Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University <p>The Annals of Pakistan Institute of Medical Sciences (APIMS) is the Official quarterly and open access journal of Shaheed Zulfiqar Ali Bhutto Medical University (SZABMU), Pakistan. Previously two separate medical journals of this institute were being published, namely, JPIMS started from 1990 and the Journal of Surgery 1991. They were officially merged into one journal APIMS in 2005. Annals of PIMS is recognized by Pakistan Medical and Dental Council (PMDC), Higher Education Commission of Pakistan ( Y category), CPSP <a href="" target="_blank" rel="noopener">(</a> index in EBSCO Host &amp; Base from Germany. </p> Shaheed Zulfiqar Ali Bhutto Medical University en-US Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University 1815-2287 <p><a href="" rel="license"><img style="border-width: 0;" src="" alt="Creative Commons License" /></a><br />This is an Open Access article distributed under the terms of the Creative Commons Attribution License (, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</p> A Management of forgotten double J Ureteric stent in a young male: A Case Report <p>A 17 years old male patient of poor socioeconomic background from a remote village of Afghanistan, presented to our out-patient department with abdominal pain at the right flank. He had history of double J stent placement during right open pyelolithotomy 6 year before. However, no further details were available. An ultrasonography was performed which showed pelvi-calyceal fullness of the right kidney with a calculus measuring 7mm in the right renal lower pole. Echogenic foci and rounded loop of stent were seen in bladder adjacent to right vesico-ureteric junction. A renal scan revealed right kidney function 16.95% with GFR 13.1ml/min and left kidney function 83.05% with GFR 64.1ml/min. A cystolitholipexy was then performed and the lower end of the forgotten double J stent was removed along with the encrusted stone in bladder using stone punch. This was followed by removal of ureteric and intra- renal fragments of double J stent using 8-Fr rigid Ureterorenoscope without any significant resistance. Complete stone clearance was achieved and patient was discharged home. In light of this scenario we believe it is necessary to educate and maintain regular contact with the patient to ensure regular follow-up visits for patients with double J ureteric stent placements in order to avoid such complications in the future.</p> Nizam Farid Chisti Copyright (c) 2022 Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University 2022-06-24 2022-06-24 18 2 SUBCUTANEOUS LIPOMA MIMICKING IRREDUCIBLE INGUINAL HERNIA <p>Groin lipoma is a rare condition(1). It can lead to a misdiagnosis of inguinal hernia. In case of incorrect diagnosis there is clinically high risk of development of intra operative complications(2). Similar picture can also be presented with spermatic cord lipoma, spermatic cord encysted hydrocoele and psoas abscess(3,4). Spermatic cord malignancy is a rare and challenging diagnosis(5). We present a case of groin lipoma mimicking irreducible right sided indirect inguinal hernia in young healthy man.</p> Syed Asad Ali Mujeeb Ur Rehman Laghari Samar Memon Shahid Ali Tufail Ahmed Baloch Copyright (c) 2022 Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University 2022-06-26 2022-06-26 18 2 Inguinal bladder hernia; A case report <p>Inguinal&nbsp;<a href="">bladder</a>&nbsp;hernia is a rare condition usually diagnosed per-operatively. Patients may present with inguinal swelling,&nbsp;<a href="">dysuria</a>,&nbsp;<a href="">hematuria</a>,or&nbsp;<a href="">urinary urgency</a>. Obesity, advancing age and poor musculature are risk factors. We hereby present a case of inguinal&nbsp;<a href="">bladder</a>&nbsp;hernia in a 47-year-old obese male presented to outpatient department with history of inguino-scrotal, partially reducible swelling, lower urinary tract symptoms, off and on haematuria and dysuria. Scrotal ultrasound showed clear fluid present in the scrotum which was communicating with bladder. This was confirmed by cystography showing “dog ear”sign. Hernia containing bladder was reduced and hernioplasty was performed.