Annals of King Edward Medical University <p style="text-align: justify;">Annals of KEMU is a biomedical research journal that is devoted to publishing the recent advances in all areas of biomedical research for physicians, surgeons, post-graduate trainees, and undergraduate students with special emphasis on clarity of presentation and accuracy of the presented data.</p> <p style="text-align: justify;">Articles published in the Annals of KEMU cover a wide range of fields from basic medical sciences, clinical specialties, and super-specialty areas. Articles describing original clinical or laboratory investigations, case reports, and public health-related studies and surveys are always considered for publication.</p> <p style="text-align: justify;">As a multi-disciplinary journal published by the most renowned and oldest medical institute in Pakistan, Annals of KEMU publishes the most relevant original research articles that form the foundations of tomorrow's medicine in Pakistan and around the globe.</p> <p style="text-align: justify;"><strong>Links:</strong></p> <p style="text-align: justify;">1) <a href="" target="_blank" rel="noopener">Tutorial on how to Upload your Submission</a></p> <p style="text-align: justify;">2) <a href=";id=911140#journal_result" target="_blank" rel="noopener">HEC Ranking</a></p> King Edward Medical University en-US Annals of King Edward Medical University 2079-7192 <p>This is an open-access journal and all the published articles / items are distributed under the terms of the&nbsp;<a href="">Creative Commons Attribution License</a>, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited. For comments <a href="" target="_blank" rel="noopener"></a></p> Relationship Between Water, Sanitation, Climate Change, and COVID-19 Climate change is the utmost crucial challenge of the 21st century with the significant potential to cause human and economic damage. COVID-19 is a global public health emergency that has caused millions of deaths worldwide.1 Studies reported that thorough sanitation practices, safe and clean water, and proper hygiene services are considered the crucial part of protecting the health of humans during the infectious disease outbreaks such as the global COVID-19 outbreak.2 Nabiha Khalid Copyright (c) 2023 2023-02-25 2023-02-25 28 4 461 462 Knowledge and Perception of Gynecologist Against Sexual Assault-Multi Center Trial Sexual harassment is a global phenomenon. Sexual Assault is highly emotive subject and still reporting of the act is limited. Awareness of women rights has increased reporting of sexual assault requiring forensic evidence. The health care professionals required to document assault are hesitant to report assault largely due to limited knowledge and training to deal with such situations. The objective of this study was to assess knowledge and perception of Gynaecologists working in Tertiary Care Hospitals of Lahore, Pakistan who have been dealing with women with sexual assault. This is a prospective cross sectional study and a questionnaire about knowledge and perception of sexual assault was used for assessment. This prospective study was carried out in Department of Obstetrics and Gynaecology in three tertiary care hospitals of Lahore from May to June 2021 by filling a questionnaire, after verbal informed consent and obtained data was analyzed by SPSS 26. 166 doctors working at different levels answered a confidential and anonymous written questionnaire. Out of 166, 63.9% were 25-30years, 94% were females and 62.7% were married. 98.8% were Pakistanis while 72.3% belonged to urban areas of Pakistan. 53% participants had basic medical qualification (MBBS) and 41% were post graduate residents.50.6% strongly disagreed that women who wear certain types of clothing are responsible for their own rape.60.2% disagreed that rape cannot occur within marriage. 42.2% agreed upon victim not knowing the attacker. 47% disagreed that a woman can't be raped by someone she has a sexual relationship with. 30.1% strongly disagreed that a woman should feel guilty while 39.8% strongly agreed that a raped woman should do everything she can do to resist. Only 41.5% knew what to do when someone disclosed their rape. 65.1% felt uncomfortable listening to rape history of patients. 