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 Childrens 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