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Pregnancy and the postpartum period are potentially high-risk periods for women with epilepsy and their babies. All women with epilepsy should have the opportunity for preconception counselling with the aim of reducing risk, optimising outcomes for the potentially developing fetus and enabling informed decision- making. This article provides an evidence- based framework for preconception counselling discussion, including the review of diagnosis and of current antiseizure medication, the risk to the fetus in relation to antiseizure medication and maternal seizures, maternal morbidity, SUDEP risk, folic acid supplements, contraception, breastfeeding and safety advice. [ABSTRACT FROM AUTHOR]

Background: Autopsy is a contraption used for research purpose for about many aeon. This study is lugged out to determine the attitude of medical students toward medico-legal autopsy. Autopsy basically typecasts into clinical, medicolegal, mini, negative, virtual and such categories but broadly into clinical and medico-legal autopsy. Objective: To determine the prejudice of Karachi Medical and Dental College students towards medico-legal autopsy, furthermore after viewing and getting responses of students, emend and amend the set up of autopsy suite. Methods: The study design is a descriptive cross-sectional study. Two hundred students from Karachi Medical and Dental College of 3rd year and 4th year M.B.B.S, 2014-2015 were selected as they had exposure with the autopsies and medico-legal section at Abassi shaheed Hospital, Karachi. The students were asked to answer anonymously to a questionnaire with reasonable reasoning. The collected data in the form of responses from the students was analyzed in terms of how useful and necessary is autopsy in medical education. Their data was analyzed to determine the frequency distribution of the student's responses. Results: Among all, 73.5% students agreed on the importance of autopsy in medical education. However, 75% students propounded that they should be allowed to participate actively in performing autopsies while 45% agreed that actual autopsy should be replaced by virtual autopsy. Most of them i.e 81.5% were not in favor of specializing in Forensic Medicine whereas only 17% intended to specialize in this field. Conclusion: It is concluded that teaching based autopsy teaches valuable skills, which no one can fully learn by literature only. However, avoidable unpleasant aspects of medico-legal autopsy demonstration should be minimized in order to keep and maintain an ideal autopsy atmosphere. [ABSTRACT FROM AUTHOR]

Background: Chemical exposure is a major health problem globally. Poison control centers (PCCs) play a leading role both in developed and developing countries in the prevention and control of poisonous chemical exposures. In this study, we aimed to assess the current state of PCCs in Pakistan and highlight capacity building needs in these centers. Methods: A cross-sectional survey of the two registered PCCs was done during August-December 2011. Necessary services of the PCCs were evaluated and the data were recorded on a predesigned checklist. Results: Both PCCs are affiliated to a tertiary care hospital. Clinical services to poisoned patients were available 24 hours a day/7 days a week. Information on common local products was available to poison center staff. Both centers were involved in undergraduate and post graduate teaching. Telephone poison information service was not available in either of centers. There was a limited capacity for qualitative and analytical toxicology. Common antidotes were available. There were limited surveillance activities to capture toxic risks existing in the community and also a deficiency was observed in chemical disaster planning. Conclusion: PCCs in Pakistan need capacity building for specialized training in toxicology, toxicovigilance, chemical disaster planning, analytical laboratory tests and telephone service for consultation in poisoning cases. [ABSTRACT FROM AUTHOR]

Objective: To determine the frequency, cause and manner of death, factors responsible, & to draw the attention towards the implementation of safety measures & building laws, for minimizing the incidences of fall from height. The autopsies were carried out in the three major hospitals i: e civil hospital, Jinnah post graduate medical center & Abbasi shaheed hospitals of Karachi. Study Design: Autopsy - based descriptive cross-sectional study. Place: Mortuaries at Civil hospital, Jinnah Postgraduate Medical Center and Abbasi-Shaheed Hospital of Karachi. Duration of study: The duration of study is based on five years, from January 1, 2007 to December 31, 2011. Materials & Methods: Data of 144 autopsies, due to fall was collected during the autopsies carried out in, three major Medico legal centers, i.e. Jinnah Postgraduate Medical Center, Civil Hospital and Abbasi Shaheed Hospital, during the study period .The findings with reference to age, gender, cause and manner of death, year wise distribution of cases and body parts sustaining injuries were recorded in the proforma. The police inquest, the crime scene reports were also examined to verify/confirm the facts of the cases. Results: Incidence rate of deaths due to fall was 1.29% .Male predominance, with 93.75% in comparison to 6.25% of females. Highest number of fall related deaths occurred in 2007 and more or less similar trend was observed during 2008, 2009 and 2011 with a decline. Two third of the studied cases belong to age group from 15-45 years. The accidental falls were the most common manner of death and head/skull was the leading part of the body, sustaining injuries either alone or combined with other parts of the body. Conclusion: Fatalities due to falls were substantially accidental, while working on heights, without safety & preventive measures in Karachi, predominantly involving males and young of 15-45 years of age group. The Head was the leading part of the body involved in majority of cases, indicating the necessity of the implementation of the building laws protecting, the rights of poor labor, working on heights & minimizing the fatal injuries. [ABSTRACT FROM AUTHOR]

