Laparoscopic appraisal of infertility and pelvic pain in Pakistani women: a 5 years audit

Five hundred and nine Laparoscopic examinations performed between 1987-91, (147 procedures for evaluation of gynaecologic pelvic pain and 313 for infertility) revealed ectopic pregnancy (27%), twisted ovarian cyst (18%) and acute pelvic inflammatory disease (14%) in cases of acute gynaecologic pain, and endometriosis (17%) and chronic pelvic inflammatory disease (16%) in chronic pelvic pain. Adhesions (20%), tubal block (15%), endometriosis (9%) and polycystic ovary (7%) were common findings in cases of infertility. These data support the usefulness of this minimally invasive procedure in accurate diagnosis of gynaecological disorders and provides insight into the spectra of diseases seen in Pakistani women with pelvic pain and infertility.

Bacteriuria and pregnancy outcome: a prospective hospital-based study in Pakistani women

The prevalence of bacteriuria in Pakistani women and its association with complications of pregnancy was studied. Out of 1579 women, 77 had bacteriuria (4.8%). There was no association of age, gravidity, parity, haemoglobin, pre-eclampsia, mode of delivery, gestational age at delivery, preterm delivery and low birth-weight with presence of bacteriuria. With detection and treatment the pregnancy outcome of women with bacteriuria in pregnancy was the same as that of those without.

A developing country's university oriented toward strengthening health systems: challenges and results

OBJECTIVES

The Aga Khan University in Karachi has a mission to educate leaders and to contribute to the development of health systems for Pakistan amid challenges of scarcity and complexity.

METHODS

Its key activities are (1) to design and test urban and rural health system prototypes, (2) to develop faculty in medical and nursing postgraduate community health sciences programs, and (3) to design and implement community-based undergraduate medical and nursing curricula.

RESULTS

The university has developed equity-based, cost-effective primary health care prototypes in Karachi slums. With government counterparts it has tested village-, facility-, and district-level interventions in a poor rural district. Federal policymakers have taken models from each for widespread replication. The university is training 49 medical and 19 nursing faculty for postgraduate programs in community health sciences. Most faculty retain institutional leadership positions, including teaching community-based, problem-solving, community health sciences as 20% of the medical and nursing undergraduate curriculum.

CONCLUSIONS

The mission and experience of the Aga Khan University in population-based health systems design and health sciences education can guide universities in both developing and developed countries.

The safety of epidural analgesia in labour and its effect on delivery--a case control study in Pakistani women

To assess the safety and effect of epidural analgesia on the course of labour and delivery in Pakistani women, a retrospective case control study was conducted from November, 1986 to November, 1991 (5 years) at the Aga Khan University Medical Centre, Karachi. All patients (n = 64) who received epidural analgesia for labour (cases) were compared with randomly selected patients (n = 18) who did not receive epidural analgesia during labour (controls). The cases and controls were matched for age, height, body mass index, parity, use of oxytocin, presentation and weight of the foetus. There was no significant difference (P > 0.05) between the two groups in duration of labour, caesarean section rate and foetal apgar scores at 1 and 5 minutes after birth. The incidence of malposition of foetal vertex at delivery and that of instrumental (forceps) deliveries was significantly higher (P < 0.05 and < 0.01 respectively) in the epidural group as compared to controls. The incidence of complications was low and the acceptance and tolerance of epidural analgesia was good in our patients.

Human immunodeficiency virus in gestational trophoblastic neoplasias--is it a poor prognostic risk factor

Three cases of HIV infection with choriocarcinoma are presented. One case had prolonged chemotherapy without remission, the second had remission only after combining hysterectomy with chemotherapy and the third who had extensively metastatic disease in the presence of other low risk factors are reported. HIV infection may predispose patients to extensive metastatic choriocarcinoma and influence the course of treatment. We propose that HIV infection be considered a poor prognostic risk for gestation trophoblastic neoplasias.

Audit of hysterectomies at the Aga Khan Hospital, Nairobi: justification of operative indications

An audit of 381 hysterectomies performed over a 5 year period (1986-1990) was carried out. In order to assess justification of the indication for hysterectomy pre-operative diagnoses were divided into two groups: those potentially confirmable by pathologic study and those not potentially confirmable by pathologic study. Out of the 273 cases studied in the first group, 246 (90.1%) were justified, while out of the 108 cases studied in the second group, 82 (75.9%) were justified. An overall 86% justification rate was observed. Adenomyosis as a histopathologic finding was seen more commonly in Asian than African patients (P < 0.005). Morbidity rate was 20% and there were no mortalities. The procedure in general was considered safe and justified.

