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JPUMHS 2020, jan - march;10;01


Journal of Peoples University of Medical & Health Sciences for women Nawabshah SBA.


Patron in Chief

Professor Gulshan Ali Memon

Vice chancellor Peoples University of Medical & Health Sciences for women SBA.


Chief Editor: Professor Rafique Ahmed Memon



Dr Anwar Ali Jamali


Associate Editor

Dr Nasrullah Aamer


Assistant Editor

Ambreen Sahito



Editorial     Board



Editorial Board national


Abdul Qadeer Q J Malhi


Muzafar Ali Shaikh

LUMHS Jamshoro



PUMHS Nawabshah

Shams Uddin Shaikh



Yasir Ahmed


Altaf Ahmed Talpur

LUMHS Jamshoro

Shams Raza Brohi

PUMHS Nawabshah

Rabia Shams


Faisal Asad


Qaiser Husain Naqvi

SRMC Tando Adam

Muhammad Ali Suhail

PUMHS Nawabshah

Abdul Jabbar Kandhro


PUMHS Nawabshah

Abdul Jabbar Pirzada


Abdul Qayoom Memon

SRMC Tando Adam

Khan Muhammad Nangrejo

PUMHS Nawabshah

Qurban Ali Rahu


Niaz Hussain Kerio


Allah Rakhio Jamali

JPMC Karachi

Muhammad Saleh Khaskheli

PUMHS Nawabshah

Ghulam Rasool Mashori Ph.D


Asadullah Nawazani 


Ghulam Hussain Baloch

Indus Medical College TMK

Muhammad Yousif jatt


PUMHS Nawabshah

Amir Hamzo Dahri

PUMHS Nawabshah



Zaheer Ahmad


English Editor

Noor-ul-Aain Sahito



Abdul Sattar Mahar


IT Managers

Ayaz Ahmad Qureshi

Muhammad Ali



Official Journal of PUMHSW & Published from Peoples University of Medical & Health Sciences for women SBA






Anwar Ali Jamali



Original Articles


Muhammad Sibtain Shah,1 Nasrullah Aamer,2 Abdul Aziz Sahito,3 Rafique Ahmed Memon,4 Noor Nabi Siyal,5 Abdul Manan Soomro,6 Ashok Kumar Lohana7



Fatima Mehmood1, Waqas Asghar2, Uzma Hamza3, Maqbool Ahmed Jamali4, Qasim Lateef Chaudhry5, Imran Manzoor6.




Tariq Feroz Memon1, Mehwish Channar2, Syed Abdul Wadood Shah3, Aiman Shaikh4, Mehwish Batool5 , NomaShri6.




Zahoor Hussain Bhellar1, Abdul Malik Sangri2,Dr:Fozia unar3, Zulfiqar Ali sher4











Aftab Ahmed1 , Hanna khan Tunio2, Mohammad Bilal3, Salma4, Faiqa Memon5, Saba Leeza Mangi6



Masood Ahmed1, Farzana Memon2, Noreen Irum3, Ghulam Mustafa Dahri4, Azhar Mughal5,Gotam Kumar6




Muhammad Faraz Jokhio1, Zameer Hussain Tunio 2, Kishore Kumar3, Muhammad Azeem Akhund4, Zameer Abbasi5 Nazeer Hussain Shah6




Owais Shams1, Nandlal Rathi2, Jagdesh Kumar3, Abdul Aziz Sahito4, Kartik Kumar Rathi5





Khalid Abdullah1, Niaz Hussain Keerio2






Corona virus –A Real Danger Alarm in Pakistan.