Objective: We retrospectively reviewed data of children who were managed for Disorders of Sexual Development (DSD) presenting after one year of age with a view to understand gender assignment issues in these children. Methodology: Patients were managed at NICH Karachi, NIRM and Shifa International Hospital Islamabad. All patients were investigated on standard lines to make a proper diagnosis. Karyotyping was performed in all patients. Hormonal essays included, serum testosterone levels, 17-OH progesterone levels, FSH, LH etc. Ultrasonography, urogenital endoscopy and laparoscopy were also performed in selected cases. The aim was to assign the genetic sex to the patient when possible. Male gender was advised to all male DSD responding to exogenous hormonal therapy. Patients with complete androgen insensitivity syndrome were advised female gender. Children having Gonadal dysgenesis (GD) responding to androgen therapy were also advised male gender. Female gender was advised to all children with congenital adrenal hyperplasia (CAH). Gender assignment was performed after a detail consultation with the family and children if they were old enough to comprehend the issue. Male gender was assigned to CAH patients reared as male if child/family insisted to keep the gender of rearing. Results: Of the 61 patients, 23 were undervirilized male (UVM), 29 had congenital adrenal hyperplasia (CAH), 4 had clitoromegaly, four gonadal dysgenesis and one aphalia. The mean age of presentation of UVM was 8.4 years and CAH was 7.06 years. Clitoromegaly without CAH mean age was 5.6 years. It was not possible to definitely establish the true nature of male DSD in few patients due to limitation of available investigations. Twenty two male DSD patients responded to exogenous testosterone therapy and had male gender assignment. One had female conversion as non-responder. Of the 29 cases of CAH, 27 decided for female assignment and had feminizing genitoplasty. Two children aged 13 and 16 years refused for a female gender assignment and were assigned male gender and reconstructions performed accordingly. Clitoral recession was performed in all the four patients with clitoromegaly. Four patient having MGD was assigned male gender. Single aphallia patient was assigned male gender however adequate phallus reconstruction is still awaited. Older UVM children reared as female accepted male gender happily but CAH children more than 10 years of age reared as male were not happy for a female conversion. Genital reconstruction was most satisfactory in CAH patients. Patients with male gender assignment had multiple procedures and patient's satisfaction response was variable according to the size of the phallus and severity of androgen deficiency. Most patients were however happy for the masculine appearance after chordee correction. Long-term results need to be evaluated. Conclusion: Older female children reared as male find it extremely difficult for female conversion whereas male children reared as female accept male conversion well. Gender re-assigment in younger children is well accepted by the family. [ABSTRACT FROM AUTHOR]

The objective of this study was to evaluate the effectiveness of mandibular canine index (MCI) in determination of sex. Possibly the dimorphism of the canines may be used as a valid tool in the forensic and legal identification of an individual. This study comprised of 89 individuals and 77 cases were enrolled in the study from Pakistan (39 males, 38 females) and 12 from UK (8 males and 4 females). Alginate impressions of mandibular arch were also made and the parameters considered were canine width, intercanine distance and mandibular canine index. It was seen that a definite statistically significant sexual dimorphism exists in mandibular canines. With standard MCI, it was possible to detect sex in the sample studied to an extent of about 76%. Hence it is considered as a quick, easy and reproducible method for determining the sex of an individual. [ABSTRACT FROM AUTHOR]

Background: Chemical exposure is a major health problem globally. Poison control centers (PCCs) play a leading role both in developed and developing countries in the prevention and control of poisonous chemical exposures. In this study, we aimed to assess the current state of PCCs in Pakistan and highlight capacity building needs in these centers., Methods: A cross-sectional survey of the two registered PCCs was done during August - December 2011. Necessary services of the PCCs were evaluated and the data were recorded on a predesigned checklist., Results: Both PCCs are affiliated to a tertiary care hospital. Clinical services to poisoned patients were available 24 hours a day / 7 days a week. Information on common local products was available to poison center staff. Both centers were involved in undergraduate and post graduate teaching. Telephone poison information service was not available in either of centers. There was a limited capacity for qualitative and analytical toxicology. Common antidotes were available. There were limited surveillance activities to capture toxic risks existing in the community and also a deficiency was observed in chemical disaster planning., Conclusion: PCCs in Pakistan need capacity building for specialized training in toxicology, toxicovigilance, chemical disaster planning, analytical laboratory tests and telephone service for consultation in poisoning cases.

