Man Sure Passes Away but Memories and Ideas Remain

Shahid Kamal

It is just over a year when the medical and scientist community lost a beloved and respected icon, my friend Prof. Dr. Tahir Sultan Shamsi (Late). Held in admiration and loved by all of us, this kind and humble doctor treated patients, colleagues, students with compassion and expertise. He was truly adored and trusted by all.
He started his early carrier in Pakistan as Consultant Hematologist at SIUT and Ziauddin Hospital to eventually begin to lay the ground work for setting up NIBD from few rooms to the first class institute that it evolved into in his later years.
He continued his services as Consultant Hematologist & Transplant Physician, Medical Director and Professor of Hematology, at the National Institute of Blood Disease & Bone Marrow Transplantation till the end.
Under his dynamic leadership NIBD flourished and metamorphosed into a world class institute for blood diseases and BMT that served all regardless of their financial background, with Prof. Dr. Tahir Sultan Shamsi (Late) arranging funds from public and private sources to ensure that no one suffered.
A supremely gifted researcher (229 publications, 133 abstracts, author and contributor of 29 books with an impressive impact factor of 473.345), he spearheaded a dynamic teaching and training program for Post Graduate doctors, nurses and technicians. He supervised 30 FCPS fellows, 15 BMT and 5 Pediatric Hematologist fellows apart from half a dozen PhD fellows. This skilled resource triggered a multiplier effect of setting up BMT in other institutes in Pakistan – a notable change indeed.
Member of various scientific and social bodies and on editorial board of various journals, Prof. Dr. Tahir Sultan Shamsi (Late) launched the National Journal of Health Sciences (NJHS) and worked tirelessly to facilitate research and raise standards. It is only his legacy and vision that the Journal is not only recognized by different international indexing agencies and has now been accredited by the Higher Education Commission (HEC).
The editorial board is indebted to our dear friend and colleague Prof. Dr. Tahir Sultan Shamsi (Late) and would Insha’Allah endeavor to continue in the guiding path set by him. May God bless Him.


Clinical Overview of Chronic Obstructive Pulmonary Disease Patients with Myocardial Perfusion Defect

Emine Afsin and Hamdi Afsin

Abstract: Background: Increased hospitalization and death rates up to 2-3 times greater due to cardiovascular diseases have been reported in Chronic Obstructive Pulmonary Disease (COPD) cases. Inflammation, neurohumoral activation, and increased oxidative stress are involved in the etiopathogenesis of both disease groups.
Objective: The study aimed to retrospectively evaluate the patients with COPD with perfusion defects (ischemia/infarct) in myocardial perfusion scintigraphy and investigate the clinical features of these patients.
Materials and Methods: Patients with COPD were included in the study by examining the files of 196 patients who had perfusion defects by performing myocardial perfusion scintigraphy (MPS) in the Nuclear Medicine Clinic of our hospital between January 2019-2021. Demographic data, comorbidities, areas of involvement in myocardial perfusion scintigraphy, pulmonary function test (PFT), smoking history, modified Medical Research Council (mMRC) score, pulse oxygen saturation, and echocardiography (ECHO) data were recorded.
Results: COPD was detected in 6 (3%) of 196 patients. All of these cases were male and the age range was 67.2 ± 7.4 years. All 6 cases were male, and the mean age was 67.2 ± 7.4 years. They all had a history of heavy smoking (52.5 ± 30.9 packs/year). The mean forced expiratory volume in 1 second (FEV1) was 49.6 ± 8.9%, and pulse oxygen saturation was 93.2 ± 3.3%. In ECHO, systolic pulmonary artery pressure (PAPs) was higher than normal in 2 patients; one had advanced mitral insufficiency and heart failure. In the MPS of 4 patients, an infarct was observed in the area supplied by the right coronary artery (RCA). While there was no comorbid disease in 2 patients, comorbid diseases were present in 4. There was no significant difference between the non-COPD group and the COPD group in terms of age and gender. In the non-COPD group, the most common LAD localized defect (35.3%) and RCA localized defect (23.2%) were detected, while the most common RCA defect (50%) was found in the COPD group. However, it was not statistically significant due to the small sample size.
Conclusion: In COPD cases, it was determined that infarct developed in the male gender, advanced age and advanced stage, and especially in the area fed with RCA if exposed to heavy smoking. It is considered that the ischemic changes observed in RCA in COPD may have a role in the development of right heart failure.