</p> akram malik Nauman Khalid Muhammad Ali Adeen Akram Asad Ramzan Muhammad Waqas Iqbal Copyright (c) 2022 Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University 2022-06-24 2022-06-24 18 2 Effect of Skeletal Muscle Strength and Body Fat Distribution on Pulmonary Functions <p class="root-block-node" data-changed="false" data-paragraphid="7"><strong><span class="red-underline" data-startindex="0" data-endindex="11" data-paragraphid="7">Objectives: </span></strong>This study aimed to assess a link between pulmonary function tests, upper and lower extremity muscular strength, and body fat distribution in Saudi males.</p> <p class="root-block-node" data-changed="false" data-paragraphid="8"><strong><span class="red-underline" data-startindex="0" data-endindex="12" data-paragraphid="8">Methodology: </span></strong>This cross-sectional study was conducted in the department of physiology at the College of Medicine, King Saud University, Riyadh, Saudi Arabia. A total of 106 participants were invited, ranging from 20<span class="red-underline" data-startindex="215" data-endindex="215" data-paragraphid="8">-</span>47 years old. The participants were divided into three groups, with ages ranging from 20<span class="red-underline" data-startindex="304" data-endindex="304" data-paragraphid="8">-</span>29 years old, 30-39 years old, and 40–47 years old. Handgrip and thigh muscle strength <span class="red-underline" data-startindex="392" data-endindex="394" data-paragraphid="8">was</span> assessed using isometric dynamometry. Pulmonary function tests were performed according to the American Thoracic Society's guidelines recommendations.</p> <p class="root-block-node" data-changed="false" data-paragraphid="9"><strong>Results:</strong> There was no significant difference between the three age groups in upper and lower limb muscle strength. The handgrip strength was stable from 20 to 47 years, ranging from 37 to 39. Also, thigh <span class="red-underline" data-startindex="204" data-endindex="210" data-paragraphid="9">muscles</span> strength was not affected by age for the three age groups. <span class="red-underline" data-startindex="271" data-endindex="279" data-paragraphid="9">Skinfold </span>measurement of the upper body showed no significant differences in <span class="red-underline" data-startindex="347" data-endindex="352" data-paragraphid="9">Biceps</span>, <span class="red-underline" data-startindex="355" data-endindex="361" data-paragraphid="9">Triceps</span>, and <span class="red-underline error-hovered" data-startindex="368" data-endindex="370" data-paragraphid="9">Sum</span> of <span class="red-underline" data-startindex="375" data-endindex="382" data-paragraphid="9">skinfold</span> <span class="red-underline" data-startindex="384" data-endindex="387" data-paragraphid="9">were</span>, <span class="red-underline" data-startindex="390" data-endindex="407" data-paragraphid="9">however, Skinfold </span>measurement of the lower body of <span class="red-underline" data-startindex="441" data-endindex="451" data-paragraphid="9">Subscapular</span> and <span class="red-underline" data-startindex="457" data-endindex="461" data-paragraphid="9">Supra</span> iliac <span class="red-underline" data-startindex="469" data-endindex="473" data-paragraphid="9">were </span>different<span class="red-underline" data-startindex="483" data-endindex="496" data-paragraphid="9"> significantly</span></p> <p class="root-block-node" data-changed="false" data-paragraphid="10"><strong><span class="red-underline" data-startindex="0" data-endindex="11" data-paragraphid="10">Conclusion: </span></strong>There was no association between the age groups in upper and lower <span class="red-underline" data-startindex="79" data-endindex="83" data-paragraphid="10">limbs</span> muscle strength. However, further studies will be conducted to explore the study findings.</p> Abdul Rahman Mohammed Alhowikan Copyright (c) 2022 Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University 2022-06-22 2022-06-22 18 2 10.48036/apims.v18i1.638 Quality Of Life of Women, Pre- and Post-Operative Breast Cancer Surgery <p>Background: Breast cancer is a painful disease that deteriorates the quality of life (QoL) of affected women in all aspects of life. It is of particular importance to determine the factors that manipulate the assessment of QoL. <br />Objective: to evaluate the Quality of Life (QoL) of women with breast cancer who came for treatment in surgery department before diagnosis and post-operative time period. The QoL findings are co-related to the socio-economic status.