32.5% agreed that rape victim had alcohol prior to rape, 43.3% say rape victims become pregnant and 51.3% agreed that sexual violence is a very common cause of post-traumatic stress disorder while 45.8% said that rape victim may need HIV preventive measures. Laws against sexual violence and workplace harassment are in place in Pakistan but there is limited knowledge and awareness in Gynaecologists reporting sexual assault. Awareness of social rights and laws is necessary to improve diagnosis and management of this pressing problem, so this should be a part of basic medical curriculum in Pakistan. Zahra Safdar Rabia Nafees Shazia Jang Sher Ayesha Iftikhar Sumera Zaib Copyright (c) 2023 2023-02-25 2023-02-25 28 4 441 448 Children of Disaster: Helping Children Recover from the Trauma of Pakistan Floods Pakistan is amongst the world's most vulnerable countries to natural disasters and climate change, but the country was not prepared for a disaster of such scale- the unprecedented floods of 2022. The floods submerged nearly a third of the country, affected more than 33 million people and have taken more than 1700 lives, approximately 600 of them children.1 Government declared 72 out of 160 districts to be disaster zones and earlier estimates put the cost of destruction at more than $10 bn.1 The situation is still evolving, with flood waters stagnant in many areas, and more than 8 million displaced people now facing a health crisis. The disaster after the disaster is looming. Copyright (c) 2023 2023-02-25 2023-02-25 28 4 384 386 Risk Factors Associated with Non-Communicable Diseases: Trends and Policy Implications in Nepal Objective: To determine the trends in the prevalence of non-communicable diseases associated risk factors and implications for policies and strategies. Background: Non-Communicable Diseases (NCDs) contribute increasingly to disease burden in Nepal. The main drivers to this situation are the NCD related risk factors; and to determine their prevalence the Nepal Ministry of Health and Population conducted WHO Stepwise Approach to NCD Risk Factor Surveillance (STEPS) surveys in 2007, 2012 and 2019. This paper, by using results of STEPS surveys, explores the trends of NCD related risk factors and their implications for policies and strategies. Methods: This paper relies on the desk review of literature and secondary data, collected from the unpublished grey literature, mainly reports of the STEPS surveys. In addition, to corroborate findings, the evidence and experience from other countries available as published literature was brought. The data were analysed manually. Findings: Overall, during the period from first survey in 2007 to the last survey in 2019, there has been an increasing prevalence of NCDs associated lifestyle and behavioural, physical, and biochemical risk factors. Taking cognisance of these, several policies, and strategic documents, some of which generic, while others targeting the specific risk factors were produced. However, indicators and techniques used, across three STEPS surveys, were not consistent, thus limiting the comparison and analysis of data. Conclusions: The study concludes that different STEPS surveys did not use standard set of indicators and techniques. Yet, an increased prevalence of NCDs associated risk factors was noted. Several policies and strategic documents, generic as well as specific, were produced. But there is a need to define methodology, as to how results feed into the framing of policies and strategic, and their impact is monitored. Lonim Dixita Hyder M Khurshid Ehsanullah Tarin Copyright (c) 2023 2023-02-25 2023-02-25 28 4 449 456 Risk Factors for Post Endoscopic Retrograde Cholangio Pancreatography(ERCP) Pancreatitis (PEP) and Efficacy of Octreotide in its Prevention Background: Pancreatitis is a potentially fatal complication of ERCP, seen in 5-15% procedures. Factors precipitating its risk and effective pharmacological intervention for its prevention need exploration to improve patient safety. Objective: To identify risk factors for post-ERCP pancreatitis (PEP) and to determine efficacy of intravenous octreotide in preventing PEP. Methodology: A quasi-experimental triple blind placebo-based study included patients undergoing ERCP and randomize them in two groups through simple random sampling. Group A to receive intravenous Octreotide 4μg/kg before attempting cannulation during ERCP and 1cc N/S as placebo for group B. Patients were followed for PEP and data were analyzed using chi square (x2) and logistic regression analysis. Results: Of 203 included patients, 101 (49.3%) received octreotide while 102 (50.7%) were in control group. Post ERCP pancreatitis developed in 32 (15.8%) patients, in 8 (7.9%) patients of octreotide group while in 24 (23.8%) patients of