Outcomes of Extended Curettage with and without Bone Allograft for Grade II Giant Cell Tumors around the Knee. A Retrospective Comparative Study / Resultados da curetagem estendida com e sem aloenxerto ósseo para tumores de células gigantes de grau II no joelho. Um estudo comparativo retrospectivo

Abstract Objective This is the first study to establish the utility of extended curettage with or without bone allograft for Grade II giant cell tumors GCTs around the knee joint with the aim of exploring postoperative functional outcomes. Methods We retrospectively reviewed 25 cases of Campanacci grade II GCTs undergoing extended curettage between January 2014 and December 2019. The participants were divided into two groups: one group of 12 patients underwent extended curettage with bone allograft and bone cement, while the other group of 13 patients underwent extended curettage with bone cement only. Quality of life was assessed by the Revised Musculoskeletal Tumor Society Score and by the Knee score of the Knee Society; recurrence and complications were assessed for each cohort at the last follow-up. The Fisher test and two-sample t-tests were used to compare the categorical and continuous outcomes, respectively. Results The mean age was 28.09 (7.44) years old, with 10 (40%) males and 15 females (60%). The distal femur and the proximal tibia were involved in 13 (52%) and in 12 (48%) patients, respectively. There was no significant difference in the musculoskeletal tumor society score (25.75 versus 27.41; p= 0.178), in the knee society score (78.67 versus 81.46; p= 0.33), recurrence (0 versus 0%; p= 1), and complications (25 versus 7.69%; p= 0.21). Conclusions Extended curettage with or without bone allograft have similar functional outcomes for the knee without any major difference in the incidence of recurrence and of complications for Grade II GCTs. However, surgical convenience and cost-effectiveness might favor the bone cement only, while long-term osteoarthritis prevention needs to be investigated to favor bone allograft.

Resumo Objetivo Este é o primeiro estudo a estabelecer a utilidade da curetagem estendida com ou sem enxerto ósseo em tumores de células gigantes (TCGs) de grau II na articulação do joelho com o objetivo de explorar os resultados funcionais pós-operatórios. Métodos Revisamos retrospectivamente 25 casos de TCGs de grau II de Campanacci submetidos a curetagem estendida entre janeiro de 2014 e dezembro de 2019. Os participantes foram divididos em 2 grupos: um grupo de 12 pacientes foi submetido a curetagem estendida com aloenxerto ósseo e cimento ósseo, enquanto o outro grupo, com 13 pacientes, foi submetido a curetagem estendida apenas com cimento ósseo. A qualidade de vida foi avaliada pela Pontuação Revista da Musculoskeletal Tumor Society (MTS, na sigla em inglês) e pela Pontuação da Knee Society (KS, na sigla em inglês), enquanto as taxas de recidiva e complicações foram avaliadas em cada coorte na última consulta de acompanhamento. O teste de Fisher e os testes t de duas amostras foram usados para comparação de resultados categóricos e contínuos, respectivamente Resultados A média de idade dos pacientes foi de 28,09 (7,44) anos; 10 (40%) pacientes eram do sexo masculino e 15 (60%) pacientes eram do sexo feminino. O fêmur distal e a tíbia proximal foram acometidos em 13 (52%) e 12 (48%) dos pacientes, respectivamente. Não houve diferença significativa na pontuação revista da MTS (25,75 versus 27,41; p= 0,178), na pontuação da KS (78,67 versus 81,46; p= 0,33) e nas taxas de recidiva (0 versus 0%; p= 1) e complicações (25 versus 7,69%; p= 0,21). Conclusões A curetagem estendida com ou sem aloenxerto ósseo tem resultados funcionais semelhantes em pacientes com TCGs de grau II no joelho, sem qualquer diferença importante na incidência de recidivas e complicações. No entanto, a conveniência cirúrgica e o custo-benefício podem favorecer a utilização apenas de cimento ósseo, enquanto a prevenção da osteoartrite em longo prazo precisa ser investigada para favorecer o enxerto ósseo.

