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Professor, Consultant Pathologist, American Board Certified Pathologist, Fellow College of American Pathologists. Areas of interest Fine Needle Aspiration Cytology, Cytology, Cancer, Ethics, Islam, Humanity

Diagnosis of Pulmonary Tuberculosis; Conventional Versus Fluorescent Microscopy and Gene Xpert MTB/RIF

Fatima Zahra, Aamer Ikram, Gohar Zaman , Luqman Satti, Farida Lalani and Maria Khan

Department of Microbiology, Armed Forces Institute of Pathology, National University of Medical Sciences, Rawalpindi, Pakistan



Tuberculosis is an infectious disease with a high prevalence with about 9 million cases occurring annually. ZN microscopy is the most widely used technique to detect AFB, but it is less sensitive. However fluorescent microscopy is more helpful with simple diagnostic criteria. Gene Xpert® MTB/RIF assay is a rapid molecular assay that enables diagnosis of TB with simultaneous detection of rifampicin resistance. The diagnostic accuracy of fluorescent microscopy and Gene Xpert MTB/RIF for the diagnosis of TB were evaluated.

A total of 352 respiratory specimens were tested among which 160 samples were positive by culture. Out of culture positive samples, 158 samples (98.7%) were GeneXpert TB positive while 2 were negative. While only 49 were positive on ZN microscopy and 89 were positive on fluorescent microscopy. Out of the culture negative samples, 2 were positive with ZN microscopy, one was positive with fluorescent microscopy and 3 were positive on Gene Xpert. Sensitivity, specificity, PPV, NPV and diagnostic accuracy of ZN Smear microscopy was 39%, 99.5%, 96%, 63% and 14.5% respectively. Sensitivity, specificity,PPV, NPV and diagnostic accuracy of fluorescent smear microscopy was 55% and 99.5%, 98%, 72% and 79% respectively. Sensitivity, specificity, PPV, NPV and diagnostic accuracy of Gene XPERT was 98 % and 99%, 98%, 99% and 98% respectively.

In countries like Pakistan where the disease is endemic, fluorescent microscopy and Gene Xpert PCR can help in making a timely diagnosis.

Key words: Pulmonary Tuberculosis, Fluorescent microscopy, Gene Xpert, Auramine phenol stain

Frequency of Endometriosis among Infertile Women on Diagnostic Laparoscopy

Nousheena Akhter Shabir*, Rubina Rafique** and Sehr ul Ain Raja*

*Department of Gynaecology & Obstetrics Combined Military Hospital (CMH)Muzaffarad, Azad Kashmir, **Department of Medicine AIMS, Muzaffarad, Azad Kashmir



Introduction: A condition in which there is failure of conceiving child after frequent sexual intercourse that is unprotected for 12 months or more is known as infertility. A variety in clinical presentation, difficult diagnosis and management makes endometriosis a challenging medical problem. Clinical information related to ovarian and tubal status, normality of uterine and some proper procedure for diagnosis of many pelvic pathological conditions such as pelvic inflammation, pelvic congestion, endometriosis and tuberculosis can be obtained by laparoscopy.

Objective: To determine the frequency of endometriosis on diagnostics laparoscopy in females with infertility.

Material & Methods: This cross-sectional study was done at the department of Obstetrics & Gynecology Combined Military Hospital (CMH) Muzaffarabad, Azad Kashmir to determine the frequency of endometriosis on diagnostics laparoscopy in infertile women. The duration of the study was 6 months (from October 30, 2016 to April 30, 2017). The participants were taken had age 18-45 years with primary complain of primary or secondary infertility were subjected to diagnostic laparoscopy and were diagnosed to have endometriosis as the cause of infertility were included in the study.  Sample size for the study was taken by non-probability, consecutive sampling of 170 females. Data from 82 female undergoing diagnostic Laparoscopy meeting inclusion criteria was taken from department of Obstetrics & Gynecology. After taking informed written consent basic demographical details like age, name and contact details were taken. A clinical examination was carried out during patient’s inclusion. The quantitative data like age and duration of infertility were reported in Mean ± S.D while the categorical data like type of infertility and endometriosis were reported in Frequency (%).  To address effect modifiers data was stratified for female’s age, duration of infertility and types of infertility (primary or secondary). Post stratification Chi-square test was used considering, p-value ≤ 0.05 as significant.

Results: The mean age of cases in this study was 31.56±8.19 years with mean duration of infertility was 10.16±5.05 months. There were 36(21.18%) who had < 6 months and 134(78.82%) cases had ≥ 6 months of duration of disease. There were 76(44.71%) cases that had primary and 94(55.29%) cases had secondary infertility. According to operational definition a total of 23(13.53%) cases had endometriosis.