control group (p value 0.002 with odds ratio (OR) for octreotide of 0.33 (95% CI 0.15- 0.71). We identified biliary surgery (p value 0.005), serum bilirubin ≥ 3 mg/dl (p value 0.03), cannulation time > 5 minutes (p value <0.000), needle knife sphincterotomy (p value 0.002), deep pancreatic duct (PD) cannulation (p value <0.000) and procedure time>30 minutes (p value 0.002) as risk factors for PEP. Conclusion: Previous biliary surgery, high serum bilirubin, cannulation time > 5 minutes, use of needle knife, PD cannulation and procedure time > 30 minutes are associated with increased risk of PEP. Intravenous octreotide before cannulation reduces risk of post ERCP pancreatitis. Abdul Aleem Shahid Sarwar Yasir Mahmud Copyright (c) 2023 2023-02-25 2023-02-25 28 4 387 392 Incidence of COVID-19 Infection in Nurses and their Families: A Prospective Cohort Study in Lahore Background: Nurses, as frontline workers, are at a higher risk of contracting COVID19 and serve as a potential source of transmitting this infection to their family members. Estimating risk in this population is critical for controlling the rate of secondary attack rate among their families. Objective: To measure the incidence of COVID-19 in nurses and their families with associated risk factors for transmission of infection. Methods: A prospective cohort study was conducted in Akhtar Saeed Medical and Dental college, Lahore and associated three hospitals. A cohort of 176 nurses was identified in March 2020 by using non-probability convenience sampling technique and was followed till September 2021. During this tenure of one and a half year, incidence was observed by following the cohort and using a self-structured questionnaire. With SPSS 23, Chi square test was applied and p value of < 0.05 was considered significant. Results: In a cohort of 176 nurses, followed for one and a half year, incidence of COVID-19 was 37(21%). Secondary attack rate among household members of these nurses was 3%. A significant association was observed between the nursing staff and exposure to their family members (p = 0.002). Vaccination rate in nurses at the start of the study was only 26%. Nurses who worked directly with COVID-19 patients reported high incidence (p = 0.009). Nurses who used Personal protective equipment (PPE) were less affected (p = 0.003). Nurses with comorbidities showed higher incidence (p =0.02). Rate of psychological distress was high (p =0.007). Conclusion: Incidence of COVID-19 among nurses was 21% with secondary attack rate of 3% in families. Protective use of N 95 mask and comorbidities were associated with incidence. Iram Manzoor Aqsa Hameed Momal Khan Allah Yar Khan Amna Ayub Copyright (c) 2023 2023-02-25 2023-02-25 28 4 393 398 Maternal Hypothyroidism Influences the Weight of Brain and Impairs the Migration of Neurons Inside the Hippocampus of Neonatal Rat Objective: To histologically observe the effects of hypothyroidism on the hippocampus of neonatal rats. Methods: A total of 10 healthy female Wistar rats, between 12-16 weeks old, were randomly divided into 2 groups; Group A was labelled as control and Group B was made hypothyroid by giving 15mg/kg of Propylthiouracyl (PTU) daily mixed in chow. The treatment was continued for a week before they were allowed to mate and conceive, and it was not interrupted throughout pregnancy and delivery until 21st day of lactation. On the 22nd day, 10 pups from each of the two groups were euthanized; 3cc of blood was drawn out from the heart immediately and the brains were scooped out, weighed, fixed in formalin after slicing out the cerebrum along with hippocampus, processed and stained to observe the arrangement and count and number of pyramidal neurons of CA3 region of hippocampus. Results: There was a significant decrease in the brain weights of group B pups (1.21 ± 0.21mg) when compared to the control group A (1.42 ± 0.01mg). The thyroxine (T4) level from the experimental group B was significantly decreased (27.7 ±1.2 ng/dl) compared to control (32.1 ± 0.9 ng/dl). Moreover, the serum levels of TSH were significantly higher in group B (21 ± 3.7ng/dl) as compared to group A (15 ± 2.4 ng/dl). The number of pyramidal cell count in group B was significantly decreased (39 ± 1.24 per unit area) as compared to group A (44 ± 2.49 per unit area). Conclusion: Maternal hypothyroidism not only exerts its' influence on the arrangement of Pyramidal neurons of CA3 area of hippocampus, but it also decreases their count. Overall, it effects the weight of the brain and significantly