Reach the leech: an unusual cause of hematuria

Leeches are found in fresh water as well as moist marshy tropical areas. Orifical Hirudiniasis is the presence of leech in natural human orifices. Leech have been reported in nose, oropharynx, vagina, rectum and bladder but leech per urethra is very rare. We report a case of leech in urethra causing hematuria and bleeding disorder in the form of epistaxis and impaired clotting profile after use of stream water for ablution. The case was diagnosed after a prolonged diagnostic dilemma. A single alive leech was recovered from the urethra after ten days with the help of forceps. The hematuria and epistaxis gradually improved over next 48 hours and the patient became asymptomatic. Natives of leech infested areas should be advised to avoid swimming in fresh water and desist from drinking and using stream water without inspection for leeches

pattern of peripheral nerve injuries among Pakistani soldiers in the War against terror

To determine the pattern of peripheral nerve injuries in Pakistani soldiers in the War against terror. Case series. Department of Electrodiagnosis at Armed Forces Institute of Rehabilitation Medicine [AFIRM], Rawalpindi, Pakistan, from June 2008 to June 2011. All new cases of war wounded soldiers with peripheral nerve injuries were consecutively enrolled. Physical examination and electrodiagnostic study was carried out by experienced physiatrists. Data was entered in pretested especially designed questionnaire which was analysed using SPSS version 17.0. Seddon's classification system was used to assess the severity of injury. There were 418 cases of peripheral nerve injuries with 504 different nerve segments. Mean age was 29.41 +/- 8 years. Blast was the main cause of nerve injury in 244 [48.5%] cases followed by gunshot in 215 [42.7%] and 45 [8.9%] cases had nerve injuries secondary to fall, burial under debris and motor vehicle accidents. Eighty six [17%] cases had multiple nerve injuries. Most commonly injured nerve was ulnar [20.6%] followed by sciatic [16.7%], median [16.5%], radial [16.3%], peroneal [8.7%], brachial plexus [8.5%], axillary [4.8%], tibial [2%], femoral [1.8%], long thoracic [0.4%] and others [3.8%]. Axonotmesis was seen in 459 [91.1%] cases, 44 [8.7%] cases revealed neurotmesis and 1 [0.2%] case had neuropraxia. Peripheral nerve injuries are a major component of war related injuries mainly involving the upper limbs. Electrodiagnostic studies help in assessing severity and determining prognosis. Precise documentation of severity of nerve injuries is important to estimate the burden on our resources and to extend rehabilitation services

Frequency of different causes of upper gastrointestinal bleeding using endoscopic procedure at a tertiary care hospital

To assess the outcome of early endoscopy in terms of frequency of different causes of upper gastrointestinal bleeding at a tertiary care hospital. Cross sectional descriptive study. Outpatients / indoor patients, Department of Medicine Military Hospital Rawalpindi from 1[st] Jan 2010 to 30[th] June 2010. Study was carried out in department of medicine Military Hospital Rawalpindi. Two hundred and forty four after cosen. Patients of upper gastrointestinal bleeding fulfilling the inclusion criteria were included in the study. Haemodynamically stable patients were kept empty stomach for at least 6-8 hours before procedure. A detailed history and thorough physical examination was carried out. Protocols for endoscopic examination were followed. Mandatory baseline investigations were obtained. Endoscopic findings were documented on a proforma. p value of less than 0.05 was considered statistically significant. There were 174 males [71.3%] and 70 females [28.7%]. The age of the patients ranged from 15 years to 75 years, mean age was 52.23 years [SD = 14.78]. The most common cause of upper GI bleed was varices in 176 [72.1%] patients; followed by gastric ulcer in 24 [9.8%] patients. Other causes in order of decreasing frequency included gastritis 16[6.55%], duodenal ulcer 14[5.73%], esophagitis 6[2.45%], Mallory Weiss tear 2[0.81%] and miscellaneous 6[2.45%]. Esophageal varices is the most common cause of upper GI bleed in our set up reflecting high prevalence of liver cirrhosis secondary to chronic HBV and HCV infection

Functional outcomes following lower extremity amputation at the armed forces institute of rehabilitation medicine using lower extremity functional scale

To assess improvement in functional outcomes following prosthetic fitting after lower limb amputation using a lower extremity functional scale in a cohort of the Pakistani population. Quasi experimental Study. Amputee rehabilitation ward [indoor] / OPD [out patient department] at Armed Forces Institute of Rehabilitation Medicine Rawalpindi. From August 2009 to August 2010. Study was carried out in the amputee rehabilitation ward of the Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan. Fifty two consenting lower limb amputees fulfilling the inclusion criteria were enrolled. All patients were provided with modular prosthesis followed by gait training and integrated amputee rehabilitation program. An assessment was done at 0, 4 and 12 weeks after the provision of prosthesis. Results were analyzed by SPSS Version 15. Most of the patients were males [98.1%]. Mean age was 30.17 +/- 9 years. Trauma was the main etiology [99%] followed by tumor [in only 1 patient who had osteosarcoma]. Transtibial amputation level was the commonest [53.8%] followed by transfemoral in 32.7% patients and Syme's [7.7%]. Lower extremity functional scale [LEFS] mean score in the first week was 35.56 [44.5% of maximum function], which improved to 49.40 [61.8% of maximum function] at week 4, and 59.27 [74.09% of maximum function] at the end of week 12. The p-value for each was 0.000. Early and multidisciplinary amputee rehabilitation improves the functional ambulation level, quality of life and satisfaction level of the individual

Pattern of combat casualties in war against terror among soldiers wearing body armor at CMH Peshawar

