Pakistan Postgraduate Medical Journal

THE PERILS OF CORPORATIZATION: RECLAIMING MEDICINE’S SOUL IN PAKISTAN’S HEALTHCARE LANDSCAPE

2025-10-02T21:03:52+00:00

The practice of medicine has always rested on service, patient care, education, and research. Corporatization, however, threatens this foundation. It redefines patients as consumers, physicians as providers, and care as a commodity, with decisions increasingly driven by revenue cycles. ¹ For Pakistan, the dangers are profound. Corporatization diverts resources toward lucrative services while neglecting primary care, trauma, and emergency medicine. ² It also accelerates the migration of skilled clinicians into private hospitals, draining the public sector. ³ Families already bearing over 60% of health costs out-of-pocket⁴ face further impoverishment through unnecessary investigations and procedures. ⁵ The ethical contradiction is stark. In Islam, healthcare is an amanah (trust), not a commodity. ⁶ International evidence is sobering as in United States alone, corporatization has produced the world’s highest health spending without better outcomes, ⁷ while in India it has fostered overuse of costly interventions. ⁸ But a LMIC like Pakistan cannot afford such distortions. A rejection of corporatization is unrealistic. Instead, Pakistan needs a hybrid model that combines efficiency with compassion. Hospitals must institutionalize clinical governance, ⁹ transparent procurement, and standardized service packages. Senior clinicians in administrative roles require managerial and leadership training to ensure fiscal responsibility without abandoning ethics. ¹⁰ However, there are good examples in Pakistan. The Indus Hospital Network offers free, high-quality care funded through philanthropy and efficiency, ¹¹ while Liaquat National Hospital demonstrates cross-subsidization where private revenue sustains charitable care. ¹² These models show that sustainability is possible without commodifying medicine. we must choose whether hospitals will be judged by profits or by lives healed. As Berwick notes, the true test of a health system is not whether it enriches shareholders but whether it relieves suffering. ¹³

PAIN SCORE IN NEONATES WHILE ADMINISTERING SURFACTANT VIA LISA METHOD WITH AND WITHOUT PREMEDICATION WITH OPIOID AND ATROPINE.

2025-10-02T21:03:31+00:00

Objective: To determine the Pain score in neonates while administering surfactant via LISA method with and without premedication with opioid and atropine.

Study Design: Quasi experimental study

Place and duration of Study: This quasi experimental study was conducted in neonatology unit of CMH Quetta from Feb 2024 to Dec 2024.

Methodology: Inclusion criteria was spontaneously breathing preterm neonates who were <35 weeks of gestation diagnosed as RDS within first 48 hours of life. Premedication with nalbuphine at 0.05mg/kg and atropine 20microg/kg was used in intervention group. The surfactant Curosurf (200 mg/kg body weight) was instilled intratracheally via the feeding tube. Pain score was assessed by NIPS (neonate infant pain score)

Results: Total 50 preterm neonates were included. Out of these 25 patients were given LISA with premedication and 25 were given LISA without any premedication. There were 26 (52%) male neonates and female neonates. The mean gestational age at birth was 30.68 + 3.67 weeks. Mean pain score in group A was 2.90 + 2.09 before LISA and after medication it reduced to 2.04 + 1.64 (p value 0.001) while mean pain score in group B was 1.92 + 1.08 which increased to 3.00 + 1.61 after LISA.

Conclusion: Nalbuphine and atropine in low dose is effective in managing pain and discomfort during LISA in pre term neonates with less post procedural complications.

INTRA-OPERATIVE AWARENESS WITH THE USE OF INFUSION DEXMEDETOMIDINE AND INFUSION PROPOFOL IN PATIENTS UNDERGOING CORONARY ARTERY BYPASS GRAFTING

2025-10-02T21:03:14+00:00

Background: Awareness under anaesthesia is defined as the patient's memory of intraoperative events while under general anaesthesia. Although uncommon, it is a well-known anaesthesia complication. Despite the improvement in anesthesia technique and anesthetics, risk of awareness during anesthesia is high.