raises the levels of TSH in the neonates. Mariyah Hidayat Khayyam Arif Rana Nabila Kaukab Copyright (c) 2023 2023-02-25 2023-02-25 28 4 399 404 Satisfaction and Self-Confidence of Undergraduate Nursing Students with Simulation-Based Learning Experiences Background: Hands-on patient care could be best experienced through clinical rotations; however, opportunities for direct patient care for student nurses are limited due to lack of clinical sites and availability of patients, faculty shortages, and some ethical and safety concerns. The purpose to measure the satisfaction and self-confidence of nursing students with their simulation-based learning. Methodology: This study used an analytic cross-sectional design. The study was conducted at a private university in Karachi, Pakistan, and recruited 230 nursing students using a total population sampling technique. A self-reporting questionnaire was used to collect data. ANOVA was used to see the differences in the mean scores, and Pearson correlation was used to assess the correlation between satisfaction and self confidence. Results: The overall mean + SD of satisfaction was 75.80 + 8.93 and for self-confidence was 32.59 + 3.61. Findings revealed a significant difference in mean scores of satisfaction and self-confidence among the study groups, p < 0.05. A strong positive correlation, Pearson r = 0.725, p = 0.001, was revealed between the satisfaction and self-confidence. Conclusion: The study discovered that simulation-based learning plays a significant role in increasing satisfaction and in building the self-confidence of nursing students, so it should be made a part of their curriculum, and integrated into all possible courses in the undergraduate nursing programs. Mamoona Iram Naghma Rizvi Nazia Ilyas Eunice Siaty Afshan Nazar Zohra Kurji Copyright (c) 2023 2023-02-25 2023-02-25 28 4 405 410 Assessment of Knowledge, Reported Attitudes and Practices Regarding Emergency Preparedness and Related Factors at Tertiary-Care Hospitals of Punjab Province Amid COVID-19 Pandemic Hospitals need to maintain a high level of preparedness of staff and systems to mitigate the consequences of health emergencies and disasters. Therefore, the knowledge, attitude and practices of the hospital staff are of key importance in strengthening the emergency preparedness of the health system. Objective: The objective of this study was to determine the knowledge, attitudes and practices of healthcare workers regarding emergency preparedness and factors related to them, at the tertiary care hospitals of Punjab Pakistan Methods: This was an analytical cross-sectional study conducted at six tertiary care hospitals in Punjab from February 2022 to August 2022, approved by advanced studies and the research board of the University of Punjab. A self-administered questionnaire was distributed among 450 staff members of these hospitals to identify gaps in the knowledge, reported attitudes and practices of healthcare workers and their willingness to report for duty, selected by multistage sampling. Data were analysed by statistical package for social sciences (SPSS) Version 22. Results: The results found that 49.8% of the participants were aware of disasters that occurred, 50% knew the hospital emergency plan, and 70% agreed that hospitals need written plans yet 72.4% were not aware of the major components of the plan. Regarding attitude of the staff, 73.8% of accepted that it is their duty to take care of patients, 33.6% thought that hospital preparedness is adequate and only 36.7% agreed that the hospital had adequate staff in catering for the increased patient influx. Regarding hospital preparedness practices, only 29.3% stated that hospital conducts exercises and drills and 30.4% reported that the hospital conducts other training sessions and workshops for staff. Conclusion: The majority of the staff at the studied hospitals had a positive attitudes and willingness to report for duties in case of health emergencies. But there were lacks in the knowledge and practices at these hospitals which needs to be addressed by making a written hospital emergency plan, conducting simulation drills and mock exercises and arranging training. Muhammad Nasir Rubina Zakar Copyright (c) 2023 2023-02-25 2023-02-25 28 4 411 416 Reflective Practice and Factors Affecting it: Perceptions of Pediatric Surgery Residents Background: There is scarcity of literature about factors affecting reflective practices in local context. By focusing on these factors, we can help promote