Punjab Medical College

Femoral shaft fractures are among the most common fractures of the lower extremity in children. Various methods of treatment can be used successfully, depending on the age of the child and the type of fracture. Immediate application of a spica cast, or traction followed by a cast, remains the standard management for most of these fractures in children. Operative treatment modalities include intramedullary nailing by flexible or rigid nails, external fixation, traditional open reduction and plate fixation, and submuscular bridging plating. The objective of this study was to compare the outcome of titanium elastic nailing and dynamic compression plating in diaphyseal fractures of the femur of children aged 6-12 years. This cross-sectional comparative study was conducted in the department of Orthopaedics, Sylhet MAG Osmani Medical College Hospital, during the period from 1st January 2016 to 31st December 2017. Thirty-six children with femoral diaphyseal fractures aged between 6-12 years of both sexes were included. Patients with pathological fractures, open fractures, fractures with associated neurovascular injury, those who weighed more than 49 kg, those with fractures longer than 2 weeks old and those unwilling to take part in the study were excluded. They were divided by random allocation into group-A (odd number) and group-B (even number) each comprised of 18 patients and treated with titanium elastic nailing and dynamic compression plating, respectively. Outcome was assessed with Flynn criteria at 6 months follow-up. The mean age was [9.56±1.98 years versus 9.67±1.46 years; p>0.05] and sex [15 (83.3%) male and 3 (16.7%) female versus 16 (88.9%) male and 2 (11.15%) female; p>0.05] did not differ significantly between group-A and group-B. Operation time [60.83±11.79 minutes versus 72.06±10.99 minutes; p<0.01], length of postoperative hospital stay [12.00±1.94 days versus 15.72±3.10 days; p<0.01] and time of union [11.11±1.71 weeks versus 12.00±0.0 weeks; p<0.05] were significantly shorter in group A than in group-B. Postoperative mobilization [2.61±1.72 days versus 2.50±0.71 days; p>0.05); time of weight bearing [6.22±0.65) weeks versus 6.33±0.77 weeks; p>0.05] did not differ significantly between the two treatment groups. The recorded complications of entry point bursitis, chronic discharge, mild pain, malalignment did not differ significantly between the two groups. Excellent functional outcome was more in group-A compared to group-B (83.3% versus 66.7%) but not statistically significant (p>0.05). This study concludes that there is no significant difference between functional outcome in TENS group and DCP group, though TENS group has slightly better outcome. Jalalabad Med J 2025; 22 (2): 61-66

Abstract not availablable Jalalabad Med J 2025; 22 (2): 51-54

Inguino-scrotal and inguino-labial swellings occur due to inguinal hernia, hydrocele, testicular torsion, epididymo-orchitis, undescended testis, inguinal lymphadenitis, inguinal abscess, testicular tumour and rarely hydrocele of the canal of Nuck. This cross-sectional study was conducted in the department of paediatric surgery, Jalalabad Ragib-Rabeya Medical College Hospital, during the period of two and a half years from January 2021 to July 2023 to find out the causes of inguino-scrotal/labial swelling in children and its pattern of management. A total of 125 patients of inguino-scrotal/labial swellings, aged up to 14 years were included. Children with hydrocele whose age was below two years were excluded from this study. Patients were diagnosed by history, examination and investigation. Patients were managed surgically and conservatively. Incidence of inguino-scrotal/labial swelling was 2.5%. The age of the patients ranged from 29 days to 14 years, with the mean age of 5.17 (SD 2.85) years. Majorities (61.6%) of the patients were below the age of 5 years. The male-female ratio was 10.36:1. More than half (56.8%) of the swellings were on the right side. Inguinal hernia (44.8%) was the commonest cause of inguino-scrotal/labial swelling, followed by hydrocele (25.6%). About 91.2% of patients were treated surgically and 8.8% of patients received medical treatment. The outcome was uneventful/cured in 94.4% of cases, while 5.6% of patients developed some form of complications. Postoperative hospital stay ranged from 2 to 8 days with a mean of 2.76 (SD 1.14) days. So, it may be concluded that inguinal hernia is the commonest cause of inguino-scrotal/labial swelling in children. The outcome of inguino-scrotal/labial swelling is excellent. Jalalabad Med J 2025; 22 (2): 78-83