Anwar Ali Jamali

Viral infections are common all over the world. Sometimes they results in out breaks leading to high morbidities and mortalities. Currently in world the infection of corona virus had created a panic situation all over the world targeting the different countries of the world.  China is the main victim of corona virus. Now the countries of world are left china cases behind. At present most of the world countries are affected by corona virus outbreaks, only the valid management options are prevention and precautionary measurements up to now. No current effective treatment is being approved by FDA, only supportive therapy is there and hypothesis based therapies are there. Nowadays it is major killer of human beings as claimed all over the world and Pakistan. Number of patients is increasing day by day here. Social distance is fail here. If we had not adopted the prevention and precaution protocol definitely there will be an unmanageable dangerous situation. At last water will be beyond the human heads. In parallel to rest of world this panic situation had been alarmed in Pakistan because many peoples of Pakistan are working, studding in different areas of china. This virus can be easily transmitted so the persons who travel from the phobia of corona virus may carry or transmit viruses to different countries. The brief description of virus is that Corona virus malady 2019 (COVID-19) is an irresistible ailment brought about by SARS-CoV-2,1 Corona viruses are an enormous group of infections found in the two creatures and people. Some contaminate individuals and are known to cause ailment extending from the normal virus to progressively extreme illnesses, for example, Middle East Respiratory Syndrome (MERS) and Severe Acute Respiratory Syndrome (SARS). A progressing flare-up of corona virus malady 2019 (COVID-19), brought about by SARS-CoV-2, began in December 2019. It was first distinguished in Wuhan, the capital of Hubei, China.2 The infection is essentially spread between individuals by respiratory beads created during hacking or sneezing.3 The time among introduction and manifestation beginning is normally 2 to 14 days.4 Symptoms may incorporate fever, hack, and brevity of breath.5 Complications may incorporate pneumonia and intense respiratory pain disorder. There is no antibody or explicit antiviral treatment, with endeavors regularly targeting overseeing side effects and strong therapy.6 Hand washing is prescribed to forestall the disease.7 Anyone who is associated with conveying the infection is encouraged to screen their wellbeing for about fourteen days, wear a careful cover, and look for clinical counsel by calling a specialist before visiting a clinic.8

There is a great phobia in this direction in Pakistan. Fearing a similar virus outbreak in Pakistan, the authorities fumigate every container imported from China which he said is delaying the clearance procedure and traders who have invested billions of dollars in import business, are facing huge losses. Pakistan is not practically prepared for corona virus except the media trials. There are no equipments vastly available here, material methods are poor, and we shout loud but do little. Understanding when tainted patients may spread the infection to others is basic for control endeavors. Point by point clinical data from individuals contaminated is expected to decide the irresistible time of 2019-nCoV. As indicated by ongoing reports, it might be conceivable that individuals tainted with 2019-nCoV might be irresistible before demonstrating noteworthy side effects. Be that as it may, in light of right now accessible information, the individuals who have indications are causing most of infection spread.

WHO has given counsel to individuals on the best way to shield themselves from 2019-nCoV disease, with respect to any infection that spreads by means of the respiratory course? Moreover, it is fundamentally significant in social insurance settings that medicinal services laborers can shield themselves from disease.

Individuals getting bundles are not in danger of getting the new corona virus. For a fact with different corona viruses, we realize that these sorts of infections don't endure long on objects, for example, letters or bundles. No, anti-microbials don't neutralize infections; they just work on bacterial diseases. The epic corona virus is an infection and, consequently, anti-toxins ought not to be utilized as methods for counteraction or treatment. Until now, there is no particular medication prescribed to forestall or treat the novel corona virus. Be that as it may, those contaminated with 2019-nCoV ought to get suitable consideration to ease and treat side effects, and those with extreme ailment should get improved strong consideration. Some particular medicines are under scrutiny and will be tried through clinical preliminaries. Why should helping coordinate endeavors to create prescriptions to treat n-CoV with a scope of accomplices? On the off chance that you need to shield yourself from getting tainted with the new corona virus, you ought to keep up essential hand and respiratory cleanliness, and safe nourishment rehearses and staying away from close contact, whenever the situation allows, with anybody indicating manifestations of respiratory disease, for example, hacking and sniffling. In late December, a bunch of pneumonia instances of obscure etiology was accounted for by wellbeing experts in Wuhan, Hubei Province, People's Republic of China. The underlying cases for the most part had epidemiological connects to the Huanan Seafood Wholesale Market and therefore the infection is thought to have a zoonotic source. The China CDC announced toward the beginning of January that the causative specialist was a novel corona virus (presently called SARS-CoV-2), which is firmly identified with bat corona viruses, pangolin corona viruses and SARS-CoV-1. Proof shows that the transmissibility of the corona virus is adequate for supported network transmission and privately obtained cases have been accounted for over the world, alongside a few deaths.9 According to accessible proof, the transmissibility of this infection is surveyed as adequate for continued network transmission. Further cases and passing’s in China are normal in the coming days and weeks. Further cases or bunches are likewise anticipated from different nations that are as of now revealing expanding quantities of cases, including network transmission. In this way, wellbeing experts in the EU/EEA and the UK ought to stay careful and fortify their ability to react to conceivable importation of cases from China or, possibly, different territories with assumed progressing network transmission; increment their ability for observation and survey their pandemic readiness plans. There are extensive vulnerabilities in evaluating the danger of this occasion, because of absence of nitty gritty epidemiological examinations. Hand washing is prescribed to forestall the spread of corona virus. The CDC prescribes that people:

A few associations around the globe are creating immunizations or testing antiviral medication. In China, the Chinese Center for Disease Control and Prevention (CCDC) has begun creating immunizations against the novel corona virus and is trying existing medication adequacy for pneumonia.10,11 Also, a group at the University of Hong Kong declared that another antibody is grown, however should be tried on creatures before directing clinical tests on humans.12

For our nation it is necessary to adopt the precautionary management options with strict entry checking’s of travelers and material contain the risk of transmission of corona virus at the borders, airports, land ports and seaports. We have to stop the entry at each and every corner otherwise any kind of misfortune may occur. We are not in such stable economical position that we can face the type of crises at national and international levels. Corona virus had created a great human phobia all over the world and responsible for the down fall of economy of china. Main option here is only take preventive steps, as there is no valid vaccine and treatment available to control this global viral issue.

Up to this level the number of COVID-19 in Pakistan is increasing day by day, initially blamed for foreign travel and now local transmission is increasing daily due to poor concept of social distance. We are at great risk of viral breakdown that may cross the other leading countries of world.

Remember the corona virus will affect billions, will ill millions and will kill thousand lacs all over the world. Till that only prevention and precaution can are main life saving procedures till the availability of treatment drugs and preventable vaccine. Stay home stay safe is the valid slogan.

Correspondence author:

Anwar Ali Jamali

Associate Professor Medicine






  1.  "What are the official names of the disease and the virus that causes it?". Q&A on corona viruses. World

Health Organization. Retrieved 22 February 2020

  1. Zhang, Yanping (14 February 2020). "The Novel Corona virus Pneumonia Emergency Response Epidemiology Team. The Epidemiological Characteristics of an Outbreak of 2019 Novel Corona virus Diseases (COVID-19) – China, 2020" (PDF). China CDC Weekly. 2.[dead link]
  2. "Corona virus Disease 2019 (COVID-19)". Centers for Disease Control and Prevention. 11 February 2020. Retrieved 24 February 2020.
  3.  "Symptoms of Novel Corona virus (2019-nCoV) | CDC". U.S. Centers for Disease Control and Prevention (CDC). 10 February 2020. Retrieved 11 February 2020.
  4. "2019 Novel Corona virus (2019-nCoV)". Centers for Disease Control and Prevention. 11 February 2020. Retrieved 18 February 2020.
  5. "Prevention and Treatment"Centers for Disease Control and Prevention (CDC). 9 August 2019. Archived from the original on 15 December 2019. Retrieved 21 January2020.
  6. "Prevention and Treatment"Centers for Disease Control and Prevention (CDC). 9 August 2019. Archived from the original on 15 December 2019. Retrieved 21 January2020.
  7.  "Updates on Wuhan Corona virus (2019-nCoV) Local Situation". moh.gov.sg. Retrieved 1 February 2020
  8. "European Center for Disease Control" (PDF).available at:


  1.  "China CDC developing novel corona virus vaccine". Xinhua News Agency. 26 January 2020. Archived from the original on 26 January 2020. Retrieved 26 January 2020.
  2. "Chinese scientists race to develop vaccine as corona virus death toll jumps". South China Morning Post. 26 January 2020. Archived from the original on 26 January 2020. Retrieved 26 January 2020.
  3. Cheung, Elizabeth (28 January 2020). "Hong Kong researchers have developed corona virus vaccine, expert reveals". South China Morning Post. Archived from the original on 28 January 2020. Retrieved 28 January 2020.