Formulation, Optimization, in vitro and in-vivo evaluation of levofloxacin hemihydrate Floating Tablets

Abstract The objective of the present investigation was to design, optimize and characterize the gastro retentive floating levofloxacin tablets and perform in-vivo evaluation using radiographic imaging. The floating tablets were prepared by using polymers i.e hydroxy propyl methyl cellulose (HPMC-K4M) and carbopol-940 individually and in combination by nonaquous granulation method. All the Formulations were evaluated for swelling index (S.I), floating behavior and in-vitro drug release kinetics. The compatibility study of levofloxacin with other polymers was investigated by FTIR, DSC, TGA and XRD. Results from FTIR and DSC revealed no chemical interaction amongst the formulation components. The optimized formulation (F11) showed floating lag time (FLT), total floating time (TFT) swelling index (S.I) of 60 sec, >16h and approximately 75 %, respectively. Moreover, F11 showed zero order levofloxacin release in simulated gastric fluid over the period of 6 h. X-ray studies showed that total buoyancy time was able to delay the gastric emptying of levofloxacin floating tablets in rabbits for more than 4 hours. In conclusion the optimized formulation (F11) can be used for the sustained delivery of levofloxacin for the treatment of peptic ulcer.

Outcomes of Direct Infrapectineal Buttress Plate for Quadrilateral Surface Fractures of Acetabulum Using an Anterior Intrapelvic Approach / 대한고관절학회지

Purpose@#Reduction and stable fixation of the quadrilateral plate are challenging primarily due to its location in the true pelvis, limited bone stock, juxta-articular nature, and its comminution. The current study aimed to investigate the quality of reduction and functional outcomes after open reduction and internal fixation (ORIF) with infrapectineal buttress plating of the quadrilateral surface via an anterior intrapelvic approach. @*Materials and Methods@#We conducted a retrospective review of twenty-one patients with acetabular fractures involving quadrilateral plate operated at Ghurki Trust Teaching Hospital between January 2017 and December 2018. Radiological assessment of the quality of reduction was conducted using criteria described by Matta. Functional outcomes were evaluated using a modified Postel Merle d’Aubigné score. @*Results@#The current study included 15 males and 6 females with a mean age of 40.67±12.17 years (range, 22-62 years). The most common fracture pattern was anterior column and posterior hemi-transverse in eight patients followed by true bicolumn and T-type fractures in seven and four patients respectively. Both transverse fractures were transtectal. The quality of reduction according to Matta criteria was anatomical in 14 patients, imperfect in five and poor in two. Functional outcomes were excellent in 47.6% cases, good in 42.9%, and fair in 9.5% cases. Both patients with fair outcomes had non-anatomical reduction, and one required total hip arthroplasty at a later time. @*Conclusion@#Quadrilateral plate reconstruction with an infrapectineal buttress plate applied though an anterior intrapelvic approach provides high rates of anatomical reduction and yields good functional outcomes.

The effective transfection of a low dose of negatively charged drug-loaded DNA-nanocarriers into cancer cells via scavenger receptors / 药物分析学报