Objectives: To assess the intra-operative awareness of patients with the use of infusion dexmedetomidine and infusion propofol in patients undergoing coronary artery bypass grafting.

Method: This cross-sectional study was conducted on 300 patients and their medical records were assessed to note the intraoperative vitals and anesthesia details. Then patients were interviewed through Brice questionnaire. On the basis of responses, awareness during anesthesia was noted. All the data was recorded in proforma and analyzed in SPSS v. 25.

Results: Overall, the mean patient age was 59.28 ± 8.68 years. Only 2 (0.67%) of 300 patients revealed awareness under anesthesia. 1 young patient (50%) and 1 geriatric patient (50%, p = 0.924) experienced awareness during anesthesia, compared to 2 females (100%) and 0% (0.000) of men. Patients with overweight and obesity were more aware than those with normal or severe obesity (p = 0.447). Anesthesia duration did not significantly affect awareness during anesthesia, with 100% of patients experiencing awareness throughout 240 min (p = 0.676). Operative and intubation time did not affect awareness (p >0.05). Two (100%) individuals with pre-operative MAP 91-120 mmHg had awareness during anesthesia, with significant impact from heart rate and ejection fraction (p <0.05) among 300 patients.

Conclusion: We conclude that with use of Dexmedetomidine and Propofol infusion, the risk of awareness during anesthesia is very low (0.67%).

Key words: intra-operative awareness, infusion, dexmedetomidine, propofol, coronary artery bypass grafting

Efficacy of itraconazole pulse therapy with adjuvant isotretinoin in the treatment of recurrent and recalcitrant dermatophytosis

2025-10-02T21:02:57+00:00

Abstract:

There is a significant increase in the number of cases presented with atypical and unusual dermatophytosis. These patients have chronic and recurrent infection and seems to be more resistant to conventional topical and systemic treatments. This necessitate the use of other adjuvant treatment options such as isotretinoin along with itraconazole that would help to cure these challenging cases.

Objective: To determine the efficacy of monthly pulse of oral itraconazole in combination with daily low dose of isotretinoin in the treatment of recurrent and recalcitrant dermatophytosis.

Methods: This study was carried out in department of Dermatology, Shalamar Hospital, Lahore. Sixty patients attending the dermatology outpatient department at Shalamar Hospital Lahore, fulfilling the inclusion criteria were enrolled in the study. Patients were given oral itraconazole 200mg two times a day for 7 days/ month for 3 months with adjuvant 20 mg isotretinoin/day for the same duration. All the patients also received topical white soft paraffin and antihistamines. Patients were followed up monthly for first three months after starting the treatment and then once at the sixth week after stopping the treatment. During each follow up visit, clinical assessment score was recorded. All the information was collected in predesigned proforma.

Results: Mean age of patients was 36.03±6.11 years, duration of disease 6.83±1.86 months, baseline and post treatment clinical assessment score (CAS) was 3.11±0.61 and 0.16±0.49 respectively. There were 55.0% (n=33) males and 45.0% (n=27) females. Among the co-morbidities studied, frequency of diabetes mellitus was 23.3% (n=14) and 15.0% (n=9) had family history of dermatophytosis. Ten percent (n=6) had history of contact with domestic or wild animal. Out of 60 patients, efficacy was achieved in 88.3 % (n=53).

Conclusion: It is concluded that pulse therapy of Itraconazole with adjuvant daily Isotretinoin is an effective treatment regimen in treating recurrent & recalcitrant superficial dermatophytosis.

Keywords

Dermatophytosis, Isotretinoin, Itraconazole.

COMPARATIVE ANALYSIS OF THE DIAGNOSTIC ACCURACY OF THE APPENDICITIS INFLAMMATORY RESPONSE SCORE AND THE ALVARADO SCORE IN ACUTE APPENDICITIS USING HISTOPATHOLOGY AS THE GOLD STANDARD

2025-10-14T06:37:06+00:00

Background: Appendicitis is difficult to diagnose, especially in children, the elderly, and reproductive-aged females, because symptoms overlap with those of other conditions. The Alvarado and Appendicitis Inflammatory Response scores have been developed as clinical scoring systems to aid diagnosis. Nevertheless, they have merits and demerits, which need to be researched further in terms of comparative accuracy.