engagement in reflective practices in our culture. Objective of this study was to explore the barriers to and facilitators of reflective practice by post graduate surgical residents. Methods: Using action research study design, qualitative research was conducted in the department of Pediatric Surgery, Mayo Hospital to explore different factors affecting reflective practice in postgraduate surgical residents in their daily practice. A workshop on reflective practices was conducted, followed by weekly morbidity/mortality meetings and case-based discussions deliberating using Gibbs' reflective cycle. After a year, focus group discussion using a heterogenous group of nine residents was conducted to explore the factors affecting reflective practice. It was transcribed and analyzed thematically. Results: Reflective practice was perceived to improve critical appraisal, deeper learning, self-monitoring, and patients' outcomes. There was resistance towards reflective writing. Themes related to factors affecting reflective practice were organization, time allocation, communication, workplace environment, interpersonal relations, guided reflection, and feedback. Involvement of multiple disciplines in 'reflection before action' was identified for future implementation. Conclusion: Provision of guided reflection and constructive feedback were the main facilitators of reflective practice. Generally, improving organization, workplace environment, interpersonal relations, and accommodating individual learning styles can enhance reflective practice in our context, and help developing habit of lifelong learning. Fatima Naumeri Copyright (c) 2023 2023-02-25 2023-02-25 28 4 417 422 Steroids use in Severe/ Life Threatening COVID-19 Pneumonia: Does the Type or Dose Matter? Objective: To compare the effect of different doses of methylprednisolone and dexamethasone on in-hospital mortality in severe COVID-19 pneumonia Methods: This retrospective chart review was done by reviewing old medical reports of patients with severe disease admitted to COVID-19 Intensive Care and High Dependency Unit from October 2020 to September 2021. Those with suspected COVID-19 infection (suggestive radiological findings but negative PCR for SARSCoV- 2 on at least two occasions) were excluded. Patients requiring high flow oxygen (>6 liters per minute) or higher levels of respiratory support were classified as having severe disease. We recorded the type of steroids used and the doses. Methylprednisolone in doses up to 40mg per day, or other steroids in equivalent doses, were considered low dose. Primary outcome of interest was in- hospital mortality. Results: There were 279 patients aged 52.53± 11.31 years, including 216 (77.42%) males. Mean hospital stay was 10.18± 3.13 days. During hospital stay, 96 (34.41%) patients died. Amongst patients receiving dexamethasone, 70 (44.87%) expired, whereas 26 (21.14%) out of 123 patients who received methylprednisolone expired (p<0.001; hazard ratio 3.037). With high dose steroids, 52 (41.27%) out of 126 patients expired, whereas 44 (28.76%) out of 153 patients treated with low dose steroids expired (p=0.029; hazard ratio 1.741). In multivariate binary logistic regression, in-hospital mortality was related to the type of steroid but not the steroid dose. Conclusion: Methylprednisolone is superior to dexamethasone for treatment of severe COVID-19 pneumonia. Abdul Rehman Arshad Bilal Saeed Sagheer Hussain Copyright (c) 2023 2023-02-25 2023-02-25 28 4 423 427 Prevalence and Associated Risk Factors of HCV Infection Among Children in Lahore, Pakistan Background: Pakistan has second highest prevalence of HCV in the world. The epidemiology and burden of HCV infection varies in people of different ages. Objective: Present study was designed to measure the prevalence of HCV among children in selected public and private hospitals of Lahore Methods: Children in the study were screened for anti-HCV test through ELISA (third generation ELISA Kit and Qaigen kit) for detecting the viral load from June 2018 to May 2019. Results: Children in the study were screened for anti-HCV test through ELISA (third generation ELISA Kit and Qaigen kit) for detecting the viral load. The average age of non-reactive and reactive children was 7.28±3.36 and 5.50±3.8 years respectively. Socio-economic status was found associated with anti-HCV. An association was found significant for birthplace, delivery assisted by, and type of milk given to the child. Conclusion: This study shows that the prevalence of HCV