<br />The determination of the factors that predict changes in quality of life provides important information for clinical practice and can be used for the development of evidence-based guidelines in the design of breast cancer follow-up protocols.<br />Study Design: Retrospective Cohort study<br />Place and Duration of Study: General surgery Department, Islamabad Medical complex, Nescom, from January 2018 to January 2020. <br />Methodology: 74 diagnosed breast cancer patients, above 18 years of age, who underwent surgical treatment (MRM and Axillary clearance), were selected. QoL was assessed with the help of EORTC QLQ C-30 and EORTC BR-23 questionnaire Proforma as assessment tool. SPSS 20 was used to analyze the data and Wilcoxon test and Kruskal-Wallis test were performed. <br />Results: The QoL assessed at pre and post operative stage showed positive results only in the future prospects and emotional function domain. Whereas, negative results were scored in rest of the domains, which are symptoms in the arm, body image, financial concerns, sexual pleasure, cognitive function and physical function.<br />Conclusion: The need for a multidisciplinary approach for breast cancer patients is required regarding different dimensions that can improve their QoL.<br />Key Words: Breast cancer, breast carcinoma, Quality of Life (QoL), women, surgery.</p> Dr Summera Ambreen Dr Ayesha Javed Dr Riaz Hussain Siddiqui Dr Hana Mehmood Dr Rizwan Sultan Dr Fatima Tuz Zahra Copyright (c) 2022 Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University 2022-06-22 2022-06-22 18 2 Association of Quantitative ST- Segment Depression with Early Mortality among Navia Patients of Non- ST- Segment Elevation Acute Coronary Syndrome <p><strong>Objective: To determine the association of quantitative ST– segment depression with early mortality within 30-day in patients with first non-ST– segment elevation acute coronary syndrome (NSTE-ACS).</strong></p> <p><strong>Material and methods:</strong> This descriptive case series study was conducted at the cardiology department of LUMHS, from October 2015 to March 2016. Patients with NSTE-ACS and positive cardiac biomarkers, patients older than 25 years and both genders admitted to CCU were included. The ST-Segment depression was assessed on 12 lead electrocardiography. The ST segment is the line that starts from the end of the QRS complex (J wave) to the beginning of the T wave. Normally ST segment is straight line and, isoelectric to base line, ST segment depressed below isoelectric line is said ST depression, down sloping or flat depressed ST segments indicate coronary ischemia, more than 0.5 mm ST depression significant for ischemia. All patients were followed for 30-days for early mortality. All information obtained was recorded on the study Performa.</p> <p><strong>Results</strong>: A total of 148 cases with acute myocardial infarction were integrated; the patient's average age was achieved as, 42.5±5.43 years, and males were in the majority 96(64%). On electrocardiography, ST-Segment depression was found in 60.13%, which is further divided into 0.5mm, &gt;0.5-0.9 mm, &gt;1-1.9 mm, and &gt;2 mm with percentages of 12.83%, 22.29%, 16.89%, and 8.12%, respectively. Short term mortality was significantly associated with the severity of ST segment depression score (p-value 0.001).</p> <p><strong>Conclusions: </strong>In the study conclusion, the severity of ST-Segment depression score was observed to be significantly correlated with short term mortality (30-day) in cases with early NSTE-ACS.</p> Ghulam Farid Shah Shahid Hussain Memon Ambreen Haidar Aijaz Ahmed Memon Mashooq Ali Dasti Tabbasum Almas Copyright (c) 2022 Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University 2022-06-22 2022-06-22 18 2 Immuno Histochemical Expression of CD10 OR CA19.9 in Urinary Bladder Transitional Cell Carcinoma <p><strong>Objectives:</strong> To determine the frequency of immune histochemical expression of CD10 and CA19.9 in patients of papillary urothelial carcinoma of the bladder following the WHO 2004 grading of the tumor.