Annals of PIMS (Pakistan Institute of Medical Sciences)
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Unveiling the Mystery of Thanatophoric Dysplasia: A Case Report on Clinical and Radiological Correlation in a Low-Antenatal Care Setting
Full text linkThanatophoric Dysplasia (TD) is a rare, lethal skeletal dysplasia caused by FGFR3 gene mutations, leading to severe bone and cartilage abnormalities. TD is classified into two subtypes: Type 1, characterized by bowed femurs and a normal skull, and Type 2, with straight femurs and a cloverleaf skull deformity. Common features include micromelia, macrocephaly, a narrow thorax, and respiratory insufficiency. We report a case of 32-year-old primigravida presented at 28 weeks gestation with reduced fetal movements and no prior antenatal visits. Ultrasound revealed breech presentation, limb shortening, and macrocephaly. Labor was induced, resulting in a preterm vaginal delivery. Postnatal examination showed bowed femurs, short ribs, and a narrow thorax. Despite intensive care, the infant developed respiratory distress and died on the fourth day. Radiological findings, including macrocephaly and telephone receiver deformity of the femurs, confirmed Type 1 TD.
Key Words: Thanatophoric Dysplasia, Macrocephaly, Craniosynostosis, Chorioamnionitis,Achondroplasi
Physics Forceps Versus Conventional Forceps in Dental Extractions – A Split Mouth Comparison
Full text linkObjective: To compare the outcomes of physics forceps with traditional forceps during dental extractions for orthodontic treatment.
Methodology: After obtaining from the Institutional Review Board (IRB) of the Dental Section, IslamabadMedical & Dental College vide letter No. IMDC/DS/IRB/220 dated 30-11-2022, participants were recruited from the OPD who met inclusion criteria, after taking informed written consents. Group A, the experimental group, had teeth extracted utilizing physics forceps, whereas Group B, the control group, had teeth extracted using standard methods.
Results: The study involved 70 extractions from 35 participants, with tooth numbers 14 and 24 extracted from each, representing 50% of the sample for each tooth. Both groups were statistically comparable at baseline (p-value > 0.05). The mean extraction time in Group A was 108.51±93.30 seconds, while Group B's was 127.29±117.09 seconds. Alveolar fractures occurred in 1 case (2.9%) in Group A and 8 cases (22.9%) in Group B. Tooth fractures were 4 cases (11.4%) in Group A and 3 cases (8.6%) in Group B. Soft tissue injuries were 4 cases (11.4%) in Group A and 10 cases (28.6%) in Group B.
Conclusion: The study found similar operational times between the groups. However, Group A had fewer alveolar fractures and soft tissue injuries. Both groups had similar tooth fracture rates, but Group A had lower complications and better comfort
Assessment of Malnutrition Among Critically Ill Adults Admitted in the ICU of a Tertiary Care Hospital at Rawalpindi, Pakistan
Full text linkObjective: To determine the prevalence and clinical implications of nutritional risk among critically ill adults admitted to the ICU at Fauji Foundation Hospital, Rawalpindi, Pakistan.
Methodology: This prospective observational study enrolled 250 adult ICU patients admitted for 7–60 days between January 2023 and July 2023. Nutritional risk was assessed at admission and discharge using validated NRS-2002 and mNUTRIC scores, and MUAC was measured as an anthropometric indicator. Multivariate logistic regression analysis was performed to evaluate the association between nutritional risk markers and clinical outcomes, including mortality and length of stay (LOS).
Results: Most patients (62.8%) were older than 40 years, with a majority being female (74%). A high prevalence of nutritional risk was observed at admission (62.4% by NRS-2002 and 27.2% by mNUTRIC), which increased to 69.6% and 88%, respectively, at discharge or death. MUAC showed a significant decline from admission to discharge (?2.10 cm in males and ?1.70 cm in females). The ICU mortality rate was 43%. Higher NRS-2002 scores (OR: 1.42; 95% CI: 1.13–1.77; p = 0.002) and mNUTRIC scores (OR: 2.85; 95% CI: 2.09–3.90; p < 0.001) at admission were independently associated with increased mortality. A decline in MUAC was also linked to higher mortality (OR: 1.26; 95% CI: 1.10–1.70; p = 0.007) and prolonged LOS (OR: 1.19; 95% CI: 1.01–1.40; p = 0.034).