To determine the pattern of gun shot and explosive injuries in soldiers equipped with body armor and helmet. Descriptive study Combined Military Hospital Peshawar, from 1st June 2008 to 30th May 2010. All combat casualties received in 'Emergency reception' of Combined Military Hospital, Peshawar were included. Data was taken from the patient's medical charts and by personal evaluation and entered in a proforma. The variables used were age, use of helmet, cause of the injury, site of injury, Haemo-dynamic Status, conscious level, intensive care treatment duration, total hospital stay, return to work and mortality. A total of 516 combat casualties were received in 'Emergency reception' of Combined Military Hospital, Peshawar, Pakistan. All patients were males with a mean age of 31.22 +/- 7.858 years. Sixty nine percent [356] cases had injury due to splinters from Improvised Explosive Devices [IED] and 31% [160] had gunshot wounds. Seventy five percent [391] patients were haemodynamically stable while 24.2% [125] were unstable. Penetrating Extremity Injury [PEI] was the commonest injury [71.9%] followed by Penetrating Injury of Face or Neck [PNFI] in 12.0% [62], Penetrating Torso Injury [PTI] in 8.9% [46] and Penetrating Injury of Cranial Vault [PCI] in 7.2% [37]. Overall mortality was 64 [12.4%] IEDs have become the weapon of choice in gorilla warfare by the terrorists in addition to guns, bombs, and anti-personnel mines. The use of body armor has decreased the mortality but the morbidity in terms of limb injuries has increased

Effectiveness of glyceryl trinitrate in the treatment of chronic anal fissure

Objective: To determine the effectiveness of glyceryl trinitrate [GTN] in the treatment of chronic anal fissure

Study Design: Prospective Study

Place and Duration of Study: Surgical Outpatient department, Khyber Teaching Hospital, Peshawar 06 months [July 2009 to Jan 2010]

Materials and Methods: Six months prospective study was carried out at surgical out patient department of Khyber teaching Hospital, Peshawar. Sixty cases of chronic anal fissure not willing for surgical procedure and fulfilling the inclusion criteria were enrolled. Pain was documented using visual analogue scale. Patients were started treatment with local application of Glyceryl Trinitrate [GTN] gel, twice daily and reassessed after 04 weeks and 08 weeks of treatment respectively. Pain and complications were documented

Results: There were 33 [55%] females and 27 [45%] males with mean age of 37. At presentation all patients [100%] perceived pain as severe pain on Visual Analogue Scale. 80% patients had significant relief with GTN application for a period of 02 months. The commonest complication was constipation [26%], followed by infection [10%], sentinel pile [6%] and fistula [5%]

Conclusion: Glyceryl trinitrate is very effective in the treatment of chronic anal fissure and is the drug of choice in conservative treatment of anal fissures and in patients with contraindications for surgery

Frequency of peripheral polyneuropathy in a cohort of diabetic patients having symptoms of polyneuropathy using electrodiagnostic procedure

To determine the frequency of peripheral polyneuropathy in patients having diabetes mellitus with symptoms of polyneuropathy using electrodiagnostic procedure. Observational descriptive study. Armed Forces Institute of Rehabilitation Medicine [AFIRM], Rawalpindi. June 2008 to June 2009 [one year]. Sixty three patients of diabetes mellitus having symptoms of peripheral polyneuropathy fulfilling the inclusion criteria were sampled by purposive sampling. Informed consent was taken. Their demographic data and common symptoms were recorded. All patients underwent Electrodiagnostic procedures for the presence or absence of polyneuropathy, using nerve conduction studies by recording amplitudes, velocities and latencies of minimal two [sural, peroneal] and maximum six nerves. Electromyography was performed only in patients with abnormalities in nerve conduction findings or conditions other than polyneuropathy. Frequencies as percentages were calculated for the presence or absence of polyneuropathy, type of polyneuropathy, associated symptoms and other related diagnosis [if any]. There were thirty three males [52.4%] and thirty female [47.6%]. Forty one [65%] patients had confirmed polyneuropathy on electrodiagnosis, out of which forty patients [97.6%] had axonal polyneuropathy, only one patient [2.4%] had demyelinating polyneuropathy. Twenty two had no polyneuropathy [35%], out of which 65% had other diagnosis like Carpal Tunnel Syndrome [CTS], Radiculopathy and other Compression neuropathies. Majority of symptomatic diabetic patients actually had polyneuropathy. Electrodiagnostic studies are a sensitive tool for early detection of peripheral polyneuropathy, its types and extent

Percentage of hepatitis B and C among young adult males from interior Sindh

Present study was planned to know the seropercentage of Hepatitis C Antibodies and Hepatitis B Surface Antigen in a population based sample of healthy male army/naval recruits from rural Sindh. Laboratory based non-interventional, descriptive study. Conducted at Combined Military Hospital Pano Aqil from 1st January 2006 to 31st October 2006.A total of 5237 healthy male recruits from various districts of interior Sind were studied. HBsAg and Anti-HCV were tested by Immunochromatographic assay and positive tests were confirmed by ELISA method. The percentage of anti-HCV was [4.37%] and was [7.39%] for HBsAg. The percentage of HBsAg in districts Nowsheroferoze [10.11%], Ghotki [9.21%] and Khairpur [7.48%] and Anti-HCV [p<0.0001] in districts Nawabshah [9.32%], Khairpur [6.71%] and Ghotki [6.64%] respectively was higher than the other districts. Both the viruses are evenly distributed among the remaining different Districts` population. There is considerable threat of HBV and HCV in interior Sindh. Screening of selected groups and vaccination against Hepatitis B may be considered in these areas. Health education to general public including barbers would be the key for control/prevention of these dreadful diseases