</p> <p><strong>Methodology: </strong>This Descriptive, Cross-sectional survey has been done in during 21<sup>st</sup> October 2017 to 20<sup>th</sup> October 2018. A total of 75 patients with a diagnosis of papillary urothelial carcinomas of urinary bladder on histopathology, using TURBT, from 40 to 80 years of age, irrespective of gender were included.</p> <p><strong>Results: </strong>Out of these 75 patients, 39 (52.0%) were male and 36 (48.0%) were female with a male to female ratio of 1.1:1. The frequency of positive expression of CD10 and CA19.9 on immunohistochemistry was found in 41 (54.67%) &amp; 39 (52.0%) cases. It was seen that positive CD10 expression was found in 12 (31.58%) low-grade tumors and in 24 (63.16%) high-grade tumors. Positive CA19.9 expression was found in 29 (78.38%) low-grade tumors and 15 (40.54%) high-grade tumors.</p> <p><strong>Conclusion:&nbsp; </strong>The study concluded that there was an increased CD10 expression in high-grade urothelial carcinomas while low-grade urothelial carcinomas showed an increased expression of CA19.9.</p> <p>&nbsp;</p> Rehana Ramzan Umm-e- Farwa Mahwish Niaz Kashif Bangash Zainab Taj Hassan Salim Copyright (c) 2022 Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University 2022-06-22 2022-06-22 18 2 Presentation and Management Outcome of Unilateral and Bilateral Prominent Ears with Standard Otoplasty Techniques <p class="root-block-node"><strong>Objective:</strong> To determine the outcome of otoplasty in terms of a satisfactory cosmetic outcome and any postoperative complications.</p> <p class="root-block-node" data-changed="true" data-paragraphid="44"><strong>Methodology:</strong> This descriptive case series was carried out over a period of five years<span data-startindex="78" data-endindex="78" data-paragraphid="44"><span class="red-underline">.</span></span> (i.e<span data-startindex="84" data-endindex="84" data-paragraphid="44"><span class="red-underline">.</span></span> from January 2017 to December 2021) <span data-startindex="123" data-endindex="124" data-paragraphid="44"><span class="red-underline">at</span></span> the Burn and Trauma Center, Department of Plastic Surgery, Hayatabad Medical Complex, Peshawar. Patients of all ages and genders who presented with prominent ears and underwent corrective procedures at our institute were included. Patients who were unwilling to undergo surgery or who did not consent to inclusion in the study were excluded. Patients with constricted ears, crytotia, shell ears, and question mark ears were also excluded.</p> <p class="root-block-node" data-changed="false" data-paragraphid="45"><strong>Results: </strong>Out of 45 patients, 29 (64.44%) were females and 16 (35.55%) were males. Their ages ranged between 11<span data-startindex="109" data-endindex="109" data-paragraphid="45"><span class="red-underline">-</span></span>30 years, with a mean of 22.28<span data-startindex="139" data-endindex="139" data-paragraphid="45"><span class="red-underline">±</span></span>5.49 years. The anomaly was bilateral in 84.44% (n = 38) of the patients, while 15.55% <span data-startindex="217" data-endindex="222" data-paragraphid="45"><span class="red-underline">(n=7) </span></span>patients had unilateral defects. 57.7% <span data-startindex="262" data-endindex="264" data-paragraphid="45"><span class="red-underline">(n=</span></span>26) of the patients were unmarried, whereas 42.3% <span data-startindex="314" data-endindex="316" data-paragraphid="45"><span class="red-underline">(n=</span></span>19) were married.</p> <p class="root-block-node" data-changed="false" data-paragraphid="46">All the patients had satisfactory cosmetic outcomes. Various complications encountered included extrusion of sutures <span data-startindex="116" data-endindex="118" data-paragraphid="46"><span class="red-underline">(n=</span></span>3; 6.66%) and superficial wound infection <span data-startindex="161" data-endindex="163" data-paragraphid="46"><span class="red-underline">(n=</span></span>1; 2.22%).