Incidence of Neutropenia in Locally Advanced Esophageal Carcinoma treated with concurrent  chemoradiation

Muhammad Sibtain Shah,1 Nasrullah Aamer,2 Abdul Aziz Sahito,3 Rafique Ahmed Memon,4 Noor Nabi Siyal,5 Abdul Manan Soomro,6 Ashok Kumar Lohana7


Objective: To analyse incidence of neutropenia in locally advanced esophageal carcinoma treated with cisplatin & 5 flurouracil based chemo radiation.  Methods: This descriptive case series study was conducted in the Department of Clinical Oncology LINAR Cancer Hospital Larkana from January  2016  to August  2017 ,on histological proven squamous cell carcinoma of esophagus with  Inclusion  criteria  locally advanced stage, good performance status (ECOG-0,01,02),normal blood counts, normal hepatic & renal profiles. Exclusion criteria with carcinoma of cervical esophagus, infiltration of tumor in tracheobronchial tree, distant metastasis. We planned our patients with EBRT have total dose of radiation 50.4Gy in 28 fractions. Inj Cisplatin 75mg/m2 IV D1 & Inj 5- Flurouracil 1000mg/m2 IV D1 to D4 were infused during 1st & 5th week of external beam radiotherapy & 8th & 11th weeks. Neutropenia   was assessed on weekly basis through complete blood counts(CBC ) during course of con current chemoradiation & later on during  two cycles of adjuvant chemotherapy infused after chemoradiation. Neutropenia grading were performed on basis of common Terminology  Criteria for Adverse Events  (CTC AE).The data was statistically analyzed.  Results:  Majority of patients have age above 40 years. The average age of patients & duration of disease were 46.45+/- 10.59 years(95%CI :46.45+/- 10.59) and 3.5 +/-1.17 months(95%CI:3.20 to 3.80) respectively.out of 62 cases 27(43.5%) were male & 35(56.5%) were female. Chemoradiation induced neutropenia was assessed on complete blood counts on weekly basis. Neutropenia grading were performed. Neutropenia grading from grade 1 to 4 were 2%,34%,48%,16% cases respectively. Conclusion: Chemotherapy induced neutropenia is most common oncological emergency. It increases morbidity and mortality if not assessed timely during cancer treatment.Key words: Esophageal carcinoma, Neutropenia, Chemoradiation, Filgristim,Cisplatin,5 flurouracil


Citation: Shah M S, Aamer N, Sahito A A. Incidence of Neutropenia in Locally Advanced Esophageal Carcinoma treated with concurrent  chemoradiation. JPUMHS jan-march 2020; 10(1).7-14



  1. Assistant Professor Oncology Medical unit I PUMHSW Nawabshah
  2. Associate Professor Medical unit I PUMHSW Nawabshah
  3. Associate Professor& Incharge Medical unit III PUMHSW Nawabshah
  4. Professor & Dean Medicine & Allied  PUMHSW Nawabshah
  5. Assistant Professor Medical unit I PUMHSW Nawabshah
  6. Associate Professor Community  Medicine  PUMHSW Nawabshah
  7. Assistant Professor Medical unit III PUMHSW Nawabshah

Correspondence: Muhammad Sibtain Shah Assistant Professor Oncology Medical unit I PUMHSW Nawabshah. Email:drmsibtain@hotmail.com
























Esophageal carcinoma is a highly lethal malignant tumor with a poor prognosis. Esophageal  carcinoma is 8th most common malignant tumor and ranking 6th most common cause of oncological mortality worldwide.1,2,3 Esophageal carcinoma is a malignant disease with wide range of global variation in its incidence.4 Esophageal carcinoma is the sixth common malignant neoplasm reported in Pakistan.5 According to KIRAN Cancer registry (KCR) report there were 19559 cancer patients registered from 1st January 2000 to 31st December 2009 in which 743 (3.8%) patients were suffering from carcinoma of esophagus with gender ratio of 395 and 348 males and females respectively.6Esophageal carcinoma may be classified as either squamous cell carcinoma or adenocarcinoma while less common histologies include adenoid cystic carcinoma, muco epidermoid carcinoma, small cell carcinoma, lymphoma and leiomyosarcoma.7Squamous cell carcinoma accounts 90% of esophageal cancer in China.8Despite much technical advancement carcinoma of esophagus still remains a therapeutic challenge. The majority of patients with carcinoma of esophagus are diagnosed in advanced stage i-e III-IV.9Surgery remains mainstay of treatment. Three years survival rate after radical surgery is 20% and post surgical mortality rate is 3 to 10%.10Patients who are surgical inoperable or denied for esophagectomy, concurrent chemo radiation is treatment of choice. The neo adjuvant & definitive chemo radiation in carcinoma of esophagus improve patients overall survival in comparison to esophagectomy alone.11,12,13

