centre, from July to November 2008. Study Design: A cross-sectional prospective study. Patients and Methods: 324 consecutive blood cultures from patients coming to Civil Hospital Karachi were scrutinized for bacterial isolates and their antibiotic sensitivity profiles were done. Results: A total of 100 (30.9%) specimens were found positive, of these 78% isolates were gram negative bacteria and 22% gram positive cocci. Salmonella typhi, seen less often in adults (20.5%), was the predominant pathogen in children (82.5%). Escherichia coli, Staphylococcus aureus, Pseudomonas and Klebsiella were isolated in neonates, and Klebsiella, Pseudomonas, Enterobacter and Acinetobacter were identified among adult patients. While all S.typhi isolates were sensitive to cefixime, ceftriaxone and the fluoroquinolones and increasingly amenable to chloramphenicol, of significance was the percentage of other multidrug resistant bacterial isolates. Methicillin resistant Staphylococcu aureus was isolated from one case. Statistical Analysis:The results were analysed by applying SPSS version 16 to derive p value. Conclusion: Amikacin, carbapenems, cefoperazone+sulbactam, fosfomycin and pipericillin+tazobactam are currently the only available drugs still active in-vitro on blood isolates, judicious use of antibiotics focused on the compliance and formation of antibiotic policy guide lines is highly recommended.

Key words: Bloodstream infections, septicemia, gram negative bacteria, gram positive bacteria. INTRODUCTION Septicemias cause significant morbidity and mortality The spectrum of organisms causing sepsis change world wide and are among the most common health- over time and vary from region to region.7,8 A five- care associated infections.1, 2 Despite being a major fold increase in the number of cases of sepsis by gram cause of hospital admissions and mortality, there is positive cocci have been reported from the developed relatively little information available on community countries.9 The epidemiologic data from developing acquired bacteremia in the tropics.3,4 Respiratory, countries show significant differences in the incidence, genitourinary tract and intra -abdominal foci are risk factors, pattern and antimicrobial susceptibility often identifiable sources of blood stream infections.5 of pathogens, and morbidity, when compared with Bacteremia due to Enterobacteriaceae other than E. that of developed countries.10-13 coli is reported to be associated with increasing . mortality as compared to gram positive species.6 There is a dire need, therefore for clinicians to be updated with the current efficiency of commonly Department of Pathology, Dow Medical College, Dow University of Health Sciences, Karachi, Pakistan. prescribed drugs and the selection of antimicrobials Correspondence: Dr. Yasmeen Taj, Department of Pathology, Dow Medical College, for empiric therapy should be based on the Dow University of Health Sciences, Karachi, Pakistan. susceptibility pattern of local pathogens isolated. E-mail: [email protected] On the other hand antibiotic treatment may be Received: February 02, 2010: accepted: April 15, 2010 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 25-30 25 Farhan Essa Abdullah,Yasmeen Taj and Shaheen Sharafat needlessly started based on false positive culture diffusion method using antibiotic impregnated discs results.13 This increases the possibility that resistant (Oxoid). Methicillin susceptibility was done for bacteria may emerge resulting in more difficult-to- Staphylococcus aureus. treat infections. Bloodstream infection is usually treated with a minimum 10-14 days of antibiotic Out of 324 blood stream specimens, a total of 100 therapy. This duration of treatment has been shown consecutive positive cultures were obtained . to be a risk factor for the subsequent emergence of The antibiotics tested on gram positive cocci included infection with antibiotic resistant bacteria.14 Previous ampicillin, amoxicillin+clavulanic acid , ciprofloxacin, studies have identified a significant association erythromycin, gentamicin and vancomycin; and between administration of inadequate antimicrobial oxacillin for confirmation of MRSA. Antibiotics used treatment and mortality. for gram-negative bacilli of the Enterobacteriaceae family included amikacin, cefotaxime, ceftriaxone, The data of our exercise emphasizes the importance ciprofloxacin and gentamicin. For S.typhi, aztreonam, of establishing the current pattern of pathogens and cefixime, cefotaxime, ceftriaxone, ciprofloxacin, their antibiotic resistant profiles. It is imperative to chloramphenicol, cotrimoxazole, nalidixic acid and correctly intemperate positive blood cultures in order fosfomycin were used. to initiate an adequate and prompt antimicrobial regimen. RESULTS

MATERIAL AND METHODS Among the 324 consecutive samples positive for blood cultures, 100 specimens yielded bacterial growth. This study was carried out at the Department of Neonates (n=49), children between 1 month-12 years Pathology, Dow University of Health Sciences, of age (n=26), adults (n=25) (The eldest patient with Karachi in collaboration with Dr Essa’s Diagnostic septicemia was an 80-year old male presenting with Centre, between July-November 2008. unstable angina.(Table 1)

Inclusion criteria: All cases suspected for bloodstream Isolates identified: infections on clinical assessment. Staphylococcus aureus (n=20), followed by S.typhi, Exclusion criteria: Cases already admitted in the Pseudomonas spp, E.coli and Klebsiella spp were the hospital and cases already on antibiotic treatment. most common isolates (Table 2); four other gram Blood samples were drawn for two blood cultures negative bacteria were also identified, as well as 2 from each case. The blood culture medium used was gram positive cocci: these were Strep.agalactiae in trypticase soya broth supplemented with thyoglycollate a neonate, and enterococci in one child. One broth in 5 ml bottles for adults, 2 ml bottles for children Staphylococcus aureus isolate was methicillin resistant. and 1ml bottles for infants..The sample was promptly The majority of isolates identified (78%) were gram introduced into each of two blood culture bottles negative rods (Table 2). and incubated at 37oC. Daily subculture was made onto blood agar, chocolate agar and McConkey’s agar The drug susceptibility results of the isolates are for up to 7 days or until positive growth was noted. presented in Table 3. Fosfomycin, imipenem, pipericillin+tazobactam, cefoperazone+sulbactam and The isolates were identified according to standard amikacin were the most effective drugs on procedures15 and their antibiotic susceptibility profiles Enterobacteriaceae isolates; only 10 of these, which determined by the conventional Kirby-Bauer disc included E.coli, Klebsiella and Citrobacter were

26 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 25-30 Current pattern of blood stream infections in a tertiary care hospital of karachi and the clinical significance of positive blood cultures resistant to this drug. Fosfomycin and pipericillin+tazobactam were also more consistent in 8% 3%1%1%1% 5% affording zones on Pseudomonas and Acinetobacter 20% isolates. Vancomycin was active on all 20 Staph.aureus 12% isolates and each of the enterococcus and Strep.agalactiae isolates. Ciprofloxacin sensitivity was recorded with all 16 S.typhi recovered from the 13% 16% blood specimens scrutinized; 10 of these were resistant 13% to Cefixime. One Pseudomonas aeruginosa and one E.coli isolate were resistant to every drug tested. Figure – 1 :

Table 3 : Antibiotic susceptibility (%) of bacteria isolated from Table1 : Age distribution of patients yielding positive growth blood cultures on blood culture Enterobacte Gram- Antibioics S.Typhi Non- positive riaceae fermenters cocci Age Number amikacin 30µg 76 62 chloramphenicol30µg 48 0-1 month 49 cotrimaxozole 25µg 44 66 1 month-12 years 26 ciprofloxacin 55 100 65 89 12 years-80 years 25 Ceftriaxone30µg 58 99 50 Cefotaxime30µg 56 52 Total 100 96 cefixime 58 90 Gentamicin10µg 48 62 Fosfomycin50µg 90 89 94 Table 2 : Percentage of Blood Culture Isolates from Civil Hospital 92 In-Patients in Karachi aztreonam 83 imipenem 78 57 AgeNumber Neonates Children pipericillin+tazobactam 78 49 Erythromycin15µg 61 Staphylococcus aureus 20 10 4 Vancomycin30µg 100 (Methicillin Sensitive) 19 cefoperazone +sulbactam 82 82 MRSA 1 ceftazidime + clavulanic 63 63 acid Salmonella 16 0 13 Methicillin 5µg 19 S typhi 12 paratyphi 4 DISCUSSION Pseudomonas 13 8 1 Esherichia coli 13 10 1 The extent of neonatal sepsis in our study was in keeping Klebsiella spp 12 7 1 with the observation that about 50% to 88% of neonatal Acinetobacter spp 8 4 2 deaths in the community are attributable to infectious Alcaligenes spp 3 1 2 causes and that 22% to 66% of all admissions in the Citrobacter spp 1 1 0 neonatal unit are due to septicemia and pneumonia.15 A Proteus spp 1 0 0 Nigerian report on neonatal septicemia observed a rate of Enterococcusspp 1 0 1 59.8% blood culture positivity16 while studies in Karachi Streptococcus agalactiae 1 1 0 suggested that 43.5% blood cultures from neonates in 1984