Objective: To study the demographic distribution of the victims of road traffic accidents that were presented for medico-legal autopsy in Karachi, identify fatal injuries, the identity of road users autopsied and the month-wise variation in performing autopsies., Methods: Descriptive cross-sectional study of autopsies conducted at the mortuaries of Civil Hospital Karachi, Jinnah Postgraduate Medical Centre and Abbasi Shaheed Hospital between March 1,2008 and February 28, 2009. Bodies brought in by police for partial/external autopsy were excluded. Data was collected on pre-designed proformas and was statistically analysed using SPSS 15., Results: Of the total 2090 autopsies performed in Karachi, 581 (27.8%) cases were victims of RTA. Of these RTA victims, 324 (55.8%) autopsies were of those between the ages of 19 and 40 years. There were 510 (87.8%) males and 71 (12.2%) females with a ratio of male: female being 7:1.This ratio was 4.2:1 for those aged 0-18 years and 11:1 for those aged 19-40 years (p = 0.05). Death was due to injury to the head in 386 (66.4%) victims, to the chest in 84 (14.5%) cases, multiple traumatic injuries in 50 (8.6%) and pelvis in 17 (2.9%) cases. The majority of the victims on whom autopsy was performed were pedestrians (n = 389, 67%) followed by motorcyclists (n = 122, 21%). On an average 48.4 +/- 7.46 autopsies were performed every month, and there was no statistically significant variation in autopsies on this count., Conclusion: There was a male preponderance, but the significant differences in two age groups need to be correlated with the incidence of RTAs in each sex in that age group and the compliance levels of getting females autopsied.

Objective: To assess the causes and manner of custodial deaths in Karachi, and to determine the factor of negligence on the part of the custodians behind such deaths., Methods: The cross-sectional study involved the deaths in custody undergoing autopsy at Civil Hospital, Karachi, from January 2005 to December 2010. Autopsy was followed by histological examination, X-ray or CT scan wherever required. A proforma was also filled as per the standard autopsy protocol., Results: There were 61 custodial deaths in Karachi during the six-year study period which met the inclusion criterion. There were 58 (95.1%) males and 3 (9.4%) females. Natural causes accounted for a majority of deaths (n = 36; 59%), the most common disease being coronary artery disease (n = 13; 21.3%). Unnatural causes accounted for 25 (41%) deaths, comprising 13 (21.3%) homicidal, 7 (11.5%) suicidal and 5 (8.2%) accidental. Deaths were more frequent in the age group ranging from 30-39 years (34.4%), while the overall age-range was from 19 to 75 years., Discussion: Measures need to be taken to provide a wholesome environment for the prisoners. Code of conduct for the prisoners should be followed and judicial procedures shall be conducted at a quick pace. Torture should be avoided under all circumstances, and proper vigilance shall be kept to prompt suicidal deaths.

Background: Sharp weapons are one of the most violent and abhorrent means of deaths. This study assesses the frequency of sharp weapon deaths in Karachi., Methods: This was a cross sectional study, and involves the deaths by sharp weapons autopsied in Karachi during Mar 2008-Feb 2009., Results: This study reports that the frequency of sharp weapon deaths in Karachi is similar to some other studies conducted in different regions of Pakistan, yet it is very high as the population of Karachi is way more than any other metropolis of Pakistan. Our study reported that out of 2090 medico-legal deaths in Karachi during the study period, 91 deaths were due to sharp weapons, including 73 (80.2%) males and 18 (19.8%) females. 100% of the deaths were homicides, so none were suicides. Deaths were more frequent in age group ranging from 20-39 years (59.3%)., Conclusion: Sharp weapon deaths continue to be a means of quite a number of deaths in Karachi. Such violence depicts intolerant and frustrated nature of the citizens.