Objectives: To compare the diagnostic accuracy of the Alvarado Score and the Appendicitis Inflammatory Response (AIR) Score in patients presenting with suspected acute appendicitis, using histopathological findings as the gold standard.

Methods: It was Comparative cross-sectional validation study. The study was conducted at Surgical Unit III, Allama Iqbal Memorial Teaching Hospital, Sialkot, from November 20, 2024, to May 20, 2025. A total of 205 patients aged 18–70 years presenting with clinical signs of acute appendicitis were included using non-probability consecutive sampling. Each patient’s Alvarado and AIR scores were calculated based on clinical, laboratory, and radiological findings. All patients underwent appendectomy, and the removed specimens were examined histopathologically. Diagnostic performance was evaluated by calculating sensitivity, specificity, positive and negative predictive value (PPV, NPV), positive and negative likelihood ratio, and overall accuracy using SPSS ver. 26.0.

Results: Among patients (63.4% male, mean age 28.04 ± 4.17 years), histopathology confirmed acute appendicitis in 161 (78.5%). The Alvarado Score showed 92.55% sensitivity, 97.73% specificity, and 93.66% accuracy, while the AIR Score had 88.20% sensitivity, 97.73% specificity, and 90.24% accuracy.

Conclusion: The Alvarado and AIR Scores are reliable for diagnosing acute appendicitis, with the Alvarado Score slightly outperforming in sensitivity and accuracy. The Alvarado Score may be preferred in emergency settings for efficient diagnosis and management.

ROLE OF ULTRASOUND IN DIFFERENTIATING BENIGN AND MALIGNANT THYROID NODULES IN COMPARISON WITH EXCISIONAL BIOPSY

2025-10-02T21:02:41+00:00

Background: Thyroid lesion classification is important for treatment plan. Ultrasound is helpful in diagnosing and differentiating the benign lesions from malignant thyroid nodules. Results of ultrasound will be compared with post excisional biopsy results.

Aim: The aim of the study is to determine the role of ultrasound in differentiating the benign and malignant thyroid nodules and results was compared with the findings of post excisional biopsy.

Methodology: This prospective cross sectional cohort study was conducted in the Department of Diagnostic Radiology for three months’ time. The study has involved 50 patients from both gender referred to the Department for diagnosing the thyroid nodule lesions. Findings of ultrasound was compared with results of post excisional biopsy.

Results: Total 59 patients were included in the study and mean age of the patients was 43.15 ±10.43. Female patients were 48(81.4%) and male patients were 11(18. 6%).Disease duration mean was 7.58± 2.82 months and nodule size mean was 4.98± 1.72 cm. Ultrasound accurately detected 6 out of 8 malignant cases when compared with post excisional biopsy results and false diagnosis was 2 out of 59 benign cases.3 cases were found true negative. All the calculation made were with confidence interval 95%. Sensitivity of ultrasound results were 92.51%, specificity was 93.96%, positive likelihood ratio was 10.86, negative likelihood ratio was 0.98, positive predictive value was 82.97%, negative predictive value was 87.03%and diagnostic accuracy of gray scale ultrasound was found 91.64%

Conclusion: Ultrasound is reliable and accurate modality to differentiate the benign thyroid nodules from malignant thyroid nodules.

Operative difficulty of laparoscopic cholecystectomy in obese patients - a THQ hospital experience

2025-10-06T07:39:38+00:00

Abstract

Objective: To determine the factors responsible for operative difficulty of laparoscopic cholecystectomy in obese patients at a THQ hospital Lahore, was the objective of this study.