Hearing loss is among the top three non-fatal disabling conditions in low- and middle-income countries (LMICs), where cochlear implantation (CI), the gold standard for severe-to-profound sensorineural hearing loss, remains underused. Conventionally, device activation occurs 2–4 weeks postoperatively; however, early activation (EA) within days of surgery has shown promising benefits. Literature reveals inconsistencies in defining EA and late activation (LA). Some studies report device activation as early as 1 to 7 days postoperatively, while others classify activation within 8 to 14 days as either EA or LA. Traditionally, activation has been reported between 9 and 46 days postoperatively. This lack of consensus complicates the development of standardized postoperative activation timelines and impedes evidence-based clinical guidelines. This narrative review aims to compare the outcomes, feasibility, and safety of EA versus traditional activation in CI patients while highlighting the variability in definitions and activation timelines across studies. A thorough literature search was conducted using PubMed, Scopus, Google Scholar, and Google. Seventeen studies were included, comprising 3 systematic reviews, 2 literature reviews, and 12 primary studies. Most studies reported EA on the first postoperative day, demonstrating benefits such as faster auditory rehabilitation, improved speech recognition, reduced anxiety, and higher patient satisfaction. EA was not associated with increased complications and was cost-effective, particularly for patients from remote areas. However, long-term impedance outcomes were similar between EA and LA. In conclusion, first-day EA appears feasible, safe, and beneficial. Still, large-scale prospective studies are needed to establish optimal activation timing and support standardized CI care protocols.

The genome editing tool, known as CRISPR-Cas9, is a powerful tool that can be employed in the fight against the multidrug-resistant opportunistic pathogen, Pseudomonas aeruginosa PAO1, which is known for causing severe infections. This review will explore the use of the CRISPR-Cas9 system in learning more about the bacterium and coming up with new ways of fighting infections. We will also look at the basic components of the CRISPR-Cas9 system, which include the Cas9 nuclease activity, specificity of the RNA, and the DNA repair machinery, which includes both homologous recombination and non-homologous end joining. We will also look at the different components of the system in the context of bacteria. This review also explores the different variants of the system, which include the catalytically dead Cas9 (dCas9) for gene silencing and the use of the system for overexpressing specific genes, known as the CRISPR activation (CRISPRa) system. This can be employed in the context of altering specific genes involved in antibiotic resistance, efflux pumps, biofilm, and virulence. We also discuss how effective it is in reversing antimicrobial resistance by targeting and degrading the genes for antimicrobial resistance, eliminating the plasmids, and making the drug-resistant strains susceptible to normal antibiotics. We also discuss the new applications for epigenetic modifications, genome-wide functional screening, and the fusion of these with phage therapy and nanoparticles. Although there have been many improvements in the field, there are still challenges in finding the most effective drug delivery methods, reducing side effects, and the ability of P. aeruginosa to alter its genes. Future perspectives include combining CRISPR-Cas9 with other cutting-edge technologies to develop synergistic approaches for combating this resilient pathogen and solving the antimicrobial resistance crisis.