Conclusion: This study reveals a high prevalence of malnutrition (62.4%–69.6%) among ICU patients, which is strongly associated with adverse clinical outcomes. These findings underscore the need for routine nutritional screening using validated tools such as NRS-2002 and mNUTRIC, particularly in resource-limited settings, to enable early detection and timely interventions that can improve patient outcomes
Liver Stiffness Distribution in Pakistani Adults Assessed by Ultrasound Sheer Wave Elastography: A Cross-Sectional Study
Full text linkObjective: To determine the normative percentiles for Liver Stiffness Measurement (LSM) using Shear Wave Elastography in an adult Pakistani population.
Methodology: This cross-sectional study was conducted at PESSI Hospital, Islamabad, from January to December 2023. Individuals aged 20 years and older, comprising both self-referred individuals, referral by plastic surgeon as part of holistic wellness evaluations in patients presenting for body contouring or reconstructive procedures, where liver ultrasound was recommended as a precautionary measure, seeking wellness evaluations and those referred for liver assessments by other medical specialties were included. Liver stiffness measurements (LSM) were obtained using 2D shear wave elastography, with image quality assessed and ten acquisitions recorded per subject. Only measurements with an interquartile range to median (IQR/M) ratio ?30% were deemed reliable.
Results: Most liver assessments (87.69%) revealed a smooth surface. surface with small round bumps or lumps were observed in 5.00% and 4.61% of cases each, while micronodules were present in 4.61%. Irregular surfaces were absent in grade 1 livers but increased in prevalence with higher grades (1.00% in grade 2, 6% in grade 3, 26.24% in grade 4, and 22.68% in grade 5). Nodular surfaces were similarly absent in grades 1 and 2, but were found in 14% of grade 3 livers, 12.20% of grade 4 livers, and 25.46% of grade 5 livers. Micronodules were present in 1.00% of grade 1 and 2 livers and increased significantly in higher grades.
Conclusion: Real-time Shear Wave Elastography is a dependable method for assessing liver stiffness. In generally healthy adults, factors such as male sex, obesity, abnormal tummy shape and hepatic steatosis significantly influence liver stiffness levels
Comparing the Effectiveness of Bite Wafers and Ibuprofen in Pain Management After Initial Orthodontic Arch-wire Placement
Full text linkObjective: This study compares the effectiveness of ibuprofen and bite wafer use on pain reduction after initial archwire placement.
Methodology: This study was conducted at the Department of Orthodontics, School of Dentistry, SZABMU, Islamabad. From October 2024 to March 2025. A total of 80 patients make up the sample (40 in each group). This comparative study involved patients who were placed under an arch wire and were randomly allocated by lottery method into two groups i.e. Ibuprofen Group (IBG) and Bite Wafer Group (BWG). Patients were given a bite wafer to chew on to relieve pain, or a 400 mg ibuprofen tablet to chew on at 8-hour intervals, for at least a week if pain persisted, after following all the study protocols. The pain intensity was assessed using a VAS questionnaire at home, and the results were analyzed at the end of the week.
Results: Out of 80 patients, 40 were males & 40 were females aged between 14 and 25 years. An independent sample t test revealed that ibuprofen initially worked better than bite wafers at 2 and 24 hours (P=0.01). However, at the end of the week, or on the seventh day, the results were not statistically significant (P=0.477). However, both the groups were satisfied with the treatment offered. Conclusion: Bite-wafers showed similar reduction in pain score after initial arch-wire placement as compared to ibuprofen over the 7 days period. Thus, offering bite wafers as an alternative to analgesics may be a reasonable solution for patients experiencing pain during orthodontic treatment
Effects of Ophthalmic Intravitreal Injection of Anti-VEGF on Renal Function in Diabetes Mellitus Patients
Full text linkObjective: To investigate the effects of ophthalmic intravitreal injection of anti-VEGF treatment on renal function in DM2 patients.
Methodology: This observation retrospective study was carried out in the Ophthalmology and Nephrology departments of Akbar Niazi Teaching Hospital, Islamabad, from February 2022 to February 2024. Total 100 patients of DM2, 50 patients received anti-VEGF treatment were included, both with and without chronic kidney disease (CKD). The progression of renal function was analyzed after the initiation of anti-VEGF treatment and in comparison, to a control group.