Received: June 09, 2022
Revised: September 05, 2022
Accepted: September 10, 2022


A Retrospective Audit of Treatment Non-Compliance among Osteosarcoma Patients from a Developing Country

Badaruddin Sahito, Sheikh Muhammad Ebad Ali, Mustafa Saleem, Noor Muhammad Soomro, Muhammad Soughat Katto and Asif Jatoi

Abstract: Background: The study aims to assess the non-compliance rate along with the factors affecting the non-compliance among osteosarcoma patients presenting in our institution.
Materials and Methods: Osteosarcoma patients who were treated at our institution between January 2014 to December 2020 were included in this study. Records were searched from Departmental Cancer Registry for details regarding treatment plans and follow-ups. The data of outcomes were compared with the standard guidelines. Patients who did not attend follow-ups, surgery or chemotherapy were termed as non-compliant. The patients or their next of kins were inquired about the factors behind non-compliance.
Results: The study sample included 46 participants where 34 (74.9%) and 12 (26.1%) were male and females, respectively with a mean age of 19.7± 9.7 years. 11 (23.91%) participants were compliant with the prescribed treatment plans that included surgery, neoadjuvant, and adjuvant treatments whereas 35 (76.1%) of the participants were non-compliant either with surgery or chemotherapy. Amongst all included participants, the neoadjuvant chemotherapy plan was followed by 18 (39.13%) and adjuvant chemotherapy was followed by 10 (21.74%) candidates. Surgery was performed in 22 (44.9%). The patients who did not received chemotherapy was attributed to affordability (P=0.008) and patients’ or next to kins’ choices (P=0.02) while age (P=0.039), patients’ consent not given (78.3%; P=0.05), and stage II (52.2%; P=0.048) were predictors of surgical non-compliance.
Conclusion: We conclude that the care deferred significantly from the guidelines regarding surgery and chemotherapy. Age, affordability, late stage, and personal choices are the significant predictors for non-compliance for chemotherapy and surgery.

Received: June 20, 2022
Revised: September 05, 2022
Accepted: September 08, 2022


Role of 68Ga-PSMA PET/CT in Patients with Recurrent Prostate Cancer and its Comparison with Serum PSA Levels and Gleason Scores

Syed Rashid-ul- Amin, Abdul Hai, Haider Ali, Najeeb Niamatullah and Altaf Hashmi

Abstract: Background: Biochemical recurrence is seen in 27–53% of carcinoma prostate patients after treatment. GS (Gleason score) and baseline PSA level are a predictor of recurrence. Post- treatment persistent rising PSA levels represent the recurrence and PSMA labelled PET-CT is an important part of imaging workup in these patients.
Objective: To detect the relationship between PSA levels and Gleason score in patients investigated for Gallium-PSMA-11 fused molecular imaging in biochemical recurrent carcinoma prostate.
Materials and Methods: This cross-sectional study was carried out at S.I.U.T Karachi. PSMA-PET/CT scans (September 2017-January 2022) of the patient who had a biochemical recurrence and not receiving any cancer-specific treatment at least 4 weeks prior scan were included. PSA level from lab reports and GS from the histopathological reports was recorded. Biochemical recurrence were defined as when PSA level > 0.4ng/ml (post-prostatectomy) or >2.0 ng/ml higher than the nadir value after radiotherapy. PET/CT scans of 106 included patients were interpreted by the nuclear physician and radiologist team. SUVmax ≥ 2.5 was considered positive for recurrence. Local recurrences, lymphnodal, osseous, and visceral metastasis were documented. Statistical analysis was done by utilizing IBM SPSS software (version 22.0).
Results: In 88 of 106 patients (83%), Gallium-PSMA-11 PET/CT scan detected at least one lesion characteristic of recurrent PCa. The median PSA level was 12.1 (.01-892.0) ng/dl. In relating PSA value, it was noted that there was a significant difference between lesion positive and negative PSMA-11 labelled Ga-68 PET/CT scan but not statically significant for GS. Local recurrences were seen in 70 patients, whereas lymph node and osseous metastases were noted in 64 and 52 scans respectively. A PSA value of 0.68 ng/ml was determined by utilizing the ROC curve with an AUC of 0.924 (95% CI 0.86-0.98) and will likely predict the positive/negative PSMA-11 Gallium PET/CT scan.
Conclusion: Raised PSA level may predict the possibility of a positive Ga-PSMA-11 PET/CT scan but there was no relationship noted between GS and Ga-PSMA-11 PET/CT findings.