DNA-nanotechnology-based nano-architecture scaffolds based on circular strands were designed in the form of DNA-nanowires(DNA-NWs)as a polymer of DNA-triangles.Circularizing a scaffold strand(84-NT)was the critical step followed by annealing with various staple strands to make stiff DNA-triangles.Atomic force microcopy(AFM),native polyacrylamide gel electrophoresis(PAGE),UV-analysis,MTT-assay,flow cytometry,and confocal imaging were performed to assess the formulated DNA-NWs and cisplatin(CPT)loading.The AFM and confocal microscopy images revealed a uniform shape and size distribution of the DNA-NWs,with lengths ranging from 2 to 4 μm and diameters ranging from 150 to 300 nm.One sharp band at the top of the lane(500 bp level)with the loss of electrophoretic mobility during the PAGE(native)gel analysis revealed the successful fabrication of DNA-NWs.The loading efficiency of CPT ranged from 66.85％to 97.35％.MTT and flow cytometry results showed biocompatibility of the blank DNA-NWs even at 95％concentration compared with the CPT-loaded DNA-NWs.The CPT-loaded DNA-NWs exhibited enhanced apoptosis(22％)compared to the apoptosis(7％)induced by the blank DNA-NWs.The release of CPT from the DNA-NWs was sustained at＜75％for 6 h in the presence of serum,demonstrating suitability for systemic applications.The IC50 of CPT@DNA-NWs was reduced to 12.8 nM CPT,as compared with the free CPT solution exhibiting an IC50 of 51.2 nM.Confocal imaging revealed the targetability,surface binding,and slow internalization of the DNA-NWs in the scavenger-receptor-rich cancer cell line(HepG2)compared with the control cell line.

Neurological manifestations of primary Sjogren's syndrome [Pss]

Objective: To determine prevalence, clinical patterns and outcomes of neurological involvement in a cohort of primary sjogren's syndrome [PSS] patients presenting to a tertiary care hospital

Study Design: Observational retrospective cross-sectional case-control

study. Place and Duration of Study: This study was carried out at Neurology department of Pak Emirates Military Hospital, Rawalpindi, from May 2015 to Jun 2016

Patients and Methods: All patients fulfilling American College of Rheumatology [ACR] criteria of PSS and having neurological involvement, who were admitted in Neurology wards from May 2015 to June 2016, were included in the study. Demographic, clinical and seroimmunological data of the patients was documented

Results: A total of 26 patients with PSS had some degree of neurological involvement. Mean age was 40.50 years. [SD 14.803, min 22, max 78]. Fifteen patients were female and 11 were male. Sicca symptoms [ocular and oral dryness] were present in 38.5 Percent. Serological marker anti Ro and La were present in 76.9 Percent and 42.3 Percent respectively while both Ro and La were present in 34.6 Percent. Lip biopsy was diagnostic in 80.8 Percent and schirmer test was positive in 46.2 Percent. Refractory headache was present in 84.6 Percent. Seizures occurred in 34.6 Percent, which were focal in 23.1 Percent and generalized in 11.5 Percent. Trigeminal neuralgia was present in 26.9 Percent, multiple cranial nerve palsies in 15.4 Percent and recurrent facial nerve palsies in 11.5 Percent. Optic neuritis was seen in 19.2 Percent. Clinical presentation mimicking relapsing and remitting multiple sclerosis was seen in 30.8 Percent of patients among whom 61.5 Percent also met revised McDonald criteria for dissemination in space [DIS] on MRI and 23.1 Percent met criteria for dissemination in time. MRI brain showed cortical lesions in 42.3 Percent. Longitudinally extensive transverse myelitis involving cervical and upper thoracic cords was present in 26.9 Percent of patients

Conclusion: The diagnosis of neuro-sjogren's syndrome [NSS] can be difficult in the absence of sicca symptoms especially when neurological manifestations precede sicca symptoms by many years. This requires a high index of clinical suspicion and low threshold for investigations like lip biopsy and autoantibody profile for the diagnosis. This study highlights the need to revise the overemphasis of sicca symptoms in various current diagnostic criteria in order to improve early recognition and initiation of treatment

Electroconvulsive therapy [ECT] for the management of neuroleptic malignant syndrome [NMS] in adults

Objective: To determine the efficacy and safety of electroconvulsive therapy [ECT] for the management of neuroleptic malignant syndrome [NMS] in adults. Study Design: Open label, unblinded series. Place and Duration of Study: This study was carried out at the Department of Neurology, Military Hospital Rawalpindi, from Jan 2015 to Dec 2015