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 25-30 27 Farhan Essa Abdullah,Yasmeen Taj and Shaheen Sharafat and 40% in 1985 were positive.17, 18, 19 While considering All our isolates from septicemic patients were aerobic; overall blood culture positivity, variable rates have been this not uncommon observation encourages recent observed by different workers, possibly reflecting the recommendations that labs should reserve the practice of methodology, manual or automation in use. In our study, routinely setting up anaerobic cultures for only pertinent while 30.9% of 324 specimens processed yielded growth, clinical conditions.28 a Canadian study found 63% blood cultures positive for pathogens,20 in Islamabad, 54% were reported positive, Data from developing countries show important differences and in Lahore, bacterial pathogens were isolated from 60% in the local pattern of antibiotic sensitivity30 and multidrug of blood specimens.21 Interestingly, in a study carried out resistance to antibiotics has noticeably increased over the in Chandigarh, India only 9.94% of the samples yielded last two decades. This situation is decidedly worse in growth.22 developing countries due to the misuse of antibiotics, including Pakistan. In our study, 24 of the bloodstream All our cultures yielded single isolates; this observation isolates were multidrug resistant; 10 of these were sensitive is common, unimicrobial growth has been reported in to only fosfomycin, a drug not in as wide use as other other studies22,23 and in also those conducted in Multan broad spectrum injectables, and one Pseudomonas and Karachi.24-27 aeruginosa and an E.coli isolate were resistant to all the indicated drugs tested. The spectrum of organisms causing sepsis is known to change over time and in different geographical areas.21,25 Our data emphasizes the observation that amikacin offers satisfactory activity (76%) against Enterobacteriaceae in Coagulase negative staphylococci (CONS) are normally particular, whereas ciprofloxacin was less effective (65%) present as commensal organisms on the skin, in recent on the non-fermenters including Pseudomonas and years they have emerged as significant etiological agents Acinetobacter spp, but active on all our S.typhi isolates. 28 of septicemia. This acceptance has occurred in the face Also, cefoperazone+sulbactam acted significantly on all of a positive staphylococcus blood culture often being gram-negative isolates (82%) in comparison with misinterpreted as a “contaminant” by both physician and ceftriaxone and amikacin, and all gram-positive cocci 29 infection control staff. were found to retain sensitivity to vancomycin. Studies reported in Western countries usually show Unfortunately, since antibiotic-resistant strains have Strep.agalactiae as a frequent neonatal isolate. This emerged we need to control the spread of these resistant organism has, however, hardly been reported in studies strains through infection control programes and continuous carried out in Pakistan and other developing countries.7,24 monitoring of drug resistant patterns. Our findings include one case of neonatal sepsis due to this Group B streptococcus. CONCLUSIONS

Our data differs in the frequency of different gram negative No gold standard other than a positive blood culture exists isolates: S.typhi among the gram negatives, for example, to confirm septicemia. However, even in the best of hands, seen occasionally in adults was the predominant pathogen blood culture positivity rates may be only 30% in clinically (81.25%) in children, while E.coli, Klebsiella and suspected cases. The practice of obtaining three blood Pseudomonas were pathogens in all ages.The p-value for cultures from different sites during febrile episodes pathogens isolated on blood culture s was found to be enhances the chances of obtaining positive results. The 0.81. life threatening nature of bacteremia and sepsis underscores

28 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 25-30 Current pattern of blood stream infections in a tertiary care hospital of karachi and the clinical significance of positive blood cultures the importance of using local surveillance data to guide 9. Rahman S, Hameed A, Roghani MT, Multidrug resistant empirical therapy as a rational strategy to minimize neonatal sepsis in Peshawar, Pakistan. Arch Dis Child Fetal Neonatal Ed 2002; 7: 52-4. escalating antimicrobial resistance. Regular referral towards latest antibiograms by the clinicians is another 10. Esel D, Doganay M, Alp E, Sumerka B. Prospective evaluation of blood cultures in a Turkish University important recommendation that needs to be emphasized hospital.Clin Microbiol Infect 2003; 9:1038-44. in our country. 11. Mondal GP, Raghavan M, Bhat BV, Srinsavan S. Neonatal REFERENCES septicemia among in- born and out-born babies in a referral hospital. Ind J Paediatr 1991; 58;529-33.

1. Karlowsky JA, Jones ME, Draghi DC. Thornsberry C, 12. Bates DW, Goldman L, Lee TH. Contaminated blood ShamDS Volturo GA. Prevalence and antimicrobial cultures and resource utilization: the true consequences of susceptibilities of bacteria isolated from blood cultures of false positive results: JAMA 1991; 265:365-9. hospitalized patients in the United States in 2002. Ann 13. Gross PA, Barrett TL, Dellinger EP, Krause PJ, Martone Clin Microbiol Antimicrob 2004; 3:1476-711. WJ, McGowan JE, et al. Quality standard for the treatment of bacteriema: Infectious Diseases Society of America. Clin 2. Wenzel RP, Edmond MB. The impact of hospital acquired Infec Dis 1994; 18:428-30. blood stream infections. Emerg Infect Dis 2001; 7:174-7. 14. Garcia LS, Procop GW, Roberi GD, Thompson RB. Overview 3. Phetsouvanh R, Phongmany S, Soukaloun D, Rasachak of convential methods for bacterial identification. pp 167- B, Soukhaseum V, Rattnaphone et al. Causes of community 181. In Forbes, BA Sahm DF, Weisfel AS (eds.), 1998 Bailey acquired bacteraemia and patterns of antimicrobial and Scott’s Diagnostic Microbiology, 10th ed. Mosby. resistance in Vientiane Laos. Am J.Trop, Med, Hyg 2006; 15. Bhutta ZA. Epidemiology of neonatal sepsis in Pakistan 5:978-85. and an analysis of evidence and implications of care. 4. Sucu N, Caylan R, Aydin K, Yilmaz G, Akotz-Boz G, JC PSP 1996; 6:12-7. Koksal I. Prospective evaluation of blood cultures in 16. Antia-Obocg OE, Utsalo SJ, Udo JJ. Neonatal septicemia medical faculty hospital of black sea Technical University in Calabar, Nigeria. Afr J Med 1992; 38:161-5. Mikrobyiol Bul 2005; 39:455-64. 17. Khan MS, Saeed M. Bacteriologic study in neonatal sepsis. 5. Weinstein MP, Towns ML, Quartey SM, Mirrett S, Reimer Pak Pediatr J 1991; 58:69-72. LG, Parmigiani G, et al. The clinical significance of positive Blood cultures in the 1990: a prospective comprehensive 18. Mondal GP, Raghavan M, Bhat BV. Neonatal sepsis among evaluation of the microbiology, epidemiology and outcome inborn and out born babies in a referral hospital. Indian J of bacteria and fungemia in adults.Clin Infect Dis 1997; Pediatr 1991; 58:529-33. 24:584-602. 19. Robert FJ, Geere IW, Coldman A. A three year study of 6. Aftab R, Iqbal I. Bacteriological agents of neonatal sepsis in positive blood cultures, with emphasis on prognosis. Rev NICU at Nishtar Hospital Multan, JCPSP 2006; 16:216-9. Infect Dis 1991; 13:34-46. 20. Khan OI, Khan NI, Izhar M, Khan JI. Changes in pattern 7. Freeman J, Platt R, Sidebottom DG, Leclair JM, Epstein of bacteremia at Shaikh Zayed Medical Complex, Lahore. MF, Goldman DA. Coagulase negative staphylococcal Pak J Med Res 1998; 36:80-2. bacteremia in the changing intensive care unit population. JAMA 1987; 258;2548-52. 21. Mehta M, Dutta P, GuptaV. Antimicrobial Susceptibility Pattern of Blood Isolates in a teaching hospital in North 8. National Nosocomial Infections Surveillance (NNIS) India. Jpm J. Infect Dis 2005; 58:174-76. System: Nosocomial Infections Surveillance Report, Data summary from October 1986-April 1997, issued May 1997. 22. Johnson JE, Washington JA, Comparison of direct and A report from the NNIS system. Am J Infect Control 1997; standardized antimicrobial susceptibility testing of positive blood 25:477-87. cultures. Antimicrob Agents Chemother 1976; 110:211-4.

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 25-30 29 Farhan Essa Abdullah,Yasmeen Taj and Shaheen Sharafat

23. Chaudhry I, Chaudhry NA, Munir M, Hussain R, Tayab and facultative anaerobes, strict aerobic bacteria and fungi M. Etiological Pattern of Septicemia at Three Hospitals in in aerobic and anaerobic blo od culture bottles. J Clin Lahore. JCPSP 2000; 10:375-79. Microbiol 1992; 30:6-10.

24. Khan IK, Akram DS. Neonatal Sepsis: etiological study. 28. Jain A, Agarwal J, Bansal S. Prevalence of coagulase JAMA 1987; 37: 327-30. negative staphylococci in neonatal intensive care units: findings in tertiary care hospital in India. J Med Microbiol 25. Stoll BJ, Gordon T, Korones SB, Shankaran S, Tysone JE, 2004; 53: 941-44. Bauer CR, Fanaroff AA, et al. Late onset sepsis in very low birth weight neonates: a report from the National 29. Darmstadt GL, Black RE, Santosham M. Research priorities Institute of Child Health and Human Devolopment Neonatal and postpartum care strategies for the prevention and Research work. J Paediatr 1996; 129:64-71. treatment of neonatal infection in less developed countries. Pediatr Infect Dis J 2000; 19:739-50. 26. Bhutta ZA, Yusuf K. Early onset neonatal sepsis in Pakistan: a case control study of risk factors in a birth cohort. Am J Perinatol 1997; 4:577-81 30. CDC.Infection control and health care.Community associated Methicillin resistant staphylococcus 27. Murray PR, Traynor P, Hopson D. Critical assessment of aureus.Overview.department of Health and Human blood culture techniques: analysis of recovery of obligate services..CDC April 2009.

30 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 25-30 ORIGINAL ARTICLE Contusion Index: Its Importance in Management of Traumatic Brain Contusions Atiq Ahmed Khan, Muhammad Aslam, Muhammad Imran, Muhammad Muzaffaruddin, Irfanullah Shah and Junaid Ashraf.

ABSTRACT Objective: To describe the changes of Glasgow Outcome Scale (GOS) and Glasgow Coma Scale (GCS) after surgical and / or conservative management of patients with contusions based on Contusion Index (C. I.). Study Design: Descriptive Study Setting: Department of Neurosurgery, Dow University of Health Sciences/ Civil Hospital, Karachi. Duration of Study: Two years and five months between August 2006 and January 2009. Subjects and Methods: 50 patients of ages between 6 to 75 years, including both sexes were evaluated on the basis of contusion index as determined by computerized tomographic scan (C.T. Scan) findings and their Glasgow outcome scores were established. Results: Patients with contusion index 0 – 3 should be conservatively managed. Patients with contusion index 6 should be given the benefit of some sort of surgical procedure first, which showed best results with surgical management and poor results with conservative management. Patients with contusion index 9, no matter what, always show a poor outcome. Conclusion: We recommend that a future study should be done to arrive at a decision regarding conservative versus surgical management of patients with cerebral contusions based on Contusion Index which will help us avoid unnecessary surgeries and vice versa.