Cervical cancer screening program in a Muslim country: three-year experience at the Aga Khan University Medical Center, Karachi

A systematic cervical cancer screening program was initiated in January 1987 at The Aga Khan University Medical Center, Karachi, Pakistan. The 8,784 cervical smears obtained in 3 subsequent years from 8,412 consecutive women attending the gynecology and antenatal clinics were reviewed. "Positive" smears were found in 111 (1.3%) patients; 107 (1.27%) smears showed squamous epithelial dysplasia and 4 smears showed adenocarcinoma. The highest incidence of abnormal smears was found in the 45-54 years age group. Colposcopy and biopsy was performed on all patients with "positive" smears except on those with atypical or mildly dysplastic ones, in whom only the persistence of the abnormality on repeated smears was considered an indication for tissue evaluation. The histopathologic diagnosis of these biopsy specimens revealed cervical intra-epithelial neoplasia in 60 patients and invasive cervical cancer in 6 patients.

Gestational diabetes in a developing country, experience of screening at the Aga Khan University Medical Centre, Karachi

In order to determine the prevalence of glucose intolerance in pregnancy, 1267 consecutive women attending the antenatal clinic of the Aga Khan University Medical Centre were subjected to a 75 g glucose challenge followed 2 hr later by plasma glucose determination irrespective of gestation on the first antenatal visit. The test was repeated at 28-32 weeks of gestation if the patients had an abnormal initial screen at less than 28 weeks gestation and a normal glucose tolerance test on diagnostic follow-up and for those who had a risk factor for gestational diabetes and a normal initial screen at less than 28 weeks gestation. The glucose challenge test was abnormal (2 hr plasma glucose greater than 140 mg%) in 8.6% of the screened population. Follow-up oral glucose tolerance test on these patients revealed a prevalence of 3.2% of gestational diabetes and 1.9% of impaired glucose tolerance test based on the modified O'Sullivan criteria. Improvement in cost effectiveness of screening programmes was adjudged possible by avoiding glucose tolerance tests in patients with 2 hr plasma glucose value of greater than 170 mg% after a 75 g oral glucose challenge for screening.

Was that hysterectomy really necessary? Audit of operative justification at the Aga Khan University Medical Centre, Karachi

Hysterectomy in Pakistan, like in other parts of the world is considered to be overused in a number of cases. As a part of a quality assurance process at the Aga Khan University Medical Centre, Karachi, 376 hysterectomies performed between January, 1987 and December, 1989 were retrospectively analysed and the results are presented. In 250 (66.5%) cases, where pathology was expected to be found, the hysterectomy was considered justified if the preoperative diagnosis was verified by the pathology report of if significant alternate pathology was present. In 126 (33.5%) cases, where no pathology was expected to be found 'validation criteria' were used to ascertain justification of the procedure. The results showed justification rates of 83% for recurrent uterine bleeding, 85% for adenomyosis, 90% for adnexal masses and endometrial carcinoma, 95% for fibroids, 97% for pelvic relaxation and 100% each for pregnancy catastrophe, endometriosis, chronic pelvic inflammatory disease and premalignant disease of uterus and cervix. In general 92.0% of all hysterectomies in this series were justified.

Epidemiology and ethics: the people's perspective

To a Western audience the terms “people” and “people's perspective” could appear somewhat perplexing. Technically, every person belongs to the class of “people”; hence, to talk of “people's perspective” seems to make an artificial division within one monolithic group. This ostensibly artificial division reflects a reality that necessitates it. In a Third World context, the term “people” has a fairly distinct connotation. It is not just a majority which is governed by a system that gives all people a minimal quality of life and allows them a meaningful participation in the political process. In a Third World context “people” are a “mass”—a faceless body of massive energy to be manipulated and kept domesticated in the interest of the powerelite. It is a power-bloc that is threatening as well as inescapable.

Adenomyosis in Pakistani women: four year experience at the Aga Khan University Medical Centre, Karachi

As part of a quality assurance programme at the Aga Khan University Medical Centre, Karachi, Pakistan, all hysterectomy specimens were reviewed from January 1986 to December 1989. Adenomyosis was found in 237 of the 419 (56.5%) specimens studied. Of these 237 patients, 232 (97.9%) were parous and 196 (82.8%) were in the fourth and fifth decades of life. This high prevalence in parous women aged 40-59 years was significant. Fibroids, cervicitis, and endometrial hyperplasia were the most common associated diagnoses. Of all the associations studied, only endometrial hyperplasia was significantly more prevalent in the group with adenomyosis. Adenomyosis was stated as an indication for surgery in 69 patients and was confirmed by histopathology in 49 (71%). Preoperative suspicion of adenomyosis was present in 49 (20.6%) patients of all those ultimately found to have the disease. There is a high prevalence of adenomyosis in the population studied, which indicates that the condition may have been underdiagnosed in the past, especially as it is difficult to diagnose without surgery and hysterectomy is currently the only treatment.