Vol 1, Issue 3

Volume 1, Issue 3
October - December, 2013
Aims and Scope

El Mednifico Journal is an open access, quarterly, peer-reviewed journal from Pakistan that aims to publish scientifically sound research across all fields of biology and medicine. It is the first journal from Pakistan that publishes researches as soon as they are ready, without waiting to be assigned to an issue. The journal serves as a healthy platform for students and undergraduates, whose articles are considered on the basis of content and not on the basis of topic or scope. However, strict quality measures ensure a high standard. The journal has certain unique characteristics: EMJ is one of the first journals from Pakistan that publishes articles in provisional versions as soon as they are ready, without waiting for an issue to come out. These articles are then proofread, copyedited and arranged into four issues per volume and one volume per year EMJ is one of the few journals where students and undergraduates form an integral part of the editorial team EMJ is one of the few journals that provides incentives to students and undergraduates
The rationale behind starting a journal offering incentives to students is three fold: To inculcate a sense of research in biomedical students by promoting healthy writing practices To provide a platform where students can publish their research (after thorough peer review) without the fear of getting rejected on the basis of topic or focus of the article To ensure global outreach for articles published in the journal
EMJ is published once every 3 months by Mednifico Publishers. Editorial correspondence should be addressed to: The Editor-in-Chief, El Mednifico Journal, C2 Block R, North Nazimabad, Karachi, Sindh - 74700 - Pakistan. Tel: (92-334-2090696); Email: editorial@mednifico.com; Website: http://mednifico.com Articles should be sent to: Submissions EMJ, C2 Block R, North Nazimabad, Karachi, Sindh - 74700 - Pakistan. Email: submit@mednifico.com Want to partner with EMJ? Send your proposal to: partnership@mednifico.com Were hiring! Send your CVs to: apply@mednifico.com i
Editorial Board
Senior Editor-in-Chief
Prof. Nazeer Khan
Executive Editors
Syed Salman Ahmed, Sajid Ali Dr. Mansoor Husain, Dr. Muzaffar H Qazilbash, Dr. Tasneem Z Naqvi, Prof. Haruhiro Inoue, Dr. Athanassios Kyrgidis, Dr. Asim A Shah, Dr. Kothandam Sivakumar, Dr. Samina Abidi, Dr. Rashid Mazhar,
Editor-in-Chief
Asfandyar Sheikh
Managing Editor
Syed Arsalan Ali
Senior Editors
Dr. Gautam Sikka, Dr. Mosaddiq Iqbal, Prof. Javed Akram, Prof. Abdul Bari Khan, Prof. Ashraf Ganatra, Dr. Raza Ur Rehman, Dr. Waris Qidwai, Dr. Muhammad Ishaq Ghori, Dr. Akber Agha, Dr. Adnan Mustafa Zubairi, Dr. Saqib Ansari, Dr. Mohsina Ibrahim, Dr. Qamaruddin Nizami, Dr. Samra Bashir, Dr. Nabeel Manzar, Muhammad Ashar Malik
Section Editors
Ali Sajjad, Hafiz Muhammad Aslam, Syed Askari Hasan, Muhammad Uzair Rauf, Syed Mumtaz Ali Naqvi, Manish Khazane, Smitha N Gowda, Supriya Kumar, Zeba Unnisa, Suhasis Mondal,
Assistant Editors Editors

Dr. Hussain Muhammad Abdullah, Asfandyar Khan Niazi, Muhammad Danish Saleem, Smith Giri, Iqra Ansari, Muhammad Hamid Gulrayz Ahmed, Raza Mahmood Hussain, Uzair Ahmed Siddiqui, Maheen Anwer, Anum Saleem, Hira Hussain Khan, Imran Jawaid, Hina Azhar Usmani, Shayan Ali, Shoaib Bhatti, Shanawer Khan, Hira Burhan, Quratulain Ghori,
Statistics Editors
Mehwish Hussain, Syed Ali Adnan
Layout Editor
Shahzad Anwar
Copyeditors
Adnan Salim, Bushra Iqbal, Maria Rahim
ii
Table of Contents
FrontPage Editorial Board Call for Papers Table of Contents i ii iii iv
Editorial
Coronary artery calcium score: Where tradition meets innovation...
Asfandyar Sheikh
56
Original Articles
Cariogenic potential in relation to plaque pH among non-alcoholic beverages: A comparative study
Manu Batra, Pradeep Tangade, Swapnil S Bumb
57
Up-to-date and age appropriate immunization coverage of EPI vaccines among children in Azad Jammu and Kashmir
Shafiq Ur Rehman, Ahmed Saud Dar, Ayesha Rahman, Muhammad Sareer, Nadia Aman, Mohammad Tahir Yousafzai
61
An insight into patient satisfaction after admission at a tertiary care hospital in Karachi
Afshan Iqbal, Saba Ali
67
Review
An insight into the perpetuating existence of malnutrition in Pakistani women and children
Shayan-ul-Haque Abbasy, Rekha Jiswant Kumar, Ruwa Rehman, Maryam Nauman, Ammarah Kamali, Maimoona Azhar
71
Case Report
Three dimensional titanium miniplates in the management of mandibular fractures
Arun K Goyal, Tarique Ansari, Ankit Jain, Vishal Sinha, Swapnil S Bumb
75
iv
Essays
Stem cells in Parkinson's research
Huma Ikram, Darakhshan Jabeen Haleem, Zia Choudhry, Adnan Maqsood Choudhry
77 79
Outbreak of measles: What should be the role of our government?

SSidra Jamal, Maryam Khan
Letters to Editor
Guillain-Barr syndrome in a patient with diabetes mellitus
Anoshia Afzal, Reema Javed
80 82
The association of dyslipidemia with osteoporosis: A case report

Atta Abbas
Appendices
Instructions to Authors Best of Blogemia vi ix
56
Coronary artery calcium score
Open Access
Coronary artery calcium score: Where tradition meets innovation
Asfandyar Sheikh
Editorial
Editorial
Cardiovascular disorders are the number one cause of mortality in adults worldwide. Most of these disorders are often a direct or indirect result of formation of fatty plaques in arteries, a process known as atherosclerosis. Atherosclerosis is not a static process, but may progress from mere fatty streaks (often considered precursors of these plaques) to disrupted, ulcerated lesions. These lesions may then calcify, leading to a loss of elasticity of the arterial wall. All of the above may lead to cardiovascular events (CVE), with or without superimposed thrombosis. CVE, which include entities such as stroke and myocardial infarction, have the highest incidence in elderly males and postmenopausal women. Risk factors often coincide with those of atherosclerosis, and include hypertension, smoking, dyslipidemias and homocysteinemia. Metabolic syndrome has long been implicated as a multidimensional risk factor for cardiovascular disease, and if present, most therapeutic regimens are aimed, at least to a particular extent, at its control. Prediction of cardiovascular events is often a difficult task, especially when only the risk factors are taken into account. The Framingham Risk Score is a reliable measure for predicting risk of CVE in asymptomatic patients. However, its limited applicability in certain populations and failure to consider all risk factors puts a question mark to its widespread use. Among invasive tools, high sensitivity C reactive protein (hsCRP) is a potent predictor of future CVE, and is widely used in risk assessment. Coronary artery calcium (CAC), which is present only in atherosclerotic arteries, can be measured in order to determine individuals at risk [1]. CAC score is a readily available and non-invasive tool which has been shown, in multiple studies, to be associated with a risk of future cardiovascular events [2]. It has been shown to be a better predictor of CVE than hsCRP [3]. CAC score is measured by electron beam computed tomography
(EBCT) and is a reflection of atherosclerotic burden in coronary arteries [4]. The main advantage of using CAC score over other markers is that it can be used to follow the progression and/or regression of atherosclerotic plaques [5]. This makes it possible to make informed decisions in time, and to determine if the current treatment modalities have a desirable effect on the prognosis of the disease [5]. Agatston Score is the diagnostic measure currently employed in assessing coronary calcification. The score is calculated by assigning a weighted value to the highest density of calcification in a specific coronary artery. The score is reported in Hounsfield Units (HU). This score is then multiplied by the area of the coronary calcification. The calcium score of every calcification in each coronary artery is then added to give the total CAC score. Only recently, another scoring protocol, namely the lesion-specific calcium score, has been shown to be superior to the Agatston score. The newer method provides a better prediction of significant blockages in the heart as it is not limited to parameters traditionally included in the Agatston score (i.e. density, length and width).
Competing interests: The authors declare that no competing interests exist. Received: 16 October 2013 Accepted: 17 October 2013 Published Online: 17 October 2013
References
1. Budoff MJ, Gul KM: Expert review on coronary calcium. Vasc Health Risk Manag 2008, 4(2):315-324. 2. Raggi P, Gongora MC, Gopal A, Callister TQ, Budoff M, Shaw LJ: Coronary artery calcium to predict all-cause mortality in elderly men and women. J Am Coll Cardiol 2008, 52(1):17-23. 3. Pletcher MJ, Tice JA, Pignone M, Browner WS: Using the coronary artery calcium score to predict coronary heart disease events: a systematic review and meta-analysis. Arch Intern Med 2004, 164(12):1285-1292. 4. Elkeles R: Computed tomography imaging, coronary calcium and atherosclerosis. Expert Rev Cardiovasc Ther 2008, 6(8):1083-1093. 5. Priester TC, Litwin SE: Measuring progression of coronary atherosclerosis with computed tomography: searching for clarity among shades of gray. J Cardiovasc Comput Tomogr 2009, 3 Suppl 2:S81-90.
Dow Medical College, Dow University of Health Sciences, Pakistan Correspondence: Asfandyar Sheikh Email: asfandyarsheikh@gmail.com
Vol 1, No 3
Batra M, Tangade P, Bumb SS
57
Open Access
Manu Batra1, Pradeep Tangade2, Swapnil S Bumb1
Original Article
Cariogenic potential in relation to plaque pH among non-alcoholic beverages: A comparative study

Abstract
Background: Consumption of beverages has increased exponentially among youth. The aim of present study is to evaluate the cariogenicity of various beverages. Methods: Eighty subjects were divided into caries free (subjects having DMFT=0) and caries active groups (subjects having DMFT>0). Each group was further equally divided in five groups randomly: cola drink (CD), fruit juice (FJ), energy drink (ED), diet cola (DC) and non-sugar fruit juice (NSFJ). Acidity of the drink and plaque pH variations at particular time intervals (1, 5, 10, 15 and 30 minutes) was measured using digital pH meter. Comparisons were done using ANOVA and Turkeys post hoc test by SPSS version 12. Results: All beverages showed fall in pH initially. Among them, cola and energy drink emerged to be highly cariogenic as they could not recover from critical pH when tested next at 5 minute interval. When comparing all caries free subgroups, significant results were reported at 1, 5 and 15 minutes with p values of 0.00, 0.01 and 0.03 respectively. While comparing all caries active subgroups, significant results were reported at 1, 5 and 10 minutes with p values of 0.03, 0.00 and 0.00 respectively. While comparing mean plaque pH values of caries free and caries active subgroup, highly significant differences were found for cola and energy drink group. Conclusion: The beverages and fruit juices seem to be having significant cariogenic potential. Emphasis should be on reduced consumption of these drinks. School based intervention programs are recommended. (El Med J 1:3; 2013) Keywords: Beverages, Caries, Cariogenic Potential, Dental Plaque, Plaque pH
Background
Rapid technological advancements in the recent era have witnessed an apparent change in dietary habits. These changes have included a substantial increase in the consumption of beverages and acidic drinks [1, 2]. The consumption of beverages has increased exponentially in last 30 years. Young population is more affected by this so called bubble revolution. People who are aware of the deleterious effect caused by carbonated beverages are shifting towards fruit juices available in market. Fruit juices are marketed aggressively and are promoted as a heath drink [3]. Next-level drinks which are getting widespread acclaim nowadays are the energy drinks, which claim to provide more energy and enhanced performance, both mentally and physically. These drinks have been found to be associated with various diseases. Obesity is a multifactorial problem in which soft drinks play a key role. Cola and fruit drinks are the biggest single source of calories and added sugar in diet. Carbonated soft drinks may increase gastric distension and consequently lead to gastroesophageal reflux disease thereby contributing to an increased risk of esophageal adenocarcinoma. Harmful effects of these drinks are more pronounced on the dentition of the population. In the present study, our concern is to bring into limelight the dental implications of consuming the beverages. These drinks are thought to cause damage to teeth via two main mechanisms. Firstly, the low pH and titrable acidity of these drinks can cause erosion of enamel surfaces as reported by Smith and Greenby [4, 5]. Secondly, the fermentable carbohydrate in drinks is metabolized by plaque microorganisms to generate organic acids in the dental plaque, thereby resulting in demineralization and leading to dental caries (Grobler and Jenkins) [6]. The pH value of resting dental plaque has been suggested to be an important indicator of
1 2
an individuals susceptibility to dental caries [7]. Plaque pH changes also serve as a reliable guide for detecting the acidogenicity or cariogenic potential of foodstuffs in vivo studies (Edgar and Jensen) [8, 9]. The authors formulated a hypothesis that the selected beverages possess no cariogenic potential. Therefore, the aim of the present study was to evaluate the cariogenicity of various carbonated beverages and fruit juices: 1. By measuring the pH and titrable acidity of these drinks, 2. Through assessing the effect of these drinks on plaque pH at various time intervals (1, 5, 10, 15, 30 minutes) and 3. By means of assessing the variability of fall in pH among caries free and caries active groups.
Methods
This study was conducted in the Department of Public Health Dentistry, Kothiwal Dental College Research Centre, Moradabad during month of January 2011. Eighty volunteers, belonging to the age group of 18-35 years with mean age of 272.5 years, with caries experience and DMFT score ranging between 05, who were not on any medication since last 6 months and who gave informed consent, were selected. The study was approved by the ethical committee of Kothiwal Dental College and Research Centre. These subjects were divided into caries free (subjects having DMFT=0) and caries active groups (subjects having DMFT>0). Each group was further equally divided into five groups: cola drink (CD), fruit juice (FJ), energy drink (ED), diet cola (DC) and non-sugar fruit juice (NSFJ).
Teerthankar Mahaveer Dental College, India Kothiwal Dental College & Research Centre, India Correspondence: Manu Batra Email: drmanubatra@aol.com
http://www.mednifico.com/index.php/elmedj/article/view/21
58 The study was performed in three stages. During stage 1 (pre-study preparation phase), which started at the commencement of the study, subjects were given thorough oral prophylaxis so as to obtain zero plaque score and ensure uniform baseline score [10]. This was determined with the help of a disclosing solution (basic fuchsin 0.075%) and the subjects were asked to abstain from oral hygiene practices for 24 hours and from eating or drinking for at least 2 hour prior to the procedure. During stage 2 (recording intrinsic pH and titrable acidity of test drinks), the intrinsic pH of the test drinks was measured by digital pH meter (Eutech Cyberscan PH310), with glass combination electrode, which was previously calibrated and standardized with pH 7 and pH 4 buffer solutions. For measuring titratability of each test drink, 0.1M sodium hydroxide was titrated against 5 ml of the drink until a pH of 7 was obtained. The volume of sodium hydroxide to do so was recorded and this gave an indication of the buffering potential of the drinks. During stage 3 (recording of pH at baseline and after consumption of test drinks), plaque pH was measured using the method of Fosdick et al modified by Rugg-Gunn et al [11, 12]. A sample of plaque was taken from the buccal surfaces of four sites of the subjects teeth using a sterile stainless steel straight probe. Subjects were asked to swallow immediately before plaque collection to minimize salivary contamination, and during sample collection, care was taken to avoid contamination with blood or saliva. This formed the baseline plaque sample. The collection time for each sample was standardized to 30 seconds. The plaque sample was mixed with 20 ml of distilled water and pH was recorded by digital meter. The pH was read after allowing the reading to stabilize for 30 seconds. Volunteers then rinsed their mouths thoroughly with 15 ml of one of the test drinks for a period of 40 seconds [13]. Plaque samples were harvested at 1, 5, 10, 15, and 30 minutes interval after rinsing, and the pH of each sample was measured as before. Since two examiners collected the data, it was important to test the standardization of examiners for plaque collection. The mean Kappa statistics for inter-examiner reliability was 0.89 for recording plaque pH which suggested that the two examiners reached an excellent inter examiner reliability. Data was analyzed by SPSS package version 12. Multivariate analysis was done by one way ANOVA to compare the mean pH level of the test groups and also among the caries free and caries active subgroups at specified time intervals. Post hoc test was used for pair wise comparison of the test groups and also among the caries free and caries active subgroups. T-test was used to compare the caries free and caries active subgroups in each group at different time intervals.
Cariogenic potential of non-alcoholic beverages
low pH, the cola drinks needed the lowest amount of base to raise the pH to 7.0 (Table 1). Table 1: Intrinsic pH and buffering capacity of test drinks Test Drink Intrinsic pH Titratable acidity* Cola Drink 2.67 1.15 Fruit Juice 3.59 1.82 Energy Drink 3.45 3.92 Diet Cola 3.24 1.86 Non-Sugar Fruit Juice 3.86 1.62
*in ml of n/10 NaOH to bring pH to 7 of 5ml of test drink
Variation of plaque pH from baseline to a period of 30 minutes is shown in Figure 1. There was steep fall in pH at 1 minute in all the groups, with energy drink and cola drink having the steepest fall and fruit juice having the lowest drop. It took 5 minutes to raise the plaque pH above the critical pH horizon after the steep fall for all but the energy drink group.
Figure 1: Mean changes of pH levels from baseline in five test groups

#Comparison of groups by one-way ANOVA, significant results seen at 1 minute (p=0.0005) and 5 minutes (p=0.0235). *using Tukeys multiple post-hoc test, significant pairs were: 1. at 1 minute - ED FJ , ED- NSFJ, FJ CD; 2. at 5 minutes - ED FJ, ED DC; 3. at 30 minutes - ED CD, FJ CD, FJ - NSFJ, CD DC.
The variation in mean plaque pH of caries free subgroup (DMFT=0) among the five test groups is shown in Figure 2. The pH of energy drink and of cola drink fell below the critical level, with cola drink group recovering very quickly in comparison to any of the other test groups. Other noticeable variation was that up till 10 minutes, the rate of recovery was on higher side, whereas after that it slowed down. The variation in mean plaque pH of caries active subgroup (DMFT>0) among the five test groups is shown in Figure 3. The pH fall at 1 minute was more than caries free subgroup; three subgroups (ED, CD, DC) showed pH fall below the critical level. Interestingly, a drastic variation was seen in the recovery pattern between cola drinks and diet cola subgroup in time period of 15 minutes.
Results
The intrinsic pH of all the test drinks was estimated to be acidic. Among them, cola drink showed the least pH followed by diet cola, energy drink, fruit juice and non-sugar fruit juice. The energy drink, despite having pH on higher side, needed the highest volume of sodium hydroxide to raise its pH to 7.0. Conversely, despite having a
Vol 1, No 3
Batra M, Tangade P, Bumb SS
59
Figure 2: Mean changes of pH levels from baseline in caries free subgroups

#Comparison of caries free subgroup (DMFT=0) by one-way ANOVA. Significant results seen at 1 minute (p=0.0003), 5 minutes (p=0.0171) and 15 minutes (p=0039). *Pair wise comparison of caries free subgroup using Tukeys multiple post-hoc test. Significant pairs: 1. at 1 minute - ED FJ , FJ CD, FJ - NSFJ; 2. at 5 minutes- ED CD; 3. at 15 minutes- FJ CD, CD DC,CD NSFJ; 4. at 30 minutes - ED CD, FJ CD, CD DC, CD - NSFJ.
Figure 3: Mean changes of pH levels from baseline in caries active subgroups