Key words: Contusion Index, Glasgow outcome score, Intracerebral Contusions.

INTRODUCTION

Head trauma constitutes one of the most important white matter, contusions are more likely to be hemorrhagic causes of morbidity and mortality in the modern world.1 6. The hemorrhagic foci may vary in size from small Traumatic cerebral contusions, by definition, must petechiae scattered throughout the larger non- primarily involve the superficial grey matter of the hemorrhagic zone of injury to multiple large confluent brain,2-5 or they are defined as bruises of brain regions of hemorrhage occupying an entire lobe. parenchyma where the subpial membrane remains Contusions tend to be multiple and bilateral. intact. If it distorts the subpial membrane then it is Contusions most commonly involve the temporal and termed as a laceration. The underlying white matter frontal is usually spared unless the contusion is extremely lobes 2, 7, 8. Temporal lobe lesions mostly occur just large. above the petrous bone or posterior to the greater sphenoid wing. Frontal lobe lesions tend to lie just Because grey matter is much more vascular than above the cribriform plate, planum sphenoidale and

Department of Neurosurgery, Civil Hospital, Karachi, Pakistan. lesser sphenoidal wing. The parietal and occipital Correspondence: Dr. Atiq Ahmed Khan, Department of Neurosurgery, Civil Hospital, lobes are implicated much less frequently. and Dow University of Health Sciences, Karachi, Pakistan. Angular acceleration forces are important in the E-mail: [email protected] development of contusions. They cause differential Received: January 01, 2010: accepted: April 15, 2010. movement of the brain within the skull and results in

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 31-37 31 Atiq Ahmed Khan, Muhammad Aslam, Muhammad Imran, Muhammad Muzaffaruddin, Irfanullah Shah and Junaid Ashraf. sliding of the cortical surface along the inner TABLE-1: MEASUREMENT OF CONTUSION table. 9-11 Cortical contusions are less frequent in INDEX: infants and young children because of the smooth Grade Depth of contusion Extent of contusion inner surface of the skull. 0 Absent Absent PATIENTS AND METHODS 1 Does not extend to Localized the full thickness of 50 patients of all ages and both sexes, having contex intracerebral contusions with the time duration of less 2 Affects the full thickness Moderately than 24 hours from time of injury were included in of contex Extensive this study after taking informed consent. It was carried out in the Department of Neurosurgery, Dow 3 Extend into the white Extensive University of Health Sciences, and Civil Hospital matter Karachi over a period of two years and five months NOTE (between August, 2006 and January, 2009). The contusion index for any anatomical locator Exclusion criteria were intracerebral contusions in selected is derived from depth x extent; it can range patients with poly trauma, patients with systemic from 0 x 0 = 0 (contusion absent) to 3 x 3 = 9 (deep illness, patients with other significant brain injuries and extensive contusion). like extradural hematomas, subdural hematomas, i.e. Depth x Extent = Contusion severe diffuse injury, intraventricular haemorrhage.5-8 etc. 0 x 0 = 0 [contusion absent / no contusion] apart from the contusions, time of duration i.e. > 24 3 x 3 = 9 [deep & extensive contusion] hours from time of injury, patients with surgical complications.5-6

All the 50 patients included were assessed carefully by proper history taking,4 examinations, CT scan findings and follow up. CT scan findings were used to determine the Glasgow Coma Scale (GCS), Glasgow Outcome Scale (GOS) and Contusion Index (Table-1) and all were divided into three groups on the basis of Contusion Index. Group-1: Contusion Index 0 – 3, Group-2: Contusion Index 4 – 6, Group- Figure – 1 : 3: Contusion Index 8 – 9. Sampling technique was non-probability convenience and the study design was descriptive. 1. (Contusion Index 0 – 3) – Conservative management. 2. (Contusion Index 4 – 6) – Conservative / Surgical management. 3. (Contusion Index 8 – 9) – Conservative / Surgical management (provided the Glasgow Coma Scale was >7) Figure – 2 :

32 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 31-37 Contusion index: Its importance in management of traumatic brain contusions

RESULTS 50 patients of ages 6 to 75 years including both sexes were evaluated on the basis of contusion index as determined by the CT scan findings.

Group-1 (Contusion Index 0-3):

16 out of 50 patients belonged to Group-1. This group was therefore conservatively managed. Of these 16 patients, 2 had a contusion index of 1, 9 had a contusion Figure –3 : index of 2 and 5 had a contusion index of 3.

15 patients out of these 16 turned out to have a Glasgow Outcome Score (GOS) of 5 (93.23%) and only 1 patient had a GOS of 3 (6.78%). This was the patient whose presenting Glasgow Coma Scale (GCS) was 5 / 15. He was aphasic and had right sided hemiparesis.

Group-2 (Contusion Index 4-6):

Figure –4 : 30 out of these 50 patients belonged to Group-2. Of these 30 patients, 14 had an index of 4 and 16 had an index of 6. This group was therefore subdivided into two groups on the basis of contusion index; i.e.Group-2a including the 14 patients with contusion index 4 and Group-2b including the 16 patients with contusion index 6 and then both the groups were individually analyzed. It was found that in Group- 2a, of 14 patients with Contusion index 4, 10 patients had a Glasgow Outcome Score of 5. Out of these 10 patients, 8 were conservatively managed and 2 were Figure – 5 : surgically managed but 1 patient out of the 2 had undergone wound debridement only and the contusion was not touched.

Group 2a [Contusion Index 4]:

1 patient out of these 14 patients with contusion index 4 had a Glasgow Outcome Score of 4 and he had received conservative management (10) only.

1 patient had a Glasgow Outcome Score of 3 and he also received conservative management (10) only. The presenting Glasgow Coma Scale of this patient was Figure – 6 : 8 / 15 which contributed to the low Glasgow Outcome

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 31-37 33 Atiq Ahmed Khan, Muhammad Aslam, Muhammad Imran, Muhammad Muzaffaruddin, Irfanullah Shah and Junaid Ashraf.

Score. 2 out of these 14 patients expired (Glasgow expanded to an index of 9 and he expired. Of the 3 Outcome Score 1). Both died of intractable seizures that were surgically managed, 1 had a poor Glasgow (11). 1 of these had undergone surgery because on the Coma Scale on admission of 5 / 15 which had 5th day of conservative management the contusion contributed to this poor outcome. 1 had expired due had expanded to an index of 6 but immediately after to seizures although his admission Glasgow Coma surgery he developed intractable seizures and died. Scale was 9 / 15. In one case expiry was not related Another patient died on the first day of admission to surgery because patient had improved to a Glasgow due to seizures. Outcome Score of 3 but because of poor nutritional status and metabolic conditions she died 10 days Group-2b [Contusion Index 6]: after surgery. Her presenting Glasgow Coma Scale 4 patients out of these 16 patients with contusion was 9 / 15. index 6 had a Glasgow Outcome Score of 5. Out of So evaluating and summarizing the second group these 4 patients, 3 were managed surgically at the of 30 patients (Contusion Index 4-6) it was found outset preoperative ,Glasgow Coma Scales being 14 that: / 15, 8 / 15 and 7 / 15 respectively, and 1 patient was managed conservatively (Glasgow Coma Score being 1 14 patients out of a total of 30 patients in this second group 15 / 15). had an ultimate Glasgow Outcome Score of 5 = 46.66% with 10 out of 14 from Contusion Index 4 group = 71.44% 4 out of these 16 patients had a Glasgow Outcome and 4 out of 14 from Contusion Index 6 group = 28.5%. Score of 4 and out of these 4 patients, 2 were managed This means that the patients with Contusion Index 4 had a better outcome compared to the patients with Contusion conservatively at the outset and 2 were managed Index 6 which was only 28.57%. surgically, Glasgow Coma Scales being 9 / 15 and 10 / 15 respectively. Of 2 that were conservatively 2 5 patients out of 30 had a Glasgow Outcome Score of 4 = managed (Glasgow Coma Scale being 15 / 15 and 11 16.66% out of which 1 was from Contusion Index 4 group / 15), the one with the lower Glasgow Coma Scale = 20% and 4 were from Contusion Index 6 group = 80%. had to be surgically dealt with because on the 3rd day contusion expanded. 3 Only 1 out of these 30 patients had a Glasgow Outcome Score of 3 and was from Contusion Index 4 group 33.33%. 8 out of these 16 patients expired with Glasgow Outcome Score 1. 4 10 out of these 30 patients i.e. 33.33% expired (Glasgow Outcome Score 1). Out of these 10, 2 were from Contusion On careful analysis of these 8 patients it was noted Index 4 group = 20% and 8 were from Contusion Index 6 group = 80%. So the major mortality was from the group that 5 out of these 8 were conservatively managed at with contusion index 6 i.e. 80% of the 33.33% with Glasgow the outset. Glasgow Coma Scales of these being 5 / Outcome Score 1. 15, 9 / 15, 7 / 15, 11 / 15, 10 / 15 respectively and 3 out of these 8 were managed surgically at the outset. 5 It is however also worth noting that of the 16 patients with Glasgow Coma Scales of these being 5 / 15, 9 / 15 contusion index 6 there were 8 patients =50% that were and 10 / 15. Of the 5 that were conservatively managed surgically managed and 8 patients = 50% that were 2 underwent surgery later after 24 hours as their initial conservatively managed at the outset. It was found that 4 Glasgow Coma Scale was 9 / 15 and 7 / 15 and the patients = 50% out of the 8 conservatively managed patients ultimately required surgery but by then their neurological contusions had expanded to an index of 9 but despite status had further deteriorated and only 1 survived with this they could not be saved. In 1 out of these 5 patients Glasgow Outcome Score 4. So of the 8 conservatively who had a Glasgow Coma Scale of 10 / 15, surgery managed only 3 had a good outcome 37.5% and 5 expired was required but because of the severe coagulopathy (Glasgow Outcome Score 1) that is 62.5%. that had developed after admission, the contusion 6 Of the 8 surgically managed, 5 had a good outcome at the