Results: The patients mean age was 69.3±9.6 years (ranging 51–85 years). The ratio of males to females was 1:1.3, with 56% (n=28) being males and 44% (n=22) being females. At 12-month mark, 75% of patients had CKD, mean decrease in estimated glomerular filtration rate (eGFR) of 20%. 26% of patients (n=13) experienced a reduction in eGFR of > 25%, while 10% of patients (n=5) had a reduction in eGFR of > 50%. By the 24-month mark, 85% of patients had developed CKD, with an average reduction in eGFR of 33.3%. The eGFR mean decline rate among patients underwent anti-VEGF was 10 ml/min/year, significant high than the 1.5 ml/min/year observed in the control group (p < 0.05). Following initial management, renal replacement was required for 20% of patients in the CKD group (n=6) in the follow up period (average duration of 21±11 months). The primary risk factors for dialysis requirement were age, baseline proteinuria, and the presence of preexisting CKD.
Conclusion: Ophthalmic anti-VEGF intravitreal for treatment is linked with an increased risk of CKD and accelerated progressive end stage kidney disease in individuals with preexisting CKD. Understanding the administration of these drugs is critical for managing progressive CKD and appropriately limiting their administration in specific patient populations
Splenectomy for Beta Thalassemia Major Among Transfusion Dependent Patients, its Effectiveness and Complications
No full textObjectives: To evaluate the effectiveness and complications of splenectomy among thalassemia major patients who need repeated blood transfusion.
Study design: retrospective descriptive
Place and duration of study: Conducted at paediatric and neonatal surgery department of tertiary care hospital from Jan 2020 to Jan 2024.
Material and methods: 43 patients with ?-thalassemia having meadian age 13 years (9 -17 years) who were taking repeated blood transfusion from thalassemia units were included in study. Ultrasonography was performed in all patients to find any accessary spleen, changes in the need for annual blood transfusion, platelets levels changes pre and post splenectomy, quality of life and complications after splenectomy like haemorrhage intra-abdominal, and from wound site, respiratory tract infections were recorded.
Results: Post splenectomy blood requirement was decreased significantly. a rise in serum platelet level was noted after splenectomy. Serum ferritin level decreased significantly. The quality of life as described by the parents was much improved. 3 patients showed incision site bleeding which managed by diathermy coagulation and blood / platelet transfusion. 3 patients presented with fever after 3 months of splenectomy and managed by paediatric medicine department.
Conclusion: After splenectomy, patients experienced a significant and sustained reduction in annual blood transfusion needs, accompanied by a rise in platelet counts and improved quality of life. However, any subsequent increase in transfusion requirements warrants thorough investigation to determine the underlying cause.
Keywords: Thalassemia; Post-splenectomy Complications; Blood transfusio
Functional Capacity in Patients with Rheumatoid Arthritis and its correlation with Disease Activity
Full text linkObjective: To identify the functional capacity in RA patients on the basis of the HAQ and to determine its correlation with the disease activity on the basis of DAS-28 ESR in a tertiary care hospital in Pakistan.