</p> <p class="root-block-node" data-changed="false" data-paragraphid="47"><span class="red-underline"><strong><span data-startindex="0" data-endindex="11" data-paragraphid="47">Conclusion: </span></strong></span>Correction of the prominent ears with the standard otoplasty techniques yields satisfactory cosmetic results. <span data-startindex="122" data-endindex="223" data-paragraphid="47"><span class="blue-complex-underline">Lasting results can be achieved by combining different otoplasty techniques that are stable over time.</span></span></p> Muhammad Hamayun Shinwari Irfan Ullah Muhammad Bilal Copyright (c) 2022 Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University 2022-06-22 2022-06-22 18 2 10.48036/apims.v18i1.630 Comparison of High Intensity Non-Invasive Ventilation With Low Intensity Non-Invasive Ventilation In Patients With Acute Copd Exacerbation <p><strong>Objective: </strong>To determine the outcome of high intensity non-invasive positive pressure ventilation (HI-NPPV) as compared to low intensity non-invasive positive pressure ventilation (LI-NPPV) in patients with acute COPD exacerbations.</p> <p><strong>Methodology: </strong>This Randomized controlled trial Department of PulmonologyFauji Foundation Hospital Rawalpindi from 31<sup>st</sup> December 2016 to 30<sup>th</sup>June 2017. Arterial blood gases will be taken at admission. If values of pH and paCO<sub>2</sub> meet the criteria for non-invasive ventilation then patients will be enrolled in the study. Patients will be randomly divided into two groups by lottery method. GROUP A and GROUP B. GROUP A will receive high intensity NIV (HI-NPPV) and GROUP B will receive low intensity NIV (LI-NPPV) by TRIOLOGY machine. Expiratory positive airway pressure (EPAP) will remain between 4 to 6 cmH<sub>2</sub>O. Arterial blood gases (ABGs) will be done at baseline and then 72 hours after admission. Improvement in PaCO2, HCO3, and FEV1 will be recorded 72 hours from baseline and collected on proforma (attached).</p> <p><strong>Results: </strong>Mean age (years) in the study was 55.54+3.81. There were 08 male patients included the study meeting the inclusion criteria. Of these, 05 and 03 male patients among both the groups respectively. Similarly, there were 92 female patients included the study meeting the inclusion criteria, of these, 45 and 47 female patients among both the groups respectively. Outcome of the study was assessed in terms of mean PaCO2 (mmHg), HCO3 (mmol/L) and FEV1 at baseline and after 72 hours. Mean PaCO2, HCO3 and FEV1 at baseline was 64.87+5.22, 33.75+4.17 and 0.66+0.04 respectively. After 72 hours, mean PaCO2 (mmHg) , HCO3(mmol/L), and FEV1 among both the groups was 63.98+6.58 vs 41.46+2.40, 33.10+4.81 vs 23.12+2.01, 0.66+0.05 vs 0.72+0.04 with following P value of (0,000, 0.000, 0.000) respectively.</p> <p><strong>Conclusion: </strong>High intensity non-invasive positive pressure ventilation (HI-NPPV) has no different outcome as compared to low intensity non-invasive positive pressure ventilation (LI-NPPV) in patients with acute COPD exacerbations.</p> Asma Sabir Kanwal Fatima Khalil Aisha Shafique Sara Duad Asma Ambreen Shomaila Awan Copyright (c) 2022 Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University 2022-06-22 2022-06-22 18 2 Predisposing Factors in Post Endoscopic Retrograde Cholangiopancreatography Pancreatitis <p><strong>Objective: </strong>To determine the frequency of predisposing factors in post endoscopic retrograde cholangiopancreatography pancreatitis at Isra university hospital Hyderabad</p> <p><strong>Material And Methods: </strong>The Descriptive cases series study was conducted in the department of gastroenterology at Isra University Hospital, Hyderabad from September 2018 to 10 March 2019.