                             Nowadays there are various chemotherapy regimens such as Cisplatin & 5 flurouracil (CF), paclitaxel & carboplatin (PC),docetaxel, cisplatin & 5 flurouracil (DCF) are used in neo adjuvant and during definitive chemo radiation of carcinoma of esophagus. The disease free survival and median overall survival with these chemotherapy regimens were 09 months & 17 months respectively.14These chemotherapy regimens results high risk of neutropenia grade III-IV, thrombocytopenia grade III-IV, diarrhea grade II-III, vomiting grade II,III,IV and esophagitis Neutropenia is most life threatening oncological  emergency. Neutropenia is defined as an an absolute  neutrophil count (ANC ) less than 1500 per microliter. Neutropenia is graded mild, moderate and severe on basis of ANC which is calculated on CBC.  Neutropenia is routinely diagnosed on complete blood counts. Severe neutropenia is defined as ANC of less than 500 per microliter. Febrile neutropenia is defined as ANC less than 500 per microliter and patient has an oral temperature more than 101F0 (38.3 C0) or has two consecutive readings greater than100.4 F0 (38.0 C0) for two hours. Neutrophil has life span of three days. Nueutropenia usually occur at 03 to 07 days after cancer chemotherapy infusion. Neutropenia management is based upon neutropenia grade, underlying risk factors, comorbid and performance status of cancer patients. Neutropenic  patients are more susceptible  for developing bacterial, fungal and viral infections, if not timely address can leads septicemia resulting in death.15 infections Neutropenia can be managed with preventive measures, prophylactic use of antibiotics and granulocyte colony stimulating factor(G-CSF).In cancer patients neutropenia results increase mortality rate and economic cost of treatment.16,17


This descriptive prospective case series study was conducted in the Department of Clinical Oncology  LINAR cancer Hospital Larkana from January  2016 to August  2017.We have  enrolled sixty two patients by non probability sampling, on histological proven squamous cell carcinoma of esophagus staged radiologically T3-T4,No,-1,Mo according to TNM Classification, ECOG performance status 0,1 or 02,normal hematologic profile & normal function of liver and  kidney by routine laboratory examination (i-e CBC, LFT,RFT).While exclusion criteria were adenocarcinoma of esophagus, carcinoma of cervical esophagus, carcinoma of gastro esophageal junction, patients with esophageal biopsy of lymphoma, leiomyosarcoma, adenocystic carcinoma, small cell carcinoma, infiltrations of tumor into tracheobronchial tree, distant metastasis (i-e liver, adrenal glands ).Radiation planning was performed on 2 dimensional external beam radiotherapy technique. Gross tumor volume and nodal involvement were delineated through CT scan neck, chest with contrast performed for staging purpose.50.4 Gy dose of radiotherapy was delivered in 28 fractions at rate of 1.8 Gy per fraction in two phases. In phase I we delivered external beam radiotherapy through 02 fields anterior & posterior up to 36 Gy, with 05 cm proximal & distal margins to tumor and 03 cm transverse margins for nodal coverage for achieving 95% dose delivery at planning target volume. In phase II external beam radiotherapy was delivered through 03 fields one anterior & two posterior oblique fields with adequate coverage of tumor target volumes through sparing organ at risk i-e lungs, spinal cord & heart to prevent from radiotherapy induced injuries to these critical organs. Inj cisplatin 75 mg/m2  IV D1 of week 1st, 5th,8th & 11th and Inj 5 Flurouracil 1000mg/m2  24 hours IV infusion during 1st, 5th, 8th & 11th weeks were infused. The nutritional support was assessed in all patients by calculating per day calories requirements. Nutritional supplements were given oral, parenteral routes routinely in our ward. Patients who presented with absolute dysphagia were planned for feeding gastrostomy & self expandible metallic esophageal stent.CBC was performed on weekly basis for evaluation of neutropenia during definitive chemo radiation and during two cycle of adjuvant chemotherapy infused.  Neutropenia grading was assessed according to basis of common Terminology Criteria for Adverse Events (CTCAE).The data was statistically analyzed.


Sixty two patients of locally advanced esophageal cancer included in study. Most of the patients were above 40 year of age. The average age of patients and duration of disease the was 46.45±10.59 years (95%CI: 46.45±10.59) and 3.5±1.17 months (95%CI: 3.20 to 3.80) respectively as presented in table I.