Objective: To determine the utility of postmortem CT (PMCT) examination in establishing the cause of death among male prisoners dying in Karachi jails., Methods: A descriptive study was carried out from February 2006 to September 2007, CT Scan section, Civil Hospital Karachi and the Mortuary, Dow Medical College, Dow University of Health Sciences, Karachi. Adult male prisoners dying in the Karachi central prison and referred to the study setting for determining the cause of death for medico legal purpose were included. Female prisoners and those cases where the final report of cause of death was not available were excluded. CT scan of the vital body regions (head, neck, thorax, abdomen and pelvis) was carried out in all cases. The scan was read and reported by two radiologists. Anatomical dissection based autopsy was carried out by the forensic expert. Final report regarding the cause of death was issued by the forensic expert based on the combined findings, histopathology, toxicology results and circumstantial evidence. The CT scan and autopsy findings were compared and percentage agreement was determined using kappa statistics., Results: There were 14 cases in all with mean age of 41.2 +/- 17 years. The alleged mode of death was custodial torture in all cases. CT scan determined the cause of death to be natural cardio-respiratory failure in 10, strangulation in 01, pulmonary tuberculosis (TB) in 02 and trauma to spine in 01 case. The autopsy determined natural death in 11 and pulmonary TB in 02 and asphyxia in 01. The percentage agreement between CT and autopsy was 92% (k = 0.92) and between CT and finalized cause of death was 100% (k = 1.0)., Conclusion: PMCT is as effective as dissection autopsy in identifying pulmonary infections and natural causes of death. It is more effective in identifying vertebral fractures which may exclude hanging and corroborate trauma to spine.

Objective: To determine the technical applicability and early postoperative outcome of anterior sagittal approach for anorectal malformations in female children., Study Design: Case series., Place and Duration of Study: Surgical Unit B of National Institute of Child Health (NICH), Karachi, from April to November 2007., Methodology: Female patients with congenital anorectal malformation who underwent anorectoplasty through anterior sagittal approach were included in the study. Surgery was done either as primary or staged procedure (with initial colostomy or cut back). Operative details were recorded. Follow-up was done in OPD., Results: Thirty patients with mean age of 11.5 months underwent anorectoplasty through anterior sagittal approach. Eighteen patients had ASARP as a primary procedure. Staged procedure with initial colostomy was done in 9 patients. Initial cut back was done in 2 cases and one redo surgery done. Vaginal tear occurred in one, while partial tear of most distal part of fistula occurred in 4 children. At follow-up, 2 patients with primary ASARP developed wound infection with superficial disruption. Bleeding with wound disruption occurred in one case. Anal mucosal prolapse, anastomotic stricture and recurrent fistula occurred in one patient each. Cosmetic appearance of perineum was good in 10, satisfactory in 5 and poor in 3. Among patients staged with colostomy, bleeding with wound disruption, anal stenosis and retraction occurred in one case each. Cosmetic results were good in 7, satisfactory and poor in one case each. Two patients with initial cut back did not have any complication and one operated for disrupted wound developed disruption again., Conclusion: Anorectoplasty can satisfactorily be done through anterior sagittal approach in females with anorectal malformations. Primary ASARP has almost the same results as staged procedure, which should be done in selected patients.

Objective: To analyze various clinical presentations and the surgical management of ovarian pathologies in pre-menarche girls., Design: Case series., Place and Duration of Study: Surgical Unit B, National Institute of Child Health, Karachi, from September 2002 to August 2004., Patients and Methods: Case records of all the pre-menarche girls child having an ovarian pathology and managed during the study period were reviewed. Age of the patients, presenting symptoms, investigations performed, surgical approaches, operative findings and final histological diagnosis were noted. Ovarian lesions were classified according to WHO criteria.System proposed by the Children's Cancer Group and the Paediatric Oncology Group was used for staging of tumors. Following resection, patients with malignant tumors were followed-up by oncologist., Results: There were 18 patients with ovarian lesions. Age range of patients was from day 1 to 13 years. Mass in abdomen was the most common presenting symptom (60% patients ) followed by pain (50%). Right ovary was involved in 12 (55%) cases and left in 6 (45%). Six patients had non-tumorous cysts, 3 had benign tumors and 9 were with malignant lesions. Of the non-tumorous cysts, 3 patients had simple follicular cysts and 2 were hemorrhagic cysts. There were 2 patients with benign teratoma and one with dermoid cyst. Four patients had malignant teratoma, 4 dysgerminoma and one yolk sac tumor. Malignant tumors were all of stage IA according to Paediatric Oncology Group staging., Conclusion: Ovarian tumors are rare in paediatric age group especially in pre-menarche girls. Except one, all malignant tumors were found in patients above 7 years of age. Benign (tumorous and non-tumorous) and malignant lesions occurred with equal frequency in pre-menarche girls in this study.