34 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 31-37 Contusion index: Its importance in management of traumatic brain contusions

outset. This means that those patients with Contusion Index cited showing comparison of our results with any 6 should be managed surgically from the beginning because previous studies (12). This is a pilot study and we can they show better results with surgery rather than with only say what the results showed in terms of conservative management. percentages of Glasgow Outcome Scores in the three groups. Much larger studies are therefore necessary Group-3 (Contusion Index 8 – 9) taking into account the different aspects of our study before a definitive management protocol can be laid Only 4 out of 50 patients belonged to Group-3. Of down on the basis of Contusion Index. these 4 patients, 2 were managed conservatively; Glasgow Coma Scale being 9 / 15, 9 / 15 respectively Group-2 of our study included the 30 patients with and 2 were managed surgically at the outset, Glasgow Contusion Index 4 – 6. It was noticed that the best Coma Scale being 7 / 15 and 10 / 15 respectively. Of Glasgow outcome score of 5 was in 46.66% only and the two conservatively managed 1 had to undergo that 71.44% of this was occupied by patients from surgery on the second day because of further contusion index 4 and only 28.57% were from deterioration in the neurological status. It was however contusion index 6 groups. noticed that no matter how this group was managed 5 out of these 14 patients were managed surgically (conservatively or surgically) there was 100% mortality. out of which 3 were from Contusion Index 6 group, These contusion index 9 patients have a poor outcome and 2 were from Contusion Index 4 group but 1 out no matter how they are managed. of these 2 patients had undergone surgery for depressed DISCUSSION fracture and wound debridement but the contusion itself was not touched. In this study of 50 patients it was found that the patients This means that the major part of good outcome in belonging to the Group-1 (Contusion Index 0 – 3), this group was seen in patients with Contusion Index conservative management was good enough. It was 4. The majority of these i.e. 8 / 10 were conservatively also noticed that the presenting Glasgow Coma Scale managed. In 2 out of these 8 patients contusion had of majority was above 10 / 15 and the only one patient expanded to an index of 6 but since the overall whose presenting Glasgow Coma Scale was very low condition was stable, the patients showed improvement (5 / 15) was the one with Glasgow Outcome Score of on conservative management only. 3 with residual deficits. So 100% patients in this group survived on conservative management out of which Although in patients with Contusion Index 6, only 1 93.23% showed Glasgow Outcome Score of 5 and did well and that too was on surgical rather than 6.78% (1 patient only) showed Glasgow Outcome conservative management. Score of 3. This means that patients belonging to this group should be given a chance of conservative Again, in this second group of 30 patients with management only when the size of contusion is small Contusion Index 4 – 6, 5 patients i.e. 16.66% had a and the chances of expansion of contusion is very low. Glasgow Outcome Score of 4. This time 80% of this Only in 1 out of these 16 of patients the contusion score was occupied by Contusion Index 4 group. It expanded to an index of 4 i.e. 6.78% and that too on was again noticed that patients with Contusion Index conservative management showed Glasgow Outcome 6 did best on surgical management rather than Score of 5. conservative because 4 out of 5 of these 30 patients had belonged to this group and 2 out of these 4 were Since there are no studies available both locally as conservatively managed at the onset and 2 surgically. well as internationally, therefore no references can be In the cases that were conservatively managed, 1 had to be surgically dealt with after 3 days, because the

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 31-37 35 Atiq Ahmed Khan, Muhammad Aslam, Muhammad Imran, Muhammad Muzaffaruddin, Irfanullah Shah and Junaid Ashraf. contusion expanded to an index of 9 and patient’s 2 of which were conservatively managed and 2 were Glasgow Coma Scale had dropped from 11 / 15 to surgically managed. Out of the 2, 1 was given the 9 / 15. benefit of surgery after 2 days because of deterioration in Glasgow Coma Scale to 7 / 15 but he also showed So the above results again favor the initial surgical poor results. Despite initial Glasgow Coma Scales of management in patients with Contusion Index 6. 7 / 15, 10 / 15, all died. So there was 100% mortality Again this is all an observation from our study and in this group whether surgically or conservatively since this is a descriptive study and we do not have managed. any previous studies relating contusion index to Glasgow outcome score on the basis of surgical CONCLUSION versus conservative management, we cannot compare our results with any other studies. In this second In our conclusion we can say that patients with group, only 1 patient had a Glasgow Outcome Score contusion index 0 – 3 should be conservatively of 3 and he belonged from the contusion index 4 and managed. Patients with contusion index 4 should be was conservatively managed. This constituted 3.33% monitored carefully and may do well with conservative of the 30 patients in this group. management only, but however, occasionally surgery may be required. Patients with contusion index 6 There was 33.33% mortality (10 out of 30) in this should be given the benefit of some sort of surgical group and the major bulk of deaths, i.e. 80% was in procedure first, because this was the group in our patients with Contusion Index 6 whereas only 20% study, which showed best results with surgical was in patients with Contusion Index 4. Careful management and poor results with conservative analysis again revealed that the high mortality in management. Patients with contusion index 9, no Contusion Index 6 patients was because 5 out of 8 matter what, always showed a poor outcome (13). In patients were initially managed conservatively and our study there was 100% mortality in this group. despite the fact that out of these, 5 patients were Our study design was descriptive and since no such offered surgeries, later they did not survive. This work has been done in the past to determine any again favors an initial surgical rather than a relationship between contusion index and Glasgow conservative approach in patients with Contusion outcome scores on the basis of conservative or surgical Index 6. management we cannot give a definitive management protocol. We have simply stated what our results The cause of mortality in the 2 patients with Contusion revealed. This study has, in no doubt, provided a Index 4 was mainly intractable surgeries. 1 of these framework for further studies in this context and is patients had presented with Glasgow Coma Scale of also free for criticism on how it could have been 6 / 15 and had died within 24 hours of admission improved. The main purpose for any future study probably because of intractable seizures and not the for patients with contusions based on Contusion Index. index of contusion. The other patient although had a Glasgow Coma Scale of 13 / 15 the contusion This is very important because this will help the on expanded on 5th day to an index of 6. He was operated call neurosurgeon to arrive at a decision regarding but post-operatively developed intractable seizures conservative versus surgical management of patients and died. with cerebral contusions based on Contusion Index and will also help to avoid unnecessary surgeries or Group-3 (Contusion Index 8 – 9) had only 4 patients. vice versa.

36 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 31-37 Contusion index: Its importance in management of traumatic brain contusions

REFERENCES

1. Adams JH, Scott G, Parker LS, Graham DI, Doyle D. 8. Boom WH, Tuazon CU. Successful treatment of The contusion index: a quantitative approach to cerebral multiple brain abscess with antibiotics alone. Rev contusions in head injury. Neuropathol Appl Neurobiol Infect Dis 1985; 7:189-99. 1980; 6:319-24.

2. Han JS, Kaufman B, Alfidi RJ, Yeung HN, Benson JE, 9. Illingworth RD. Operative surgery. Neurosurgery 3rd Haaga JR, et al. Head trauma evaluated by magnetic ed. 1979. p. 53-4. resonance and computed tomography: a comparison. Radiology 1984; 150:71-7. 10. Stein SC, Ross SE. Moderate head injury: a guide to 3. Marshall LF, Klauber MR. The outcome of severe initial management. J Neurosurg 1992; 77:562-4. closed head injury. J Neurosurg 1991; 75:28-36.

4. Kraus JF. Epidemiology of head injury. Copper PR. 11. Temkin NR, Dikmen SS, Wilensky AJ, Keihm J, Editor. Head Injury. 2nd ed. Baltimore: Williams & Chabal S, Winn HR. A randomized, double-blind Wilkins; 1987. p. 1-19. study of phenytoin for the prevention of post-traumatic seizures. N Engl J Med 1990; 323:497-502. 5. Macpherson BC, MacPherson P, Jennett B. CT evidence of intracranial contusion and hematoma in relation to the presence, site and type of skull fracture. Clin Radiol 12. Jennett B, Teasdale G, Galbraith S, Pickard J, Grant 1990; 42:321-6. H, Braakman R. et al. Severe head injuries in three 6. Adams JH. The Neuropathology of head injuries. In: countries. J Neurol Neurosurg Psychiatry 1977; Vinkemn PJ, Bruyn GH editors. Handbook of Clinical 40:291-8. Neurology, Vol. 23. Amsterdam: North Holland; 1975. p. 35-65. 13. Narayan RK, Greenberg RP, Miller JD, Enas GG, Choi SC, Kishore PR, et al. Improved confidence of 7. Gudeman SK, Kishore PR, Becker DP, Lipper MH, Girevendulis AK, Jeffries BF. Computed tomography outcome prediction in severe head injury. A in the evaluation of incidence and significance of post- comparative analysis of the clinical examination, traumatic hydrocephalus. Radiology 1981; 141:397- multimodality evoked potentials, CT scanning, and 402. intracranial pressure. J Neurosurg 1981; 54:751-62.