 27(43.5%) were male and 35(56.5%) were female figure1. Dysphagia was the commonest clinical presentation i.e. 37(59.7%) followed by vomiting in 18(29%) and weight loss in 7(11.3%) cases. Stage III-C 34%, stage IIIB 26% and stage IIB 17% was found in patients table II, figure II. Neutropenia was assessed on weekly basis on CBC. Neutropenia grading was Neutropenia grading from grade 1 to 4 were 2%, 34%, 48%,16% cases respectively according to common Terminology  Criteria for Adverse Events  (CTCAE) presented figure III.








Table I.  Descriptive Statistics of Patients( n=62)



Age (Years)

Duration of Disease


Mean ± SD



95% Confidence Interval

43.76 to 49.14

3.20 to 3.80

Median (IQR)











   Table II. Stage of Disease (n=62)




Stage IIB


Stage IIIA


Stage IIIB


Stage IIIC





      Figure -1.Gender Distribution (n=62) 








Figure II:Clinical Presentations(n=62) 



Figure III.Grading of febrile neutropenia(n=62) 




                        Neutropenia is most common life threatening oncological emergency. Neutropenia is  common cause of caner chemotherapy related mortality and morbidity. Neuropenia imposes economic burden on health care resourrces and source of anxiety and stress for  treating physicians and patients. In cancer patients there is alteration in cell mediated and humoral immunity defense mechanisms. And these sequele of neoplastic lesion itself or related to treatment offered to patients in form of chemotherapy and radiotherapy.Anti neoplatic drugs target rapidly dividing cells of body that includes bone marrow cells,germinal layer of dermis & epithelia of gastro intestinal tract.Severity of neutropenia depends upon dose,duration and infusional timiming of chemotherapy infusion.Frequency of febrile neutropenia also increase when radiotherapy is combined with chemotherapy(concurrent chemoradiation).Neutropenia grading also depends upon type of radiation,dose per fraction,duration and radiotherapy  field sites &sizes.Neutrophil count usually begin to decrease three to seven days after chemotherapy and achieve nadir level usually seven to ten days after infusion of chemotherapy.Neutropenia is diagnosed on CBC and graded according absolute neutrophil count(ANC).Neutropenic patients usually presents in OPD and emergency department with complain of fever,rigors,oral ulcers,sore throat,cough,diarrhea,hypotension,tachycardia, tachypenea,skin lesions and focus of infection on intravenous cannula,central venous access device and perianal area.In extreme  conditions changes in mental status such as confusion or even loss of consciousness.Neutropenia management is based upon grade of neutropenia,general condition of patient includes performance status of cancer patient and underlying risk factors.

In neutropenic patients preventive measurses that include use of gowns,gloves,face masks by health care providers,strict attention to hand washing must be implemented.Cancer patients should avoid from large crowds,avoid consumption of undercoocked meat,fish,raw eggs,avoid from handling pets birds and animals.Female patients should use sanitary napkins instead of tampons.In febrile neutropenic   patients broad spectrum antibiotics is recommended even infection source is not obvious.18Prophylaxis use of granulocyte colony stimulating factor(G-CSF) is recommended for  patients who have high risk features for developing neutropenia,include old age, siginificant co morbid,poor performance status, poor nutritional status and 20 percent or more  myelosuppresion on chemotherapy drugs.19

Cancer chemotherapy induced neutropenia in 06 to 50% of patients depend upon type of malignancy,tumor stage,patient performance status and chemotherapy regimen.19So identification of these high factors are very essential for justifiable use of granulocyte colony stimulating factors(G-CSF).In Granulocyte colony stimulating guidelines taxene based,platinum based chemotherapy regimens were not classified as high risk regimens for developing neutropenia.20,21Prophyactic use of granulocyte stimulating factor(G-CSF) improves patients quality of life and reduced prolonged hospitilization.22,23

  In our study chemotherapy induced neutropenia was most common in elderly patients with poor performance status,poor nutritional status and advanced stage.Majority of patients has developed  neutropenia grade III &IV.Neutropenia was less in patients of young age,good performance status and adequate nutritional intake and support.Our study results were similar to study of Wakui-R,et al for definitive chemo radiotherapy for elderly patients.24In our study three patients expired due to neutropenia grade IV.Three patients refused second cycle of chemotherapy due to development of neutropenia grade III and vomiting grade III. Five patients had finacial problems and discontinue chemotherapy and received radical dose of radiotherapy  50.4Gy as per protocol.Chemo radiation was completed in fifty one patients as per decised protocol.In locally  advanced esophageal cancer literature review showed neutropenia grade III range from 11% to 50% of patients which is similar to our study.25,26,27our study is single institute based study with small number of patients,so further studies with suffient sample size and with long term surveillance is required.