#Comparison of caries active subgroup (DMFT>0) by one-way ANOVA. Significant results seen at 1 minute (p=0.0328), 5 minutes (p=0.000) and 10 minutes (p=0.0002). *Pair wise comparison of caries active subgroup by Tukeys multiple post-hoc test. Significant pairs: 1. at 1 minute - CD - NSFJ; 2. at 5 minutes - ED FJ, ED DC, ED NSFJ, FJ CD, CD DC CD - NSFJ; 3. at 10 minutes - FJ CD, CD DC, CD NSFJ.
Comparison of mean pH values of caries free and caries active subgroups among each test group was made using Ttest (Table 2). Significant values were found for cola test group and energy drink group in all time intervals; for fruit juice group significant values were found at 10 and 15 minutes time interval. There were no significant results for diet cola and non-sugar fruit juice groups.
Discussion
Although there is no single test which can unambiguously determine the cariogenecity of any food or drink, in vivo studies on their ability to depress plaque pH may give insight into their potential to cause demineralization. Measurement of plaque acidity, principally as change in plaque pH over a period of time, forms an important group of tests for assessing potential cariogenicity of foods and drinks [13].
This study primarily focused on five common substrates, cola drink, fruit juice, energy drink, non-sugar fruit juice and diet cola drink, whose intrinsic pH ranged from 2.6 to 3.8. Reports have shown that it is not only the pH of a drink that has the potential to erode enamel, but also, more importantly, its buffering effect [14]. Fruit juices, in particular, have a greater effect on enamel erosion, due in part to their organic acid content. Edwards et al reported on the pH effects, in vitro, on a number of drinks, including fruit juices and carbonated beverages [15]. They concluded, through titration analysis, that fruit juices are more difficult to buffer at a point of neutrality than carbonated beverages. The initial pH value of all the drinks analyzed gave no indication of the underlying buffering capacity, which indirectly is associated with erosion potential. Interestingly, the fruit juices taken in the study had an initial pH value higher than the carbonated beverages but resulted in a lower buffering capacity. 15 minutes Caries Caries Free Active 6.58 6.13 p=0.000* 6.28 6.11 p=0.0262* 6.42 6.16 p=0.0002* 6.36 6.37 p=0.9393 6.27 6.32 p=0.6546
Table 2: Comparison of plaque pH values in caries free and caries active subgroups in all groups Test Drink Baseline 5 minutes 10 minutes Caries Caries Caries Caries Caries Caries Free Active Free Active Free Active 6.86 6.56 6.19 6.26 6.42 6.58 Cola Drink p=0.0006* p=0.0006* p=0.000* 6.67 6.71 5.97 5.90 6.16 5.97 Fruit Juice p=0.7394 p=0.6066 p=0.0179* 6.75 6.55 5.72 5.45 6.21 6.92 Energy Drink p=0.0329* p=0.0002* p=0.0016* 6.81 6.52 5.85 6.05 6.21 6.23 Diet Cola p=0.009* p=0.2478 p=0.8761 6.76 6.67 5.85 5.86 6.12 6.16 Non-Sugar Fruit Juice p=0.3475 p=0.8980 p=0.7603
*p<0.05, significant at 5% level of significance
60 Variation in plaque pH with time after consumption of test drinks can be influenced by buffering capacity of saliva as well as the flow rate which vary amongst individuals. Other host factors such as the pattern of mastication and the frequency of consumption can contribute to the total acidogenic potential [16]. Weatherall, et al showed that the pH varied from site to site within the oral cavity [17]. The maxillary teeth generally possessed a lower pH than did the mandibular teeth, which can be correlated to the rate of oral clearance. Another factor associated with this studys methodology was the way the drink was consumed. The subjects in this study were asked to swish for one minute with the respective drink. Grobler et al proposed that by drinking through a straw or swallowing a drink quickly, the acidogenic potential was decreased when compared to the swishing of a drink instead [6]. Ireland et al also reported that agitation, such as swishing, created a greater rate of loss of ions from enamel than in a static environment [18]. Hence, this report could have been altered, had the subjects quickly swallowed either substrate or simply held the substrate still in their mouth. In present study, significant variation in plaque pH between caries free and caries active group has been found. Plaque from caries free subjects exhibited a higher initial pH, a modest fall in pH after consumption of different test drinks and a more rapid return to resting levels as compared to caries active subjects. This finding is similar to the study conducted by Vrastsanos et al [19]. Plaque in caries-prone individuals contains increased proportions of bacteria capable of synthesizing intracellular polysaccharides of the glycogen-amylopectin type. Laboratory studies have shown that degradation of these polysaccharides occurs in absence of environmental sugar and leads to production of lactic acid. Thus, the higher proportions of glycogen synthesizing bacteria in caries active persons not only helps to explain why the resting pH of their plaques is lower, but also why such plaques generate more acid from exogenous carbohydrates [20]. The presence of phosphoric and citric acid is common in soft drinks and fruit juices. It was demonstrated that diet soft drinks caused less of a decrease in plaque pH when compared to regular soft drinks at 5, 10 and 20 minutes following consumption. One of the studies analyzing the pH of various soft drinks including diet soft drinks, found that the buffering capacity of diet soft drinks may be higher than in regular soft drinks. It was suggested that the sugar content of a regular soft drink created more saliva flow than with diet soft drinks, thereby providing for a greater buffering potential [21]. The current study opens new vistas as studies can be done by measuring plaque acidity in terms of hydrogen ion concentration, which gives a better idea of acid production in dental plaque than expressing the pH value which represents the logarithmic scale and makes it difficult to envisage the true acidity.
Cariogenic potential of non-alcoholic beverages
the reduction of consumption of these drinks. In the current scenario, more and more beverage companies are stressing on school based marketing as a cost effective way to build the share of mind and market. To counter this strategy, school based intervention programs can play an important role in lowering the consumption of these drinks; the next important point to stress is to stress on consumer education, that is making the consumer aware of the ill effects of the bubble revolution.
Competing interests: The authors declare that no competing interests exist. Received: 25 June 2013 Accepted: 14 August 2013 Published Online: 31 October 2013
References
1. Lehl G, Taneja JR, Chopra SL: Evaluation of the cariogenicity of sugar containing drinks by estimating changes in pH of human dental plaque and saliva. Journal of the Indian Society of Pedodontics and Preventive Dentistry 1993, 11(1):9-14. 2. Mythri H, Chandu GN, Prashant GM, V. SRV: Effect of Four Fruit Juices on pH of Dental Plaque A Four Period Cross-over Study. . Journal of the Indian Association of Public Health Dentistry 2008, 11:53-58. 3. Banan LK, Hegde AM: Plaque and salivary pH changes after consumption of fresh fruit juices. The Journal of clinical pediatric dentistry 2005, 30(1):9-13. 4. Smith AJ, Shaw L: Baby fruit juices and tooth erosion. British dental journal 1987, 162(2):65-67. 5. Grenby TH, Mistry M, Desai T: Potential dental effects of infants' fruit drinks studied in vitro. The British journal of nutrition 1990, 64(1):273-283. 6. Grobler SR, Jenkins GN, Kotz D: The effect of consumption and method of drinking. British dental journal 1985:158-163. 7. Huang GF, Guo MK: Resting dental plaque pH values after repeated measurements at different sites in the oral cavity. Proceedings of the National Science Council, Republic of China Part B, Life sciences 2000, 24(4):187-192. 8. Edgar WM, Bibby BG, Mundorff S, Rowley J: Acid production in plaques after eating snacks: modifying factors in foods. Journal of the American Dental Association (1939) 1975, 90(2):418-425. 9. Jensen ME: Responses of interproximal plaque pH to snack foods and effect of chewing sorbitol-containing gum. Journal of the American Dental Association (1939) 1986, 113(2):262-266. 10. Edgar WM, Geddes DAM: Plaque acidity models used for cariogenicity testing. J Dent Res 1986, 65:1498-1502. 11. Frostell G: A method for evaluation of acid potentialities of foods. Acta odontologica Scandinavica 1970, 28(5):599-622. 12. Rugg-Gunn AJ, Edgar WM, Geddes DAM, Jenkins GN: The effect of different meal patterns upon plaque pH in human subjects. 1975; 139: 351-356. British dental journal 1975, 139:351-356. 13. Taumba KJ, Duggal MS: Effect on plaque pH of fruit drinks with reduced carbohydrate content. Br Dent J 1999; 186:626-30. 14. Larsen MJ, Nyvad B: Enamel erosion by some soft drinks and orange juices relative to their pH, buffering effect and contents of calcium phosphate. Caries Res 1999; 33:81-87. 15. Edwards M, Creanor SL, Foye RH, Gilmour WH: Buffering capacities of soft drinks: the potential influence on dental erosion. J Oral Rehabil 1999; 26:923927. 16. Schachtele CF, Jensen ME: Comparison of methods for monitoring changes in the pH of human dental plaque. J Dent Res 1984; 61:1117-25. 17. Weatherell JA, Duggal MS, Robinson C, Curzon ME: Site-specific differences in human dental plaque pH after sucrose rinsing. Arch Oral Biol 1988; 33:871873. 18. Ireland AT, McGuiness N, Sherriff M: An investigation into the ability of soft drinks to adhere to enamel. Caries Res 1995; 29:470-476. 19. Vratsanos S.M, Mandel I: Comparative plaque acidogenesis of caries resistant vs. caries susceptible adults. J Dent Res 1982; 61:465-68. 20. Nikiforuk G: Understanding dental caries, Etiology and Mechanisms, Basic and Clinical Aspects. 4th edition:Karger 1985 p 152-53. 21. Roos EH, Donly KJ: In vivo dental plaque pH variation with regular and diet soft drinks: Pediatr Dent 2002;24: 350-53.
Conclusion
The results discussed above clearly demonstrate the cariogenic potential of beverages. It is difficult to imagine and would be nave to believe that the use of beverages can ever be stopped completely. However, given the concerns of the dental profession and the known possible detrimental effects of such drinks, emphasize should be on
Vol 1, No 3
Rehman SU, Dar AS, Rahman A et al.
61
Open Access
Original Article
Up-to-date and age appropriate immunization coverage of EPI vaccines among children in Azad Jammu and Kashmir
Shafiq Ur Rehman1,2, Ahmed Saud Dar3, Ayesha Rahman4, Muhammad Sareer5, Nadia Aman1, Mohammad Tahir Yousafzai1
Abstract
Background: Vaccination through the Expanded Program on Immunization (EPI) is one of the most cost-effective public health interventions, which has resulted in reduction in the morbidity and mortality from a number of vaccine preventable diseases. This study aimed to investigate up-to-date and age-appropriate EPI immunization coverage in two districts of Azad Jammu & Kashmir. Methods: A cross sectional survey was conducted between October, 2007 and December, 2007. A total of 420 children of 12-23 months were studied. The thirty clusters sampling technique by World Health Organization was used to collect the data. The up-to-date and age appropriate immunization coverage for the children was determined for both the districts. Pearsons Chi-square test for categorical and T-test for continuous variables were used. Results: Overall 73.1% (CI=67.0-79.1%) of the children between 12-23 months had received up-to-date immunization in District Bagh. However, only 16.5 % (CI= 11.2-21.7%) were age-appropriately immunized. The dropout rates for DTP vaccine was 11.4% (CI=9.9-15.3%). For District Neelum, overall 60.5 % (CI=51.6-69.8%) children of 12-23 months had received up-to-date immunization. Only 33.3 % (CI=22.7%-44.0%) of children were age-appropriately immunized. The dropout rates for District Neelum for DTP vaccine was 28.2% (CI=21.3-35.7%). Conclusion: While up-to-date immunization coverage is above 60%, age appropriate immunization coverage is very low and almost less than 30% in Azad Jammu and Kashmir. (El Med J 1:3; 2013) Keywords: Immunization, EPI, Vaccination, Immunization Programs, Pakistan
Introduction
Vaccination through the Expanded Program on Immunization (EPI) is one of the most cost-effective public health interventions [1]. It has resulted in the reduction in the morbidity and mortality from polio, measles, diphtheria, tetanus, and pertussis worldwide [2, 3]. For measles alone, without the global immunization efforts approximately 125 million cases, and about 2 million deaths per year would have occurred [1]. By reducing morbidity and mortality of children due to vaccine preventable diseases (VPDs), immunization can successfully contribute to the Millennium Development Goal (MDG) of reducing child mortality [1]. The Global Immunization Vision and Strategy (GIVS) for 2006-2015 is the global initiative led by United Nations that provides support for immunization programs to governments worldwide [2, 4]. The Reaching Every District (RED) strategy of EPI, targets an increase in the coverage of scheduled vaccines in all countries. It focuses on greater than 80% vaccination coverage at district level, thereby contributing to the achievement of the GIVS target of 90% immunization coverage at national level [5]. The need for the immunization globally, can be recognized from the fact that in 2010, 19.2 million children worldwide had not been immunized for DTP3 [3] Seventy percent of these unimmunized children were in ten countries, which included Pakistan, and its neighbors India and Afghanistan [3]. For Pakistan, studies conducted in previous years have reported lower immunization coverage. A study done in the city of Karachi reported coverage of 44.8% for children under-1 year of age [6]. Pakistan demographic and Health survey (PDHS) reports up-to-date coverage of 47.3% for children aged 1223 months [7]. The annual statistics by Ministry of Health (MOH) and
Aga Khan University, Pakistan. Human Development Program, Pakistan 3Khyber Teaching College Allied Hospitals, Pakistan 4Army Medical College, Pakistan
1 2
World Health Organization (WHO) however have reported higher immunization coverage [8]. Complete and timely immunization provides immunity to children against VPDs. Studies in South Asia and globally, however, have reported that immunization coverage of children can be low [9-13]. Lack of information regarding immunization services, low awareness of the need for vaccines, mothers education, mothers occupation, low family income and living at a distance from health facilities are only some of factors known to affect the utilization of immunization services [6, 9-14]. Misinformation about the program like wrong beliefs, socio-cultural barriers and time and resource constraints also have their effects [9, 14]. Immunization coverage surveys are important and provide valuable information for EPI program assessment and help in determining the factors that are hindering immunization coverage. Conducting these surveys at periodic time intervals provide independent assessments of the coverage provided by national statistics through routine Health Information System. This study can, therefore, help EPI program managers to check the progress made for children immunization in the study area, and to set their priorities while planning EPI services to the community.
Methods
Design and setting This community-based cross-sectional study was conducted from October, 2007 to December, 2007 in the districts of Bagh and Neelum in Azad Jammu and Kashmir (AJK), Pakistan. Both of these
Association for Community Development, Pakistan Correspondence: Shafiq Ur Rehman Email: shafiq.rehman80@gmail.com
62 districts had also been affected by a major earthquake, two years prior to the conduction of the study (2005). Participant selection and sampling strategy All children who were in the age range of 12-23 months, and were permanent residents of the study area were included in the study. The sample size for prevalence of vaccination coverage was calculated using EPI-Info software, with the level of significance () as 5%, and bound of error of estimation (B) of 10%, and assuming 50% prevalence of vaccination, the required minimum sample size for this study was 210 children for each district. In each of the districts, WHO 30/7 multistage cluster sampling technique was used. Within each district, first 30 clusters were randomly selected out of the total frame of clusters. Then seven children each were systematically selected within the selected cluster, giving a total of 210 children per district. Questionnaire and data collection process The primary outcome variable was immunization coverage. The routine EPI schedule by MOH at the time of the study included BCG, OPV, Hep-b, DTP, and measles vaccine. The up-to-date and age appropriate immunization coverage for the children was determined for both the districts. The up-to-date immunization of children aged 12-23 months was either reported by the parent of the child or recorded from the vaccination cards [15]. The age-appropriate immunization by the age of 1 year was determined only for those children who had vaccination cards and had been administered valid doses [15]. Data on variables such as maternal factors and socio-demographic factors was also obtained through a structured questionnaire by a team of surveyors that had been well-trained in data collection and quality control methods. As the study area was a post-earthquake area, factors in the backdrop of earthquake that could have affected immunization of the children e.g. migration after the earthquake, living in camp settings etc. were also collected. The Aga Khan University Karachi, Ethical review committee (ERC) provided ethical approval. Permission for study was also obtained from the district health authorities of area. Before conducting the interview, well-informed consent was taken from the parents of the children. Statistical analysis SAS version 9.1 was used for analysis. The up-to-date and age appropriate immunization coverage was determined using SAS to account for clustering in the analysis. Descriptive statistics were performed to report the socio-demographic characteristics of the study participants. The proportions of coverage for each vaccine and the 95% CIs were calculated. Cross tabulations between the independent variables and the outcome variables were done, in order to observe the vaccination coverage across different categories of independent variables. Chi-square was used for binary and T-test for continuous variables.
Up-to-date and age appropriate immunization coverage
Results
District Bagh
Immunization coverage: Overall 73.1% (CI=67.0-79.1%) of the children aged 12-23 months were fully immunized based on the vaccination card and the parental history. This is up-to-date coverage for the District Bagh (Table 1).
Table 1: Vaccination coverage and drop-out rates of EPI vaccines for children (N=210) of age 12-23 months in District Bagh. Vaccine Doses Overall Prevalence Valid Doses1 (95% CI) (95% CI) BCG 90.8 (86.1-95.5) 89.5 (84.5-94.5) DPT1 89.5 (84.5-94.5) 19.2 (13.3-25.1) DPT2 81.3 (75.3-87.3) 18.7 (13.0-24.4) DPT3 78.1 (71.6-84.6) 18.3 (12.7-23.8) HEP1 86.3 (81.0-91.6) 18.7 (13.0-24.4) HEP2 81.3 (75.3-87.3) 18.7 (13.0-24.4) HEP3 78.1 (71.6-84.6) 18.3 (12.7-23.8) OPV0 93.2 (89.6-96.7) 19.2 (13.3-25.1) OPV1 93.1 (89.6-96.7) 19.1 (14.2-26.1) OPV2 87.7 (83.2-92.1) 19.2 (13.5-24.9) OPV3 84.5 (79.4-89.5) 16.5 (11.1-21.9) Measles 73.9 (67.8-80.2) 13.8 (8.7-18.8) Immunization Status of 12-23 months children (up-to-date)2 Immunized 73.1 (67.0-79.1) Non-immunized 26.9 (20.9-32.9) Immunization at age 1 (age-appropriate)3 Immunized 16.5 (11.2-21.7) Non-immunized 66.7 (55.9-77.4) Utilization indicator (dropout rates) of immunization program in District Bagh4 Vaccine Used Dropout Rates DTP1 & DTP3 11.4 (9.9-15.3) Hep1 & Hep3 9.5 ( 7.7-11.6) DTP1 & MCV 17.4 (15.1-19.8) BCG & MCV 18.6 (16.1-21.3)
1. For valid doses only, children with cards are considered. Doses administered 4 days before the recommended age for each of the vaccine in the EPI schedule were considered as valid. A minimum interval of 28 days (4 weeks) is necessary between individual doses of vaccines to be recorded as valid. 2. Up-to-date coverage indicates the proportion of children aged 12-23 months with complete immunization. 3. Age appropriate immunization indicates proportion of study children with cards that indicate complete immunization with valid doses before one year of age. 4. Dropout rates was calculated by subtracting the last vaccine from the first vaccine and dividing the result by the first dose.
For complete immunizations by the age of 1 year, a total of 16.5% (CI=11.2-21.7%) of the children in District Bagh were age-appropriately immunized (Table 1). However majority [83.6% (CI=78.4-
Vol 1, No 3
63 (87.6%).
Immunization coverage across categories of independent variable: The immunization overage was significantly high for children of families possessing vaccination cards compared to families not having vaccination cards (p=0.007), and for children whose mothers were more educated (compared to children of uneducated mothers, p=0.02) (Table 2). The immunization coverage was high (marginally significant) for female children as compared to male children (Table 2).
88.8%)] of the children were not age-appropriately immunized (Table 1). The age appropriate immunization is much lower as it only considers immunization based on vaccination cards and valid doses only. The possession rate of the vaccination cards for the children by the parents in District Bagh was very low (23.8%). The dropout rates for District Bagh are given in table 1. The dropout rate for the DTP vaccine was 11.4% (CI=9.9-15.3%).
Coverage for individual vaccines:
Vaccination coverage for BCG was 90.8% (CI=86.1-95.5%). Vaccination coverage for DTP3 vaccine was 78.1% (CI= 71.6-84.6%). The valid doses for DTP3 were much lower i.e. 18.3% (CI=12.7-23.8%). Coverage for OPV3 was 84.5% (CI= 79.489.5%). The coverage for valid doses for OPV3 was 16.5% (CI=11.121.9%). The vaccination coverage for the measles vaccine was 73.9% (CI=67.8-80.2%) (Table 1). istics of study children in Bagh are given in Table 2. The mean age of the study children in District Bagh was 17.00.3 months. Majority of the children belonged to Pahari ethnicity (88.6%). About 7.1% of the families had undergone migration after earthquake. The average time taken to reach the nearest basic health facility for immunization of the children was 42.16.1 minutes. Most of the parents had to take their child by feet to the basic health facility for immunization
Basic characteristics of study children: The socio-demographic character-
In response to possible obstacles that can affect the utilization of immunization services by the families in the area, majority (55%) of the families reported that place of immunization was too far from them. Other factors that hindered the utilization included family related problems i.e. mother too busy or mothers illness with 34% of respondent reporting such an obstacle. A minority of families (5%) reported child illness as an obstacle. Of children who were unimmunized, 43% of the parents reported that they were unaware of need of immunization. Another 12% of the parents reported that they were not aware of need to come for 2nd and 3rd doses, and another 8% reported both the above reasons. A smaller number (7%) reported fear of side effects or misbeliefs about immunization programs.
Table 2: Socio-demographic characteristics of children aged 12-23 months in District Bagh. Variable Overall Vaccinated N (%) N (%) Males 120 (57.1) 81 (67.5) Gender Females Ethnicity Mothers Education Migration status Socioeconomic Status Possession of Vaccination Card Family problems related obstacles Pahari Others Uneducated 8 years & lesser More than 8 years Yes No High Middle Low Yes No Yes No 90 (42.8) 186 (88.6) 24 (11.4) 102 (48.6) 57 (27.1) 51 (24.3) 15 (7.14) 195 (92.8) 100 (47.6) 50 (23.8) 60 (28.6) 50 (23.8) 160 (76.2) 71 (33.9) 139 (66.1) 71 (78.9) 138 (74.2) 16 (66.6) 67 (65.7) 43 (75.4) 44 (86.3) 9 (60.0) 145 (74.4) 73 (73.0) 36 (72.0) 45 (75.0) 44 (88.0) 116 (72.5) 48 (67.6) 105 (75.6)
Unvaccinated N (%) 39 (32.5) 19 (21.1) 48 (25.8) 8 (33.3) 35 (34.3) 14 (24.6) 7 (13.7) 6 (40.0) 50 (25.6) 27 (27.0) 14 (28.0) 15 (25.0) 6 (12.0) 52 (32.5) 23 (32.2) 34 (24.4)
P-Value 0.08 0.3
0.02
0.2
0.9
0.007 0.2
64 District Neelum
Immunization coverage: Overall
60.5% (CI=51.6-69.8%) children of 1223 months were fully immunized based on the vaccination card and the parental history (Table 3). This is up-to-date coverage for the district Neelum. Of the 40.5% of children who were not immunized, 34.3% (CI=26.0-42.5%) were partially immunized, and 5.2% (CI=1.78.8%) of children had not received even a single dose of vaccine (Table 3).
A total of 33.3% (CI=22.7%-44.0%) of children in district Neelum were age-appropriately immunized (Table 3). However majority 66.7% (CI=56.0%-77.4%) of children were not age-appropriately immunized (Table 3). The dropout rates for District Neelum are given in table 3. The dropout rate for the DTP vaccine was 28.2% (CI=21.335.7%).
Coverage for individual vaccines: Vaccination coverage for BCG was 93.3% (CI=89.3-97.2%). The vaccination coverage for DTP3 vaccine was 66.7% (CI=56.9-76.4%). The valid doses for DTP3 were much lower i.e. 35.7% (CI=23.9-47.6%). The coverage for the OPV3 was 66.7% (CI= 57.8-75.5%). The vaccination coverage for the measles vaccine was 63.8% (CI 54.5-73.1%) (Table 3). Basic characteristics of study children: The socio-demographic characteristics of study children in Neelum are given in Table 4. The mean age of the study children was 17.20.3 months. Majority of the children belonged to Pahari ethnicity (82.4%), and most of the children belonged to middle (62.4%) socioeconomic class. The average distance to reach the nearest basic health facility was 41.65.2 minutes, and 92.4% of parents reported taking their child by foot to the nearby health facility for immunization (Table 4). The possession rate of the vaccination cards of the children by the parents was 56.7%. Mothers of children were found to be more illiterate then their fathers (81.4% vs 31.0%). Immunization coverage across categories of independent variable: Immunization coverage was significantly high for children whose mother had primary education (as compared to children of uneducated mothers, p=0.02) (Table 4). Also family related obstacles affected the immunization coverage (marginally significant, p=0.1). Illness of the children was also found to significantly affect immunization (p=0.01). (Table 4)
Table 3: Vaccination coverage and drop-out rates of EPI vaccines for children (N=210) of age 12-23 months in District Neelum. Vaccine Doses Overall Prevalence Valid Doses1 (95% CI) (95% CI) BCG 93.3 (89.3-97.2) 92.9 (88.9-96.8) DPT1 92.8 (88.6-97.0) 54.3 (42.9-57.1) DPT2 78.5 (71.9-85.0) 44.8 (34.0-55.5) DPT3 66.7 (56.9-76.4) 35.7 (23.9-47.6) HEP1 91.9 (87.7-96.1) 53.8 (42.5-65.1) HEP2 77.6 (70.3-84.9) 43.8 (32.9-54.7) HEP3 66.9 (57.4-76.6) 35.4 (23.9-46.9) OPV0 91.9 (87.3-96.5) 50.0 (38.4-61.6) OPV1 91.9 (87.9-95.8) 50.0 (39.3-60.7) OPV2 79.1 (72.4-85.7) 43.8 (32.8-54.8) OPV3 66.7 (57.8-75.5) 34.1 (22.9-45.4) Measles 63.8 (54.5-73.1) 25.4 (15.2-35.5) Immunization Status of 12-23 months children (up-to-date)2 Immunized 60.5 (51.6-69.8) Non-immunized 39.5 (27.7-51.3) Immunization at age 1 (age-appropriate)3 Immunized 33.3 (22.7-44.0) Non-immunized 83.6 (78.4-88.8) Utilization indicator (dropout rates) of immunization program in District Bagh4 Vaccine Used Dropout Rates DTP1 & DTP3 28.2 (21.3-35.7) Hep1 & Hep3 27.1 (20.3-34.6) DTP1 & MCV 31.3 (24.6-38.5) BCG & MCV 31.6 (24.8-39.0)
1. For valid doses only, children with cards are considered. Doses administered 4 days before the recommended age for each of the vaccine in the EPI schedule were considered as valid. A minimum interval of 28 days (4 weeks) is necessary between individual doses of vaccines to be recorded as valid. 2. Up-to-date coverage indicates the proportion of children aged 12-23 months with complete immunization. 3. Age appropriate immunization indicates proportion of study children with cards that indicate complete immunization with valid doses before one year of age. 4. Dropout rates was calculated by subtracting the last vaccine from the first vaccine and dividing the result by the first dose.
In response to possible obstacles that affected utilization of immunization services, 30% of these families reported that place of immunization was too far. Family related problems (39.1%) i.e. mother too busy or mothers illness were another important obstacle noted. Another 11% of families reported child illness as an obstacle, and a minority of families (4%) reported that the timing of immunization was inconvenient for them. Of the children who were unimmunized, 30% of parents reported that they were unaware of need of immunization. Another 21% reported that they were not aware of need to come for 2nd and 3rd doses, and 14% reported both the above reasons. A smaller group (10%) reported fear of side effects or misbeliefs about immunization programs.
Discussion
Immunization coverage surveys are used to indicate the performance of the EPI programs [16]. Up-to-date immunization coverage and age appropriate immunization coverage are commonly used as indicators to assess and report immunization status of the children [6, 9, 11-13, 17-18].
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65 P-Value 0.6 0.3 0.02 0.01
Table 4: Socio-demographic characteristics of children aged 12-23 months in District Neelum. Variable Overall Vaccinated Unvaccinated N (%) N (%) N (%) Males 124 (59.1) 74 (59.7) 50 (40.3) Gender Females Ethnicity Mothers Education Illness of child Socioeconomic Status Possession of Vaccination Card Family problems related obstacles Pahari Others Uneducated 5 years or more Yes No High Middle Low Yes No Yes No 86 (40.9) 173 (82.4) 37 (17.6) 171 (81.4) 39 (18.6) 25 (11.9) 185 (88.1) 51 (24.3) 131 (62.4) 28 (13.3) 119 (56.7) 91 (43.3) 82 (39.1) 128 (60.9) 53 (61.6) 102(59.0) 25 (67.6) 97 (56.7) 30 (76.9) 5 (20.0) 122 (65.9) 29 (56.9) 78 (59.5) 20 (71.4) 68 (32.4) 59 (28.1) 45 (54.8) 82 (64.1) 33 (38.4) 71 (41.0) 12 (32.4) 74 (43.3) 9 (23.1) 20 (80.0) 63 (34.1) 22 (43.1) 53 (40.5) 8 (28.6) 51 (24.3) 32 (15.2) 37 (45.1) 46 (35.9)
0.4
0.02 0.1
In this study, up-to-date immunization for District Bagh was 73.1% and the age appropriate immunization coverage was 16.5%. For District Neelum, the up-to-date immunization was 60.5% and the age appropriate immunization was 33.3%. The DTP3 coverage target of 80% was not achieved for both districts. In fact, DTP3 coverage was well below the target (66.7%) for District Neelum. The up-to-date immunization coverage for the study districts in this study is similar to that reported previously for Pakistan. A study conducted in three districts of N.W.F.P province had reported an up-todate coverage rate of 65% for children of age group 12-35 months [9]. Another study conducted in a tertiary care facility in Peshawar in 2007, had reported up-to-date coverage of 67.1% for children from the urban areas [10]. A survey conducted in two earthquake hit districts (Mansehra and Bagh) found that the polio vaccine coverage was above 90% for OPV3 [19]. This is similar to OPV3 coverage of above 90% reported by our study. The coverage for the BCG from this survey is also similar to one reported by our study [19]. The age appropriate immunization reported for our study is lower than the one reported by Siddiqi et al. for Karachi, who reported a coverage of 44.8% for children under one year [6]. However, the age appropriate immunization reported for District Neelum is similar to the estimates reported by Pakistan Demographic Health Survey (39%) [7]. Due to very little possession of vaccination cards by the parents in our study, the age appropriate immunization was low. This is because the age appropriate immunization relies only on valid doses of vaccines reported from the vaccination cards. Moreover, even for children who had the immunization card available, one-fifth
of the children in District Bagh, and one third of children in District Neelum had not been vaccinated validly i.e. without considering the minimum age, and minimum time intervals between vaccine doses. The importance of immunization lies in proper vaccination of the children, and not merely providing them with a vaccine dose without time consideration. It is stressed that training for the EPI program staff including the vaccinators, should focus on improvements in administration of the valid doses of vaccine, so that children are immunized with full consideration of the proper timing and intervals between doses. The dropout rates for District Bagh and Neelum was also high. There is a need to increase the coverage for the last doses of the vaccines in order to increase the immunization coverage. Some of the strategies can include providing supplementary immunization activities, and outreach services. Outreach activities for the people living in remote areas will be helpful as majority of the parents in our study had to cover considerable distances on foot to health facilities in order to get their children vaccinated. Another important finding from this study is that parents of unimmunized children were not aware of the need of immunization and the dose schedules. Parents also identified that family related obstacles, and inconvenient place and timing of immunization were potential barriers to immunization. Lack of information of the EPI program including schedule and timing of doses, and unawareness of the importance of the immunization have been extensively reported in literature as well [9, 14]. Socio-cultural barriers, and time and resource constraints have also been reported to affect immunization
66 [9, 14]. Even a study from an affluent community in United States has identified some of these barriers as a hindrance to immunization [20]. Family related obstacles hindering the immunization have also been reported previously by Ahmad et al. for Pakistan [9]. In this study for both the districts, children of mothers having a primary or higher education had significantly higher up-to-date immunization coverage as compared to children of uneducated mothers. Illness of the children was also found to significantly affect immunization of child in district Neelum. Yawn et al. in their study had also reported that mother education and child illness are associated with under-immunization [20]. Similarly, other studies have reported mothers education as an important factor affecting child immunization [6, 10-11]. Some of the factors identified as potential obstacles to immunization, are due to ignorance of the families for immunization services and their importance for children. The mobilization of the community through social mobilization and health education programs can be helpful in addressing these factors. Evidence from literature shows, that educating communities and mothers can help in increasing the immunization coverage [21, 22]. Also for our study, the possession of vaccination cards was quite low. There is also a need for health education of the parents by the EPI staff on the importance of maintaining immunization cards. Our study had few limitations. Being a cross-sectional study, it cannot provide temporal evidence of the studied barriers to the immunization. Also, the possession of immunization cards by parents in both the districts was quite low. So in calculation of the up-to-date immunization, there can be over or under-estimation of the outcome due to recall or reporting bias of the parents. We, however, have provided age appropriate immunization coverage as well. Previous studies in study area had mostly reported up-to-date immunization coverage [19].
References
1. Brenzel L, Wolfson LJ, Rushby JF, Miller M, Halsey NA: Vaccine Preventable Diseases. In: Millenium Development Goals A custom publication of the Disease Control Priorities Project. edn. 1818 H street NW, Washington DC, USA.: The World Bank; 2006. 2. GIVS - Global Immunization Vision and Strategy, 2006-2015 [http://whqlibdoc.who.int/hq/2005/WHO_IVB_05.05.pdf] 3. World Health Organization. Global Immunization Data. 4. GIVS goals [http://www.who.int/immunization/givs/goals/en/index.html] 5. The RED strategy [http://www.who.int/immunization_delivery/systems_policy/red/en/] 6. Siddiqi N, Khan A, Nisar N, Siddiqi AE: Assessment of EPI (expanded program of immunization) vaccine coverage in a peri-urban area. JPMA The Journal of the Pakistan Medical Association 2007, 57(8):391-395. 7. Demographic and Health Survey, 2006-07 [http://www.measuredhs.com/pubs/pdf/FR200/FR200.pdf] 8. WHO vaccine-preventable diseases: monitoring system [http://whqlibdoc.who.int/hq/2010/WHO_IVB_2010_eng.pdf] 9. Ahmad N, Akhtar T, Roghani MT, Ilyas HM, Ahmad M: Immunization coverage in three districts of North West Frontier Province (NWFP). JPMA The Journal of the Pakistan Medical Association 1999, 49(12):301-305. 10. Khan H, Jan N, Hameed A: Vaccination practices and factors influencing Expanded Programme of Immunization in the rural and urban set up of Peshawar. The Middle East Journal of Family Medicine 2007, 5(6):21-23. 11. Jamil K, Bhuiya A, Streatfield K, Chakrabarty N: The immunization programme in Bangladesh: impressive gains in coverage, but gaps remain. Health policy and planning 1999, 14(1):49-58. 12. Islam R, Rahman M, Rahman M: Immunization coverage among slum children: a case study of Rajshahi city corporation, Bangladesh. Med East J Family Med 2007, 5:17-20. 13. Kenyon TA, Matuck MA, Stroh G: Persistent low immunization coverage among inner-city preschool children despite access to free vaccine. Pediatrics 1998, 101(4 Pt 1):612-616. 14. Ahun M: Immunization essentials: a practical field guide. Bulletin of the World Health Organization 2004, 82(9):709-709. 15. Immunization coverage cluster survey-reference manual. [http://whqlibdoc.who.int/hq/2005/who_ivb_04.23.pdf] 16. Bos E, Batson A: Using immunization coverage rates for monitoring health sector performance. Washington, DC: The World Bank 2000. 17. Luman ET, McCauley MM, Stokley S, Chu SY, Pickering LK: Timeliness of childhood immunizations. Pediatrics 2002, 110(5):935-939. 18. Luman ET, Barker LE, McCauley MM, Drews-Botsch C: Timeliness of childhood immunizations: a state-specific analysis. American journal of public health 2005, 95(8):1367-1374. 19. PRIDE Project Knowledge, Practice and coverage (KPC) Baseline survey, 2007. [http://pdf.usaid.gov/pdf_docs/PNADY312.pdf] 20. Yawn BP, Xia Z, Edmonson L, Jacobson RM, Jacobsen SJ: Barriers to immunization in a relatively affluent community. The Journal of the American Board of Family Practice / American Board of Family Practice 2000, 13(5):325332. 21. Streatfield K, Singarimbun M, Diamond I: Maternal education and child immunization. Demography 1990, 27(3):447-455. 22. Anjum Q, Omair A, Inam SN, Ahmed Y, Usman Y, Shaikh S: Improving vaccination status of children under five through health education. JPMA The Journal of the Pakistan Medical Association 2004, 54(12):610-613.
Conclusion
While up-to-date immunization coverage is above 60%, age appropriate immunization is very low and almost less than 30% in AJK. In order to further improve the immunization coverage, efforts should give consideration to outreach activities, refresher trainings of the EPI staff on proper vaccination techniques, and health education activities.
Acknowledgement: The authors acknowledge the guidance of Dr Attaullah Saeedzai and Mr Iqbal Azam during the analysis of the study. Competing interests: The authors of this study declare that there were no conflict of interest in conducting the study, and this was an independent evaluation of immunization coverage and barriers to immunization in the study area. The authors also take complete responsibility for the integrity of the data and the accuracy of the data analysis. Received: 17 September 2013 Accepted: 29 October 2013 Published Online: 29 October 2013
Vol 1, No 3
Iqbal A, Ali S
67
Open Access
An insight into patient satisfaction after admission at a tertiary care hospital in Karachi
Afshan Iqbal1, Saba Ali1
Original Article
Abstract
Background: Patient satisfaction is an area that has received a tremendous amount of interest, and therefore, a lot of research has been done on it. The studies carried out worldwide on this subject have generally concluded that patients are most satisfied with the care they received and with the doctor-patient communication level, and are least satisfied with the cleanliness and management. Our aim was to ask our subjects not only these questions, but to cover a broader aspect of issues which they may face while being admitted in a large teaching hospital. Methods: A questionnaire-based cross-sectional survey was conducted on patients admitted to specific wards of surgery, medicine and gynecology in Civil Hospital, Karachi. Patients were randomly selected by the research participants and were subjected to an interview regarding specific issues that they may have faced during their stay in the hospital. Satisfaction was assessed using the standard 5 point satisfaction scale. Data was entered and analyzed using SPSS version 16. Results: A total of 329 patients responded to the questionnaire. Patient satisfaction rate was high with regards to the healthcare provided by the doctors and associated staff (37.8% and 28.6% respectively). However, more than half (51.9%) of the patients complained of the unhygienic and unhealthy conditions of the wards. 66.6% of patients in the gynecology ward felt the need for more comprehensive and accurate provision of treatment than they were receiving at present. Also, 37.8% of patients in the surgery ward were extremely dissatisfied with the food provided by the hospital management and 34.0% patients from the medicine ward encountered poor communication and delivery of information in regard to their health from their attending physicians. Conclusion: Although the hospital seems to lack in the basic services which should be provided by a tertiary care center, in general, patients remained highly satisfied with the knowledge and attitudes of their attending physician. Areas which received a low satisfaction score can be corrected by simple measures. Similar surveys are needed to continuously assess the situation. (El Med J 1:3; 2013) Keywords: Patient Satisfaction, Patient Care, Healthcare Issues, Tertiary Care, Hospital, Pakistan
Background
Satisfaction is defined as the fulfillment of one's wishes, expectations or needs. Medical professionals must not only administer the best treatment available to the patients, but must also try to make their hospital stay as comfortable as possible by fulfilling these wishes, expectations and needs. Studies show that satisfied patients are less likely to require readmission within 30 days after discharge and this notion further highlights the importance of keeping the patients content [1]. Patient satisfaction is an area that has received a tremendous amount of interest, and therefore, a lot of research has been done on this genre. Among studies carried out worldwide on this subject, only a few have been conducted on patients who had actually been admitted at a hospital [2-5]. The studies generally concluded that patients were most satisfied with the care they received and with the doctor-patient communication level, and that they were least satisfied with the cleanliness and management. Out of these four studies, only two studies were found to have been conducted in Pakistan, but none of those was conducted in the city of Karachi [4, 5]. Hence it was felt that a major city of Pakistan had been neglected, and this formed a considerable scope for our research. Our aim was to ask our subjects not only the questions mentioned in the above studies, but to cover a broader aspect of issues that they might have faced while being admitted to a large teaching hospital. The significance of our study lies in that only two studies could be retrieved from a Pakistani journal regarding patient satisfaction
[4, 5]. For this reason, it seems that there is a dearth of information regarding this issue specifically in the context of Pakistani hospitals. The purpose of this research was to extract all the factors that have a positive as well as a negative effect on the satisfaction level of patients, and also to discover any aspects which the patients feel are either lacking or need improvement. It is hoped that conclusions from our study will be used for developing efficient policies and implementing them not only in Civil Hospital Karachi, but in centers throughout the country.
Methods
A questionnaire-based cross-sectional study was conducted on patients admitted to the medicine, gynecology and surgery wards in Civil Hospital, Karachi (CHK). The sample size for the study was calculated by the open EPI sample size calculator using a confidence interval of 95% and a level of significance of 5. The satisfaction prevalence was assumed to be 69% [6]. Using this method, a sample size of 329 was calculated for this study. CHK has 5 medicine units, 6 surgery units and 3 gynecology units. These particular units were chosen because not only are they the main wards in the hospital, but they also have the greatest patient turnover rate. Two wards from each unit were chosen randomly. Research conductors performed a pre-tested questionnaire-based interview personally after taking an informed, verbal consent from the patients. Names of patients were not documented to ensure confidentiality. The patients were also explained that their responses
Dow Medical College, Dow University of Health Sciences, Pakistan Correspondence: Afshan Iqbal Email: snitchseeker_i@msn.com
68 would not be conveyed to the doctors or to the medical staff, to ensure that the patients would freely and truthfully answer all the questions in the form without any fear of retribution in regard to their care. Every patient admitted in the above mentioned wards was included in the study. However, if a patient was unable to understand the language, they were excluded. Each ward was visited every alternate day so as to interview any new admissions. The research was conducted over a time period of four months, from December 2011 to March 2012. Ethical approval was obtained from the Institutional Review Board at the Dow University of Health Sciences. The questionnaire used in the study was developed by the research conductors and was approved by the research supervisors (supplementary file 1). The advantage of our questionnaire was that it has a suitable number of questions (27) to which the patients could willingly find time to answer. A standard 5-point satisfaction scale, with 1 indicating extremely satisfied, and 5 indicating extremely dissatisfied, was used to assess the satisfaction level of each patient. Questions included the attitude of the doctor (kindness, friendliness), time spent by the doctor, professional efficiency and ethical routine of the doctor, personal manner of nurses and other staff, patient education on the treatment they were receiving, cleanliness and maintenance of the hospital, food quality, and overall satisfaction and patients suggestions. Data was entered and analyzed on SPSS version 16. Descriptive statistics were used to analyze variables based on three categories: patient-doctor satisfaction, patient-staff satisfaction, and patient-hospital satisfaction.
An insight into patient satisfaction after admission
37.8% of the patients were extremely satisfied with their doctors. The attitude of the doctors was judged on both their politeness and their willingness to teach the patients about health improvement. 45.7% of the patients were satisfied by their doctor's politeness, but a significant percentage of the patients (34.0%) was extremely dissatisfied by their doctor's unwillingness to teach them about further health improvement. This finding was, again, most pronounced in the medicine ward. The doctors were then judged on their efficiency by the following four factors: the answers and explanations they provided to the patients' questions, their thoroughness in treating and examining patients and the amount of time they devoted to each patient. Although 51.4% of the patients were extremely satisfied with the explanations they received regarding their illness and 46.2% of the patients were satisfied with the amount of time the doctor spent with them, 66.6% of the patients still felt that the doctors needed to be more thorough in treating and examining them. The patients of the gynecology ward comprised the major proportion in this category. In parallel to the above findings, 38.9% and 41.3% of the patients were satisfied with the medical staff's willingness to help and the promptness of their response, respectively. It was also seen that patients who had been admitted for 1-5 days were the most satisfied with the promptness and helpfulness of the medical staff (16.7% and 15.8%, respectively) and these percentages fell as the length of hospital stay increased, falling to as low as 0.31% and 0.91% for promptness and helpfulness, respectively. 47.9% of the patients were satisfied with the neatness and cleanliness, but many still suggested that management should consider planning proper hygienic conditions of the hospital. The majority of the complaints were received from the medicine ward. 96.6% of patients were enthusiastic to seek services of CHK again and the same percentage of patients was willing to recommend it to others too. Table 1 represents some further attributes of the patients encountered at CHK with respect to their wards. Responses to a few other minor items in the questionnaire are also included. As can be seen from the above table, most of the patients reported similar levels of satisfaction. Notable exceptions are as follows: Patients in the surgery wards were satisfied with the information they received regarding the reason for their lab tests and were also satisfied with their involvement in decision making. This finding does not hold true for the medicine and gynecology wards, where the patients were extremely dissatisfied with both issues. Figure 1 represents the overall satisfaction level of patients, irrespective of their ward or any other physical attribute. It is seen that patients are mostly satisfied with all categories, and are extremely satisfied with their attending doctors. Patients were finally asked about any suggestions, if any, that they had for the further improvement of the facility. 15.0% of the patients felt that the bathrooms should be cleaner than they were at present. 3.0% of the patients had cleanliness issues with the ward as a whole. Other responses were related to ward housekeeping, time-consuming admission procedures and the provision of permission and space for the patients' relatives to stay with them.
Results
A total of 329 patients were interviewed for the study. Patients from the medicine ward comprised the greatest percentage (40.4%), with the gynecology ward having the second highest percentage (33.1%) and the surgery ward having the third highest (26.4%). Females consisted of 63.5% of the patients and males were formed the remaining 36.5%. In order to appropriately judge the satisfaction scale of patients, the following 4 criteria were chosen for analysis:

The food provided to the patients Patients' satisfaction with the attitude and efficiency of the doctors Patients' satisfaction with the medical staff Patients' satisfaction with the cleanliness of the ward and hospital
A significant proportion of the patients was satisfied with the quality and the quantity of the food which they were given by the hospital (34.3% and 39.2%, respectively). However, 17.9% of the patients chose to eat home-cooked food, and so their responses were not deemed valid for this section of the questionnaire. This finding was most pronounced in the medicine ward. Out of the patients that were extremely dissatisfied with their food, the majority was from those in the surgery ward.
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Iqbal A, Ali S
69 The results show that the patients in all three wards gave similar responses to most of the questions, implying a similarity in the care provided to patients in the wards. Although the patients remained mostly dissatisfied with various aspects of the hospital such as cleanliness and management issues, 37.8% were overall extremely satisfied with their attending physicians. However, during daily rounds, it is not these physicians themselves who visit the patient; rather it is mostly the postgraduate doctors (residents) and the house officers (interns) who do so. These doctors have other numerous tasks to perform due to the chronic shortage of nurses, as a result of which they are not able to provide the quality of care that is expected from them. This is the reason why 53.8% of patients were dissatisfied with the amount of time the doctors spent with them and 48.6% were dissatisfied with the information given to them regarding their health. The patients in the gynecology ward comprised the greater part of this category as the patient turnover is very high in this ward and, correspondingly, the doctors have a proportionately increased workload. The attending physician mostly visits only when there is deterioration in the health of the patients. Patients in all wards of CHK are served the same food regardless of their ability to eat. Although 34.3% and 39.2% of the patients were satisfied with the quality and quantity of the food respectively, the remainder complained that the food was either too tasteless or was not of sufficient quantity to fulfill their hunger. Still, other patients commented that due to their illness, they were not able to eat and digest such greasy food, and therefore 17.9% of the patients got fresh home-made food each day from their relatives. This finding was most pronounced in the gynecology ward, where the patients who had just given birth, felt they needed more nutritious food than what was provided to them by the hospital management. Although 47.9% of the patients were satisfied with the cleanliness of the wards, the majority of the patients still felt that the cleanliness of the bathrooms and the beds needed particular attention. Patients complained about the lack of water in the bathrooms and bedbugs and other insects in their beds. Often the beds are non-operational in terms of elevation or lowering of either the head or the foot end; as a result, most patients are acutely uncomfortable. In order to prevent the transmission of diseases, and also to protect the healthcare workers, resources such as gloves, gowns, masks etc, should be present at every procedure (according to guidelines) [7]. Unfortunately, this is not followed at CHK. No isolation rooms for the infected patients are available, and there are no proper counseling rooms. This can ultimately lead to rapid spread of communicable diseases. Suggestions of the patients were noted and drafted which furnished the view of the patient with regard to healthcare facilities. Despite the frequent complaints by patients of poor management, unhygienic conditions and improper treatment by staff members and workers, a high percentage (96.6%) were willing to come to CHK again for any future health problems. The most common reason cited for this was that the patients were too poor to afford healthcare at other private hospitals. As mentioned previously, only two similar studies conducted in Pakistan could be retrieved [4, 5]. The first study entitled "Patient satisfaction; An experience at IIMC-T Railway Hospital" concluded that
Table 1: Attributes of patients grouped according to their wards Medicine Gynecology Surgery 42.9 27.6 39.8 Mean age (SD=17.9) (SD=8.6) (SD=14.5) Mean duration of 1.9 1.6 6.1 (SD=1.1) (SD=0.9) (SD=8.8) stay Extremely Extremely Extremely Overall satisfaction satisfied satisfied satisfied with the doctor (36.4%) (36.7%) (41.4%) Satisfaction with Extremely Extremely information Satisfied dissatisfied dissatisfied (34.5%) received regarding (37.6%) (32.1%) lab tests Satisfaction with Extremely Extremely Satisfied dissatisfied dissatisfied involvement in (28.7%) (32.3%) (45.0%) decision making Whether treatment Yes (75.9%) Yes (91.7%) Yes (86.2%) is affordable Overall, the patients of CHK are satisfied with the doctors and with the care received. However, although satisfaction levels are seen to be low with regards to cleanliness and hospital management, an overall percentage of 32.9% of patients at CHK was satisfied with all of the above mentioned categories. Overall satisfaction level of patients
50 40 30 20 10 0 Extremely Satisfied Satisfied Neutral Dissatisfied Extremely Dissatisfied
Figure 1: Overall satisfaction level of patients
Discussion
The basic aim of this study was to determine the patient satisfaction levels with various aspects of hospital care. CHK is a large hospital which caters to mostly needy and uneducated patients and provides treatment free of charge. As a result, it was felt that the situation in such a hospital would be different as compared to a contemporary, conventional hospital, and this laid the foundation stone of our research. It was hypothesized that patients in different wards would have different views with regard to the daily routine of being admitted in a hospital. Thus, the wards of medicine, gynecology and surgery were chosen, which have a diverse range of patients which differ vastly in their age, educational status and health complaints.
70 patients were satisfied with the availability of doctors, but were dissatisfied with the cleanliness of the hospital [4]. The second study entitled "Pattern of satisfaction among neurosurgical patients" obtained the results that patients remained satisfied with their care and with the behavior of the staff, but were dissatisfied with the management [5]. The conclusions from these studies are comparable with ours. However, a few limitations should be acknowledged. Although the purpose of the study was thoroughly explained to the patients as well as each question being asked, it is possible that the patients may not have been able to fully understand the situation because of their lack of education. The study was only conducted at the medicine, gynecology and surgery wards of CHK. Although this is just one center, we firmly believe that the whole of CHK, and possibly other hospitals, can benefit from such a study by implementing any changes that may seem necessary to increase the comfort of the patients during their stay at the hospital.
An insight into patient satisfaction after admission
Authors Contribution: AI participated in questionnaire development, data entry, collection and analysis. AI was also involved in writing the manuscript and is the corresponding author. SA also participated in questionnaire development and printing, as well as in data entry, collection and analysis. SA was also involved in manuscript writing. Both authors have seen and approved the final draft. Acknowledgement: The authors are grateful to Dr Quratulain Azeem for helping in developing the questionnaire. Competing interests: The authors declare that no competing interests exist. Received: 7 September 2013 Accepted: 2 November 2013 Published Online: 2 November 2013
References
1. Boulding W, Glickman SW, Manary MP, Schulman KA, Staelin R: Relationship between patient satisfaction with inpatient care and hospital readmission within 30 days. The American journal of managed care 2011, 17(1):41-48. 2. Quintana JM, Gonzalez N, Bilbao A, Aizpuru F, Escobar A, Esteban C, SanSebastian JA, de-la-Sierra E, Thompson A: Predictors of patient satisfaction with hospital health care. BMC health services research 2006, 6:102. 3. Hajifathali A, Ainy E, Jafari H, Moghadam NM, Kohyar E, Hajikaram S: In-patient satisfaction and its related factors in Taleghani University Hospital, Tehran, Iran. Pakistan Journal of Medical sciences 2008, 24(2):274. 4. Danish KF, Khan UA, Chaudhry T, Naseer M: Patient satisfaction; An experience at IIMC-T Railway Hospital. Rawal Med J 2008, 33(2):245-248. 5. Saaiq M, Zaman KU: Pattern of satisfaction among neurosurgical inpatients. Journal of the College of Physicians and Surgeons--Pakistan : JCPSP 2006, 16(7):455-459. 6. Sultana A, Riaz R, Rehman A, Sabir SA: Patient Satisfaction in Two Tertiary Care Hospitals of Rawalpindi. JRMC 2009, 13(1):41-43. 7. Hospital hygiene and infection control [http://www.who.int/water_sanitation_health/medicalwaste/148to158.pdf]
Conclusion
From our study, we can conclude that despite being low in available resources, CHK is provides high levels of satisfaction in terms of the services provided by the attending doctors to their patients. However, other core elements of a tertiary health center such as hygiene, contraptions, safe methods, isolation rooms, and administration are still deficient at CHK, and the hospital is in dire need of facilitative management. The dissatisfaction seen by a majority of the patients in these minor areas can be improved by simple interventions. Thus, more of such studies are needed in order to improve the quality of care offered to the patients of CHK.
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Open Access
An insight into the perpetuating existence of malnutrition in Pakistani women and children
Shayan-ul-Haque Abbasy1, Rekha Jiswant Kumar1, Ruwa Rehman1, Maryam Nauman1, Ammarah Kamali1, Maimoona Azhar1
Review
Abstract
Introduction: Malnutrition is a condition that occurs when the body does not get enough nutrients, mainly as a result of an unbalanced diet. Pakistan is a developing country with a high poverty rate which affects the nutritional status of the people. In addition to political and economic instability, Pakistan also hosts many refugees and internally displaced people. Therefore, the magnitude of the problem is large and despite the presence of several policies, the demand for basic nutrition for the citizens is unmet. Gender discrimination and lack of health education are also major contributors to the state of malnutrition in women and children under 5 years of age. Hence, we provide a review of articles to assess the existing reasons behind malnutrition in women and under-five children in Pakistan along with ways to improve the condition. Methods: For this review, 626 articles were reviewed out of which 40 met the inclusion criteria. The abstracts (and the full sources where abstracts were not available) were screened by two authors to identify studies adhering to our objectives. Any argument on selecting studies between these two authors was resolved by a third reviewer. After retrieval of the full texts of all the studies that met the inclusion/exclusion criteria, each study was double data abstracted into a standardized form. The key variables elicited were study setting, location, study design, participants, intervention delivered, and outcome effects. All selected studies were entered into the Endnote XI database. Results: The results from this review showed that up till 2010, the under-five mortality rate was 74 per 1000 and the maternal mortality ratio was 260 per 100,000 live births. Obstetrical hemorrhage causes 42.16% and hypertensive disorders causes 24.63% of the maternal deaths in the country, hence becoming the major reason for these deaths. Vitamin A deficiency was discovered to be high in the females, and consequently, Vitamin A deficiency in children with mothers deficient in this nutrient was high. Zinc and Vitamin D deficiencies were also seen in the female population. The incidence of maternal anemia was 27.1% during pregnancy out of which 10.5% had severe anemia. Conclusion: The review acknowledges that the status of malnutrition is well recognized in the country and the solutions to address the problem are also formulated as policies and strategies. However, due to lack of political will and leadership, implementation and sustainability of health programs fails to address the needs of the affected population. The use of nutritional surveillance system and interventions is imperative for the improvement of the nutritional status of women and children. (El Med J 1:3; 2013) Keywords: Nutrition, Malnutrition, Infant Mortality, Pakistan
Introduction
Nutrition is fundamental for the survival, health and well-being, growth and mental development, cognition and performance of an individual throughout ones lifespan. It is a key public health concern in humanitarian crisis and conflict management. Malnutrition remains one of the most serious health related concerns worldwide and is a major contributor to the total global disease burden. While mostly it is referred to as under nutrition, it also encompasses the extra intake of calories which leads to obesity. More than one-third of the child deaths worldwide are attributed to under nutrition. On the other hand, industrialization, urbanization and economic development have led to rapid changes in diets and lifestyles. These changes have led to obesity a major risk factor for diabetes mellitus, cardiovascular diseases, stroke and various forms of cancer causing significant disability and premature death. The major determinants of the nutritional status of women and children are food security, adequate care and health status [1]. As defined by WHO, food security is when all people at all times have access to sufficient, safe, nutritious food to maintain a healthy and active lifestyle. Pakistan portrays a perfect picture of the effect of poverty and affluence on the nutritional status of the people, and of policy and strategies which are present yet non-functional, or not scaled enough to meet the basic nutritional demands of the population [2]. Pakistan has faced political uncertainty with intermittent military rule
1
over decades. Faced with unsustainable budgetary deficits, high inflation, and hemorrhaging foreign exchange reserves, the Pakistani rupee has depreciated significantly. Beside political and economic instability, Pakistan also receives the burden of refugees and its own internally displaced persons (IDPs) [3]. Malnutrition is a condition that occurs when the body does not get enough nutrients, mainly as a result of an unbalanced diet. Adequate diet and good nutrition is essential for normal functioning of the body. Ideally, a balanced diet involves fruit, vegetables, grains and poultry products like meat and milk etc. The need of proper nutrition for children and women (especially of reproductive age) is high and while adequate nutrition begins at home, gender discrimination, traditional practices, and inadequate nutritional awareness, commonly witnessed in the Pakistani society, limits the food intake of women and children. The gender inequalities may even result in women and girls eating last, finishing what remains after the males of the family have eaten. As such, exclusive breastfeeding, which is the best nourishment for infants in the first six months of their lives, mostly comes from a malnourished mother. Most women become mothers at a young age. They are unable to space their births appropriately, and lack awareness regarding good nutrition and child nurturing practices. They often become anemic during pregnancy due to lack of iron in their diet. This notion is not
Dow Medical College, Dow University of Health Sciences, Pakistan Correspondence: Shayan-ul-Haque Abbasy Email: abbasy.shayan88@gmail.com
72 merely restricted to the mothers alone, but it also increases the risk of low birth weight in their babies, perpetuating a vicious circle of malnourishment [4].
The existence of malnutrition in Pakistani women and children
Methods
The following search strategy was modified for various databases and search engines: [Malnutrition [Mesh] OR "Protein-Energy Malnutrition" [Mesh] OR " Infant Nutrition Disorder*" [Mesh] OR "child nutrition disorder* [Mesh] OR "Fetal Nutrition Disorder*" [Mesh] OR Obesity [Mesh] OR "Infant, Low Birth Weight" [Mesh] OR "Emaciation"[Mesh] OR "Anemia, Neonatal [Mesh] OR "Maternal Mortalit*"[Mesh] OR "Anemia, Iron-Deficiency"[Mesh] OR "Infant Nutritional Physiological Phenomena [Mesh] OR "Zinc" [Mesh] OR "Dietary Supplements" [Mesh] OR malnutrition OR "protein energy malnutrition" OR obesity OR "low birth weight" OR micronutrients OR emaciation OR wasting OR stunting OR overweight OR breastfeeding OR "exclusive breastfeeding" OR "immediate breastfeeding" OR anemia OR "maternal anemia" OR "neonatal anemia" OR "maternal mortalit*" OR "complimentary feeding*" OR "vitamin A supplementation" OR "multiple micronutrient*" OR "severe acute malnutrition" OR "zinc fortification" OR "promotion of WASH strategy" OR "iodization of salt" OR "Neonatal mortalit*" OR "Infant mortalit*" OR "child mortalit*" OR "iron/folate supplementation*" OR "fortifi* food" OR sanitation OR "hand wash*" OR "Maternal Death*" OR "Neonatal Death*" OR "Child Death*"]. Language restrictions were not applied and the search strategy included relevant Library of Congress Subject Headings, and MeSH terms. Studies in languages other than English were included after relevant translation. The abstracts (and the full sources where abstracts were not available) were screened by two authors to identify studies adhering to our objectives. Any argument on selecting studies between these two authors was resolved by a third reviewer. After retrieval of the full texts of all the studies that meet the inclusion/exclusion criteria, each study was double data abstracted into a standardized form. The key variables elicited were study setting, location, study design, participants, intervention delivered, and outcome effects. All selected studies were entered into the Endnote XI database.
The search strategy for this review yielded 626 studies, out of which 40 were included. Studies in which the primary objective was assessment of nutritional status of women and of children under the age of five were included in this review where as those which did not meet this inclusion criterion were excluded (Figure 1). The health and nutrition status in Pakistan can be judged from the fact that in spite of declining trend, the under-five mortality and the maternal mortality ratio are still very high and far off from the targets set by the Millennium Development Goals (MDG) [5]. Two of the targets of MDG were to reduce the under-five mortality by two thirds (MDG Goal 4) and to reduce the maternal mortality ratio by three quarters (MDG Goal 5). However in 2010, the under-five mortality ratio was 74 per 1000 and the maternal mortality ratio was 260 per 100,000 live births. The countrys progress on achieving the MDG Goal 4 has been rated as insufficient [6]. Women have inadequate knowledge regarding obstetric care and have limited access to healthcare options [7]. Obstetrical hemorrhage causes 42.16% and hypertensive disorders cause 24.63% of the maternal deaths in the country, hence becoming the major reasons for these deaths [8, 9]. The high birth rate in Pakistan points towards the reproductive stress on women which further deteriorates their nutritional status. The high incidence of grand multipara in rural areas leads to a higher rate of serious complications such as anemia, increased abortion rate and abruption placenta, which in turn endangers the lives of both mother and the fetus [10]. Previous poor obstetric history is also found to be relevant to the delivery of preterm babies which further contributes to the number of neonatal deaths [11]. The poor nutritional status of mothers, as presented by anemia, is another contributing factor to the birth of low birth weight babies with questionable survival [12-15]. A study revealed that prenatal exposure to wood fuel instead of natural gas is also associated with birth of low birth weight babies [16]. Hyder et al. adjusted mortality data from Pakistan Demographic Survey to estimate the burden of mortality using Healthy Life Year (HeaLY) methodology and found it to be 367 HeaLYs lost per 1000 population [17]. According to a WHO report, Pakistan has the 4th highest prevalence of stunting [18]. A study has shown that the height status of children and adults improved with the increasing income level [19]. Amongst the age group 2-18 years, those belonging to lower income families tend to be underweight, whereas those belonging to middle income families are mostly overweight [19]. Based on BMI, a quarter of Pakistans population is classified as overweight or obese [20]. In obese adults, central obesity is found to be highly prevalent and is also associated with several complications [21]. The major complications noted are hyperlipidemia, hypertension, diabetes mellitus, gallstones and ischemic heart diseases while osteoarthritis and sleep disorders are the other observed complications [21]. Studies conducted on the status of Vitamin A levels in the Pakistani population showed that its levels in women are lower than those in men. They also revealed that the babies of Vitamin A deficient mothers have inadequate levels of this vitamin as compared to those whose mothers are not deficient in this micronutrient [22, 23]. It is a well-known fact that Vitamin A supplementation reduces mortality in children from age 6 to 59 months: a Cochrane review has shown
Evidence from the literature