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 31-37 37 CASE REPORT Knotting of Urethral Catheters: a Preventable Complication Muhammad Shahab Athar, Muhammad Sajjad Ashraf, Muhammad Talat Mehmood and Shero Moti

ABSTRACT A number of complications are associated with Urethral catheterization. Feeding tube is usually used for this purpose in children. Spontaneous intravesical knotting of such urethral catheters is a known but rare complication. We are reporting two cases of intravesical knotting of feeding tube used to drain bladder in patients who underwent urethroplasty.

Key words: Catheter knotting, urinary.

INTRODUCTION

Feeding tubes are commonly used to drain the bladder resistance was encountered. Intravesical knotting was for a variety of indications, e.g. surgery on bladder and suspected, so catheter was removed with gentle steady urethra, for obtaining urine to measure output & urinary traction under sedation without any harm. Patient was analysis and for retrograde cystourethrography etc1, of kept under observation for 24 hours for any detrimental various complications, spontaneous intra vesical knotting effect of urethral injury. is rare but a known complication.2 It has drastic consequences.3 However this complication can be prevented. We are reporting two cases to increase the awareness of the complication.

CASE REPORTS

Case No. 1 A 6-year-old boy underwent repair of distal hypospadias. An 8 Fr feeding tube was used to drain the bladder. Removal of Feeding tube post-operatively was encountered Figure – 2 : with resistance. Catheter came out with complete breakdown of the repair on forceful removal. A knot was DISCUSSION found in the catheter (photograph -1) In 1976 Haris & Ramilo 4 were the first to report the case of catheter knotting in a pediatric patient, and since then Case No. 2 few other cases have been reported 5-7 Spontaneous intra An eight year old boy had hypospadias repair (Bracka I). vesical knotting is a rare complication. The incidence is An 8 Fr feeding tube was used for urinary drainage. In about 0.2 cases per 100,000 catheterizations.1 In most of this case when removal of catheter was attempted, these cases feeding tube was used.

Department of Paediatric Surgery, Dow Medical College & Civil Hospital Karachi, The probable mechanism of catheter knotting is the presence Pakistan of excessive length of catheter tubing inside the bladder, Correspondence: Dr. Muhammad Talat Mehmood, Department of Paediatric Surgery, which becomes coiled up with distal tip passing through Dow Medical College & Civil Hospital Karachi, Pakistan. one or more loops of the catheter to form a knot and when E-mail: [email protected] the catheter is pulled out it becomes tight, preventing its Received: May 28, 2009: accepted: November 11, 2009. removal. 8

38 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 38-39 Knotting of urethral catheters: a preventable complication

The treatment options reported in the literature include, REFERENCES untying of the knot by passing an angiography guide wire 5 1. Foster H, Ritchey M, Bloom D. Adventitious knots in alongside the catheter under fluoroscopic guidance , urethral catheters: report of 5 cases. J Urol 1992; 148: Gentle steady traction under sedation or general anaesthesia 1496-8. has been reported successful in some female children with 2. Gonzalez CM, Palmer LS. Double knotted feeding tube short & relatively pliant urethra.2, 3, 9 The last option is in a child’s bladder. Urology 1997; 49:772. surgical removal through cystostomy10. 3. Khattak IU, Akbar M, Nawaz M, Al-Saleh A, Noor B, Rehman ZU. An Audit of Single Stage Hypospadias We encountered this problem in 2 cases. Both underwent Repair at Ayub Hospital Complex, Abbottabad 2004; hypospadias repair. In the first case, the condition was not 16:21-5 recognized and removal of catheter with force resulted in 4. Haris VJ, Ramilo J. Guide wire manipulation of knot disruption of repair. In second case, it was suspected and in catheter used for cystourethrography. J Urol 1976; 116:529. so the catheter was removed with steady gentle traction 5. Gaisie G, Bender TM. Knotting of urethral catheter without any adverse effects. Singh et al. has also reported within bladder: an unusual complication in successful and safe removal of knotted catheter in a patient cystourethrography. Urol Radiol 1983; 5:271-2. who had hypospadias repair by steady gentle traction and 6. Turner TW. Intravesical catheter knotting: an unusual lubrication12, while Khattak et al. required cystostomy to complication of urinary catheterization. Pediatr Emerg remove knotted catheter in a patient who had hypospadias Care 2004; 20:115-7. repair.3 7. Konen O, Pomeranz A, Aronheim M, Rathaus VA. Urethral catheter knot: a rare complication of This complication can easily be prevented by an awareness cystourethrography. Pediatr Radiol 1996; 26:757-8. of the possibility of spontaneous intravesical knotting. The 8. Sujijantararat P. Intravesical knotting of a feeding tube only precaution needed is to avoid the insertion of excessive used as a urinary catheter. J Med Assoc Thai 2007; 90:1231-3. length of the catheter in the urinary bladder. The catheter 9. Arena B, McGillivray D, Daugherty G. Urethral catheter should be inserted only till the urine starts coming out in knotting: be aware and minimize the risk. CJEM 2002; the tube & then only a few 5,8,11 centimeters of further 4:108-10. insertion is required to ensure intravesical placement and 10. Pearson-Shaver AL, Anderson MH. Urethral catheter balloon inflation in case of Foley’s catheter. This precaution knots. Pediatrics 1990; 85:852-4. should be taught to all the healthcare personnels carrying 11. Kanengiser S, Juster F, Kogan S, Ruddy R. Knotting of out urethral catheterization. 9 a bladder catheter. Pediatr Emerg Care 1989; 5:37-9. 12. Singh RB, Pavithran NM, Parameswaran RM. Knotting This awareness is most important in cases of Urethroplasty of feeding tube used for bladder drainage in hypospadias where removal of the catheter with a knot can have a repair. J Indian Assoc Pediatr Surg 2005; 10:199. drastic complication (disrupt the repair).

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 38-39 39 CASE REPORT Pulmonary Alveolar Microlithiasis Nisar Ahmed Rao and Arsalan Ahmed

ABSTRACT Pulmonary alveolar microlithiasis (PAM) is a rare disorder. It is characterized by accumulation of calcium phosphate (microlith) within the alveoli. Knowledge of this condition is important because radiologically it mimics miliary tuberculosis that can lead to the wrong treatment.

Key words: Microlithiasis, crazy pavement, calcispherytes.

INTRODUCTION Pulmonary alveolar microlithiasis (PAM) is an autosomal unremarkable. The chest radiograph [Fig1] showed diffuse recessive disorder, for which mutation in the SLC34A2 bilateral micronodular, calcified shadows involving whole gene was recently found to be responsible for the disease.1 lung fields sparing the extreme apices. These nodular It has some peculiar characteristics including the formation opacities were sharply defined and discrete. This picture of numerous tiny stone-like structures is characteristically called “SAND STORM” pattern or “CALCISPHERYTES” within the alveoli. Five hundred “DESERT LUNG”. HRCT was done [Fig 2], which showed seventy six cases have been reported up to 20042, most presence of septal thickening and calcification along with of them came from Europe (42.7%) and Asia (40.6%). intra-alveolar calcifications called calcispherytes. This The countries involved were fifty-one and twelve of them pattern is called as “CRAZY PAVEMENT”. His spirometry were attributed with at least ten cases each (Bulgaria, revealed mild restrictive pattern. Lung biopsy was done France, Germany, India, Italy, Poland, Spain, Russia, using trucut biopsy needle, which showed presence of Japan, Turkey, USA and ex-Yugoslavia). Only few cases multiple laminated structures within the alveoli called have been reported from Pakistan.3-5 calcispherytes [Fig.3]. As part of treatment we did the whole Lung Lavage followed by Alendronate sodium 70 CASE REPORT: mg weekly. At three month follow-up, patient was feeling better subjectively though there was no improvement in A 16 years old boy was admitted in the hospital with spirometric values. complaints of chest pain and shortness of breath for two years. Initially he noticed these symptoms while playing cricket. The shortness of breath has progressed slightly and now he is breathless on walking one flight of stair. He was comfortable while at rest. He was prescribed anti- tuberculosis treatment, which he took for nine months without any improvement. His clinical examination was

Department of Pulmonology, Ojha Institute of Chest Diseases, Dow university of Health Sciences, Karachi. Pakistan. Correspondence: Dr. Nisar Ahmed Rao, Department of Pulmonology, Ojha Institute of Chest Diseases, Dow university of Health Sciences, Karachi. Pakistan. Figure – 1 : Sand storm pattern showing nodular opacities E-mail: [email protected] involving the whole lung field relatively sparing extreme apices. Received: January 23, 2010: accepted: April 15, 2010.

40 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 40-42 Pulmonary alveolar microlithiasis

are done for other reason. The symptoms usually develop in third or fourth decades in the form of slowly progressive dyspnea and dry cough.12,13 These patients commonly show progressive deterioration of the pulmonary function and they die in their midlife due to respiratory failure / corpulmonale.14 Pneumothorax can be observed in the early course of the disease.14 Restrictive pattern is the usual pattern seen on spirometry.11