Material and Methods: All the patients with the diagnosis of NMS during the study period were included in the study. Consective non-probability sampling technique was used. Patients were divided into two groups; uncomplicated and complicated cases of NMS

Results: A total of nineteen patients were included in this pilot study. Out of all, thirteen [68.4%] were males and six [31.6%] were females. Mean age of the patients was 35.05 [SD 13.362] years. The drug classes causing NMS were antipsychotic medicines in 73.7% of patients and antiemetics in 26.3% of patients. Mean electroconvulsive therapy [ECT] sessions given were 6.16 [SD 2.062]. Following treatment n=16 [84.2%] patients had complete recovery while n=3 [15.3%] patients died

Conclusion: In this small, open label, unblinded study ECT appears effective and safe in treating NMS in adults. Larger randomized studies will help to confirm data emerging from this preliminary study

Characteristics and outcomes in patients with anti N-Methyl-D-Aspartate receptor auto-immune encephalitis

Objective: To study characteristics and outcome in patients with anti-N-Methyl-D-Aspartic Receptor encephalitis. Study Design: Retrospective observational cohort. Place and Duration of Study: Neurology Department Military Hospital Rawalpindi, from Feb 2015 to Sep 2016

Material and Methods: Data of patients admitted with anti-n-methyl-D-aspartate receptor encephalitis was analyzed retrospectively. Patients were classified as having definite or probable anti-N-methyl-D-sspartate receptor encephalitis whether antibody testing in CSF was positive or negative respectively and fulfillment of other defined parameters. Patient characteristics, treatment protocols and outcomes were noted

Results: Eleven patients were included in this cohort. Six [54.5%] were males and 5 [45.5%] were female. Mean age was 31.18 years [SD 14.865]. Mean day to symptom onset was 18.51 days [SD 16.646]. Abnormal behavior was seen in 90.9%, Seizures and movement disorder in 81.8%, speech dysfunction in 72.7%, decreased level of consciousness in 63.6% and autonomic dysfunction in 54.5% anti-N-methyl-D-aspartate receptor antibodies were done in CSF in 3 patients only out of which 2 were positive. In remaining nine patients antibody testing was not done due non availability of facility and or affordability. Out of eleven patients 2 [18.25%] had definite encephalitis and 7 [81.8%] had probable encephalitis. CSF was abnormal in 63.6% with pleocytosis in 18.2% and oligoclonal bands in 45.5%. EEG was abnormal in 72.7% and MRI was annormal in 36.4%. Outcome was favorable in 63.6% and unfavorable in 36.4%

Conclusion: In this study we were able to determine that patients with anti-N-Methyl-D-Aspartate Receptor encephalitis have a favorable outcome if diagnosed and treated aggressively early in the course of disease

Neuro-psychiatric manifestations of hashimoto thyroiditis; a case series

Hashimoto Encephalopathy [HE] or Steroid-Responsive Encephalopathy associated with Autoimmune Thyroiditis [SREAT] is a rare autoimmune disease characterized by encephalopathy and elevated anti-thyroid antibodies in the absence of a central nervous system [CNS] infection, tumour or stroke. Clinical presentation of HE includes amnestic syndrome, seizures including status epilepticus, ataxia, myoclonus and psychiatric manifestations like depression, mania, psychosis and hallucinations. A good clinical response can be achieved with corticosteroid therapy so early diagnosis and treatment is very beneficial for patients. Here we report four patients with Hashimoto encephalopathy who had neuro-psychiatric manifestations of the disease and had detectable thyroid specific antibodies in the serum [thyroperoxidase antibody formerly known as antimicrosomal antibody]. All these patients showed an objectively significant response to methylprednisolone treatment

Crigler massage for congenital blockade of nasolacrimal duct

Objective: To determine the success rate of non-surgical management of congenital nasolacrimal duct obstruction [CNLDO] with Crigler massage in infants below the age of one year