</p> <p>All the patients aged 18 to 50 years, both genders and diagnosed as case of post ERCP pancreatitis were included. All the patients were undergoing ERCP procedure. Procedure was done under conscious sedation or propofol where needed. Antibiotic prophylaxis 1gm intravenous will be used. All patients were discharged after 5 hours; if there will be no any complications. Serum amylase level was assessed in all patients at 4 hours. Patients diagnosed as a case of post ERCP pancreatitis on the basis of new onset or worsening of abdominal pain and elevated serum amylase level three times the upper normal limit were further studies. After the selection of the cases, patients will be evaluated for the presence or absence of contributing factors like age, gender, cannulation attempts, cannulation time, precut papillotomy, pancreatic duct contrast injection, previous history of post ERCP pancreatitis and sphincter of Oddi dysfunction. All the data will be recorded in the proforma. The data was entered and analyzed in statistical program SPSS version 26.0.</p> <p><strong>Results: </strong>Mean age of the patients was 42.7 years. Majority of the patients 65.47% were males and 32.90% were females. Mean duration of pancreatitis was 3.1 days. Sphincter of oddi dysfunction was in 17.1% cases. Precut papillotomy was done in 18(23.7%) cases. Repeated pancreatic duct injury was seen in 10(13.2%) cases. No significant difference was found of effect modifiers on predisposing factors in post endoscopic retrograde cholangiopancreatography pancreatitis, p-values were almost insignificant.</p> <p><strong>Conclusion: </strong>It was concluded that frequency of pancreatitis after endoscopic retrograde cholangiopancreatography in patients with obstructive jaundice was found not very high in our practice and in agreement with other studies. Female gender, pre-cut papillotomy and repeated pancreatic duct injection were the most important risk factors associated with/ contributing to the development of post ERCP acute pancreatitis</p> <p><strong>Key words:</strong> PERCP, predisposing factors</p> Gotam Das Prem Kumar Muhammad Akram Bajwa Sajan Sawai Muneer Sadiq Shabnam Rani Copyright (c) 2022 Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University 2022-06-22 2022-06-22 18 2 Our Nuts and Bolts in The Permanent Pacemakers’ Explanation Techniques <p><strong>Background: </strong></p> <p>Explantation like implantation of devices is an art. Box change may be needed alone or it may accompany by lead extraction. If it is just box change then the strategy from very start is different to make it as simple as possible but if lead extraction is part of the procedure then it should be planned differently before incision to shorten the procedure time and minimize the complication rate. For successful explantation if the role of gadgets and expertise cannot be subvert, then at the same time a well-planned procedure cannot be undermine. We are going to share our experience of device explantation in the last one decade at Hayat Abad Medical Complex Peshawar.</p> <p><strong>Methodology: </strong>All patients who presented for box change or explantation of devices were prepared with standard protocol. After baseline patient were brought nil by mouth to catheterization laboratory (Cath: lab). Temporary pacemaker (TPM) implanted for backup. After local anesthesia, with blunt dissection the device recovered and detached from the lead. In case of box change new device attached after checking the integrity of the lead and device placed in the same pocket. But if there was need of lead extraction, then stylet put inside the lead and with twisting movement and mild traction the lead removed and new lead implanted with Seldinger,s technique, battery attached and wound closed in layers.</p> <p><strong>Results:</strong><strong> </strong>Total 1670 were performed during the study period. There were 1535 (91.9%) new implantation and 135 (8.08%) repeat procedures. Pulse generator was replaced without lead replacement in 59 (3.5%) patients. In 36 (2.15%) patients the ventricular lead or atrial lead was successfully reposition. Total 32 (1.9%) successful explanations were performed in the study period.</p> <p><strong>Conclusion: </strong>Explanation for box change and lead extraction needs to be individualized and the whole procedure needs to be planned before instead as a default or provisional procedure for both together<strong>.</strong></p> <p> </p> Shahab Saidullah Bakhtawar Shah Salman Habib Asma Rauf Copyright (c) 2022 Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University 2022-06-14 2022-06-14 18 2 Comparative study of early neonatal vs late circumcision in terms of post operative complications: a prospective randomized study. <p><strong>OBJECTIVE: T</strong>o compare early neonatal versus late circumcision by plastibell in terms of postoperative complications.