626 articles were screened from the data base [PubMed: 544; Cochrane Reviews: 30; ScienceDirect: 52].
583 full text articles were excluded. [Reasons for exclusion: Study setting, location, study design, participants, intervention delivered, and outcome effects did not meet the inclusion criteria; language translation was not relevant; arguments between two authors reviewing a screened abstract could not be resolved by a third reviewer].
43 full text articles were assessed for eligibility
40 studies were included in the qualitative synthesis
Figure 1: Flow diagram of study selection
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73 towards nutrition is dependent on urban or rural residence [41]. People living in urban area have access to healthcare practitioners, better food variety and education, whereas rural residents often do not have those facilities or guidance from knowledgeable people and tend to follow their cultural norms. Although colostrum is administrated to the babies, risky feeding practices such as those of prelacteals and delayed first feed are also existent in the society [42]. Several constraints to appropriate breastfeeding have been unveiled and include perception of insufficient breast milk, fear of dehydration and the concept of early initiation of breastfeeding as a further stress after child birth [43, 44]. An intervention by Akram et al. has used health education, through photographs, flip charts and videos to promote administration of colostrum and exclusive breastfeeding practices [45].
that Vitamin A supplementation not only reduces mortality but also decreases the incidence of diarrhea and measles [24]. Deficiency of trace elements in the population of the developing world is a very common finding [25]. Akram et al. estimated the zinc level in cord and placental blood sample taken immediately following delivery. The study demonstrated the importance of maternal anthropometry, levels of placental IGF-I and IGF-II mRNA levels as well as that of zinc in fetal growth [26]. Hafeez et al. have therefore recommended zinc supplementation in pregnant women [27]. In fact, a study has shown that the zinc supplementation is practically more attainable as compared to the iron supplementation [25]. A review revealed that zinc supplementation can significantly reduce childhood morbidities by reduction in the incidence of diarrhea and respiratory disease and also contributes to linear growth [4]. A study by Rashid et al. in the year 1983 stated that there is no deficiency of vitamin D in the Pakistani population due to adequate sun exposure [28]. However, a study conducted in 1998 found that the incidence of deficiency is higher in the nursing mothers and infants of upper socioeconomic class [29]. Additionally, Iodine also carries significance with regards to malnutrition. For e.g., Stewart et al. collected samples of potable water from areas where goiter was endemic and found that iodine was overall deficient in the water samples [30]. The study emphasized on the need of up scaling already existing supplementation by iodized oil [30]. Severe anemia in pregnancy is considered a contributing factor to the maternal and perinatal mortality [31]. Different studies have found that the prevalence of anemia (Hb<11g/dL) during pregnancy is 27.1%, whereas the prevalence of severe anemia (Hb<7g/dL) is 10.5% [31, 32]. This condition is rectifiable with iron supplementation and has shown an even higher response with better treatment adherence [31]. The hemoglobin status of women in urban areas is low, irrespective of their socioeconomic status [33]. It is usually associated with pica, tea, less consumption of eggs and red meat [32]. Iron deficiency anemia has been found to be the commonest type of anemia, and is more common in females [34-36]. A study revealed that the deficiency of folate and vitamin B12 also increase the risk for IUGR [37]. A Cochrane review by Pena-Rosas and Viteri included 49 trials involving 23,200 pregnant women and showed that daily iron supplementation increases hemoglobin levels in maternal blood both before and after birth and hence reduces the risk of anemia at term. These effects do not signicantly change between women receiving intermittent or daily iron or iron with folic acid supplementation [24]. Dietary restriction during pregnancy and lactation is a common practice amongst Pakistani women [38]. A positive relation has been found between the nutritional status of the infants and the educational level of mothers [39]. As such, majority of the malnourished infants belong to mothers with no school education [39]. Mothers illiteracy, older age and increased parity also contribute to the increased use of bottle feeding in infants [40]. The assessment of nutritional beliefs of lactating mothers revealed that 16% lack nutritional knowledge and are further affected by poor economy; out of the women who do have the knowledge, 34.5% do not follow them [41]. However, it was also found that the major difference in attitude
Methods
Pakistan has a high level of acute and chronic child malnutrition, widespread micronutrient deficiencies, and emerging overweight and obesity in some socio-economic subgroups. Reasons for these nutritional deficiencies in women and under five children are several; poverty and food insecurity top the list. Evidence reviewed in this article reveals that the root cause is not the lack of awareness of the situation. Rather, it is due to the lack of political will and leadership in implementation and sustainability of known effective interventions. A national surveillance system to regulate the nutritional needs and provision of fortified foods in different areas as per the need is highly essential in the country. It is strongly suggested that the political commitment should be provided to implement the use of nutritional surveillance system and interventions in order to provide proper nutrition. Promotion of healthy food choices via media and health workers is also essential, while the prices of food should be controlled so that it is within the reach of the lower socioeconomic group. Besides, heavy taxation should be put on unhealthy and addictive products like tobacco and beetle nuts. Issues pertaining to the nutritional status of women and children younger than 5 years of age are of paramount importance in the context of national growth and development and should be given their due importance in the making of health and developmental strategies.
Competing interests: The authors declare that no competing interests exist. Received: 10 June 2013 Accepted: 27 October 2013 Published Online: 27 October 2013
References
1. Black RE, Allen LH, Bhutta ZA, Caulfield LE, de Onis M, Ezzati M, Mathers C, Rivera J: Maternal and child undernutrition: global and regional exposures and health consequences. The Lancet 2008, 371(9608):243-260. 2. Bhutta ZA, Belgaumi A, Rab MA, Karrar Z, Khashaba M, Mouane N: Child health and survival in the Eastern Mediterranean region. British Medical Journal 2006, 333(7573):839. 3. The World Fact Book [https://www.cia.gov/library/publications/the-worldfactbook/geos/bg.html] 4. Imdad A, Sadiq K, Bhutta ZA: Evidence-based prevention of childhood malnutrition. Current Opinion in Clinical Nutrition & Metabolic Care 2011, 14(3):276. 5. UNICEF: The State of the World's Children 2009 - Maternal and Newborn Health. In. 6. Bhutta ZA, Chopra M, Axelson H, Berman P, Boerma T, Bryce J, Bustreo F, Cavagnero E, Cometto G, Daelmans B: Countdown to 2015 decade report
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(200010): taking stock of maternal, newborn, and child survival. Lancet (London, England) 2010, 375(9730):2032. Safdar S, Inam SN, Omair A, Ahmed ST: Maternal health care in a rural area of Pakistan. J Pak Med Assoc 2002, 52(7):308-311. Begum S, Aziz un N, Begum I: Analysis of maternal mortality in a tertiary care hospital to determine causes and preventable factors. J Ayub Med Coll Abbottabad 2003, 15(2):49-52. Fikree FF, Karim MS, Midhet F, Berendes HW: Causes of reproductive age mortality in low socioeconomic settlements of Karachi. J Pak Med Assoc 1993, 43(10):208-212. Aziz-Karim S, Memon AM, Qadri N: Grandmultiparity: a continuing problem in developing countries. Asia Oceania J Obstet Gynaecol 1989, 15(2):155-160. Tabussum G, Karim SA, Khan S, Naru TY: Preterm birth--its etiology and outcome. J Pak Med Assoc 1994, 44(3):68-70. Janjua NZ, Delzell E, Larson RR, Meleth S, Kristensen S, Kabagambe E, Sathiakumar N: Determinants of low birth weight in urban Pakistan. Public Health Nutr 2009, 12(6):789-798. Badshah S, Mason L, McKelvie K, Payne R, Lisboa PJ: Risk factors for low birthweight in the public-hospitals at Peshawar, NWFP-Pakistan. BMC Public Health 2008, 8:197. Rizvi SA, Hatcher J, Jehan I, Qureshi R: Maternal risk factors associated with low birth weight in Karachi: a case-control study. East Mediterr Health J 2007, 13(6):1343-1352. Lone FW, Qureshi RN, Emanuel F: Maternal anaemia and its impact on perinatal outcome. Trop Med Int Health 2004, 9(4):486-490. Siddiqui AR, Gold EB, Yang X, Lee K, Brown KH, Bhutta ZA: Prenatal exposure to wood fuel smoke and low birth weight. Environ Health Perspect 2008, 116(4):543-549. Hyder AA, Wali SA, Ghaffar A, Masud TI, Hill K: Measuring the burden of premature mortality in Pakistan: use of sentinel surveillance systems. Public health 2005, 119(6):459-465. UNICEF: TRACKING PROGRESS ON CHILD AND MATERNAL NUTRITION. In.; 2009. Hakeem R: Socio-economic differences in height and body mass index of children and adults living in urban areas of Karachi, Pakistan. Eur J Clin Nutr 2001, 55(5):400-406. Jafar TH, Chaturvedi N, Pappas G: Prevalence of overweight and obesity and their association with hypertension and diabetes mellitus in an Indo-Asian population. CMAJ 2006, 175(9):1071-1077. Khurram M, Paracha SJ, Khar HT, Hasan Z: Obesity related complications in 100 obese subjects and their age matched controls. J Pak Med Assoc 2006, 56(2):50-53. Ibrahim K, Hassan TJ, Jafarey SN: Plasma vitamin A and carotene in maternal and cord blood. Asia Oceania J Obstet Gynaecol 1991, 17(2):159-164. Lindblad BS, Patel M, Hamadeh M, Helmy N, Ahmad I, Dawodu A, Zaman S: Age and sex are important factors in determining normal retinol levels. J Trop Pediatr 1998, 44(2):96-99. Pena-Rosas J, Viteri F: Effects of routine oral iron supplementation with or without folic acid for women during pregnancy (Review). 2009. Abdulla M, Suck C: Blood levels of copper, iron, zinc, and lead in adults in India and Pakistan and the effect of oral zinc supplementation for six weeks. Biol Trace Elem Res 1998, 61(3):323-331. Akram SK, Akram M, Bhutta ZA, Soder O: Human placental IGF-I and IGF-II expression: correlating maternal and infant anthropometric variables and micronutrients at birth in the Pakistani population. Acta Paediatr 2008, 97(10):1443-1448.
The existence of malnutrition in Pakistani women and children
7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26.
27. Hafeez A, Mahmood G, Hassan M, Batool T, Hayat H, Mazhar F, Bangash K, Alvi R: Serum zinc levels and effects of oral supplementation in pregnant women. J Coll Physicians Surg Pak 2005, 15(10):612-615. 28. Rashid A, Mohammed T, Stephens WP, Warrington S, Berry JL, Mawer EB: Vitamin D state of Asians living in Pakistan. Br Med J (Clin Res Ed) 1983, 286(6360):182-184. 29. Atiq M, Suria A, Nizami SQ, Ahmed I: Maternal vitamin-D deficiency in Pakistan. Acta Obstet Gynecol Scand 1998, 77(10):970-973. 30. Stewart AG: Drifting continents and endemic goitre in northern Pakistan. BMJ 1990, 300(6738):1507-1512. 31. Christian P, Shahid F, Rizvi A, Klemm RD, Bhutta ZA: Treatment response to standard of care for severe anemia in pregnant women and effect of multivitamins and enhanced anthelminthics. Am J Clin Nutr 2009, 89(3):853861. 32. Baig-Ansari N, Badruddin SH, Karmaliani R, Harris H, Jehan I, Pasha O, Moss N, McClure EM, Goldenberg RL: Anemia prevalence and risk factors in pregnant women in an urban area of Pakistan. Food Nutr Bull 2008, 29(2):132-139. 33. Ayub R, Tariq N, Adil MM, Iqbal M, Jaferry T, Rais SR: Low haemoglobin levels, its determinants and associated features among pregnant women in Islamabad and surrounding region. J Pak Med Assoc 2009, 59(2):86-89. 34. Idris M, Anis ur R: Iron deficiency anaemia in moderate to severely anaemic patients. J Ayub Med Coll Abbottabad 2005, 17(3):45-47. 35. Karim SA, Khurshid M, Memon AM, Jafarey SN: Anaemia in pregnancy--its cause in the underprivileged class of Karachi. J Pak Med Assoc 1994, 44(4):9092. 36. Hamedani P, Hashmi KZ, Manji M: Iron depletion and anaemia: prevalence, consequences, diagnostic and therapeutic implications in a developing Pakistani population. Curr Med Res Opin 1987, 10(7):480-485. 37. Lindblad B, Zaman S, Malik A, Martin H, Ekstrom AM, Amu S, Holmgren A, Norman M: Folate, vitamin B12, and homocysteine levels in South Asian women with growth-retarded fetuses. Acta Obstet Gynecol Scand 2005, 84(11):1055-1061. 38. Ali NS, Azam SI, Noor R: Womens' beliefs and practices regarding food restrictions during pregnancy and lactation: a hospital based study. J Ayub Med Coll Abbottabad 2004, 16(3):29-31. 39. Liaqat P, Rizvi MA, Qayyum A, Ahmed H: Association between complementary feeding practice and mothers education status in Islamabad. J Hum Nutr Diet 2007, 20(4):340-344. 40. Shamim S, Jamalvi SW, Naz F: Determinants of bottle use amongst economically disadvantaged mothers. J Ayub Med Coll Abbottabad 2006, 18(1):48-51. 41. Mahmood S, Atif MF, Mujeeb SS, Bano N, Mubasher H: Assessment of nutritional beliefs and practices in pregnant and lactating mothers in an urban and rural area of Pakistan. J Pak Med Assoc 1997, 47(2):60-62. 42. Fikree FF, Ali TS, Durocher JM, Rahbar MH: Newborn care practices in low socioeconomic settlements of Karachi, Pakistan. Soc Sci Med 2005, 60(5):911921. 43. Badruddin SH, Inam SN, Ramzanali S, Hendricks K: Constraints to adoption of appropriate breast feeding practices in a squatter settlement in Karachi, Pakistan. J Pak Med Assoc 1997, 47(2):63-68. 44. Kulsoom U, Saeed A: Breast feeding practices and beliefs about weaning among mothers of infants aged 0-12 months. J Pak Med Assoc 1997, 47(2):5460. 45. Akram DS, Agboatwalla M, Shamshad S: Effect of intervention on promotion of exclusive breast feeding. J Pak Med Assoc 1997, 47(2):46-48.
Vol 1, No 3
Goyal AK, Ansari T, Jain A et al.
75
Open Access
Three dimensional titanium miniplates in the management of mandibular fractures
Arun K Goyal1, Tarique Ansari1, Ankit Jain1, Vishal Sinha1, Swapnil S Bumb1
Case Report
Abstract
Introduction: In 1992, Farmand developed three dimensional (3D) plate with quadrangular design, formed by joining two miniplates with interconnecting crossbars. 3D titanium plates and screws were then gradually developed. Here we report two cases in which 3D titanium miniplates were used in the management of mandibular fractures. Case presentation: A 21 year old male patient presented with the chief complaint of pain and swelling in the anterior region of the jaw due to road traffic accident. On further clinical and radiological evaluation, mandibular symphysis fracture was diagnosed and was posted for surgery under general anesthesia using 3D titanium miniplates through lower anterior vestibular incision. The fracture segment was reduced anatomically and fixed with 3D non-locking miniplates following which closure was done using 3-0 silk/vicryl suture and was followed for 6 months Another 24 year old male patient reported with the chief complaint of pain and inability to open the jaw due to a history of assault. Right mandibular parasymphysis fracture was diagnosed and was posted for surgery under general anesthesia using 3D titanium miniplates through intraoral approach. The healing was uneventful. Conclusion: 3D titanium miniplates are a superior method of fixation as they restore normal form and function early and lead to better approximation and stability. (El Med J 1:3; 2013) Keywords: Mandibular Fractures, Titanium Miniplates
Introduction
The purpose of all therapies for fractures is the restoration of the original form and function. An important requirement for this is immobilization. Failure to achieve these conditions of healing results in infection, malocclusion, nonunion or malunion. Osteosynthesis implies functionally stable internal fixation of bone fractures, which allows the early recovery of function. Since the work of Michelet et al, and later Champy et al, mini plate osteosynthesis has become an important fixation method in maxillofacial and craniofacial surgery [1, 2]. Since then, several systems have been developed. Rigid systems have been replaced by more functionally oriented systems and the term semi rigid has gained more importance. Rigid fixation can produce three dimensional stability of the fracture site, promoting primary fracture healing. In 1992, Farmand developed three dimensional (3D) plate with quadrangular design, formed by joining two miniplates with interconnecting crossbars [3]. 3D titanium plates and screws were then gradually developed, and reported by him and Dupoirieux [4-6]. The stability is gained over defined surface area in three dimensions due to its configuration, not by thickness or length and it offers good resistance against torsional forces. We report two cases of mandibular fracture which were treated using 3D titanium miniplates. For fixation of a fracture segment, one has to consider many things such as size, number of fixation devices, their location ease of adaptation and fixation biomechanical stability, surgical approach and amount of soft tissue disruption necessary to expose the fracture and place the fixation devices [5, 6].
3D titanium miniplates through lower anterior vestibular incision. The fracture segment was reduced anatomically and fixed with 3D non-locking miniplates following which closure was done using 3-0 silk/vicryl suture and was followed for 6 months (Figures 1-6).
Figure 1: Pre-Operative Occlusion
Figure 2: Pre-Operative OPG
Figure 3: Intra-Operative
Figure 4: After fixation with 3D plate
Case presentation
Case 1 A 21 year old male patient presented to the Department of Oral surgery with the chief complaint of pain and swelling in the anterior region of the jaw due to road traffic accident. On further clinical and radiological evaluation, mandibular symphysis fracture was diagnosed and was posted for surgery under general anesthesia using
1
Figure 5: Post-operative OPG
Figure 6: Post-operative occlusion
Teerthanker Mahaveer Dental College & Research Centre, India Correspondence: Ankit Jain Email: ankitjain123in@gmail.com
76 Case 2 A 24 year old male patient presented to the Department of Oral Surgery with the chief complaint of pain and inability to open the jaw due to a history of assault. On further clinical and radiological evaluation, right mandibular parasymphysis fracture was diagnosed and was posted for surgery under general anesthesia using 3D titanium miniplates through intraoral approach. The fractured fragments was reduced anatomically and fixed with miniplate following which closure was done using 3-0 silk suture and followed up to 6 months (Figures 7-12). The healing was uneventful.
Three dimensional titanium miniplates
The major disadvantage of 3D plates is that their adaptability is difficult at comminuted and oblique fracture sites. In addition, they are difficult to place at fractures around mental foramen because of their quadrangular shape [8]. The overall high cost of the titanium is also a great deterrent to its wider use [9]. Hence, despite its advantages, the use of 3D miniplates is not common. In a recently published survey on AO/ASIF surgeons, only 6% stated that they use these types of plates [10].
Conclusion
After regular follow ups, we can safely conclude that 3D titanium miniplates are a superior method of fixation as they restore normal form and function early. Radiologically, they are seen to provide better approximation and stability. Maxillomandibular fixation is not required for more than 10 days with 3D titanium miniplates fixation. Titanium is the most biocompatible material and superiority of quadrilateral configuration of 3D plate over the conventional 2D design is reported throughout the literature. Thus, 3D plates made of titanium are most desirable mode of treatment of mandibular fracture whenever economic condition of patient is not an issue.
Consent: Appropriate informed consent was taken from the patients. Competing interests: The authors declare that no competing interests exist. Received: 3 September 2013 Accepted: 27 October 2013 Published Online: 27 October 2013
Figure 7: Pre-Operative Occlusion
Figure 8: Pre-Operative PNS
References
Figure 9: Intra-Operative Figure 10: After fixation with 3D plate
Figure 11: Post-operative PNS
Figure 12: Post-operative occlusion
Discussion
One of the advantages of 3D plate is simplified adaptation to the bone, without distortion or displacement of the fracture and simultaneous stabilization at both the superior and inferior borders, making the 3D plates a time-saving alternative to conventional miniplates [7]. In osteosynthesis, the requirement of a minimum of implant material with maximum stability should always be considered [6]. 3D titanium miniplates aim to fulfill this requirement ideally. Due to the closed quadrangular geometic configuration of the plates, less foreign material is needed to stabilize the fragments [8]. As they are of miniature sizes, they can be placed easily through an intraoral approach. The horizontal crossbars of the miniplates are placed perpendicular to the fracture line, whereas the vertical crossbars are placed parallel to the fracture line. Hence, only a minimal amount of surgical exposure is necessary for the placement of plates and screws. Periosteal stripping is minimal, when compared to other conventional miniplate osteosynthesis techniques.
1. Michelet FX, Deymes J, Dessus B: Osteosynthesis with miniaturized screwed plates in maxillo-facial surgery. Journal of maxillofacial surgery 1973, 1(2):7984. 2. Champy M, Lodde JP, Schmitt R, Jaeger JH, Muster D: Mandibular osteosynthesis by miniature screwed plates via a buccal approach. Journal of maxillofacial surgery 1978, 6(1):14-21. 3. Farmand M, Dupoirieux L: [The value of 3-dimensional plates in maxillofacial surgery]. Revue de stomatologie et de chirurgie maxillo-faciale 1992, 93(6):353-357. 4. Bochlogyros PN: A retrospective study of 1,521 mandibular fractures. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons 1985, 43(8):597-599. 5. Gear AJ, Apasova E, Schmitz JP, Schubert W: Treatment modalities for mandibular angle fractures. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons 2005, 63(5):655-663. 6. Babu S, Parmar S, Menat M, Kapadia T: Three dimensional miniplate rigid fixation in fracture mandible. Journal of Maxillofacial and Oral Surgery 2007, 6(2):14-16. 7. Jain MK, Manjunath KS, Bhagwan BK, Shah DK: Comparison of 3-dimensional and standard miniplate fixation in the management of mandibular fractures. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons 2010, 68(7):1568-1572. 8. Farmand M: [Experiences with the 3-D miniplate osteosynthesis in mandibular fractures]. Fortschritte der Kiefer- und Gesichts-Chirurgie 1996, 41:85-87. 9. Parr GR, Gardner LK, Toth RW: Titanium: the mystery metal of implant dentistry. Dental materials aspects. The Journal of prosthetic dentistry 1985, 54(3):410-414. 10. Zix J, Lieger O, Iizuka T: Use of straight and curved 3-dimensional titanium miniplates for fracture fixation at the mandibular angle. Journal of oral and maxillofacial surgery : official journal of the American Association of Oral and Maxillofacial Surgeons 2007, 65(9):1758-1763.
Vol 1, No 3
Ikram H, Haleem DJ, Choudhry Z et al.
77
Open Access
Stem cells in Parkinsons research
Huma Ikram1, Darakhshan Jabeen Haleem2, Zia Choudhry3, 4, 5, Adnan Maqsood Choudhry3
Essay
Abstract
Degeneration of dopaminergic nigrostriatal neurons results in the progressive development of Parkinson's disease (PD). Considerable progress has been made in creating dopamine-producing cells from stem cells. However, a major barrier in this area of research is the lack of progressive and predictive cell models of PD. Despite the fact that stem cells can provide a valuable option for the treatment of PD and related disorders, there are many challenges associated with their use. Although it is promising that stem cells can regenerate dopaminergic neurons and overcome the functional deficiency of dopamine, risk factors associated with them cannot be neglected. Stem cells can not only serve as a treatment option for PD, but their derivatives can also serve as cell models for PD, and can be used to study the molecular and neurochemical mechanisms involved in the pathophysiology of the PD, in vivo. (El Med J 1:3; 2013) Keywords: Parkinsons Disease, Stem Cells
Essay
Degeneration of dopaminergic nigrostriatal neurons results in the progressive development of Parkinson's disease (PD). Tremor, rigidity, bradykinesia, and postural instability are regarded as primary symptoms of PD. Considerable progress has been made in creating dopamine-producing cells from stem cells [1]. However, a major barrier in this area of research is the lack of progressive and predictive cell models of Parkinsons disease. Also, the screening of neuroprotective agents does involve targeting early PD mainly. A controversy regarding the modeling of early PD is there: it is suggested that a series of studies assessing candidate neuroprotective agents should not be limited to mild PD models. The most profound Parkinsonian syndrome model (four intrastriatal injections model) should be included along with the mild PD models, to provide maximal neuroprotective properties [2]. Current focus of the research in this area should be deriving cell models of PD from stem cells. This could help in generating neuronal phenotypes through cellular reprogramming. This would not only offer a unique tool for disease modeling but also would help understanding the molecular pathogeneses involved in the progression of PD [3]. Before considering stem cells for treating PD, associated challenges must be overcome, for effective stem cell-based cell replacement therapies, since stem cells bring tumorigenic and ethical issues with them [4]. Also, capacity of the stem cells to convert into nigral dopaminergic cells is also subjected to the interplay of several factors involved in the dopamine neurogenesis [1]. Neural stem cells, which can be found in various regions of the nervous system in developing embryos, are good treatment options. However, it is difficult to identify and study these neural stem cells, in vivo. Since they can differentiate into cells that make up the nervous system, neural stem cells are good treatment option for PD. It has been reported that neural stem cells transplanted into the striatum migrate to susbstantia nigra and result in the reduced apomorphine-induced circling behavior of PD rats [5]. However, differentiation protocol is not fully established.
Embryonic stem cells can also differentiate into dopaminergic neurons. However, this involves several in vitro cell differentiation conditions and genetic manipulations. However, the problems associated with their use include contamination of unwanted cells and formation of teratomas after transplantation of contaminated embryonic stem cells [6]. In contrast, the major problem associated with the use of induced pluripotent stem cells include their unlikeliness to embryonic stem cells. However, morphological and electrophysiological analyses have demonstrated that the grafted neurons derived from induced pluripotent stem cells integrate functionally into host brain and also have mature neuronal activity [7]. Despite the fact that stem cells can provide a valuable option for the treatment of PD and related disorders, there are many challenges associated with their use. Although it is promising that stem cells can regenerate dopaminergic neurons and overcome the functional deficiency of dopamine, risk factors associated with them cannot be neglected. Stem cells can not only serve as a treatment option for PD, but their derivatives can also serve as cell models for PD, and can be used to study the molecular and neurochemical mechanisms involved in the pathophysiology of the PD, in vivo.
References
1. Kim HJ: Stem cell potential in Parkinson's disease and molecular factors for the generation of dopamine neurons. Biochimica et biophysica acta 2011, 1812(1):1-11. 2. Emborg ME: Evaluation of animal models of Parkinson's disease for neuroprotective strategies. Journal of neuroscience methods 2004, 139(2):121-143. 3. Dawson TM, Ko HS, Dawson VL: Genetic animal models of Parkinson's disease. Neuron 2010, 66(5):646-661. 4. Matos Rojas IA, Bertholdo D, Castillo M: [Stem cells: implications in the development of brain tumors]. Radiologia 2012, 54(3):221-230.
Neurochemistry and Biochemical Neuropharmacology Research Unit, Department of Biochemistry, University of Karachi, Pakistan 2Neuroscience Research Laboratory, Dr. Panjwani Center for Molecular Medicine and Drug Research, University of Karachi, Pakistan 3Division of Research & Medical Education, International Maternal & Child Health Foundation, Canada
1
4 5
Douglas Hospital Research Centre, Canada Department of Human Genetics, McGill University, Canada Correspondence: Adnan Maqsood Choudhry Email: am.choudhry@live.com
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5. Zhu Q, Ma J, Yu L, Yuan C: Grafted neural stem cells migrate to substantia nigra and improve behavior in Parkinsonian rats. Neuroscience letters 2009, 462(3):213-218. 6. Kim DW, Chung S, Hwang M, Ferree A, Tsai HC, Park JJ, Chung S, Nam TS, Kang UJ, Isacson O et al: Stromal cell-derived inducing activity, Nurr1, and signaling
Stem cells in Parkinsons research
molecules synergistically induce dopaminergic neurons from mouse embryonic stem cells. Stem cells (Dayton, Ohio) 2006, 24(3):557-567. 7. Takahashi K, Yamanaka S: Induction of pluripotent stem cells from mouse embryonic and adult fibroblast cultures by defined factors. Cell 2006, 126(4):663-676.
Vol 1, No 3
Jamal S, Khan M
79
Open Access
Outbreak of measles: What should be the role of our government?
Sidra Jamal1, Maryam Khan1
Essay
Abstract
Pakistan has been facing a measles epidemic in the past few years. In 2013 alone, as many as 25,401 cases have been reported throughout the country. Punjab leads the picture with 16,608 cases, whereas Sindh leads the mortality rate at 62. It is the right of every child and the duty of the parents to get their children vaccinated against measles. Vaccination camps should be set up at every nook and corner in order to ensure nobody misses out. Banners with preventive measures should be put up at public places. There is also a dire need to establish quality medical institutions in rural areas so that people dont have to come to cities for healthcare. For furthering the goal of measles eradication, continued research on biological and operational aspects of measles epidemiology, pathogenesis, diagnosis, and prevention is crucial. (El Med J 1:3; 2013) Keywords: Measles
Essay
Pakistan has been facing a measles epidemic in the past few years. In 2013 alone, as many as 25,401 cases have been reported throughout the country. Punjab leads the picture with 16,608 cases, whereas Sindh leads the mortality rate at 62. Measles is an acute viral disease caused by an RNA paramyxovirus transmitted by respiratory droplets [1]. It mostly affects children below five years of age, but adults too can contract the disease if they have not been vaccinated previously [2]. It is characterized by the prodromal symptoms of fever, cough and conjunctivitis. Small white Koplik's spots appear on the internal oral mucosa, which are pathognomic of the disease. As the disease progresses, antibodies develop and a maculopapular rash appears, which extends from the face to the extremeties [3]. The chief complications of measles are bacterial pneumonia, otitis media, diarrhea and generalized lymphadenopathy [4]. Late complications include encephalitis and subacute sclerosing panencephalitis. Person to person transmission through coughing and sneezing is the easiest and most common mode of transmission. The infected individual remains contagious four days before the rash appears and four days after. Diagnosis of measles is mainly clinical. There is no effective treatment regime for although antibiotics can be administered for secondary infections and complications [4]. Deaths from subsequent complications can be reduced by the administration of Vitamin A supplements [3]. A major cause behind the epidemic in our setup is incomplete inoculation. Complete inoculation includes two doses of the vaccine, one at 12-15 month and the other at four years. However in Pakistan, most children are vaccinated with only first inoculation owing to both consumer and provider factors.
It is imperative that in order to tackle the measles epidemic, the parents, government and concerned NGOs should work in unison. Education of public regarding the dangers of the mode of transmission and possible complications is advocated. Hence under the circumstances prevalent in the country, the only possible way to curb this nuisance seems to be adequate promotion of awareness in the masses. Lady health workers should be mobilized and instructed to provide literature on relevant preventive measure. It is the right of every child and the duty of the parents to get their children vaccinated against measles. Vaccination camps should be set up at every nook and corner in order to ensure nobody misses out. Banners with preventive measures should be put up at public places. There is also a dire need to establish quality medical institutions in rural areas so that people dont have to come to cities for healthcare. For furthering the goal of measles eradication, continued research on biological and operational aspects of measles epidemiology, pathogenesis, diagnosis, and prevention is crucial.
References
1. Yanagi Y, Takeda M, Ohno S: Measles virus: cellular receptors, tropism and pathogenesis. The Journal of general virology 2006, 87(Pt 10):2767-2779. 2. Measles epidemic [http://tribune.com.pk/story/540081/measles-epidemic/] 3. Ray SK, Mallik S, Munsi AK, Mitra SP, Baur B, Kumar S: Epidemiological study of measles in slum areas of Kolkata. Indian journal of pediatrics 2004, 71(7):583586. 4. Asaria P, MacMahon E: Measles in the United Kingdom: can we eradicate it by 2010? BMJ (Clinical research ed) 2006, 333(7574):890-895.
Sindh Medical College, Pakistan Correspondence: Sidra Jamal Email: sidra205@live.com