Study Design: A cross-sectional observational study

Place and Duration of Study: Department of Ophthalmology at HBS General Hospital, Hazrat Bari Sarkar Medical and Dental College, Islamabad from November 2015 to May 2016

Methodology: One hundred children with watering of eyes, due to congenital blockage of the distal part of the nasolacrimal duct [at the valve of Hasner], unilateral or bilateral were included in the study. Initially, Crigler massage was advised to all the parents for a period of 1-3 months with practical demonstration and the results were documented every fortnight

Results: There were 52 infants up to the age of 6 months and 48 infants between 6-12 months, 53% were boys and 47% were girls. Among them, 67% had unilateral complain while 33% were bilaterally affected. At the end of 1-3 months, 90% of the children achieved patency and only 10% of the cases were subjected to Bowman's probing under short anesthesia

Conclusion: CNLDO mostly resolved through conservative approach by Crigler massage as an initial management, if done consistently. Probing and other surgical procedures should not be considered before the age of 12 months

Antimicrobial and toxicological studies on fruit pulp of Citrullus colocynthis L.

The methanolic extract of dried fruit pulp of Citrullus colocynthis [Cucurbitaceae] has been studied with respect to antimicrobial and toxicological properties. The antimicrobial profile was investigated against thirty bacterial isolates [10 Gram +ve and 20Gram-ve] and five fungal species. None of the bacterial or fungal culture used in the study showed sensitivity against the extract. Acute toxicity studies carried out in Albino mice NMRI indicated the highly toxic nature of the colocynth. A very significant decrease in body weight of test animals was noted at P<0.05. The LD[50] was calculated as 1000mg/kg body weight. Within four days of experimentation mortality was 100%. Histopathological studies confirmed the toxic nature of extract. Gross changes in histology of Heart, Liver and Kidneys were noted. Section of spleen did not exhibit any abnormality

Frequency of pyruvate kinase [PK] deficiency in neonates with haemolytic anaemia

Objective: To determine the frequency of pyruvate kinase deficiency in neonates presenting with haemolytic anaemia

Study Design: Cross sectional descriptive study

Place and Duration of Study: Haematology department, Armed Forces Institute of Pathology, Rawalpindi [AFIP] from Jan 2011 to Jan 2012

Material and Methods: Study was done in collaboration with neonatology department of Military Hospital. Informed consent from parents of neonates was obtained. Two hundred and twenty five neonates with haemolytic anaemia based on low haemoglobin [<14g/dl], raised reticulocyte counts [>5%] and indirect hyper bilirubinaemia [as per CDC nomogram for evaluation of hyper bilirubinaemia in term neonates] were selected. Qualitative pyruvate kinase enzyme assay was done using Bio vision PK assay kit. Estimation of enzyme was based on generation of pyruvate by addition of substrate with change in optical density [OD] of sample in presence of enzyme. Dilution of standard as recommended by manufacturer was made and standard graph was plotted. The OD was measured using wave length of 570 nm at two points [start and at 25 min]. Cut off limit of less than 25% activity was considered positive for pyruvate kinase deficiency. Confirmation was done by running in parallel negative and positive controls [provided]

Results: Seven [3.1%Confidence Interval: +/- 3.33] out of 225 patients were found deficient. Among these 4 were male and 3 were female neonates. The age range was between 1 to 3 weeks. The mean age of presentation was 1.89 +/- [0.832] weeks

Conclusion: We conclude that pyruvate kinase deficiency is not uncommon in our setup and all patients with congenital non-spherocytic haemolytic anaemia where cause cannot be established should be screened for pyruvate kinase deficiency

Comparative clinical study on the efficacy of biocor plus compared with simvastatin for the management of hypercholesterolemia