is 3.85% in children in lahore city of Pakistan, which is alarming situation for healthcare providers, researchers and policy makers. Copyright (c) 2023 2023-02-25 2023-02-25 28 4 428 432 Histopathological Frequency of Helicobacter Pylori among Patients of Dyspepsia Background: The condition known as dyspepsia, commonly referred to as indigestion, is characterized by the pain or discomfort in upper abdomen, most frequently occurring after ingestion of food or drinking. Following receiving treatment for H. pylori, many patients diagnosed have dyspepsia do show signs of improvement. Objective: To determine the histopathological frequency of Helicobacter Pylori (H pylori) in patients presenting with dyspepsia in a tertiary care hospital. Methods: This cross-sectional study was conducted in a teaching hospital, Lahore. The study duration was six months from October 2018 to April 2019. A total of 85 cases aged 18–70 years, presenting with dyspepsia and of either gender, were included. After taking written informed consent, patients underwent upper gastrointestinal endoscopy. Biopsy samples were obtained, which were sent to the pathology laboratory of the hospital to assess the presence of H. pylori. All of the information was put into a study proforma and analyzed by SPSS version 21. Results: The mean age of patients was 44.67±14.67 years. Males were 59 (69.4%) and females were 26 (30.6%). The BMI of patients was approximately 24.77±4.94kg/m2. The mean duration of dyspepsia was 9.99±5.08months. There were 62 (72.9%) patients who had H. pylori, while 23 (27.1%) patients did not have H. pylori. Conclusion: As per the study conclusion, H. pylori was observed to be highly frequent among patients presenting with dyspepsia. Hafsa Farooq Muhammad Awais Abid Ambreen Butt Mujahid Israr Imran Khan Tayyab Mehmood Copyright (c) 2023 2023-02-25 2023-02-25 28 4 433 436 Learning with Trisomy 21: Life Skills Training of a Child with Down's Syndrome Trisomy 21 is one of the commonly identified genetic causes of Intellectual Disability. Such children experience a lack of attention and neglect by parents and teachers due to their slow response to intervention, which sometimes becomes demotivating for caregivers. However, with the recent medical advances and institutional support, avenues have been opened to help overcome the challenges related to Down's Syndrome. The present case study highlights the life skills training of a 7 year old child with Down's Syndrome, studying in a special education institute of Lahore. The post-assessment showed that consistent practice of behavior modification procedures led to significant improvements in the adaptive functioning of the child. Halima Khurshid Ayesha Jabeen Copyright (c) 2023 2023-02-25 2023-02-25 28 4 437 440 Hepatitis E Vaccination in Pakistan: Where Do We Stand Hepatitis E is not something new when it comes to hepatology practice. We have been hearing it for years just like any other hepatitis but the troublesome dilemma is that we didn't have any vaccination for it until few years recently and the main treatment was conservative. It is obviously guided by monitoring of liver function tests. The magnitude of the problem is colossal and can trigger catastrophe. About 12 million people are the victims of Hepatitis B or C in our country and around 150,000 new cases are emerging annually. Hepatitis E has been affecting 3.3 million people all over the world. The numbers are huge in Pakistan where people do indulge in poor hygiene and the sanitation system is dismal serving as a root of all infective diseases and Hepatitis E is one of them.1 Jibran Umar Ayub Khan Ayesha Qaiser Azhar Zahir Shah Copyright (c) 2023 2023-02-25 2023-02-25 28 4 457 458 Tomato Flu - Should Pakistan be Worried? A new virus has emerged as an endemic in India and due to its highly contagious nature, is of great concern.1 The population of Kerala is 3.34crores, population growth of 4.91% current decade, contributing to about 2.76% of the total population of India. Making the spread of infections easier.2 Tomato flu is a viral infection that predominantly infects children under the age of 5 years. Tomato flu gets its name from red-coloured, tomatoshaped blisters that develop on different parts of the body, similar to those developed during monkeypox infection.1 Tomato flu presents symptoms like any other viral infection including COVID-19 infection, but it is not associated with SARS-CoV-2.3 Abdullah Haroon Javaria Saleem Copyright (c) 2023 2023-02-25 2023-02-25 28 4 459 460