80
Open Access
Anoshia Afzal1, Reema Javed1
Letter to Editor
Abstract
Introduction: Guillain-Barr syndrome (GBS) is a disorder of peripheral nervous system characterized by progressive, symmetrical, ascending paralysis. It is caused by inflammation and demyelination of peripheral nerves and roots of spinal nerves. Common features include absent muscle reflexes and loss of sensation. The aim of this case report is to delineate it from diabetic neuropathy on the basis of symptomatology, and to diagnose it earlier as it can lead to respiratory failure and cardiac arrhythmias in severe cases. Case presentation: A 40 years old female known case of diabetes mellitus for 4 years and hypertension for 2 years presented with paresthesias of both lower limbs which was progressive along with bilateral leg weakness and difficulty in walking without support and standing up from sitting position. Later, she also developed bilateral upper limb paresthesias and weakness. Two months before developing neurological symptoms, she had an episode of fever which lasted for about 7 days without associated symptoms of either respiratory or gastrointestinal tract. Considering her symptoms, GBS was suspected and multiple investigations were performed including lumbar puncture, ECG and NCV, all of which suggested GBS instead of diabetic neuropathy. Hence, sessions of plasmapheresis were started which improved her symptoms and she was discharged after 5 cycles of plasmapheresis as she had no complains of autonomic dysfunction or paralysis of any part of her body. Conclusion: Peripheral neuropathy in a diabetic patient is not always due to diabetes mellitus so other conditions should be considered as well. In such circumstances, specific investigations are required to make an accurate diagnosis. (El Med J 1:3; 2013) Keywords: Guillain-Barr syndrome, Diabetes Mellitus
Introduction
Diabetic patients present with varying neurological symptoms of periphery, including weakness, paralysis, numbness, tingling etc. If atypical symptoms are present, other causes should be considered because diabetic patients may harbor other types of neuropathy [1]. Among these, Guillain-Barr syndrome (GBS) is a disease that should be considered whenever there is acute flaccid weakness or paralysis along with absent reflexes and sensory changes [2]. Guillain-Barr syndrome is an acute disorder of the peripheral nervous system resulting from an autoimmune response targeting the myelin protein of spinal roots, peripheral and cranial nerves. On the other hand, Diabetic neuropathy is insidious in onset and progressive, which damages and targets peripheral nerves in the body. Both diabetic neuropathy and GBS can present with loss of reflexes, altered sensations and motor weakness or paralysis. The aim is, therefore, to differentiate them on the basis of appropriate investigations as wrong diagnosis and entirely different management may increase the mortality and morbidity associated with GBS.
Case presentation
A 40 years old female, known case of diabetes mellitus for 4 years and hypertension for 2 years, presented with paresthesias of both lower limbs which was progressive, along with bilateral leg weakness and difficulty in walking without support and standing up from sitting position. Later, she also developed bilateral upper limb paresthesias and weakness to the extent that she was unable to raise her hands above her head. There was no associated history of fits, urinary or fecal incontinence. She also complained of not feeling the shoe in her feet since 2 weeks. Two months before developing neurological symptoms, she had an episode of fever which lasted for about 7 days and was not associated with cough or diarrhea. She is a known diabetic for 4 years and for that she previously used to take insulin
1
70/30, but then started taking metformin and glimepiride. She was also hypertensive for 2 years for which she was taking amlodipine and atorvastatin. There was no associated autonomic dysfunction or respiratory muscle involvement. Detailed clinical examination was carried out which showed considerable decline in muscle strength in all four extremities along with hypotonia and areflexia. Multiple investigations were carried out including lumbar puncture, CBC, UCE, LFT, RBS, ECG, CXR, U/S Abdomen, CRP, Urine D/R, HbA1c, FLP, Serum B12 and folic acid levels, NCV, HepBsAg, Anti HCV, PT/APTT/INR, Serum calcium, magnesium, phosphate and total protein A/G. CSF analysis revealed elevated protein along with normal cell count, a characteristic feature of GBS. Her nerve conduction velocities were borderline in both upper limbs and mildly reduced in both lower limbs, whereas amplitude study was normal in all four limbs suggesting mild demyelination without axonal damage. There was no finding on chest X-ray or ECG suggesting that respiratory and cardiac muscles were not involved. Rest of the labs were normal except RBS which was 286 mg/dl. Plasmapheresis was started to remove the antibodies from the blood and her symptoms improved considerably. Along with plasmapheresis, she was also given amlodipine, glimepiride, folic acid, sitagliptin, metformin, aspirin and atorvastatin. She was discharged after 5 cycles of plasmapheresis as there was no muscular dysfunction or cardiac problem which would require regular monitoring.
Discussion
Many diabetic patients suffer from symptoms involving sensory and motor nerves including weakness, paralysis, numbness, tingling etc. If symptoms are atypical and persisting, other causes should be considered because diabetic patients may have other types of neuropathy [1]. Among peripheral neuropathies, GBS should be suspected when patient complains of acute onset of weakness, numbness or paralysis progressing rapidly in a symmetrical way initially involving
Dow Medical College, Dow University of Health Sciences, Pakistan Correspondence: Anoshia Afzal Email: anoshia.afzal@hotmail.com
Vol 1, No 3
Afzal A, Javed R
81 prognosis in many patients, it is essential that the physician must be aware of the possibility of other causes of peripheral neuropathy, so that prompt evaluation and specific investigations can be performed followed by appropriate treatment.
Abbreviations: GBS: Guillain-Barr Syndrome; ECG: electrocardiogram; CSF: cerebrospinal fluid; CBC: complete blood picture; UCE: urea, creatinine and electrolytes; LFT: liver function tests; CXR: chest X-ray; FLP: fasting lipid profile; NCV: nerve conduction velocity; RBS: random blood sugar; HepBsAg: hepatitis B surface antigen; PT: prothrombin time Consent: Verbal informed consent was taken from the patient. Acknowledgement: We would like to thank the patient and her family for giving us permission to publish this case report. Competing interests: The authors declare that no competing interests exist. Received: 7 July 2013 Accepted: 17 October 2013 Published Online: 17 October 2013
the lower limbs and later on progressing to involve the upper limbs as well. The clinical picture is dominated by ascending paralysis. A medical exam may show muscle weakness and problems with autonomic body functions, such as blood pressure and heart rate. The examination will also show that reflexes, such as the ankle or knee jerk, are absent. For the diagnosis of GBS, CSF findings of increased protein and normal cell count is helpful. In addition, nerve conduction studies are required for the confirmation of GBS. Plasma exchange or intravenous immunoglobulin have been recommended for effective treatment [3]. On the other hand, diabetic peripheral neuropathy is categorized on the basis of pattern of involvement. Peripheral neuropathy is the most common neuropathy encountered in diabetes. In general, symptoms may include tingling, numbness, tightness, or pain in the feet, hands, or other parts of the body, altered sensations, weakness and loss of balance and co-ordination [4]. Diabetic neuropathy can also present with loss of reflexes and sensori-motor pattern identical to GBS, which necessitates specific investigations to be done in order to reach a correct diagnosis. In the above mentioned case, elevated protein on CSF analysis without an associated increase in cell count (i.e. albumino-cytologic dissociation) strongly suggested GBS along with NCV reports revealing mild demyelination of peripheral nerves with no axonal damage suggesting GBS on its initial stage.
References
1. Boulton AJ, Gries FA, Jervell JA: Guidelines for the diagnosis and outpatient management of diabetic peripheral neuropathy. Diabetic medicine: a journal of the British Diabetic Association 1998, 15(6):508-514. 2. Stewart JD, McKelvey R, Durcan L, Carpenter S, Karpati G: Chronic inflammatory demyelinating polyneuropathy (CIDP) in diabetics. Journal of the neurological sciences 1996, 142(1-2):59-64. 3. Kanra G, Ozon A, Vajsar J, Castagna L, Secmeer G, Topaloglu H: Intravenous immunoglobulin treatment in children with Guillain-Barre syndrome. European journal of paediatric neurology: EJPN: official journal of the European Paediatric Neurology Society 1997, 1(1):7-12. 4. Ropper AH, Samuels MA: Diseases of the peripheral nerves. In: Adams and Victor's Principles of Neurology. 9th edn. New York; 2009: 1277-1319.
Conclusion
A patient presenting with diabetes mellitus might get neuropathies other than diabetic neuropathy. Since early diagnosis can improve
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The association of dyslipidemia with osteoporosis
Open Access
The association of dyslipidemia with osteoporosis: A case report
Atta Abbas1
Letter to Editor
Abstract
Introduction: Previous studies have reported that there is a significant association of dyslipidemia with osteoporosis. However, very few cases studies have shown the actual picture. The present case study reports this association. Case presentation: This is a case report of a 55 years old male patient with normal weight, who appeared to have co-morbid conditions since a year or two. He did not smoke but consumed considerable amount of alcohol and had a family history of metabolic diseases. The history of the patient revealed that the chief diagnosis was dyslipidemia which was due to genetic predisposition. Moreover, excessive alcohol intake supplemented the adversary and over the long run it led to osteoporosis which was diagnosed when the condition expressed itself as a fracture. Diabetes mellitus was suspected in the beginning but the lab findings nullified the suspicion and the focus was shifted towards management of dyslipidemia alone. The ignorance of likelihood of osteoporosis led to fracture of the femur which paved the way for the diagnosis of osteoporosis. The main goal of management of dyslipidemia was to lower the LDL-C first. Once it was achieved, the other factors were treated. Lowering of the cardiovascular risk and improvement in the quality of life of the patient was considered. The goals of management of osteoporosis were to prevent further bone loss and any incidence of fracture, reduce pain and prevent any kind of disability due to the disease and its progression. Conclusion: This is a classic example of association of dyslipidemia with osteoporosis. The risk of osteoporosis can never be ruled out in association with dyslipidemia and needs to be carefully assessed in patients. (El Med J 1:3; 2013) Keywords: Dyslipidemia, Osteoporosis
Introduction
Past studies have shown that elevated LDL and low levels of HDL are associated with low bone mineral density [1]. However, none of them have reported this finding in a clinical setting. The present case study is based on a patient of dyslipidemia in a health care setting in the UK who was observed to have low bone mineral density and consequently osteoporosis.
Case presentation
A 55 year old retired male patient with normal weight and physique, who appeared to have co-morbid conditions since a year or two, presented to our department with a history of pain in the lower limb. He did not smoke, but consumed considerable amount of alcohol and had a family history of metabolic diseases. It was clear from the medical history of the patient that the chief diagnosis was dyslipidemia which was due to genetic predisposition. Moreover excessive alcohol intake supplemented the adversary and the ignorance of this issue over the long run had led to osteoporosis, which was diagnosed when it expressed itself as a fracture. In the beginning, the patient was suspected to have diabetes mellitus, but the lab findings nullified the suspicion and the focus was shifted towards management of dyslipidemia. However, the healthcare team did not assess the risk of osteoporosis and after a year and half, the patient had a fracture of the femur whilst walking. This fracture paved the way for the clinicians to measure bone mineral density (BMD) and hence osteoporosis was reported. Management of the patient The main goal of management of dyslipidemia was to lower the low density lipoprotein, LDL-C, first. Once it was achieved, the other factors were treated. Lowering of the cardiovascular risk and improvement in the quality of life of the patient was considered. Usually, the
1
goal of management is a two-way approach i.e. drug therapy and therapeutic lifestyle changes (TLC), with the latter being the first line and a combination of both being used in high risk patients [2, 3]. The drug used for the treatment of dyslipidemia was simvastatin 40mg OD (at night), a cholesterol lowering HMG CoA reductase inhibitor. According to AACE Guidelines, the recommended starting dose of simvastatin is 20-40mg. The range of the dose is 5-80mg although simvastatin is not recommended at 80mg in patients with signs of myopathy [4]. The major side effect of simvastatin is headache (>15%) and muscle pain (>10%) [5]. However, in this case no adverse effects were reported; the pain was due to osteoporosis associated fracture. However, it is difficult to establish accurately, the real cause of pain, but since the patient did not suffer from pain before the incidence of fracture, the clinicians established fracture as the cause of pain. The drug used to treat osteoporosis was a bisphosphonate i.e. risendronate, 35 mg PO once weekly. The NICE and SIGN guidelines recommend the use of alendronate 10mg once weekly for men with or without previous fracture [6, 7]. Alendronate is also dominant in ICER calculations performed by NICE [7]. The use of risendronate is not indicated and hence this therapy was not compliant to the guidelines mentioned above. The most common adverse effect of risendronate is gastrointestinal problems such as dyspepsia. In this case as well, the patient suffered from dyspepsia, although prescription-event monitoring studies have shown high incidence of dyspepsia in the UK [7]. Monitoring and investigations The monitoring factors for the disease were lab investigations of lipid profile and follow up after 3-6 months depending upon the condition [2, 3]. Monitoring was carried out for any signs of muscle soreness initially, as well as during visit and evaluation of CK, ALT/AST initially and during therapy was done to keep dyslipidemia in check [8]. When osteoporosis was diagnosed, the monitoring of the disease
University of Sunderland, England, United Kingdom Correspondence: Atta Abbas Email: bg33bd@student.sunderland.ac.uk
Vol 1, No 3
Abbas A
83 aggressive pharmacotherapy coupled with appropriate lifestyle modifications.
was initiated and periodic BMD testing and assessment by GP was recommended [9]. For the drug therapy involving risendronate, monitoring of creatinine clearance, serum alkaline phosphate, serum calcium, serum phosphate and any sign of pain in the pelvic region was done as recommended [7, 10].
Conclusion
This is a classic example of association of dyslipidemia with osteoporosis. The risk of osteoporosis can never be ruled out in association with dyslipidemia and needs to be carefully assessed in patients. The patient in this case was genetically predisposed to dyslipidemia which over the long run led to osteoporosis. The treatment strategy for the diseases involved the use of statins and bisphosphonates, respectively. Both the medications also work synergistically to treat the said conditions. The adverse reactions of bisphosphonates are common and can be treated with suitable interventions. By managing dyslipidemia and ensuring medication adherence to bisphosphonates, reduction in fractures results. Follow ups and assessment will reduce risk factors and improve the quality of life over the long run.
Consent: The patient was informed and a verbal consent was obtained from the patient prior to the recording of the information. Competing interests: The author declares that no competing interests exist. Received: 12 October 2013 Accepted: 17 October 2013 Published Online: 17 October 2013
Discussion
The management of dyslipidemia requires multidimensional approach. In this case, apart from the drug therapy the therapeutic lifestyle change i.e. dietary modification and incorporation of healthy activity was of core importance in the overall care plan. The lifestyle modifications recommended were: consumption of diet low in saturated fats along with inclusion of healthy activities such as walking. The patient was also counseled for limiting alcohol consumption and adherence to medication therapy and therapeutic lifestyle changes as recommended by different guidelines and studies [2-4]. The ignorance of the likelihood of low BMD in this case had led to the occurrence of osteoporosis and its negative outcome in the form of a fracture. The management of osteoporosis in this case was to increase BMD, prevent incidence of fracture and improve quality of life by preventing any disease associated disability. Regular follow up with a GP and screening for BMD is very important and essential in devising a treatment strategy which again includes pharmacological and non-pharmacological treatments. Regular follow up visits to GP and routine assessment and periodic testing of BMD will help in assessing the treatment outcomes. Calculation of 10 year probability of fracture and assessment of risk factors are also necessary. In terms of dietary modifications, the patient should ensure a dietary intake of 1000 mg calcium per day. The pharmacological treatment of osteoporosis with bisphosphonates requires adherence to medication therapy which sometimes prove to be a daunting task for the patients as they have adverse reactions which sometimes result in nonadherence and consequently to outcomes associated with noncompliance. It is extremely important that the patients should be counseled for correct use of the drug and also be explained the possible consequences of non-adherence. In some cases, high intensity strength training and low impact weight bearing exercises are recommended [9-12]. Dyslipidemia is a risk factor for cardiac complications [13]. Osteoporosis and the diseases of cardiovascular system, which are usually viewed as separate diseases, are similar to some extent in their pathophysiological mechanisms. Elevated LDL and low HDL are associated with low BMD and are also risk factor for cardiac complications such as HTN. Statin therapy and bisphosphonates work synergistically as statins reduce cholesterol thereby reducing the risk of cardiac complications and also stimulates bone formation. On the other hand, bisphosphonates have been reported to inhibit atherogenesis along with performing their desired action of increasing BMD [13]. The adverse reactions of bisphosphonates are common and need intervention at times. The management of such conditions requires
References
1. McFarlane SI, Muniyappa R, Shin JJ, Bahtiyar G, Sowers JR: Osteoporosis and cardiovascular disease: brittle bones and boned arteries, is there a link? Endocrine 2004, 23(1):1-10. 2. Ito MK: Dyslipidemia: management using optimal lipid-lowering therapy. The Annals of pharmacotherapy 2012, 46(10):1368-1381. 3. Goals of treating and managing dyslipidemia. LDL-C Goals, LDL-C vs. Non-HDLC Goals, Management of low HDL-C, and the management of elevated triglycerides (TG) [http://www.empr.com/lipid-management/article/123829/] 4. Jellinger PS, Smith DA, Mehta AE, Ganda O, Handelsman Y, Rodbard HW, Shepherd MD, Seibel JA: American Association of Clinical Endocrinologists' Guidelines for Management of Dyslipidemia and Prevention of Atherosclerosis. Endocrine practice : official journal of the American College of Endocrinology and the American Association of Clinical Endocrinologists 2012, 18 Suppl 1:178. 5. Simvastatin Side Effects [http://www.simvastatin-side-effects.co.uk/] 6. Management of osteoporosis | A national clinical guideline [http://www.sign.ac.uk/pdf/sign71.pdf] 7. Alendronate, etidronate, risedronate, raloxifene and strontium ranelate for the primary prevention of osteoporotic fragility fractures in postmenopausal women (amended) [http://www.nice.org.uk/nicemedia/live/11746/47176/47176.pdf] 8. ECE D: Pharmacy Perspectives in Dyslipidemia Management. us pharmacist 2010. 9. Osteoporosis: Treatment Goals and Prevention [http://www.spineuniverse.com/conditions/osteoporosis/osteoporosistreatment-goals-prevention] 10. Monitoring Osteoporosis [http://www.spine-health.com/conditions/osteoporosis/monitoringosteoporosis] 11. Risedronate (Rx) [http://reference.medscape.com/drug/actonel-risedronate342835#5] 12. WHO Fracture Risk Assessment Tool [http://www.shef.ac.uk/FRAX/tool.jsp] 13. Miller M: Dyslipidemia and cardiovascular risk: the importance of early prevention. QJM: monthly journal of the Association of Physicians 2009, 102(9):657-667.
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al Students elective program. I applied and luckily got accepted in Gold Surgery (Acute General and Trauma Surgery) The Journey to Morgantown, West Virginia (WV) Morgantown is the third largeat city of WV. A city with tonnes of students and many resturants (though you cant eat much from them) and a few places to be. The best possible route is finding a relative willing to drop you off at WV, or you can take the flight to washington DC, go to Union Station, grab a seat on megabus and it will drop you off in about $30. Its is 4.5 hr drive thorugh pittsburgh to morgantown. Though i took the relative option. The Real Experience First day was Merlin training. Everything here runs on computer and the software is called Merlin or Epic. It has all patient details, the OR (operating room) schedule and everything you can think related to hospital administration. After which you get your pager and ID and meet with your department colleagues. From day 2 onwards you are expected to report at 6 or max 7 with the residents in the wards. A patient is assigned to you and you are supposed to prepare his/her case. Then there is a morning meeting exactly at 8 after which the round begins led by the attending physician/surgeon. This where you present your case, his/her history and examination and your plan for the patient today. Then you go to OR or ED. In OR you assist the surgeon while in ED you manage traumas. Your mentor is a busy person so you mostly hangout with the residents. Stick with them, they will show you how things work here. Moreover there are followup clinics on tuesday and grand rounds on wednesday. My experience till now has been awesome. I have scrubbed into 25 surgeries and assisted most of them. Presented 1 case on daily basis and procured a research from my mentor. You just dont get an LOR by default in US, you have to earn it. Impress your mentor show your strengths, ask questions and take interest.
Living and Eating For living, you wont get much of an option. Most apartments are rented out on longterm lease, so the only option you have is Medical Center Apartments, which are under the administration of WVU. They are costly (two bed room with attached bath, a small kitchen with a fridge and wifi costing you around $32.7 per day), but sharing it with a fellow saves you more than 450 bucks. There is a laundry in the basement which charges $1.25 for every wash. Everything is self service, so you need to carry your detergent. You need to book the room with Stephani, the incharge at Medical Center Apartments. Finding halal food is tough here, but in morgantown there is a Halal store called Kasaar where you can get halal meals and groceries along with frozen food at rates a bit expensive but worth it. Then you can always have Cheese Pizza and Salads in hospital cafeterias or Cooked fish or scrambled eggs and cheese or tacos without meat at Health Sciences Cafe. You can visit Pizza outlets or enjoy fish sandwiches at Subway or KFC or Burger king. You can try taco-bells beans too. For groceries you can visit Krogers and buy eggs or milk with cereal for breakfast or fresh fruits, veggies for cooking expeditions. Entertainment Morgantown doesnt offer much of entertainment. There is a State forest near by called Cooper Rock where you can go for trailing and hiking and sight seeing of the cheat lake and the city. However, Pittsburgh is always a good option to visit. On Thursday-Saturday there are movie shows at Mountain Lair. Mountain Lair is a student hangout place in downtown constructed by the WVU. You can go bowling there, play billiards or even enjoy free food and drinks being offered after 10 pm, How to move about in morgantown? You need a car for this purpose. Morgantown is precisely a hilly terrain, so walking is tough. You can always travel in Personal Rapid Transport (PRT) for 50c or in Campus buses for 75c. Campus PM and Campus bus 1 are the options that take you to the Lair, while for PRT you need to get off at Bechurst Street Station and walk a bit.
Best of Blogemia
Roadway to WVU Electives Gulrayz Ahmed
http://blogemia.com/roadway-to-wvuelectives/ Electives are an opportunity that a medical student should always seize, and should definitely go for it if they are lucky enough to get in US. Overtime trends have changed, at present med students aspiring for a career in US have to go through rigorous processing where you are filtered and chosen among thousands of applicants. Few years back elective was something rare, but with increasing competition and ever growing applicants, med students are looking for opportunities that make them stand out of the rest. The most important are your Step scores, then comes research papers followed by US Clinical Experience and social work. These are the areas that every med student can try working on to improve his/her resum. Back in October 2012, I got to know about West Virginia University (WVU) Internation-
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Offering Prayers There is a Islamic Center about 5 mins from the hospital. Choudry Sohail is the Imam there, a Pakistani American from Lahore. Mosque is the best place to socialize. I made friends there, mostly Pakistanis and used to play cricket. To Dos and Not to Dos 1) Dont carry much books, you wont get that much time to study. 2) Carry a lab coat or else people will think you are a resident which creates awkward moments, like professor placing up a hifi question. 3) Dont carry your scrubs if you are in surgery, scrubs are provided by hospital admin. Just ask any resident where to get them from. 4) Its cold out here do carry warm clothes but usually spring starts in the mid of April which brings the temperature to around 20 C. So plan accordingly How to Apply Babette Taylor is the women who manages international electives. She can be reached at btaylor@hsc.wvu.edu or contacted at 304-293-2323. Calling her is a better option. Then she will send you the application form. Currently she isnt accepting any request as their policy is being reconsidered. She has over 14000 mails in her inbox at the moment. So mailing is not a good option. Apply atleast 6 months earlier to your desired date. Documents required 1) Application signed and stamped by Dean of School 2) Letter of good standing 3) Grade Transcript 4) English Waiver 5) Valid Passport 6) Criminal Background Check Certificate ((Visit your areas police station for this)) 7) All semesters Markheet
8) Malpractice insurance ($284 www.academicsin.com or $40 www.proliability.com) 9) Two passport size photos
from from
10) Immunization Card/titres/booster proofs (Mumps Measles Varicella titres can be done at Rahila lab cheaper as compared to AKU, while Hep B, Rubella and Montox can be done at Dow lab the cheapest) HIPA OSHA Trainings are arranged by the WVU after your acceptance, so need to worry about them. Fields available are Dual Diagnosis Psychiatry (Contact Maria Shoaib D14 for a program feedback), Emergency Medicine, Occupational Medicine, Neurosurgery, OB, Midwifery, Future Ophthalmology, Otolaryngology, Pathology, Pediatrics Hem/Onc., Pediatric Neurology (Contact Adeel Memon D13), NICU, PICU (contact Mairah Usman D14), Pediatrics (Ramza Haq D13), Neuroradioloy, Cardiothoracic (Farhan D13), Gold Surgery, Pediatric Surgery, Plastic Surgery, SICU, Trauma Surgery (Tayyab Siddiqui D13), Urology and Vascular Surgery. Non-refundable fee of $300, paid through a bank draft made in name of West Virginia University (this can be made at HBL currency outlet at Shahrah e Faisal for extra charge of Rs 1200, carry rupees no need of dollars) The VISA (Brief overview) Procuring a VISA B1/B2 or F1 as per Medical University requirements. Documents you need include Acceptance letter, valid passport not expiring in the next 6 months, old passports, a visa letter from dow,every document you can think from dow (marksheets, certificates, LORs), Sponsor letter and bank statement of the financial sponsor. Rest you can carry any document that justifies your ties in Pakistan and your reason to return. Visit the US consulate site, fill in DS 160, pay your fee of Rs. 16830 at the American Express, Shaheen Complex opposite Peral Continental and get your interview date. Give your interview and leave the rest in Allahs hand. For more details you can contact any of the seniors who have been through the process.
HELP! If you need help, dont hesitate, just ask for it. The best things about Americans is that they mostly are willing to help except for few exceptions. People might say hello to you or good morning randomly or simply nod at you or hold door or lift for you. So greet them or reply to them warmly. P.S: Babette Taylor has requested that she wont be replying to people before the new policy is released, you should start eating her head up from 1st June onwards. For rest, if you need any help feel free to contact me.
My Journey Dilpat Kumar Dilpat Kumar