Plain chest radiographs usually reveal bilateral, diffuse Figure – 2 : HRCT showing CRAZY PAVEMENT pattern micronodular calcifications ("sand storm"), involving with septal thickeningand calcifications. predominantly mid and lower lung fields.11, 12 The lung bases appear denser owing to the greater thickness of lung tissue in these areas, as well as the increased surface densities.15 Regardless of the effect of superimposition or summation of shadows, individual deposits are usually identifiable particularly with magnification roentgenography. Very sharply defined, they measure less than 1 mm in diameter and are discrete.16 The heart borders and the diaphragm are usually obliterated. Other typical findings include small apical bullae and a black pleural line, which is demonstrated as an area of increased 17 Figure – 2 :.Lung biopsy showing laminated structures translucence between the lung parenchyma and the ribs. (calcispherytes) within the alveoli and chronic inflammatory cells surrounding the alveoli. The chest radiographs of our patient showed similar pattern DISCUSSION of diffuse symmetric, dense micronodular lung lesion. The CT scan usually demonstrates12,15,17 diffuse Friederich6 first described pulmonary alveolar micronodular calcified nodules involving predominantly microlithiasis (PAM) in 1856 as "Corpora-Amylacea in middle and lower zones. They are more marked in the den lungen". Some investigators claim that Harbitz subpleural region and along the bronchovascular bundle. described it first in 1918.7 Later in 1933, Puhr8 named A predominance of calcifications in the medial areas when it and used the term ‘Microlithiasis alveolaris pulmonum’. compared with the lateral portions of the lungs is also PAM is associated with formation of ‘calcispherytes’ evidenced in the CT scan. High resolution CT scans may (lamellar concretions of calcium/ microlith) within the reveal small cysts in the subpleural lung parenchyma, alveoli. Microlith has been reported in other tissues like pleural calcification and small calcispheryte, within the gonads, prostate, kidneys and sympathetic chain.9 thickened pleura. Murch and Carr18 described the crazy-paving pattern The mechanism of formation of calcipherytes is not (scattered or diffuse ground-glass attenuation with known. It is suggested that it is caused by inborn error superimposed interlobular septal thickening and intralobular in metabolism at alveolar level which leads to alkalinity lines) as characteristic of pulmonary alveolar proteinosis / increased mucopolysacchride deposition, promoting but this finding has been described in several other local calcium accumulation. In these patients studies of conditions like PAM, ARDS (Acute respiratory distress calcium metabolism are normal so the deranged calcium syndrome), Pneumocystis carinii pneumonia, mucinous metabolism is unlikely cause of PAM.10,11 bronchioloalveolar carcinoma, sarcoidosis, nonspecific The patients suffering from Pulmonary alveolar interstitial pneumonia, organizing pneumonia, exogenous microlithiasis (PAM) are usually asymptomatic for many lipoid pneumonia and pulmonary hemorrhage years and are diagnosed incidentally if their chest x-rays syndromes.19,20 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 40-42 41 Nisar Ahmed Rao and Arsalan Ahmed

Serum levels of surfactant proteins A and D correlate with 13. Helbich TH, Wojnarovsky C, Wunderbaldinger P, the progression of the disease, and may be a useful Heinz-Peer G, Eichler I, Herold CJ. Pulmonary alveolar monitoring tool.21 At present, no effective treatment is microlithiasis in children: radiographic and high- available. Therapeutic modalities including systemic resolution CT findings. AJR Am J Roentgenol 1997; corticosteroids, calcium-chelating agents, and 168:63-5. bronchopulmonary lavage have been shown to be ineffective.22 Lung transplant is being performed in severe 14. Wallis C, Whitehead B, Malone M, Dinwiddie R. Pulmonary cases.23 alveolar microlithiasis in childhood: diagnosis by transbronchial biopsy. Pediatr Pulmonol 1996; 21:62-4. REFERENCES 1. Huqun, Izumi S, Miyazawa H, Ishii K, Uchiyama B, 15. Cluzel P, Grenier P, Bernadac P, Laurent F, Picard JD. Ishida T, et al. Mutations in the SLC34A2 gene are Pulmonary alveolar microlithiasis: CT findings. J associated with pulmonary alveolar microlithiasis. Am Comput Assist Tomogr 1991; 15:938-42. J Respir Crit Care Med 2007; 175:263-8. 2. Mariotta S, Ricci A, Papale M, De Clementi F, Sposato 16. Shah MS, Nanavati KI, Airon N, Shah RR, Joshi BD. B, Guidi L, et al. Pulmonary alveolar microlithiasis: Case report - pulmonary alveolar microlithiasis. Indian report on 576 cases published in the literature. J Radiol Imaging 2003; 13:277-9 Sarcoidosis Vasc Diffuse Lung Dis 2004; 21:173-81.

3. Aslam K, Shahid J, Nadira M, Sajid M, Siddique M. 17. Korn MA, Schurawitzki H, Klepetko W, Burghuber OC. Pulmonary Alveolar Microlithiasis-a case report. pak J pathol Pulmonary alveolar microlithiasis: findings on high- 2006; 17:125-7. resolution CT. Am J Roentgenol 1992; 158:981-2.

4. Saleem A, Chaudhary A, Lqbal ZH. 2008; 14:11-4. 18. Murch CR, Carr DH. Computed tomography Pulmonary Alveolar Microlithiasis-a case report. pak J chest Med 2008; 14:11-4. appearances of pulmonary alveolar proteinosis. Clin Radiol 1989; 40:240–3. 5. Saad A, Waqar A, Farzana H, Haleema S. Treatment of Pulmonary Alveolar Microlithiasis with Alendronate 19. Johkoh T, Itoh H, Müller NL, Ichikado K, Nakamura Sodium Biomedica 2004; 20:32-5. H, Ikezoe J, et al. Crazy-paving appearance at thin- 6. Friederich N. Zur Entwickelungsgeschichte der corpora section CT: spectrum of disease and pathologic findings. amylacea in den Lungen. Virchows Arch Path Anat Radiology 1999; 211:155-60. 1970; 10:507. 7. Harbitz F. Extensive calcification of the lungs as a 20. Murayama S, Murakami J, Yabuchi H, Soeda H, distinct disease. Arch Intern Med 1918; 21:139-46. Masuda K. Crazy paving appearance on high resolution CT in various diseases. J Comput Assist Tomogr 1999; 8. Puhr L. Microlithiasis alveolaries pulmonum. Virchows 23:749–52. Arch Path Anat 1933; 290:156-60. 9. Coetzee T. Pulmonary alveolar microlithiasis with 21 Tachibana T, Hagiwara K, Johkoh T. Pulmonary alveolar involvement of the sympathetic nervous system and microlithiasis: review and management Curr Opin Pulm gonads. Thorax 1970; 25:637–42. Med 2009; 15:486-90. 10. Sosman MC, Dodd GD, Jones WD, Pillmore GU. The familial occurrence of pulmonary alveolar 22. Prakash UB, Barham SS, Rosenow EC 3rd, Brown microlithiasis. Am J Roentgenol Radium Ther Nucl ML, Payne WS. Pulmonary alveolar microlithiasis. A Med 1957; 77:947-1012. review including ultrastructural and pulmonary function 11. Barbolini G, Rossi G, Bisetti A. Pulmonary alveolar studies. Mayo Clin Proc 1983; 58:290-300. microlithiasis. N Engl J Med 2002; 347:69–70. 23. Edelman JD, Bavaria J, Kaiser LR, Litzky LA, Palevsky 12. Hoshino H, Koba H, Inomata S, Kurokawa K, Morita HI, Kotloff RM. Bilateral sequential lung transplantation Y, Yoshida K, et al. Pulmonary alveolar microlithiasis: for pulmonary alveolar microlithiasis. Chest 1997; high-resolution CT and MR findings. J Comput Assist Tomogr 1998; 22:245-8. 112:1140-4.

42 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 40-42 SHORT COMMUNICATION Frequency of Smoking Among Employees at a Tertiary Care Children Hospital, Karachi Ashfaq Ahmed Memon1, Muhammad Ayaz Mustufa1 and Muhammad Ashfaq2

ABSTRACT: Objective: To determine the frequency of smokers among employees at National Institute of Child Health, (NICH) Karachi. Subjects and Methods: Total no. of 150 employees from NICH (including doctors, paramedics, administration staff, security staff, account staff, house keeping staff and others) participated in the study after giving verbal consent. A self-administered pre-coded proforma was used as an instrument to collect the information. Results: A total no. of 150 health care professionals and others participated in the study. There were 111(74%) males, 39(26%) were females. The male to female ratio was 1:2.8. No female was found to be a smoker in our setting. 14.6% of smokers were in between 25-36 years of age. Frequency of smoking was found to be high in both Matric and MBBS categories i.e. 7.3% and 6.7% respectively. The frequency of smoking was found to be much higher (17%) in married males as compared to un-married employees (06%). More than seventy percent (24) had started smoking in between 12-24 years of age. Around 44% of smokers used more than ten cigarettes per day. More than 97% of the participants were aware of potential health hazards of smoking. Conclusion: In our setting, overall frequency of smoking is still high (22.7%) in health care workers indicated it is that in spite of awareness regarding injurious effects of smoking, the health care professionals do not realize that smoking is one of the major causes of increase in morbidity and mortality due to respiratory and cardiac ailments.

Key words: Smoking, non-smokers, smokers, health care workers.

INTRODUCTION Tobacco smoking is considered to be one of the major number and severity of respiratory illnesses decrease precursors of cardiovascular and lung disorder leading physical fitness. Smoking is not only risky for the smokers’ to severe life threatening health problems like cancer, health but also for those who are around them. Meta- stroke and other heart diseases,1 as it is previously proven analysis of previous studies shows that frequency of that about 60 constituents of tobacco are carcinogens, smoking varies from 19% to 33% in different communities tumor initiators and tumor promoters.2 So, the analogous of the country.9-14 In light of these variations, we conducted relationship of smoking with disease related to lungs, our study among health care workers (assuming the most heart, blood vessels and cancer of bronchus, oral cavity part of the community was aware of the health hazards of and kidney are well established.3-5 Every year around 4 smoking) of National Institute of Child Health (NICH), a million people loose their lives due to smoking.6 tertiary health care facility of Karachi with a head count

Smoking is increasing in Pakistan,7 it is estimated that of around six hundred employees. The aim of this study 36% of adult males, and 9% of females smoke, and the was to determine the frequency of smokers among cigarette consumption per person per year in Pakistan is employees at National Institute of Child Health, Karachi. among the highest in South Asia.8 Tobacco smoking produces health problems among smokers and increased SUBJECTS AND METHODS