Hypercholestriolemia is major risk factor that enhances the incidence of cardiovascular disease and coronary artery disease. The present study was conducted to normalize the lipid profile in the blood by using Biocor Plus for hypercholesterolemia compared with Simvastatin. It was prospective randomized case control study conducted on 70 diagnosed patients of hypercholesterolemia at Sohail Memorial Hospital, Karachi and Amir Habib Medical Center and Maternity Home, Karachi. Patients of both genders [30-70 years] with clinical diagnosis of Hypercholesterolemia. Sample sizes for this study included total of 70 subjects. There was statistically significant difference when comparing the effectiveness of test drug, Biocor Plus to control drug, Simvastatin for the treatment of primary hypercholesterolemia. This is clearly evident that the herbal coded test drug, Biocor Plus possesses a therapeutic value for the treatment of primary hypercholesterolemia. There were no untoward or significant side effects associated with the use of Biocor Plus that proved its good acceptability by the patients. Moreover there was subjective feeling of wellbeing regarding breathlessness and chest tightness or pressure in the patients taking Biocor Plus. This makes an interesting point to focus on this effective alternative drug for primary hypercholesterolemia

Sputum neutrophilia in severe persistent asthmatics

Objective: To determine the frequency of sputum neutrophilia in patients with severe persistent bronchial asthma. Study Design: A cross-sectional study. Place and Duration of Study: Department of Medicine, Military Hospital, Rawalpindi, from November 2009 to November 2010

Methodology: Cases of severe persistent bronchial asthma, aged between 12 and 40 years, were included. Sputum samples were collected by induction with hypertonic saline [4.5%]. All samples were centrifuged and differential neutrophil count was calculated. Data was analyzed using SPSS 11

Results: Out of 195 patients, there were 129 [66.2%] males and 66 [33.8%] females. The mean age was 27.01 +/- 6.92 years. Mean sputum neutrophilic count was 126.47 +/- 16.52 x 106/ml and the mean neutrophilic percentage was 63.187 +/- 8.3363. Sputum neutrophilia was present in 84 patients [43.1%], out of whom, 56 were males and 28 females. In patients with sputum neutrophilia, mean neutrophilic count was 142.40 +/- 8.49 x 106/ml and the mean neutrophilic percentage was 71.2024 +/- 4.2441%

Conclusion: Sputum neutrophilia is a frequent finding in cases with severe persistent bronchial asthma. Presence of sputum neutrophilia in such cases can lessen the inappropriate use of corticosteroids with their associated long-term side effects

Frequency of resistant hypertension in a hypertensive population

To determine the frequency of resistant hypertension in hypertensive population. Descriptive study. CMH Kohat, Pakistan from Aug 2010 to Dec 2010. One hundred and fifty patients were selected for the study. All had blood pressure > 140/90 mmHg despite use of 3 antihypertensive drugs including one diuretic. Once admitted, patients were given the same medicines in the doses which they were taking under DOT [direct observed therapy] programme executed by a nursing assistant to exclude non-compliance to treatment. All the data was analyzed using SPSS version 16. Out of total 150 patients, 96 [64%] patients were males and 54 [36%] were females. Male to female ratio was 1: 1.8. Mean age was 46.93 years [SD +/- 16.38]. Compliance of patients to anti hypertensive treatment was ensures by DOT. There was no step up treatment. Mean BMI was 25.95 kg/m[2] [SD +/- 2.38], patients 71.3% were overweight i.e. BMI > 25 kg/m[2]. Out of total 150 patients, 16 [10.7%] patients had resistant hypertension using the cut off value of BP >140/ 90 mmHg. A significant number of hypertensive patients are suffering from resistant hypertension. Such patients need further evaluation to rule out any genetic, secondary and life style/diet related cause

Mesenteric cyst of abdomen in a young girl- a rare entity

Mesenteric Cysts are often asymptomatic and are found incidentally, although patients may present with lower abdominal pain. Due to non specific clinical presentation, very low incidence and lack of adequate classification these cysts represent a diagnostic and therapeutic challenge. Clinical examination, ultrasound and CT imaging combined together help in the diagnosis. We present a case of mesenteric cyst in a 4.9 years old girl that was successfully removed surgically. She presented with history of intermittent abdominal pain for the previous 8 months and it was associated with high grade fever. It was successfully treated by complete excisional surgery.