http://blogemia.com/my-journey-dilpatkumar/ I am an individual who is motivated to dream and accomplish it, with both rigor and dedication. Besides my ambition of becoming a doctor, I have always desired to experience diversity and new things in my life. Specifically, I have always wished to explore my intrinsic hidden talents and individual qualities. Through the Global U Grad program, I was given an enriching and golden opportunity to not only explore my hidden talents, but to also represent my culture and country. In other words, I was selected as a Cultural Ambassador; an Exchange student by United States Educational Foundation in Pakistan, sponsored by International Research and Exchange Bureau (IREX) in collaboration with Department of States. After many phases, some memorial in pleasant way and others in harsh and bitter, I made it to the US. During my journey I came across many individuals from different parts of my own country-some places I havent been to- with the same motivation to work for the country. It was helpful to learn more about the essential parts of my countrys culture before representing it. This part of my experience was not only a great way to bridge knowledge, but also a way to make everlasting friends. I was placed in Utica College New York. I would say, like every
other pupil, my college is one of the best colleges in the US and even around the globe. It was the best placement that they could have found for me. It was my second home, actually third! I forgot, I live here in hostel, too. Living far away with different people, from all different cultures made me feel like I had limitless boundaries. Being within a bunch of people, with no one I knew helped me discover myself. It also helped me learn my rigor to befriend new people. Staying in a different part of the globe, with people from diverse cultures and traditions, made me understand that we are the same in the sense that we share the same basic needs, including LOVE and PEACE. Living far away from my culture made me love diversity. It also helped broaden my potency and approach. I no longer see a closed door, rather I try to accept challenges. Over the course of my stay, I attended various festivals. Some of them include: Martin Luther King Day, Asian Lunar New Year, Valentines Day and the event that I organized: Holi The festival of colors. I still remember that day when an unexpected person, my college president, showed up to my event. He said to me, Dilpat, we are going to continue the trend of this never before organized festival in Utica. Thanks for making it possible. Before the start of my event, I was quite unsure of how would I manage so many people. However, blissfully my group and I made it a huge success. At end of my event, my own host advisor said, Dilpat, you are the best! I responded with a smile, Haaan! Thank you! Now I see myself as more self-motivated, selfhelping, self-hoping, self-confident, and intellectual individual. I am more welcoming to changes especially those that are beneficial. Besides the celebration of festivals, dilpat5I experienced a more adventurous side of life with my shaky hands. I went snowboarding, snow tubing and skiing on one of the largest mountainous rows in New York State. I also went kayaking on a deep river and last but not the least hiked on a slippery, snowy mountains. I explored Chicago, New York City, Niagara Falls, Syracuse, Washington DC, San Francisco, Los Vegas, Los Angeles, and San Diego.
The things that I liked the most about Americans The thing that I liked the most about Americans is that they always are ready to say THANK YOU and SORRY. Whatever the situation may be, even the smallest thing, they would appreciate it. Furthermore, they are welcoming of change. For example, I once made chicken biryani during my stay at the college. I worked with an Aunt Chef. She was around 60 and was not familiar with biryani. She said to me, Dilpat, you are my teacher. You have taught me one of the delicious things of the world. And the man who was in charge of our cafeteria told me he is going to put biryani on the menu in the fall semester, so people can taste the spices of Pakistan. Not only do Americans show love and care for a great deal of things, they also are very appreciative. How did I represent Pakistan? I was sent as a connecting link between two nations in order to clarify stereotypes. Therefore, the major goal that I had before going there was to represent my country. I gave presentations on Women, The strength of Pakistan and Festivals in Pakistan: Holi. I remember, when I mentioned the names of Benazir Bhutto and Arifa Karim during my presentation, they were puzzled, as they did not know about them and their stories. One of my friends, at the end of presentation said to me, Now I know Pakistani women are not limited to wearing Weil and household works. In my second presentation, I introduced them with festivals in Pakistan, their significance and celebration. Besides that, I introduced them with Pakistani Cuisines and Pakistani outlets. Once I wore Sindhi Shalwar kamiz with Sindhi topi, and one of my friend said to me, You look like the Prince of Pakistan. And I presented cultural items like Ajrak, topi, Khusa and Churiyan to my friends. I also introduced them with our own Road Cricket. The most memorable moments Once I was interviewing my Neuroanatomy and Neurophysiology professor as required by the program, he mentioned to them, If they have more Dilpats, they need them. In addition, he asked me to do research with him, one on one. Another day that was memorable is a celebration where the students were able to throw pie on the professors. My professor wouldnt let anyone
throw pie on him except me. However, the moment that I am going to remember the most was after the celebration of Holi. One of my friends came to me and said, Dilpat, you have made the history at Utica College! You will always be here. Another memorable moment was when I worked in a tree house with children. I was able to teach them and play with them. In fact, on the very 1st day, one of the kids said to me,Dilpat, be my buddy. Please come next week, otherwise I am going to miss you. By doing volunteer work in the US and attending a Social Problems class I learned that the problems of society can be solved by returning something good to it. I learned all the things get better when people work together with willingness and dignity. I have started to work with innovative forums for awareness, and I also have started to work with disabled and needy children with Darul-Sakun after my return. Besides all that I and my mates are working to educate the middle aged individuals who couldnt get education due to early age due to any reason, we are focusing on education because education makes the drowning boat to float. Experience is the lesson of past to lessen the Burden of future. ~ Michael Sage At the end I would like to thank USEFP, IREX, and the US Embassy Pakistan for their never ending support and encouragement. Their efforts are highly commendable.
PCM in Children Madeeha Shoukat