1. PMRC Specialized Research Centre NICH, Karachi, Pakistan. The study was conducted at National Institute of Child 2. National Institute of Child Health, Karachi, Pakistan. Health from June 2008 to December 2008. Total of 150 Correspondence : Muhammad Ayaz Mustufa, PMRC Specialized Research Centre, employees of the institute irrespective of their age and NICH, Karachi, Pakistan. gender participated in the study after giving informed E-mail : [email protected] verbal consent. Equal percentages (around 25% from each Received: August 05, 2009: accepted: November 11,2009 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 43-46 43 Ashfaq Ahmed Memon, Muhammad Ayaz Mustufa and Muhammad Ashfaq category) of participants were randomly included. Doctors Table 1: Demographic Characteristics of Health Care Providers at a category included 45 clinicians out of 180 doctors, the Tertiary Care Hospital second category consisted of 272 paramedics out of which Characteristics No. of Subjects Smokers Non-Smokers 68 were included, third category comprised 24 participants N N (%) N (%) out of 96 working individuals in security and house keeping Age Categorization section and final category comprised 13 admin. and Up to24 years 21 3 (2) 18 (12) 25-36 years 101 22 (14.6) 79 (52.7) accounts section participants with a head count of 56. 36 + 28 9 (6) 19 (12.63) A structured, close ended proforma was used togather information from the participants. First section of proforma Gender contained, demographic information including age, gender, Male 111 34 (22.7) 77 (51.3) education status, department, designation, ethnic distribution Female 39 - 39 (26) and marital status of participants. Second part includes, age at first use, knowledge about potential health hazards Job Category* Doctors(MBBS) 45 10(22.22) 35(77.78) of smoking, reasons for smoking and attitude of non- Paramedical Staff 68 08(11.76) 60(88.24) smokers with smokers. The study population consisted Security and 24 11(45.83) 13(54.17) almost all categories of health care professionals including housekeeping staff doctors, nurses, para-medics and other health care workers Admin. And accounts 13 05(38.46) 08(61.54) including clerical staff, security guards, peons etc. Trained *Note : Injob category percentages are calculated and expressed individually for each category research staff interviewed the participants individually to Ethnic Distribution collect data. All the data were recorded on computer Urdu 36 8 (5.33) 28 (18.67) through SPSS version 13 for final analyses. Sindhi 43 8 (5.33) 35 (23.33) Punjabi 45 14 (9.33) 31 (20.67) RESULTS Balochi 8 1(0.66) 7(4.66) Pushto 8 1(0.66) 7 (4.66) A total no. of 150 employees of NICH participated in the Others 10 2 (1.33) 8 (5.33) study after giving informed verbal consent. There were 111(74%) males and 39(26%) were females. The male to Marital Status Married 83 25 (16.66) 58 (38.67) female ratio was 2.8:1. No female health care worker was Un-Married 67 9 (6) 58 (38.67) a smoker in our setting while every third male employee was a smoker. Frequency of smoking was found to be very high in security and housekeeping staff (45.83%) and 6% participants from admissible and accounts section (38.46%). 24% Majority (42%) of participants were just matric, representing clerical staff, security guards (chowkidars), sweepers, 12-24Y rd 70% 25-36Y peons and khakroobs. While the 3 largest smoking 36Y category embodied MBBS doctors (22.22%). Paramedical participants were highest in number but was the smallest group (11.76%) in terms of tobacco smoking among all four categories. Very high rate (14.6%) of smoking was found between 25-36 years of age. The frequency of Figure – 1 : Age at First Use of Cigarette smoking was much higher (17%) in married male employees as compared to un-married employees (06%). that they had started smoking in between 12-24 years of More than 97% of the participants were aware of the age. While, only 6% had become addicted to tobacco potential health hazards of smoking (see Table I). smoking in the age of 36 years or more (Fig. I). Around 44% of smokers used more than ten cigarettes per day, More than seventy per cent of the study participants told more than 35% were using 5-10 cigarettes per day, while

44 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 43-46 Frequency of smoking among employees at a tertiary care children hospital, Karachi. remaining 21% were using less than five cigarettes per due to the weakness of small sample size, our findings day (Fig. II). cannot be generalized for the whole population. A significantly higher prevalence of smoking among men (33%) in comparison to women (9%) has been reported earlier in Pakistan.9-15 Similarly, in our study frequency of 21% male smokers is very high (30.6%), while no female smokers 44% < 5 were found in our setting. Earlier it is also reported that 5_10 11+ male identity and socialization are key influences in determining smoking behavior among Pakistani 35% population.16 The sample population in our study started smoking at the age of 12-24 years, closely similar to the earlier published work on house physicians.17 Figure – 2 : Number Of Cigarettes per day burned by smokers Majority of the smokers (44%) smolder more than 10 cigarettes per day, showing high level of addiction to Around 35% of the smokers told us that they smoked to tobacco. Effective measures are needed to prevent smoking relieve anxiety, tension and for mental satisfaction. More in this age group. than 23% smoked cigarettes without any reason. Around 17% smokers reflected that it was a cheap and affordable Over the past few decades, not much change has been seen habit, while about 24% believed that they smoked because in the frequency of smoking in Pakistan.18 Previously, there it was a luxurious habit (Fig. III). Attitude of non smokers had been calls for mass health education and enforcement with smokers during cigarette smoking was categorized of a ban on smoking in public places, in order to reduce as normal attitude (30%), excusing attitude (50%) and the number of smokers. Studies had underlined the abusing attitude (20%). importance to educate physicians and the general public about cardiac and carcinogenic effects of smoking, but unfortunately there is no clear policy on tobacco control 17% in Pakistan.7,19 Interestingly, great majority (97%) of the 35% Better respondents were aware and knew that smoking is unhealthy No reasons and yet they continued to smoke. It was noted that most of 24% Luxurious Cheap the smokers (35%) smoked to relieve anxiety, tension and 24% for mental satisfaction. The ratio between married and unmarried smokers was 3:1, which was also very alarming and pointed out to the socio-economic and family issues. Figure – 3 : Reasons of Smoking Finally, in our setting overall frequency of smoking was still high (22.7%) in health care professionals than others DISCUSSION which also indicated that in spite of awareness regarding injurious effects of smoking, health care workers did not Information on the health hazards of smoking is a part of realize that smoking was one of the major causes of increase a number of disciplines in medical curriculum and it is in morbidity and mortality due to respiratory and cardiac expected that health care providers including Doctors, Nurses, Paramedics, and other staff of health care facilities ailments. So, there is a need to execute preventive strategies, knowing these hazards and would not take up smoking, to discourage people of smoke initiation. Public health but contrary to above argument, in our setting the frequency education programs through mass media can also help to of cigarette smoking is still high (22.7%) in health care prevent people from smoking. The awareness about adverse workers. It is also necessary to mention that here maybe effects of smoking, including cancer and heart diseases can be exploited in order to quit smoking in future strategies. Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 43-46 45 Ashfaq Ahmed Memon, Muhammad Ayaz Mustufa and Muhammad Ashfaq

REFERENCES 10. Ahmad K, Jafary F, Jehan I, Hatcher J, Khan AQ, Chaturvedi N, et al. Prevalence and predictors of 1. Warren CW, Jones NR, Eriksen MP. Global tobacco smoking in Pakistan: results of the National Health Surveillance System (GTSS) Collaborative Group. Survey of Pakistan. Eur J Cardiovasc Prev Rehabil Patterns of global tobacco use in young people and 2005; 12:203-8. implications for future chronic disease burden in 11. Ahmed EN, Jafarey NA, Smoking habit’s among medical adults. Lancet 2006; 367:749-53. students of Sind Medical College. J Pak Med Assoc 1983; 33:39-44. 2. Jaleel MA, Nooreen R, Hashmi KA, Malik KN. Comparison of Smoking pattern between citizens 12. Agha F, Sadarudin A. Teenager, smoking- a great public of Karachi, Multan and Abbottabad. Med Channel problem, renewing the pool of smokers. J Pak Med Assoc 2001; 7:22-5. 1996; 45:84-6.

3. Dr. Carl.J.Brandt. revised by Gavin petric 13. Omair A, Kazmi T, Alam SE. Smoking prevalence and “Smoking-health risks” 2005. Available at awareness about tobacco related disease among medical http://www.netdoctor.co.uk. students of Ziauddin Medical University. J Pak Med Assoc 2002; 52:389-92. 4. Haskell WL. Cardiovascular disease prevention and lifestyle interventions: effectiveness and 14. Ford ES, Malarcher AM, Herman WH, Aubert RE. Diabetes efficacy. J Cardiovasc Nurs 2003; 18:245-55. and cigarette smoking: findings from the 1989 National Health Interview Survey. Diabetes Care 1994; 17:688-92. 5. Cayuela A, Rodríguez-Domínguez S, López- Campos JL, Otero Candelera R, Rodríguez Matutes 15. Ahmed R, Rashid R, McDonald PW, Ahmed, W. Prevalence C. Joinpoint regression analysis of lung cancer of cigarette smoking among young adults in Pakistan. J Pak Med Assoc 2008; 58:597-601. mortality, Andalusia 1975-2000. Ann Oncol 2004; 15:793-6. 16. Bush J, White M, Kai J, Rankin, J, Bhopal R. Understanding influences on smoking in Bangladeshi and Pakistani adults: 6. Bruntland G.H. Personal Communication, 11 World community based, qualitative study. BMJ 2003; 326:962. Congress on Tobacco, 7th August, 2000. 17. Piryani RM, Rizvi N. Smoking habits amongst house 7. Nasir K, Rehan N. Epidemiology of cigarette physicians working at Jinnah Postgraduate Medical Center, smoking in Pakistan. Addiction 2001; 96:1847-54. Karachi, Pakistan. Trop Doct 2004; 34:44-5.