Conclusion: The frequency of endometriosis in females with infertility is considerably higher. In future these females can be prevented from endometriosis by early screening and with appropriate medication.

Keywords: Pregnancy, Infertility, Laparoscopy, Endometriosis

Clinical and Histopathological Spectrum of Ameloblastoma

Uzma Bukhari*, Durr-e-Sameen Kamran* and Hira Salam**

*Department of Histopathology,

**Department of Oral Pathology

Dow University of Health Sciences, OJHA campus, Karachi



Introduction: Ameloblastoma is a rare neoplasm of odontogenic origin with estimated global incidence at 0.5 per million-person years. Tumor, although benign has the tendency to invade adjacent tissues. Regional variations in occurrence of various odontogenic tumors have been reported. With this experiential data, we aimed to identify the prevalent pattern for presentation of ameloblastoma in our population over 6 years of study period.

Patients and Methods: All biopsy specimens diagnosed as ameloblastoma at histopathology section of Dow Diagnostic Research and Reference Lab (DDRL), Dow University of Health Sciences (DUHS),during the study period (January 2010 – December 2015) were included in the study. The slides were reviewed along with the clinical information was recorded on specifically designed proforma.

Results: 42 cases of ameloblastoma diagnosed by histopathology department at DDRL (DUHS) during the entire study period. A wide age range (3 years to 80 years) was observed with mean age 32 years at presentation. Highest incidence was recorded in 20-40 years age group. A slight male preponderance was noted (57%). Majority of the cases were intraosseous (76%) amongst which mandible (87.5%) was the most frequent site.

Conclusion: Ameloblastoma is a rare neoplasm, a fact highlighted by our recording only 42 biopsied cases over a span of 6 years. Even though the tumor has a predilection for higher age group and males, we recorded cases in both extremes of age. Therefore, ameloblastoma should be considered in differential diagnosis of odontogenic tumors at both extremes of age.

Keywords: Ameloblastoma, Mandible Tumors, Dental Tumors, Oral Pathology

Geodemographic Variations in Subtypes of Esophageal Carcinoma among Afghanis and Pakistanis Patients in Northwest Pakistan

Nuzhat Sultana*, Shifa Basharat**, Mohammad Hanif***, Ikramullah Khan***, Saeed Ullah*** and Walayat Shah**

*Khyber Medical College, Peshawar and Northwest General Hospital & Research Centre, Peshawar

**Institute of Basic Medical Sciences Khyber Medical University, Peshawar, ***Northwest General Hospital & Research Centre, Peshawar




To determine the variation in occurrence of two major histological types of esophageal cancer stratified by various factors.

Patients & Methods: 122 cases were selected between June 2011 and June 2013, at Northwest General Hospital and Research Center (NWGH & RC) Khyber Pakhtunkhwa. The selected patients were either from Khyber Pakhtunkhwa (26) or Afghanistan (96). The H&E stained slides were re-assessed microscopically. Types of carcinoma and demography of disease were evaluated. The variation in occurrence of the two subtypes of cancer was determined through multivariate analyses using morphology as dependent factor and gender, geographic area and anatomical location of the esophagus as independent factors.

Results: Majority of the lesions were of squamous cell type (87%). Adenocarcinoma was marginally more prevalent among Pakistanis as compared to Afghanis (23% vs. 10%). The number of younger patients was high in Afghanis as compared to Pakistanis (87.5% vs 12.5%). 76 (62%) patients were male with no significant difference of the proportions of gender between the two nationalities. Majority of the malignancies (n = 76, 62%, 95% CI = 53 – 71%) were located in the lower esophagus. For the outcome of squamous cell carcinoma, the Odds Ratio of being an Afghani was 2.7 while for that of adenocarcinoma it was 0.3. Both measures fail to achieve statistical significance (z = 1.3, P = 0.083).

Conclusions: Squamous cell carcinoma was the most common malignancy in both populations. Adenocarcinoma was marginally more prevalent in Pakistanis while esophageal carcinoma was common in younger patients in Afghanis that may point towards different etiology and pathogenesis of the disease. Further large-scale studies are therefore required to evaluate these factors.

Keywords:  Esophageal carcinoma, Geographic area of residence, squamous cell carcinoma

Clinical Spectrum of Dengue Fever: A Single Center Study

Shahzad Ahmad*, Mohammad Sajjad Ali Khan*, Muhammad Zaheer ullah Babar*, Iftikhar Ali Shah* and Afsheen Mahmood**

*Department of Medicine, Northwest School of Medicine & General Hospital, Hayatabad, Peshawar, **Department of Physiology, Khyber Girls Medical College, Peshawar



Objectives: To assess the clinical features, diagnostic modalities and clinical outcomes in patients of dengue fever and dengue hemorrhagic fever to guide clinician for an early diagnosis and effective treatment.