http://blogemia.com/pcm-in-children/ While taking history from a childs mother in NICH (National Institute of Child Health), it had seemed to me that he would be approximately 2 years old . It struck me when on questioning about his age , his mother said 4 yearsPCM is one of the major threats to the upcoming new generation of not only this country but worldwide. One of the serious and important depletion disorders, protein caloric malnutrition presents as MARASMUS (protein caloric deficiency) characterized by growth retardation and muscle wasting and KWASHIORKOR (protein deficiency) seen as tissue edema and dam-
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age. Both can be further classified into mild, moderate and severe depending on the level of stress and time of deprivation. PCM predisposes a patient to deaths from pneumonia, measles, chicken pox and tuberculosis. CAUSES: Marasmus and Kwashiorkor affects the under privileged as well as residents of underdeveloped countries where their diet is deficient in essential amino acids. Kwashiorkor affects age group of around 1 years as weaning takes over breast feeding while marasmus affects 6 to 18 months due to breast feeding failure or chronic diarrhea. SIGNS AND SYMPTOMS: Children suffering from chronic PCM are small for their chronological age and appear mentally apathetic, physically down and are prone to infections while those of acute PCM have dull, dry lust-less skin, retarded growth, brown yellow spacey hair. Such children are usually hungry with low B.P, pulse and temp but some might present with diarrhea and anorexia. These kids are generally weak, lethargic and irritable. Kwashiorkor generally does not show growth retardation but as fat metabolizes to fulfill energy demand, adipose deposits deplete and severe edema masks the muscle wasting. DIAGNOSIS: When the physician suspects PEM, A thorough physical examination is performed, and these areas assessed: 1. Nutritional status 2. Eating habits and weight changes 3. Presence of underlying illness
4. Developmental delays and loss of acquired milestones in children 5. Body-fat strength composition and muscle
6. Gastrointestinal symptoms Some doctors further quantify a patients nutritional status by: comparing height and weight to standardized norms calculating body mass index (BMI) measuring skin fold thickness or the circumference of the upper arm
PROGNOSIS: Recovery from marasmus usually takes longer than recovery from kwashiorkor. The long-term effects of childhood malnutrition are uncertain. Some children recover completely, while others may have a variety of lifelong impairments, including an inability to properly absorb nutrients in the intestines, as well as mental retardation. Most children can lose some of their body weight without side effects, but losing more than 40 percent is usually fatal. Death usually results from heart failure, an electrolyte imbalance, or low body temperature. Patients with certain symptoms, including semi consciousness, persistent diarrhea, jaundice, and low blood sodium levels, have a poorer prognosis than other patients. The outcome appears to be related to the length and severity of the malnutrition, as well as to the age of the child when the malnutrition occurred. PREVENTION: Every child being admitted to a hospital should be screened for the presence of illnesses and conditions that could lead to PEM. The nutritional status of patients at higher-than-average risk should be more thoroughly assessed and periodically reevaluated during extended hospital stays. Breastfeeding a baby for at least six months is considered the best way to prevent earlychildhood malnutrition. Liesbet Delport, a registered dietician and co-founder of the Glycemic Index Foundation of South Africa says, There is no such thing as a bad fruit. However, when you have diabetes, it is important to control your blood glucose levels at all times, which means that you also have to look at the glycemic index of foods a measure of the effects of carbohydrate-rich foods such as fruit on blood sugar levels.
TREATMENT: Individuals treated for protein-energy malnutrition are at risk for re-feeding syndrome, in which hypophosphatemia, hypokalemia, and hypomagnesemia may lead to disturbances in the cardiac, neurological, gastrointestinal, respiratory, hematologic, skeletal, and endocrine systems. Guidelines have been developed to help prevent these complications and to establish a transition to normalcy. Treatment consists of 2 phases: stabilization and rehabilitation. In patients with severe PEM, the first stage of treatment consists of correcting fluid and electrolyte imbalances, treating infection with antibiotics that do not affect protein synthesis, and addressing related medical problems. The second phase involves replenishing essential nutrients slowly to prevent taxing the patients weakened system with more food than it can handle. Physical therapy may benefit patients whose muscles have deteriorated significantly.
We require avid bloggers and medical writers to lead our sister blog, Blogemia. We are looking for section heads, editors and contributors. Those hired will be responsible for submitting at least five blogs (>500 words) per month. Individuals working in any of the aforementioned capacities will receive a share of the advertisement revenue. To apply, send your CVs along with samples at: apply@mednifico.com
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We accept Original Articles, Review Articles, Case Reports, Opinions and Debates, Essays, Letters to the Editor. There are no paper submission charges. Submit your articles via the online system or send as an email to: submit@mednifico.com We require editors, programmers, layout designers and proofreaders for our editorial staff. We also require avid medical bloggers for our sister website, http://blogemia.com. We are also looking for journal representatives from different medical schools. To apply, send your CV to: apply@mednifico.com El Mednifico Journal, Address: C2 Block R, North Nazimabad, Karachi 74700 Pakistan. Email: editorial@mednifico.com. Phone: (92-334)2090696.