Abstract Background: Anemia is a common comorbidity in patients with heart failure and is strongly associated with adverse clinical outcomes. Sodium-glucose cotransporter-2 (SGLT2) inhibitors, specifically dapagliflozin, may improve anemia-related biomarkers. However, findings from individual trials have been inconsistent, leaving the magnitude and consistency of these effects unclear. Objective: Our study aims to clarify the effects of dapagliflozin on anemia in patients with heart failure. Methods: We conducted a systematic search of PubMed, Embase, Cochrane CENTRAL, and trial registries for randomized and non-randomized clinical trials. Outcomes included changes in hemoglobin, ferritin, transferrin saturation (TSAT), and serum iron. Mean differences (MD) and 95% confidence intervals (CIs) were pooled using random-effects models. We performed sensitivity analyses by sequentially excluding studies and assessed bias using Cochrane tools and ROBINS-I, grading evidence via GRADE. Results: Six studies (n=5,075) were included. Dapagliflozin significantly increased hemoglobin (MD 1.05; 95% CI 0.75–1.35; P < 0.00001). Ferritin was significantly reduced (MD –14.50; 95% CI –22.13 to –6.86; P = 0.0002); sensitivity analyses excluding Bhaganagarapu et al. amplified this reduction (MD –23.37; 95% CI –34.57 to –12.17; P < 0.00001). While TSAT changes were non-significant overall (MD 0.37), sensitivity analysis demonstrated a significant reduction (MD –1.36; 95% CI –2.37 to –0.35). Serum iron remained unchanged (MD –0.09). Evidence certainty was moderate-to-high for hemoglobin and ferritin but low for TSAT and serum iron. Conclusion: In heart failure patients, dapagliflozin reliably increases hemoglobin and decreases ferritin. While the primary analyses for transferrin saturation were non-significant, sensitivity testing revealed significant changes. These findings suggest that dapagliflozin may beneficially influence iron metabolism. However, further large-scale, dedicated trials are warranted to confirm these mechanisms.

Background In high-income countries, early intervention in psychosis (EIP) services provide treatment for first episode psychosis (FEP) as early as possible, proving to effectively improve health outcomes. These services rarely exist in low- and lower-middle-income countries (LMICs). The TRANSLATE programme aims to evaluate the effectiveness of EIP services in terms of implementation outcomes in two LMIC countries, and to develop a clinical tool to predict the risk of Treatment Resistant Schizophrenia (TRS) in patients with FEP. Methods This is an observational implementation research study, conducted across five sites in Pakistan and one in Sri Lanka, with recruitment of 670 FEP patients. The key clinical such as status of functioning, quality of life, psychopathology, family burden, stigma and physical health, will be assessed at baseline and periodically over 1 year period. A descriptive analysis of baseline data and service utilisation data will be conducted, stratified by site. For implementation outcomes, the probabilities of disengagement and remission will be modelled using logistic regression models adjusting for duration of untreated psychosis, baseline symptom severity, and geographical location. For secondary implementation outcomes, selected key clinical outcomes and a process evaluation will be conducted. To develop a clinical model prediction model for TRS, a penalised multivariable logistic regression model will be fitted to estimate the one-year risk of TRS following an FEP diagnosis, incorporating up to 15 predictor variables identified within the study cohort. Model performance will be assessed using calibration plots and the C-statistics for discrimination. Internal validation will be carried out by bootstrapping, and the optimism-adjusted calibration slope will be used as a global shrinkage factor to account for overfitting, with the model intercept re-estimated to ensure calibration-in-the-large. Discussion This will be the first large study that will implement and evaluate the EIP service in a LMIC country setting. The findings of this study and the process evaluation will inform the adoption and scaling-up of EIP services in routine clinical practice. The clinical prediction model for the early detection of TRS will help initiate effective treatments for TRS at the earliest possible stage and potentially reduce the significant burden of disease associated with TRS.