Methods and Material: This retrospective study was conducted at department of General surgery, Government THQ Hospital Sabzazar, Lahore from May 2021 to October 2023 and included 189 obese patients with gall bladder disease. All Patient underwent laparoscopic cholecystectomy by single consultant surgeon. Patient`s demographics and factors responsible for operative difficulty were recorded.

Results: Mean age of obese patients was 48.63±10.72 years. There were 41 (21.69%) male and 148 (78.30%) female patients. Mean BMI was 37.89±1.29Kg/m². Out of 189 obese patients, 72 (38.09%) patients were diabetic and 127 (67.19%) patients were hypertensive. Indication of surgery was biliary colic in 183 (96.82%) patients and gall bladder polyp in 6 (3.17%) patients. Mean operative time and mean hospital stay were 112.03±6.89 minutes and 3.01±1.27 days, respectively. Factors responsible for operative difficulty in obese patients were difficult umbilical access in 97 (51.32%) patients, insufficient gall bladder retraction in 73 (38.62%), visceral hindrance in getting adequate calot’s triangle exposure in 128 (67.72%), problematic calot’s triangle dissection in 149 (78.83%), gall bladder perforation in 7 (3.70%), troublesome gall bladder bed dissection in 37 (19.57%), hemorrhage in 64 (33.86%), biliary injury in 0 (0.00%) and difficult port closure in 119 (62.96%) patients during laparoscopic cholecystectomy.

Conclusions: Perplexity in Calot’s triangle dissection is the quotidian factor responsible for operative difficulty of laparoscopic cholecystectomy in obese patients to implement safe cholecystectomy.

Key-words: Laparoscopic cholecystectomy; obese; operative difficulty

COMPARISON OF INTRAOPERATIVE MEAN BLOOD LOSS BETWEEN UTERINE ARTERY TOURNIQUET AND VAGINAL MISOPROSTOL IN CASES UNDERGOING TRANSABDOMINAL MYOMECTOMY

2025-10-05T06:40:44+00:00

Background: Transabdominal myomectomy is a common surgical procedure for the removal of uterine fibroids, often associated with significant intraoperative blood loss. Effective techniques to minimize blood loss are essential for improving surgical outcomes and reducing complications. Uterine artery tourniquet and vaginal misoprostol are widely used methods, but comparative data on their efficacy remain limited.

Objective: To compare the intraoperative mean blood loss, operative time, and hospital stay duration between uterine artery tourniquet and vaginal misoprostol in patients undergoing transabdominal myomectomy.

Study Design: Randomized Controlled Trial

Settings :Department of Obstetrics and Gynaecology, Bahawal Victoria Hospital, Bahawalpur.

Duration: 23-Feb-2024 to 23-Aug-2024.

Results: A total of 54 patients were included, with 27 assigned to the uterine artery tourniquet group and 27 to the vaginal misoprostol group. The mean intraoperative blood loss was 432.59 ± 191.31 ml in the uterine artery tourniquet group and 371.19 ± 204.46 ml in the vaginal misoprostol group (p = 0.260). The mean operative times were 121.93 ± 35.23 minutes and 123.81 ± 36.94 minutes (p = 0.848), respectively. The mean hospital stay durations were 2.93 ± 1.49 days and 2.85 ± 1.35 days (p = 0.849). Subgroup analyses based on parity and myoma characteristics showed no statistically significant differences between groups.

Conclusion: Both uterine artery tourniquet and vaginal misoprostol are equally effective in minimizing intraoperative blood loss, operative time, and hospital stay duration during transabdominal myomectomy. These findings support their use as viable options based on patient profiles and surgical requirements.