Methods: A single-centered retrospective cross-sectional study which included 150 patient of confirmed dengue fever admitted at Northwest General Hospital, Peshawar, Pakistan in the year 2017.

Results: Our study showed that the incidence of dengue fever was more common in male patients. Blood counts show that thrombocytopenia and leukopenia are common in such patients. NS1 (dengue antigen) and IgM when tested were positive in 100% and 48.6% of the patients. Out of total 6.6% of the patients progressed to DHF. Diagnostic clinical features are myalgia (most common), orbital pain, anorexia in dengue fever while vomiting, diarrhea and rash were more common in DHF. In addition, 22.7% of the patients presented with bleeding manifestation, gum bleed (most common), Petechiae, epistaxis and hematuria. Only 2 patients developed acute kidney injury. Among total 10% of the patients also developed plasma leakage syndrome. Mean hospital stay was higher for patients who developed DHF.

Conclusion: Dengue fever incidence is greater in males. Thrombocytopenia and leucopenia are associated with the disease. Bleeding tendency increases with severe thrombocytopenia. Myalgia is the common symptoms and rash the least common. Vomiting, diarrhea and rash is more common in DHF patients.  Peri-orbital puffiness was a relatively newer finding in patients suffering from this disease. NS1 dengue antigen and IgM dengue antibodies testing when combined has a higher diagnostic sensitivity. Hospital stay is lengthened by higher drops in platelet counts, bleeding tendency, renal failure and with the development of plasma leakage syndrome

Keywords: Dengue fever, thrombocytopenia, leukopenia, Bleeding tendency, renal failure, plasma leakage syndrome

Prevalence and Severity of Diabetic Peripheral Neuropathy & its impact on Quality of life of Diabetics in Hayatabad, Peshawar

Maryam khan Kundi, Mujeeb Ur Rahman, Ikram Ali, Summaya Farman khan and Shafaq Wadood

Khyber Medical University IPM&R Peshawar, Pakistan



Background: Diabetes Mellitus may lead to long-standing complications, comprising of diabetic nephropathy, diabetic retinopathy and diabetic peripheral neuropathy and a few other diabetic vascular abnormalities. Diabetic peripheral neuropathy is most common chronic and long-term complication of diabetes mellitus and it is the leading cause of mortality, morbidity and consequently disability causing huge economic burden on the health system.

Objective: To determine the prevalence of diabetic peripheral neuropathy in diabetic population and to assess its severity and its impact on Quality of life.

Methodology& setting: Prevalence, severity of diabetic peripheral neuropathy and its impact on QOL of Diabetic population were determined in a sample of 386 diabetic patients using non-probability Convenience sampling, living in Hayatabad, Peshawar. In this cross-sectional study self-designed questionnaire using LANSS pain scale and McGill Pain Scale was used. The study ‘duration was 4 months from September 1st to December 30th2017.

Results: The prevalence of Diabetic Peripheral Neuropathy in Diabetic Population is 39.9%. 22% of the subjects reported having moderate symptoms related to DPN. 14.8% participants described the DPN, somewhat affecting their quality of life.

Conclusion: Diabetic Peripheral Neuropathy is highly prevalent in the diabetic population, majority falling in age range 45-65, of Hayatabad, Peshawar. The most common variety of symptoms described by the participants were numbness and pins and needles.

Keywords: Diabetes Mellitus, Diabetic Peripheral Neuropathy, Quality of Life, Numbness, Paraesthesia

Perceptions of Undergraduate Medical Students regarding Objective Structured Practical Examination and Objective Structured Clinical Examination as an Assessment Method

Abdus Salam Khan*, ArslaanJavaeed**, Rubab Ayesha Rasheed***, Sanniya Khan Ghauri* and Khawaja Junaid Mustafa*

*Department of Emergency Medicine Shifa International Hospital, Islamabad, ** Department of Pathology, Poonch Medical College, Rawalakot, Azad Kashmir, ***Poonch Medical College, Rawalakot, Azad Kashmir



Introduction: At present student’s assessment in MBBS course is mainly based on Traditional Practical Examination. The studies have shown that it  can have certain disadvantages which can be overcome by adopting Objective Structured Practical Examination and Objective Structured Clinical Examination.

Objective: To evaluate the perception of MBBS students towards Objective Structured Practical Examination and Objective Structured Clinical Examinationas an assessment method.