Initial experience of fractional flow reserve in 30 patients with moderate coronary artery lesions at armed forces institute of cardiology

To evaluate our initial experience of Fractional Flow Reserve [FFR] for decision making in coronary revascularization in moderate lesions. A descriptive study. Armed Forces Institute of Cardiology/National Institute of Heart Diseases from August 2009 to August 2010. A total of 30 consecutive patients who underwent FFR at AFIC/NIHD from August 2009 to August 2010. These were the cases in which decision regarding PCI was difficult on visual assessment alone as experienced operators differed in their opinion. A 0.014" FFR wire was used and pressure gradients across the lesions were noted A total of 30 patients with 44 moderate lesions on coronary angiography were evaluated in our initial experience. Amongst these, 27 [61.4%] LAD lesions were studied [20 lesions had an FFR > 0.80 while 7 [15.9%] had an FFR 0.80 or less]. Seven [15.9%] lesions of LCX were evaluated [5 had an FFR > 0.80 and 2 had 0.80 or less]. Seven [15.9%] lesions were of RCA [4 had an FFR >0.80, 3 had 0.80 or less]. One case of LMS lesion was found to be non-critical. Two [4.5%] vein graft lesions were included of which one was found to be angiographically critical, [FFR 0.72]. Out of the total 44 lesions studied 14 [31.82%] lesions were critical with an FFR 0.80 or less, which were stented. Thus 30 stents were saved. This reduced the cost, as well as the un-necessary hazards and risks associated with PCI and the issue of difference in opinion was put to rest. We thus conclude that FFR is a very important tool in guiding the interventionist for planning PCI in moderate lesions

Accelerated 2 hour regimen of streptokinase for pulmonary embolism

To assess the safety and efficacy of accelerated 2 hour regimen of streptokinase [SK] in acute massive pulmonary embolism. The primary end point of study was immediate hemodynamic improvement and safe discharge from the hospital. Quasi-experimental study. Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD], March 2010 to Sept 2010. Twenty five patients referred to AFIC-NIHD Rawalpindi with recent symptoms [<5 days] suggestive of acute massive pulmonary embolism were considered for entry into the study. On confirmation of acute massive pulmonary embolism, they were thrombolysed with 1.5 million units of streptokinase over two hours followed by unfractionated heparin infusion intravenously at a dose of 1,000 IU/h. They were observed for immediate hemodynamic and clinical improvement and followed up till discharge from the hospital. Safety of Streptokinase was assessed by observing for major bleed [requiring blood transfusion]/fatal bleeding/intracranial haemorrhage confirmed on CT scan or anaphylaxis secondary to accelerated regimen. Mean age of the patients was 55 years [range 24 to 85 years] and 60% [15] were males and 40% [10] were females. CT pulmonary angiogram in all 25 cases confirmed massive pulmonary embolism. Streptokinase 1.5 million units were given to all 25 patients in infusion form over a period of 2 hours followed by unfractionated heparin infusion at 1000 IU/hour. No bleeding complication was observed in any of these cases. Eighteen [72%] patients showed immediate hemodynamic and clinical improvement but 28% [7] expired on the same day. Average hospital stay of the patients was 6 days. Mortality of patients with massive pulmonary embolism is high even after thrombolysis. Accelerated 2 hour regimen of streptokinase can be routinely used in patients with massive pulmonary embolism without obviously compromising efficacy or safety but further randomized controlled trials to compare the two SK regimens are required to better predict the efficacy and outcome of the two regimens