8. Colagar AH, Jorsaraee GA, Marzony ET. Cigarette 18. Maher R, Devji S. Prevalence of smoking among Karachi smoking and the risk of male infertility. Pak J Biol population. J Pak Med Assoc 2002; 52:250-3. Sci 2007; 10:3870-4. 19. Memon SB, Memon AM. Why physicians and lay people 9. Mahmood Z. Smoking and chewing habits of people smoke and how can it be reduced. J Pak Med Assoc 1999; of Karachi. J Pak Med Assoc 1982; 32:34-7. 49:2-4.

46 Journal of the Dow University of Health Sciences 2010, Vol. 4(1): 43-46 ACKNOWLEDGMENT OF REVIEWERS The Editorial team of JDUHS greatfully acknowledges the contribution of the following honorable reviewers who helped and guided to improving the quality of the manuscripts published / evaluated in the year 2009 Abdul Gaffar Billoo Arif Amir Nawaz Professor and Chairman of Paediatrics Consultant Gastrointestinal Aga Khan University Hospital, 460-Y, Defense Housing Society Karachi, Pakistan. Lahore, Pakistan.

Abdul Rauf Memon Bilqis Afridi Professor of Medicine Professor of Obstetrics & Gynaecology Department of Medicine Unit iii Civil Hospital, Khyber Medical College/ Khyber Teaching Hospital Dow University of Health Sciences, Karachi, Pakistan. Peshawar, Pakistan.

Abdul Wahab Ejaz Ahmed Vohra Department of Psychiarty Professor of Medicine Ayub Medical College, Zia Uddin Medical University Hospital, Abbottabad, Pakistan. Karachi, Pakistan.

Abdullah AlDosari Farooq Ahmed Mian Professor and Head Department of Maxillofacial Surgery Professor and Head Department of ENT College of Dentistry, Allama Iqbal Medical College, Saudi Arabia. Lahore, Pakistan.

Abdullah Hadi Ferdose Sultana Professor of ENT, Professor and Head Department of Anatomy Shaikh zayed Hospital Services Institute of Medical Sciences Lahore, Pakistan. Lahore, Pakistan.

Afroze Ramzan Sherali Ghulam Qadir Malik Professor of Paediatrics Professor of Community Medicine National Institute of Child Health 253, Shams abad Colony, Karachi, Pakistan. Multan, Pakistan.

Afzal Memon Huma Musrrat Khan Professor Department of Forensic Medicine and Toxicology Department of Anatomy Liaquaqt University of Medical & Health Sciences Foundation Medical College, Jamshoro, Pakistan. Islamabad, Pakistan.

Aisha Mehnaz Javaid Ahmed Khan Professor of Paediatric Professor and Head Pulmonary Section Civil Hospital/ Dow University of Health Sciences Aga Khan University Hospital Karachi, Pakistan. Karachi, Pakistan.

Amir Ali Shoro Javed Akram Principal and Dean Professor of Medicine Baasic Medical Sciences, Liaquat National Medical College King Edward Medical University Karachi, Pakistan. Lahore, Karachi.

Arif Ali Khalid Mahmood Department of Research Professor of Medicine Dow University of Health Sciences Dow Medical College / Civil Hospital Karachi Pakistan Karachi, Pakistan.

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): iii-v iii Acknowledgement of reviewers

Khatoon Akhtar Bano Muhammad Abdullah Chief Research Officer Professor and Head Department of Neurology PMRC Research Centre, Fatima Jinnah Dow Medical College/ Civil Hospital Medical College, Lahore, Pakistan. Karachi, Pakistan.

Lt. Col. Abeera Choudry Muhammad Amin Department of Obstetrics and Gynecology Professor and Project Director Combine Military Hospital University Medical and Dental College Multan, Pakistan. University of Faisalabad, Pakistan.

Lt. Col. Azad Ali Azad Muhammad Aslam Chaudhry Department of Prosthodontics Department of ENT Head & Neck Surgery, Armed Forces Institute of Dentistry Rawalpindi General Hospital, Rawalpindi, Pakistan. Rawalpindi, Pakistan

M. Ashraf Sultan Muhammad Rafiq Khanani Professor and Head Department of Paediatric Unit-1 Director Dow Diagnostic King Edward Medical University/ Mayo Hospital References and Research Laboratories, Dow University Lahore, Karachi. of Health Sciences, Karachi, Pakistan.

M. Saeed Shafi Muhammad Zia Iqbal Professor and Head of Anatomy Department Professor of Anatomy Akhtar Saeed Medical and Dental College, Dow University of Health Sciences, Bahria Town Lahore, Pakistan. Karachi, Pakistan.

Mahjabeen Khan Musrrat Nafees Department of Research Professor and Head Department of Anatomy Dow University of Health Sciences Karachi Medical and Dental College, Karachi Pakistan Karachi, Pakistan.

Major Asim Ashfaq Nasim Karim Classified Neurosurgeon Department of Pharmacology Combine Military Hospital Malir, Sindh Medical College, Dow University Karachi, Pakistan. of Health Sciences, Karachi, Pakistan.

Maqbool Qadri Nasir Khokhar Department of Paediatrics and Child Health Professor of Medicine Aga Khan University Hospital, Shifa International Hospital Karachi, Pakistan. Islamabad, Pakistan,

Mehnaz Roohi Nazeer Khan Professor of Obstetrics and Gynecology Professor and Director 175-P, Jinnah Colony, Department of Research and PhD Program Faisalabad, Pakistan. Dow University of Health Sciences, Karachi, Pakistan.

Mohammad Aasim Yusuf Nazia Yazdanie Medical Director & Consultant Gastroenterologist Professor and Principal Shaukat Khanum Memorial Cancer Hospital de’Montmorency College of Dentistry Lahore, Pakistan. Lahore, Pakistan. iv Journal of the Dow University of Health Sciences 2010, Vol. 4(1): iii-v Acknowledgement of reviewers

Nighat Nisar Shaukat Ali Department of Community Medicine Head Department of Neurology Sindh Medical College, Jinnah Postgraduate Medical College Karachi, Pakistan. Karachi, Pakistan.

Obaidullah Sohail Akhtar Department of Plastic Surgery Department of Medicine Hayatabad Medical Complex Ziauddin University, Peshawar, Pakistan. Karachi, Pakistan.

Samina Sultana Habibullah Department of Neurosurgery Senior Medical Officer Quaid-e-Azam Post Graduate Medical College, PMRC Research Centre, Dow Medical College PIMS, Islamabad, Pakistan. Karachi, Pakistan.

Sardar Muhammad Malik Syed Muhammad Zahid Azam Department of Cardiology Additional Director, NILGD and CTU PGMI, Lady Reading Hospital Medical Superintendent Dow University of Peshawar, Pakistan. Health Sciences, Ojha Campus, Karachi, Pakistan.

Saulat Ullah Khan Tahir Shafi Department of Pulmonology Professor and Chairman Mayo Hospital, Department of Nephrology, Shaikh zayed Hospital Lahore, Pakistan. Lahore, Pakistan.

Shahab Abid Tazeen H. Jafar Department of Gastroenterologist Director Clinical Epidemiology Unit Aga Khan University Hospital Professor of Medicine & Community Health Sciences Karachi, Pakistan. Aga Khan University Hospital, Karachi, Pakistan.

Shahid Mehmood Waris Qidwai Principal Dental Section Professor and Chairman Lahore Medical and Dental College Department of Family Medicine Lahore, Pakistan. Aga Khan University Hospital, Karachi, Pakistan.

Shahina Nusrat Yasmin Hasan Medical Superintendent Department of Neurology Punjab Dental Hospital, Dow University of Health Sciences Lahore, Pakistan Karachi, Pakistan.

Journal of the Dow University of Health Sciences 2010, Vol. 4(1): iii-v v INSTRUCTIONS TO AUTHORS

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Highlights of provisional scientific programme

Pre Conference Workshops * The right to know & open access * Statistics for Non statisticians * Medical Writing for authors policy of biomedical journals. * Readers Perspective: Are * Medical Editing for Editors Scientific Sessions Editors listening * Quality assessment Panel Discussion * Biostatistics * Challenges in Medical Journalism in Eastern Mediterranean Region * Editors Exchange programme Invited Talks * Plagiarism * Opportunities for * Ensuring Integrity in biomedical * Regional Databases international collaboration * Impact Factor and post publication publications. indexes Conference Workshops: * Status of Biomedical Journals in * Peer Review Research Eastern Mediterranean Region: * Training of Editors and Reviewers * Indexation of Journals. Challenges and Strategies. * Economic aspects of medical * Electronic (e) Publishing journals * Transition of Biomedical Journals * Biostatistics * Medical writing in electronic era * Publication Ethics from print to Online: Accepting the * Bilingual publications: Challenges to * Peer Review / Referencing Change. the editors * Industry Funded Research Skills For Registration: Contact: Dr. Nazeer Khan Email: [email protected] Mobile: 0334-3471677

Organized by Pakistan Association of Medical Editors (PAME) WHO Eastern Mediterranean Regional Office In collaboration with * College of Physicians & Surgeons Pakistan (CPSP) * Eastern Mediterranean Association of Medical Editors (EMAME) * Dow University of Health Sciences, Karachi. Pakistan. * Aga Khan University, Karachi. Pakistan. * Supported by Ministry of Health, Government of Pakistan Conference Secretariat Pakistan Association of Medical Editors Room No. 522, 5th Floor, Panorama Centre, Building No. 2, Raja Ghazanfar Ali Road, Sadder, Karachi - Pakistan. Phone: +92-21-35688791, +92-21-35689285 URL:www.pame.org.pk/emmj5 E-mail: [email protected] [email protected]

Dr. Maqbool H. Jafary Shaukat Ali Jawaid Dr. Jamshed Akhtar viii Conference President Organizing Secretary Journal of the Dow UniversityChairman of Health Sciences Scientific 2010, Committee Vol. 4(1): vi-viii [email protected] [email protected] [email protected] OJHA Institute of Chest Diseases