Received: June 18, 2022
Revised: September 10, 2022
Accepted: September 12, 2022


Frequency and Etiology of Pediatric Trauma, Experience at Tertiary Care Hospital

Muhammad Kashif Bashir, Aisha Ishtiaq and Shazia Bashir

Abstract: Objectives: To determine etiology and spectrum of trauma in children and to make recommendations for its prevention.
Materials and Methods: This Hospital based Retrospective observational study was conducted in Department of Pediatric Surgery King Edward Medical University / Mayo Hospital Lahore from March 2021 to February 2022. All patients presented in Pediatric Surgical emergency King Edward Medical University/ Mayo Hospital Lahore were included in this study. Data regarding age, gender, mechanism and severity of trauma and its management was analyzed and recorded on a prescribed Performa.
Results: During the study period a total of 3850 patients having trauma were presented in pediatric surgical emergency. There were 2206 (57.3%) male patients and 1644 (42.7%) females with male to female ratio of 1.3:1. Majority of children affected were 8 to 10 years age. Burn trauma was noted in 2400 (62.3%) while 1450 (37.7%) patients have poly trauma due to different etiological factors. Regarding burn trauma, majority of patients 1620 (67.5%) were having scald burn injury. Pedestrians 260 (17.9%) hitting with motor vehicle was noted to be major mechanism of trauma.
Conclusion: Motor vehicle collision is most common mechanism of pediatric trauma after pediatric burn injury. There is a need for parental education and strict implementation of traffic laws to prevent trauma at pediatric age group.

Received: July 15, 2022
Revised: September 10, 2022
Accepted: September 15, 2022


Current Trends Regarding Perioperative Pharmacological Anticoagulation in Lower Limb Surgeries among Orthopedic Surgeons of Pakistan -An Audit

Sheikh Muhammad Ebad Ali, Badaruddin Sahito, Syeda Iqra Qadri, Hira Iqbal Naviwala, Hina Khan, Omer Awan and Muhammad Mohsin Mushtaq

Abstract:Perioperative anticoagulation has been recommended by AAOS, AACP, and ASH during orthopedic procedures of the lower limb. Guidelines show a difference of opinion regarding the optimum duration and drug of choice giving a way to use different methods of anticoagulation. This audit assessed the preferences for pharmacological anticoagulation in lower limb surgeries among orthopedic surgeons of Pakistan.
Materials and Methods: An online questionnaire-based cross-sectional study was started from June-September 2021 in Dr Ruth K.M. Pfau Civil Hospital Karachi where Orthopedic surgeons (n=632) were invited to fill those questionnaires. A total of 85 orthopedic surgeons responded completely. An electronic eight-question survey was designed which included questions about demographics of surgeons, the drug of choice, perioperative duration, preferred surgeries, and average incidence of thromboembolism per year.
Results: 12.9% surgeons use anticoagulation for all surgeries while 82.3% of orthopedic surgeons use anticoagulants in selective surgeries. LMWH (94.1%) and Rivaroxaban (17.6%) were the drug of choice for most surgeons. 70.6% of respondents never used anticoagulation preoperatively. 17.7% used it three days preoperatively. 28.24% of surgeons prescribed anticoagulation for 3 days postoperatively while 17.7% of surgeons prescribed anticoagulation for 2 weeks postoperatively. 10.6% of surgeons never used anticoagulation postoperatively. Arthroplasty (71.7%), trauma (55.3%), and pelvis and acetabulum (54.1%) were the subspecialties with routine anticoagulation. 81.2% and 17.7% of surgeons reported less than 1% and 1% to 3% incidence of thromboembolism, respectively. No surgeon reported any incidence of thromboembolism above 5%.
Conclusion: Use of anticoagulation is prevalent among orthopedic surgeons in Pakistan. However, significant differences are observed regarding the perioperative duration. The surgeons need to prescribe DOAC such as Rivaroxaban and Dabigatran as agents of choice while extended postoperative pharmacological anticoagulation of 28-35 days needs to be adopted.