Methods: A cross-sectional study was conducted amongst MBBS students from all academic years of Poonch Medical College, Rawalakot, Azad Kashmir, Pakistan from June to August 2018. A self-administered questionnaire containing 13 items was used for the data collection.

Results: 267 students from all academic years participated in this survey. Majority of the students believed that OSPE/OSCE can remove inter-examiner variations.  Maximum students agreeing with the statement that “OSPE is better than conventional examination”, were from the third year (63.93%) followed by 4th year (60.0%). Highest number of students who agreed that “OSPE/OSCE should replace viva-voce”, was from 4th year. Overall, 73.12% MBBS students, inclusive of all academic years, agreed that the OSPE should be preferred method of assessment in every subject.

Conclusion: The present study has shown good acceptability of Objective Structured Practical Examination and Objective Structured Clinical Examinationby the students with majority of them considering it better than conventional method.

Key Words: Students, Examinations, Medical Education, Objective Structured Practical

CR_ 8 Synovial Hemangioma Of The Ankle Joint – A Rare Entity

Sahar Iqbal, Tahmina Gul, Sadaf Zahid, Naila Atif and Ikram-ul-Haq

Department of Histopathology, Azra Naheed Medical college, Lahore


Abstract: Synovial hemangioma is a rare benign tumor of vascular origin usually effecting joint spaces and tendon sheaths. Patient may present with non-traumatic pain and swelling, sometimes giving the clinical impression of bursitis. Rarity of the condition, vague clinical symptoms and non-specific radiological findings may lead to delayed diagnosis. We present a case of synovial hemangioma of ankle joint which is quite an infrequent site for this lesion.

Keywords: Hemangioma, ankle joint, synovium

Editorial: Use of Internet and Social Media in Learning

Prof. Anwar Ul Haque


Internet is one of the most useful and used modern devices. All over the world we see many people including children totally submerged in smart phones and laptops. Some are addicted; an addiction that could be as bad as drug addiction or even worse! I remember a cartoon showing a newborn whose umbilical cord was about to be cut; saying “Wait a minute first let me update my status”!

Devices are not good or bad, it’s their use which makes the difference! We may use Facebook all day telling people what fashion we did, what we cooked or what we ate or where we went. These things add very little value for others and for us it may be shear waste of time and energy making us very tired at the end of the day that may have considerable toll on our health. Positive use of internet and social media on the other hand could be very rewarding; but we must not let it conquer us.

OA_Molecular Subtypes of Breast Cancer by Immunohistochemical Profiling

Rubina Gulzar, Ruqaiya Shahid and Omema Saleem

Dow International Medical College, Dow University of Health Sciences, Karachi, Pakistan



Objective: To evaluate the frequency of molecular sub types of breast cancer on core needle biopsy and to correlate the subtypes with these clinico-pathologic parameters: age of the patient, histologic type and grade of cancer and lymph-vascular invasion (LVI).

Methods: A cross-sectional, observational study, conducted at Dow University of Health Sciences, Karachi, from December 2014 to December 2015. It included core needle biopsies of 285 patients of breast cancer. Immunohistochemical staining with antibodies for Estrogen Receptor (ER), Progesterone Receptor (PR) and Human Epidermal Growth factor 2 (Her 2) was performed and breast cancers were classified into four molecular subtypes: Luminal A (ER/PR +, HER2-), Luminal B (ER/PR +, HER2+), Triple Negative Breast cancer (TNBC) (ER/PR -, HER2-) and HER 2 (ER/PR -, HER2+). Clinical parameters were compared using chi-square test.

Results: 285 cases were included in this study. The mean age of the patients was 43.3 years (17-88). The frequency of the molecular subtypes of breast cancers was Luminal B 139(48.77%), Luminal A 60(21.05%), Her2 54(18.94%) and Triple Negative Breast cancer 32(11.22%). The most common diagnosis of breast cancer was Invasive Ductal Carcinoma 258 (90.52%) and grade II 230 (80.70 %). There was significant association of molecular subtype of breast cancer with the grade of tumor (p<0.001) and with lympho-vascular invasion (p<0.011). Her 2 cancers showed the highest frequency of grade 3 and Triple Negative Breast cancer had the highest frequency of lymph-vascular invasion.

Conclusion: Luminal B is the most common molecular subtype of breast cancers in our population. The mean age of breast cancer was younger than most studies. We recommend that the molecular subtyping of breast cancers using immunohistochemistry should be incorporated into histopathology reporting of core needle biopsies, as this may facilitate the clinicians in selection of treatment for the patients.

Key words: Breast cancer, molecular subtypes, receptor status, hormone receptors, immunohistochemistry, Triple negative breast cancer, ER, PR, HER2, HER2/neu