</p> <p><strong>MATERIAL AND METHODS: </strong>It was a randomized controlled trial study conducted at Department of Pediatric Surgery Shifa International Hospital Islamabad from January 2018 to November 2019. The present study is a prospective analytical review of 482 uncircumcised patients. Variables which were observed in this study were age, mode of presentation and complications. We divided patients in 2 groups, in Group A circumcision was done within first 3 days of life and in Group B circumcision was done from in conventional manner after one week of life till 3 months of age.</p> <p><strong>RESULTS: </strong>Total 482 patients were presented during this study period out of which 70 belong to Group A and 412 belong to Group B. In Group A, bell retraction was seen in 4 patients (5.71%), infection of glans in the form of flakes of pus was seen in 1 patient (1.42%), delayed fall was seen in 2 patients (2.85%) and meatal ulcer was seen in 1 patient (1.42%). In Group B, bell retraction was seen in 8 patients (1.94%), infection in 4 patients (0.97%) and delayed fall in 4 patients (0.97%). Complications like bleeding, over/under circumcision, smegmal cyst, meatal stenosis and urethrocutaneous fistula were not seen in any group.</p> <p><strong>CONCLUSION: </strong>We conclude that neonatal circumcision done within first 3 days of life or even soon after birth is safe and has no significant difference of complications as compared to patients in whom circumcision is done at a later stage. We recommend to perform circumcision before discharge of the mother. Thus the apprehension amongst the medical community regarding early neonatal circumcision is unjustified.</p> Anwar Ul Haq Copyright (c) 2022 Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University 2022-06-22 2022-06-22 18 2 The Role of Serum C - reactive protein, White Blood Cell Count and Neutrophils Percentage in the Diagnosis of Childhood Acute Appendicitis <p><strong><em>Objective:</em></strong><em> To find out the role of CRP, white cell count and granulocytosis in accurately diagnosing Acute Appendicitis. Sensitivity, specificity, positive predictive value negative predictive values of these tests was calculated. </em><strong><em>Place and Duration of the study</em></strong><em>: This cross sectional study was conducted in immunology department of the children’s hospital and University of Child Health Sciences, Lahore over a time period of six months from July 2019 to December 2019. </em><strong><em>Material and Method:</em></strong><em> Total 91 suspected patients of Acute Appendicitis were including. The blood samples were taking from the patients and sent to the lab immediately for the estimation of serum CRP, WBC count and Neutrophil Percentage. The sensitivity, specificity, positive predictive value and accuracy were calculated for each test and then combine sensitivity, specificity, positive predictive value and accuracy calculated. </em><strong><em>Result:</em></strong><em> There were 55 (60.4%) males and 36(39.6%) females under the age of 2-16 years. Out of 91 patients, 71 patients had acute appendicitis and 20patients had normal Appendix. Out of 71 there were 46 Patients had Acute Appendicitis, 22 patients had perforated appendix and 3 patients who had gangrenous appendix. The sensitivity, specificity, accuracy, positive predictive value and negative predictive values of these 3 test 93.87%, 83.63%, 88.5%, 92% and 63.63% respectively. </em><strong><em>Conclusion:</em></strong> <em>The combination of clinical signs and symptoms along with measurements of Serum CRP, WBC count and neutrophils percentage can enhance the pre-surgical decision and save the children both ways that is from negative surgery and complication of appendicitis if un-operated.</em>&nbsp;</p> <p><strong><em>Key Words:</em></strong><em> CRP, WBC, Nu%, Appendix, Accuracy, Sensitivity, Positive Predictive Value. </em></p> Aqsa Anam Copyright (c) 2022 Annals of PIMS-Shaheed Zulfiqar Ali Bhutto Medical University 2022-06-22 2022-06-22 18 2