Double stick approach for chronic total occlusion of coronary arteries

To describe experience of double stick access to arterial system with contralateral injection of the opposite artery to visualize the distal cross filling vessel when a totally occluded vessel has no antegrade flow. A Quasi-experimental study. Armed Forces Institute of Cardiology / National Institute of Heart Disease Rawalpindi from Jan 2009 to Aug 2010. Retrospective analysis of 20 coronary angiograms performed for CTO at the cardiac catheterization laboratory of AFIC/NIHD were included in the study. Double stick access was gained through femoral artery in the groin 1cm apart. Twenty patients with chronic total occlusions underwent PCI with contralateral injection technique. Out of them 70% were male and 30% were female. The mean age was 53.65 years. Multivessel coronary artery disease was seen in 45% of patients. Left anterior descending artery lesion was present in 60%, while right coronary artery lesion in 40%. There was no LCX lesion. Single wire was used in 55% of cases while 40% required a second wire which was stiffer and heavier than the previous one. Pilot 50 was successful in 70% and 10% required cross it 200. Predilation was done in all cases using multiple balloons. DES was used in 93.75% cases of CTO. The procedure was successful in 80% while in 20% it was unsuccessful. There was no death during the procedure, nor any other periprocedural or access site complications. We conclude that double stick approach with contralateral injection is a safe and effective way to cross total occlusion

Transulnar access for coronary angiography and intervention

To assess the safety and efficacy of a transulnar approach for coronary catheterization. Descriptive study. Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD], October 2009 to January 2010. Twenty five patients underwent coronary catheterization by the transulnar approach. Patients were selected for ulnar approach coronary angiography if they had a weak radial pulse with a stronger palpable ulnar pulse with a positive reverse Allen's test [< 10 sec]. No attempt was made at cannulating radial artery in the same sitting. A 6F sheath was placed inside the ulnar artery as per standard Seldinger technique, and cardiac catheterization or angioplasty was performed. The patients were examined before discharge from the hospital for any access site complications. Mean age of the patients was 48 years [range 30 to 62 years] and 80% [n= 20] were men and 20% [n=5] were females. Successful puncture was achieved in 100% [25/25]. One out of twenty five patients had same sitting PCI with stenting to LAD and LCX. No case of arterial spasm, haematoma, pseudoaneurysm, vascular perforation or loss of pulse was observed. We conclude that the transulnar approach is a safe and efficacious alternative for diagnostic and therapeutic coronary intervention in presence of weakly palpable radial artery and a stronger palpable ulnar artery with positive reverse Allen's test

Relationship between BMI and severity of coronary artery disease in female population of Pakistani origin

Objective: To assess relationship between BMI and severity of coronary artery disease in female population of Pakistani origin

Design: Cross sectional observational study

Place and Duration of Study: Armed Forces Institute of Cardiology-National Institute of Heart Diseases [AFIC-NIHD], 1st February 2010 to 31st August 2010 Patients and Methods: The study population included 132 female patients undergoing coronary angiography. Obesity was classified according to the BMI using the National Institutes of Health [NIH] criteria as Normal [BMI 21-24 kg/m2], overweight [BMI 25-29 kg/m2], obesity class I [BMI 30-34 kg/m2], Obesity class II [BMI 35 to 39 kg/m2 and obesity class III [BMI 40 or above kg/m2]. Coronary angiography data were obtained from the Siemens Queries software system, which maintains the database including detailed angiographic findings of all patients at this institution. Significant lesions were defined as those with>70% diameter narrowing of coronary arteries [>50% for the left main coronary artery]. We attempted to quantify the "severity of CAD" by ascertaining the prevalence of high-risk coronary anatomy [HRCA, defined as>50% stenosis of the left main coronary artery and/or significant three-vessel coronary artery disease]

Results: Comparing overall obese [BMI >/= 30] vs. non obese groups, a statistically significant low prevalence of HRCA was encountered in the obese group [26 of 56, 46.4% vs. 54 of 76, 79.5% p<0.05] We concluded that obesity is associated with less severe coronary artery disease in women population of Pakistani origin