Received: June 03, 2022
Revised: September 15, 2022
Accepted: September19, 2022


Inherited Bone Marrow Failure Syndromes – Challenges and Updates

Shahzad Ali Jiskani, Saleem Akhtar Shaikh and Rizwan Ali Talpur

Abstract: Congenital or inherited bone marrow failure syndromes are hereditary syndromes of diverse nature which are characterized by inadequate production of blood cells causing cytopenias. Failure of bone marrow can be limited to one or more lineages of blood cells, along with symptoms specified to lineage, through it can affect all cell lineages leading to clinical picture like aplastic anemia. These syndromes are genetic diseases of heterogenous nature caused by germline mutations affecting basic pathways of cell including telomerase biology, biogenesis of ribosomes, structural proteins, and repair of DNA. Common inherited bone marrow failure syndromes consist of Schwachman – Diamond syndrome, Diamond – Blackfan anemia, Fanconi anemia, and Dyskeratosis Congenita. These syndromes have different prognosis and tendency to develop solid or hematological malignancies. Therefore, the adequate diagnosis of these disorders and their differentiation from other bone marrow failure syndromes and/or other etiologies of the boe marrow failure is very significant for surveillance and management of patients. Acquired causes may also lead to bone marrow failure including radiations, chemicals, drugs, immune diseases, viral infections, myelodysplastic syndromes, large granular lymphocytic leukemia, or paroxysmal nocturnal hemoglobinuria (PNH). Inherited bone marrow failure syndromes are heritable and affects family members as well, therefore need genetic counselling. In this review, differential diagnosis, various causes, and their pathogenesis are discussed for better understanding of inherited bone marrow failure syndromes.

Received: July 12, 2022
Revised: September 02, 2022
Accepted: September 10, 2022


Anti-NMDA Receptor Encephalitis: A Rare but Important Auto-Immune Cause of Encephalitis

Muhammad Sohail Ajmal Ghoauri, Nauman Ismat Butt, Muhammad Umair Javed, Muhammad Bilal Rasheed, Shoaib Luqman, Sabir Ali

Abstract: A previously healthy 30-year old lady presented with 1-day history of high grade fever and drowsiness. Five days prior to presentation, she developed insomnia and visual hallucinations of seeing unknown faces. Three days prior to presentation, she suffered from 5 episodes of generalized tonic colonic fits. On admission, she had a temperature of 102oF and GCS of 10/15 with no signs of meningeal irritation, no focal neurological deficit, normal deep tendon reflexes and down-going plantar reflex bilaterally. Her brain MRI scan showed mild hyper-intense signals in right cerebellum. Her CSF was tested for Anti-NMDA receptor antibodies which were positive. She was diagnosed as having Anti-NMDA Receptor Encephalitis and started on immediate Plasma Exchange with drastic improvement.

Received: June 12, 2022
Revised: September 10, 2022
Accepted: September 13, 2022


Complete Labial Fusion in a Post Menarche Adolescent Girl

Anum Fatima Parekh, Ayesha Khan and Shahzad Ali

Abstract: Labial fusion is commonly seen in pre-pubertal girls but is rarely reported in adolescent females after menarche. Its main cause is low estrogen levels. A patient can be completely asymptomatic and self-limiting or present with a wide range of symptoms which can vary from urinary tract infection, urine retention, incontinence, dyspareunia, etc. We present a case of a 12-year-old female who presented in our department with a complaint of difficulty in voiding and lower urinary tract symptoms. After a detailed examination, she was diagnosed with labial fusion for which adhesiolysis was done and patient remained asymptomatic after it.

Received: July 09, 2022
Revised: September 15, 2022
Accepted: September 19, 2022

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NJHS Front Page v7.n3
2022 VOL 7 , Issue 3