Chemotherapy induced neutropenia is most common oncological emergency. It increases morbidity and mortality if not assessed timely during cancer treatment.


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20.  Aapro MS,  Bohlius J, Cameron DA, Dal Lago L, Donnelly JP, Kearney N, et al.European Organisation for Research and Treatment of Cancer. 2010 update of EORTC guidelines for the use of granulocyte-colony stimulating factor to reduce the incidence of chemotherapy-induced febrile neutropenia in adult patients with lymphoproliferative disorders and solid tumours. Eur J Cancer 2011; 47:8–32

21. Crawford J, Allen J, Armitage J, Blayney DW, Cataland SR, Heaney ML, et al.Myeloid growth factors. J Natl Compr Canc Netw 2011; 9:914–932.

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23. Vogel CL, Wojtukiewicz MZ, Carroll RR, Tjulandin SA, Barajas-Figueroa LJ, Wiens BL, et al. First and subsequent cycle use of pegfilgrastim prevents febrile neutropenia in patients with breast cancer: a multicenter, double-blind, placebo-controlled phase III study. J Clin Oncol 2005; 23:1178–1184.

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Mean Reduction In Foveal Thickness After Four Weeks Of Injection Bevacizumab (Avastin) Intravitreally For The Management Of Diabetic Macular Edema

Fatima Mehmood1, Waqas Asghar2, Uzma Hamza3, Maqbool Ahmed Jamali4, Qasim Lateef Chaudhry5, Imran Manzoor6.

Abstract: Aim: To determine the mean reduction in foveal thickness after 4 weeks of Intravitreal Bevacizumab (Avastin) for the management of diabetic macular edema Patients and methods: This Quasi experimental study included 95 eyes of 95 patients, which were diagnosed with diabetic macular edema, and treated between November 2016 and May 2017 at Ophthalmology department of  Jinnah Hospital, Lahore. The aim and procedure of study was explained and informed consent was taken from all patients. A detailed history and ocular examination in these cases was done. Basic ophthalmological examination was done. The macular thickness was assessed one week before procedure by OCT (Zeiss 4000). Injection Bevacizumab (avastin) 1.25mg/0.05 ml was given intravitreally under topical anesthesia 3.5-4mmaway from limbus by researcher herself. After 4 weeks of injection, OCT was done on all patients and the outcome was decided on the modulation in thickness of of central maculi, which was recorded by the researcher herself. Results: The mean pre-procedure central macular thickness was 387.11+18.07 µm which reduced to 318.75+18.87 µm at 4 weeks after treatment, the mean decrease was recorded as 68.36+7.60 µm; p value was 0.0001, showing a significant difference. Conclusion: The mean reduction in foveal thickness after 4 weeks of Intravitreal Bevacizumab (Avastin) for the management of diabetic macular edema is significantly different as compared with pre-treatment macular thickness.

Keywords: Diabetic macular edema, Central macular thickness, Intravitreal Bevacizumab (Avastin), Mean decrease.

Citation: Mehmood F , Asghar W , Hamza U , Jamali MA , Chaudhry QL, Manzoor I. Mean Reduction In Foveal Thickness After Four Weeks Of Injection Bevacizumab (Avastin) Intravitreally For The Management Of Diabetic Macular Edema.JPUMHS jan-march 2020;10(1),15-21.