Objective: To assess the correlation of the size of undescended testis with its location in children of various age groups, per-operatively., Design: Cross-sectional study., Place and Duration of Study: Surgical Unit B, National Institute of Child Health, Karachi from February 2004 - November 2005., Patients and Methods: Children presenting with undescended testis at surgical outpatient were recruited. Physical examination and relevant investigations (haemoglobin, ultrasound for location and size of testes) were performed. Patients were divided randomly into three age groups, group I (8 months - 2.5 years), group II (2.6 - 8 years), group III (8.1-13 years). At orchiopexy location and size of undescended testis were noted. Patients were further sub-divided into groups according to peroperative location of undescended testis, group A (intra-abdominal), group B (intra-canalicular), group C (distal to superficial inguinal ring - pubic). Where no testis was found, a separate group D was assigned. The size of undescended testis at different locations in various age groups was compared with reference to normal descended testicular size in the respective age group, for statistical significance. ANOVA test was used for intergroup comparison for the size of undescended testis and Student t- test was applied for comparison with reference to normal values of the size of testis., Results: A total of 102 patients with undescended testis were included in the study. The total number of 107 testicular units were assessed. Group I had 28, group II, 41 and group III, 38 testes. There were 24 intra-abdominal, 68 intra-canalicular and 12 pubic in location. In 3 cases, no testis was found at exploration. We found no statistically significant difference amongst groups (p-value=0.090) between the size of the undescended testis at different peroperative locations. The size of undescended testis grew with the age as undescended testis of larger size were found in older age group as compared to younger age group. By applying Student t-test, we did not find statistically significant difference in relation to the size of undescended testis in various age groups in comparison to the reference of mean volume of normally descended testis in the respective age groups., Conclusion: Pre-pubertal size of undescended testis does not differ significantly from that of normal reference value of descended testis in relation to age and location. The ultimate size of the testis can only be assessed after puberty whether it is a normally descended or undescended testis.

Objective: To determine the postoperative complications of elective inguinal hernia surgery in children, Design: Descriptive study., Place and Duration of Study: Surgical Unit B, National Institute of Child Health, Karachi, from February 2004 to November 2005., Patients and Methods: Children with inguinal hernia, admitted electively through surgical outpatient, were included. Patients operated earlier and presenting with complications were excluded. Patients with concomitant diseases, regarded as predisposing factors for hernia development, were also excluded. Physical examination and relevant investigations (hemoglobin level and ultrasound of scrotum) were performed. Inguinal hernia was repaired electively by Rehbein procedure. Patients were followed at day 7, 1 month, 3 months and 9 months to note the postoperative complications of the surgery. Ultrasound was repeated at 6 and 9 months postoperatively for the size of testes., Results: A total of 223 patients with inguinal hernia were included in the study. Age ranged from 8 days to 12 years. There were 188 males with 75 patients under 1 year of age. The longest follow-up was upto 9 months in 133 patients. The complications of scrotal edema occurred in 6 (2.97%), haematoma in 1(0.49%), wound infection in 2 (0.99%) and 5 events of recurrence of hernia in 4 patients. All appeared within 3 months of follow-up. Four recurrent hernia were operated. In all cases intact sac was found. No patient developed decrease in size of testes nor ascent of testes was noted at follow-up., Conclusion: in this series, there were minimal complications observed in relation to inguinal hernia surgery.

Sirenomelia is a rare anomaly that rarely occurs as an isolated lesion. Several theories have been proposed regarding the etiopathogenesis. In this communication, we report a case of sirenomelia. Our patient was referred to hospital at the age of four hours. On examination, fusion of both lower limbs with hook shaped appendage, attached distally, absent genitalia and absent anal orifice was found. Spine was deficient in sacral region. Upper torso looked normal. Baby also had frothing from mouth. Abdomen was non-distended. Feeding tube no.10 was tried to pass through mouth, which got obstructed at the level of upper esophagus that suggested oesophageal atresia. The skeletogram revealed absence of pelvic bones, sacral agenesis, absent fibulae and fracture of both femora. The patient died at the age of 12 hours.

Two cases of congenital pyloric atresia (CPA) are, hereby, reported. One was suspected on antenatal ultrasound and turned out to be an isolated anomaly. Other patient had a rare association of aplasia cutis congenita with congenital pyloric atresia. The lesions of aplasia cutis congenita were multiple while congenital pyloric atresia was of type II. The patient with an isolated lesion survived following surgery while the other baby died of sepsis in postoperative period.

This report describes the management of a 7-month-old baby who aspirated one and ingested two paper pins at a time. Bronchoscopic removal was done for aspirated pin and ingested pins were observed for spontaneous passage in stool, which occurred in 48 hours without any untoward incidence.

A seven month old male baby presented to emergency room in shock. Patient had 3 hours history of massive fresh bleeding per rectum. Emergency laparotomy revealed Meckel's diverticulum (MD) with large vitello-intestinal artery responsible for massive bleeding. Diverticulectomy was performed.