INTRAOPERATIVE BLOOD LOSS IN JUVENILE NASOPHARYNGEAL ANGIOFIBROMA FOLLOWING PRE-OPERATIVE EMBOLIZATION

2025-10-02T21:01:51+00:00

ABSTRACT

Background: Juvenile nasopharyngeal angiofibroma (JNA) is very rare and benign neoplasm of vascular system. It occurs almost in complete nasopharynx of teenage boys. The place of JNA origin is still debatable. Objective: To study the mean intraoperative blood loss in juvenile nasopharyngeal angiofibromas with pre-operative embolization. Material and methods: This descriptive cases series was conducted at Department of ENT, Lahore General Hospital, Lahore for 6 months. A total of 35 cases were included in this study. Embolization was done 23 hours before surgery and gel foam (spongeston) was used for embolization. The amount of intraoperative blood loss was recorded on proforma. Intraoperative blood loss was recorded as per operational definition. Results: All patients were male, aged between 15 and 25 years with mean age of 18.69±3.46 years. 15 patients (42.8%) were presented as stage I to II and 20 patients (57.2%) were presented as stage III. 17 patients (48.6%) were having size of tumour between 2-4 cm and 18 patients (51.4%) were having tumour size between 5-6 cm. Mean amount of intraoperative blood loss (mL) was 748.56±204.89. Mean size of tumour was 5.03±2.05 cm. Conclusion: In conclusion, mean intraoperative blood loss in juvenile nasopharyngeal angiofibromas with pre-operative embolization was 748.56±204.89 mL.

Keywords: Juvenile nasopharyngeal angiofibroma, Pre-operative embolization, Intraoperative blood loss

FREQUENCY OF NON-ALCOHOLIC FATTY LIVER DISEASE (NAFLD) RELATED CIRRHOSIS IN DIABETES MELLITUS USING ASPARTATE AMINOTRANSFERASE TO PLATELET RATIO INDEX (APRI) AND FIBROSIS-4 SCORE

2025-10-14T21:04:42+00:00

Background: Diabetes mellitus is a metabolic disorder characterized by high blood sugar levels. This results from the body's inability to properly use insulin, leading to impaired carbohydrate metabolism and overproduction of glucose.

Objectives: To study the frequency of NAFLD related cirrhosis in Diabetes Mellitus (DM) using APRI and fibrosis-4 (FIB-4) score.

Methods: We conducted a descriptive cross-sectional study to include 180 individuals of DM with NAFLD presenting at Pakistan Railways Hospital, Rawalpindi from 21^st July, 2024 till 20^th January, 2025. Patients were included by non-probability consecutive sampling between 18 to 75 years of age. Venous sample was taken for fasting blood glucose, random blood glucose, ALT, AST and platelets. APRI and fibrosis-4 scores were calculated. A higher and lower cut off value of >3.25 and <1.45 for FIB-4 and APRI values of >1.5 and <0.5 were be taken as the higher and lower cut off for identifying individuals with cirrhosis. Scores that had come in between these cut off were taken as inconclusive. SPSS version 26.0 was used for data analysis.

Results: Out of 180 individuals, 56 (31.1%) were male and 126 (68.9%) were female. The mean age was 59.90 ± 9.71 years. NAFLD-related cirrhosis was detected in 18 individuals (10%) using the APRI score and in 26 people (14.44%) using the FIB-4 score. Among patients with Grade 1 NAFLD, cirrhosis was present in 16 (8.88%) and 24 (13.33%) patients based on the APRI and FIB-4 scores, respectively. No cases of cirrhosis were observed in Grade 2 NAFLD. In Grade 3, cirrhosis was observed in 2 patients (1.11%) according to each scoring system.

Conclusion: This study emphasizes the demand for routine screening of diabetic and NAFLD patients for advanced fibrosis to enable timely intervention or referral to hepatology specialists.

SURGERY CASE REPORTS: ADVANCES AND TECHNIQUES ERRONEOUS SURGERIES: TWO CASE REPORTS OF GOSSYPIBOMA IN PAKISTAN

2025-10-15T03:13:10+00:00

A surgical sponge or other relatable substance that remains inside the patient's body after surgery is referred to as a "gossypiboma." One of the rarest but most inexplicable surgical side effects is gossypiboma. Gossypiboma is rare because of the regulatory procedures regarding patient entitlement and the lack of medical information for patients. Complications include abscess formation, bowel obstruction, perforation and sepsis. This case series means to report two instances of gossypiboma in ladies who went through routine obstetrical procedures.