Methodology: This cross-sectional study was conducted in the Rheumatology Department of Pakistan Institute of Medical Sciences (PIMS), Islamabad, from Nov, 2024 to April, 2025. A sample of 196 patients with Rheumatoid Arthritis (RA) who were all adults and fulfilled the 2010 ACR/EULAR classification criteria. The Health Assessment Questionnaire (HAQ) was used to measure functional status, and Disease Activity Score in 28 joints (DAS28) with erythrocyte sedimentation rate (ESR) was used to measure disease activity. We analyzed the correlation between the DAS28 and HAQ scores based on the descriptive statistics, Pearson and Spearman correlation, linear regression, and multinomial logistic regression. The adjusted regression models were based on age, disease duration and socio-demographic factors.Results: The average age of the participants was 43 (SD±12.4) years and the average disease duration of the participants was 8.7 (SD ±7.2) years. Mean DAS28 score was 4.56 (SD ±1.06) and Health Assessment Questionnaire (HAQ) was 0.86 (SD ±0.56). Approximately eighty-eight percent of the patients had moderate to high disease activity, and seventy-one percent had moderate disability. There was a strong positive correlation between DAS28 and HAQ scores (r 0.630, p 0.001). Conclusion: There is a strong correlation between functional disability and disease activity in rheumatoid arthritis patients, with higher scores on DAS28 correlating with greater impairment
A Comparative Outcome of Oral Versus Tropical Calcium Channel Blocker (CCB) For Chronic Anal Fissure Treatment
No full textBackground: Topical pharmacological agent local application is the first line therapy for chronic anal fissure and is recommended along with strong analgesics and sitz bath for at least 6-weeks. Calcium Channel Blockers (diltiazem and nefidipine) are associated with similar efficacy with fewer side effects compared to commonly used GTN (0.2%). Objective: To review the effectiveness of Oral versus Topical CCB in the treatment of Chronic Anal Fissure (CAF) in respect of healing and pain relief.Methodology: This was a randomized control study conducted at Department of Surgery District Headquarter Hospital Kotri District Jamshoro Sindh from 1st November2022 to June 2023. Relevant published articles were searched to formulate our study.Total calculated sample size was 60 patients, 30 in each group, group A (Oral CCB) group B (Topical CCB). Both genders were diagnosed as a case of chronic anal fissure (CAF) having age ranges between 25-45 years. Patients with co-morbid like hepatitis B & C, cardiovascular diseases and hypersensitivity to calcium channel blockers were excluded from the study.After taking written Ethical Approval from the Medical superintendent of the concerned Hospital, all the patients filling the selection criteria were included in the study. Inform consent was taken and patients were randomly divided into 2 equal groups A & B. Randomization was done through by lottery method. In group Patients in group A were prescribed tropical Nefidipine(0.2%) application at the anal verge 8-hourly for 4-weeks. Similarly in group B patients were prescribed oral CCB (20mg) 12-hourly for 4-weeks. All patients were encouraged for high fiber diet (green leafy vegetables, salad & fruits) and warm sitz bath for 10 to 15 minutes 2-3 times daily. On each follow up OPD visit wound healing and pain relieve (VAS) is recorded onproforma. Wound healing was assessed by local inspection of the anal verge by separating the buttocks. Development of granulation tissue and re-epithelization was assessed. Effectiveness was judged by patients' oral feedback in terms of no pain during defecation and patients' satisfaction. All data was entered in a proforma analyzed using SPSS version 22.Results: 60 patients were enrolled in the study including both genders with a diagnosis of CAF. 30-patients (group A) were given Oral CCB, and other 30- patients were kept on Topical CCB. On random analysis Topical CCB was associated with lower incident of unhealed anal fissure compared to Oral CCB. There was no significant difference in side effects or fissure recurrence.Conclusion: Topical CCB has better healing and pain-relieving effects with fewer side effects compared to Oral CCB.Keywords: Chronic Anal fissure, calciu
Closed Distal Tibia Fractures in Adults: The Outcome of Locking Plate Through the MIPO Technique
Full text linkObjective: To study the functional outcome of lock plates in distal tibia fractures through the MIPO (minimally invasive plate osteosynthesis) technique, in Mardan Medical Complex, Mardan.
Methodology: This prospective study (consecutive case series) was conducted on a total of 45 patients from June 2018 to December 2021. Adult Patients with isolated distal tibia fractures consented to lock plate (3.5mm) fixation through the MIPO technique after fulfilling the inclusion criteria. The fracture was classified according to the AO/OTA system. The mean delay from injury to operation was 6 days (0-8). Patients were followed up from 9 months to 24 months with a mean follow-up of 19 months. At last follow-up data was recorded. Functional results were graded according to the Olerud-Molander functional evaluation score (OMFS).
Results: The total number of patients who underwent locking plate fixation through the MIPO technique is 45, with a mean age of 55 years (22-88) at the time of surgery. The mechanism of injury was road traffic accidents (47%) in most of the cases followed by falls from height (36%). All fractures united at an average of 19 weeks (15-24) with acceptable length and alignment, except in two cases that united at 26 weeks. No complications like deformities, compartment syndrome, non-union, implant irritation/skin impingement, or implant failure were seen in our study. Functional results were graded according to the Olerud-Molander functional evaluation score (OMFS), 47% were excellent, 44% were good, 7% were fair and 2% were poor.
Conclusion: MIPO is a safe alternative to conventional ORIF in achieving union for plating fracture of the distal tibia. Its functional outcomes are good with the least soft tissue dissection and complications associated with conventional open reduction