Dr. Fatima Mehmood Medical Officer, Eye Department, Jinnah Hospital, Lahore Address: House # 424, Block G, Johar Town, Lahore Email: fatiwaqas60@gmail.com

Dr. Waqas Asghar Medical Officer, Eye Department, Jinnah Hospital, Lahore Email: waqasasghar2008@gmail.com

Dr. Uzma Hamza Assistant Professor of Ophthalmology Allama Iqbal Medical College, Jinnah Hospital, Lahore Email: druhamza@gmail.com

Dr. Maqbool Ahmed Jamali Senior Registrar of Ophthalmology People’s University of Medical and Health Sciences, Shaheed Benazirabad Email: mjamali74@yahoo.com

Dr. Qasim Lateef Chaudry Associate Professor OphthalmologyAllama Iqbal Medical College, Jinnah Hospital, Lahore Email: docqasim@gmail.com of

Dr. Imran Manzoor Medical Officer, Eye Department, Jinnah Hospital, Lahore Email: doctoremran35@gmail.com

Correspondence: Maqbool Ahmed Jamalimjamali74@yahoo.com






Diabetes mellitus (DM) is a common health problem in Pakistan. Our country is considered in top ten nations with higher frequency of Diabetes Mellitus in its population. In 2025, Pakistan may cross 10 million people having DM in its population.1 Approximately 10% of the people aged >30 years are suffering from type II DM.2 Patients with DM may have a serious eye diseases, without developing any symptoms, and this leads to the irreversible visual loss.3 The most common cause of impairment of vision in patients who are suffering from diabetes mellitus is macular edema. This edema results from chronic increase of serum glucose levels. The persistent elevation of serum glucose leads to capillary damage which results in formation of micro aneurysms in the retina. These leaky micro aneurysms cause decrease in vision if leaky fluid involves foveal centre..4   Bevacizumab  (Avastin, Genentech /Roche) is recombinant humanized monoclonal antibody, which is FDA approved for metastatic colorectal and breast cancer treatment.  In under-developed and developing countries there is widely off label use of avastin by Ophthalmologists. The reason being, it is cost effective, easily available and has relatively good safety profile. In spite all having encouraging and good results in choroidal neovascularization, macular edema and diabetic retinopathy, there is no long-term guarantee  on safety of Avastin .5In a previous study, pre avastn mean  foveal thickness was 384.38±40.51µm and after one month of giving  Avastin OCT  showed mean thickness of 323.19±32.58µm,  showing mean decrease as 61.19+7.93 µm.6 Another study revealed that mean retinal thickness at baseline was calculated as 411+170 µm while after one month of Avastin it was recorded as 380+159µm, mean decrease was 31.0+11 µm,7 i.e. (0.031+0.011mm) which is significant difference from the previously mentioned study.

The rationale of the study is that the previous studies are showing significantly varying results, it needs another study to clarify the above variation in our targeted population and also record the mean decrease of central macular thickness in our population, the results of the study would also be helpful for timely management of the morbidity.

Patients and methods:


This Quasi experimental study included 95 eyes of 95 patients, which were diagnosed with diabetic macular edema, and treated between November 2016 and May 2017 at   Ophthalmology department of , Jinnah Hospital, Lahore.

The aim and procedure of study was explained and informed consent was taken from all patients. A detailed history and ocular examination in these cases was done. Basic ophthalmological examination was done. The macular thickness was assessed one week before procedure by OCT(Zeiss 4000). Injection Bevacizumab (avastin) 1.25mg/0.05 ml was given intravitreally under topical anesthesia 3.5-4mmaway from limbus by researcher herself. After 4 weeks of injection, OCT was done on all patients and the out come was decided on the modulation in thickness of of central maculi, which was recorded by the researcher herself.

The data was recorded in a pre-designed performa analyzed using Statistical Package for Social Sciences (SPSS, IBM Statistics, Chicago, IL, USA version23.0) standard and Mean  deviation was calculated for quantitative variable like age, pretreatment macular thickness, post treatment macular thickness and mean decrease in  thickness in fovea after 4 weeks of Intravitreal Bevacizumab (Avastin) was recorded. Frequencies and percentages were calculated for qualitative variables like sex of the patients. Paired sample t test was used to compare before and after treatment macular thickness. if p value <0.05 was considered as significant. Stratification for age, gender and duration of disease was recorded to address the effect modifiers. Post stratification paired t test was applied to see the significance.  P value <0.05 was considered as significant.




The study included 95 eyes to determine the mean reduction in thickness of fovea after 4 weeks of Injection Bevacizumab (Avastin) intravitreally for the management of diabetic macular edema. Age distribution of the patients showed that 45.26%(n=43) were between 40-55 years of age whereas 54.74%(n=52) were between 56-70 years of age, mean ± SD was calculated as 55.63+8.40 years. (Table No. 1) Gender distribution of the patient showed tha