Uremia has been associated with slowed intestinal motility, resulting in loss of peristalsis and the development of paralytic ileus. We present a case of uremia-induced paralytic ileus in a 70-year-old woman. The patient was admitted with a 7-day history of abdominal pain, vomiting, and constipation. Initial evaluation revealed a soft non-tender abdomen with decreased bowel sounds. Urgent ultrasonography showed dilated gut loops and sluggish gut motility, while atrophic kidneys with hydronephrosis were also appreciated. Routine biochemistry labs revealed elevated creatinine and potassium levels, and an erect abdominal X-ray showed mild to moderate air-fluid levels. Notably, common risk factors for paralytic ileus, such as recent surgery or gastrointestinal procedures, immobility, hypokalemia, hypothyroidism, hypercalcaemia, hypocalcemia, hypomagnesemia, and diabetes mellitus, were ruled out. The patient also had no history of anticholinergic or opioid use. Given the absence of other causes, uremia was established as the underlying cause of paralytic ileus. After initial treatment for ileus, the patient underwent hemodialysis, which led to significant improvement in symptoms. This case highlights the importance of recognizing uremia as a potential cause of unexplained ileus, contributing to the limited literature on uremia-associated ileus.

Background: Appendicitis is a common surgical emergency that has a spectrum of mild cases of inflammation, gangrene, and perforation. Systemic inflammatory markers could play a significant role in predicting disease severity before surgery. Objectives: To determine the relationship between the healthcare objective of appraising systemic inflammatory physiology and the severity of appendicitis in patients who have undergone appendectomy. Methods: A cross-sectional study was conducted on 89 patients who underwent appendectomy. Preoperative laboratory investigations, including TLC, neutrophil count, CRP, ESR, PCT, NLR, and PLR—along with clinical examination and imaging findings were documented. The severity of appendicitis was categorized intraoperatively and histopathologically into simple, suppurative, gangrenous, and perforated types. Associations between inflammatory biomarkers and disease severity were assessed using statistical comparisons and correlation analyses. Results: The majority of patients (64%) reported within 24-48 hours of symptom onset. The distribution of severity of appendicitis was straightforward (36.0%), suppurative (30.3%), gangrenous (20.2%), and perforated (13.5%). CRP, PCT, NLR, PLR, and TLC demonstrated a progressive tendency in increasing by the severity. A correlation was greater with CRP (r = 0.71, p < 0.001) than with PCT (r = 0.66), NLR (r = 0.62), and TLC (r = 0.54). Conclusion: CRP, PCT, and NLR are systemic inflammatory biomarkers with strong associative relationships to the severity of appendicitis and can be useful predictors of complicated disease. By introducing these parameters into clinical assessment, early detection, risk assessments, and operations could become better and more notable in resource-limited environments.

Glaucoma is the second leading cause of blindness worldwide. It is a neuropathic disease, mostly inherited in an autosomal recessive form. Primary congenital glaucoma (PGC) is characterized by increased intraocular pressure and optic nerve damage. It is a clinically and genetically heterogeneous eye disorder. To date, four genetic loci are reported to have been linked to PCG, including GLC3A, GLC3B, GLC3C, and GLC3D. The CYP1B1 gene resides in the GLC3A locus on chromosome 2. Mutations in the CYP1B1 gene are linked to PCG. It is most prevalent in countries like Pakistan, where consanguinity is common. Both familial and sporadic forms of PCG are common in Pakistan. This study was undertaken to analyze the mutations in the CYP1B1 gene in the cause of PCG in consanguineous Pakistani families. The CYP1B1 mutations linked to PCG in consanguineous Pakistani families were analyzed from a thorough analysis of the data available to date on Google Scholar, Medline, and PubMed, and were further demonstrated by a pie-chart diagram. The graphical representation of the percent prevalence of these mutations was accessed. A total of 98 missense, frameshift, and nonsense mutations were found. The missense mutation, p.Arg390His, was the most significant, particularly in Punjab, followed by the p.Glu229Lys mutation. In Pakistan, there is a higher prevalence of PCG in consanguineous families. Several mutations in the CYP1B1 gene cause PCG in the Pakistani population, with p.Arg390His being the dominant one. Knowledge of prevalent PCG-causing mutations in a population is useful in establishing prenatal and pre-symptomatic diagnoses for better glaucoma management.