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Vol 1, Issue 3

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Volume 1, Issue 3

October - December, 2013

Aims and Scope

Assistant Editors Editors

Outbreak of measles: What should be the role of our government?

The association of dyslipidemia with osteoporosis: A case report

Coronary artery calcium score

Batra M, Tangade P, Bumb SS

Cariogenic potential in relation to plaque pH among non-alcoholic beverages: A comparative study

Cariogenic potential of non-alcoholic beverages

Figure 1: Mean changes of pH levels from baseline in five test groups

Batra M, Tangade P, Bumb SS

Figure 2: Mean changes of pH levels from baseline in caries free subgroups

Figure 3: Mean changes of pH levels from baseline in caries active subgroups

Cariogenic potential of non-alcoholic beverages

Rehman SU, Dar AS, Rahman A et al.

Up-to-date and age appropriate immunization coverage

Rehman SU, Dar AS, Rahman A et al.

Basic characteristics of study children: The socio-demographic character-

P-Value 0.08 0.3

Up-to-date and age appropriate immunization coverage

Rehman SU, Dar AS, Rahman A et al.

65 P-Value 0.6 0.3 0.02 0.01

Up-to-date and age appropriate immunization coverage

An insight into patient satisfaction after admission

Figure 1: Overall satisfaction level of patients

An insight into patient satisfaction after admission

Abbasy S, Kumar RJ, Rehman R et al.

The existence of malnutrition in Pakistani women and children

Evidence from the literature

43 full text articles were assessed for eligibility

40 studies were included in the qualitative synthesis

Figure 1: Flow diagram of study selection

Abbasy S, Kumar RJ, Rehman R et al.

The existence of malnutrition in Pakistani women and children

Goyal AK, Ansari T, Jain A et al.

Figure 1: Pre-Operative Occlusion

Figure 2: Pre-Operative OPG

Figure 4: After fixation with 3D plate

Figure 5: Post-operative OPG

Figure 6: Post-operative occlusion

Three dimensional titanium miniplates

Figure 7: Pre-Operative Occlusion

Figure 8: Pre-Operative PNS

Figure 11: Post-operative PNS

Figure 12: Post-operative occlusion

Ikram H, Haleem DJ, Choudhry Z et al.

Stem cells in Parkinsons research

Sindh Medical College, Pakistan Correspondence: Sidra Jamal Email: sidra205@live.com

Guillain-Barr syndrome in a patient with diabetes mellitus

The association of dyslipidemia with osteoporosis

83 aggressive pharmacotherapy coupled with appropriate lifestyle modifications.

For short reports: Background Methods Findings Conclusions

For case reports: Introduction Case report(s) Discussion Conclusions

My Journey Dilpat Kumar Dilpat Kumar

PCM in Children Madeeha Shoukat

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