Outcomes of gastric pull-up reconstructive surgery following laryngopharyngoesophagectomy in hypopharyngeal and upper esophageal carcinomas

Objective: To determine the commonest stage of hypopharyngeal and upper esophageal carcinoma at presentation, common complications after surgery, perioperative mortality, and one-year survival rate after surgery. Study Design: A descriptive prospective study. Place and Duration of Study: Combined Military Hospitals, Rawalpindi, Lahore, and Malir, from Oct 2008 to Oct 2016

Material and Methods: Through consecutive sampling, 25 individuals were sampled after staging disease through TNM classifications provided by the 1983 American Joint Committee on Cancer Classification for hypopharyngeal cancers. Total laryngopharyngoesophagectomy and gastric pull-up reconstructive surgery was performed by two teams. The total operation time in hours and the approximate blood loss in ml during the procedure was documented. The patients were monitored post-operatively for pulmonary [respiratory failure requiring ventilatory support, atelectasis, pneumonia, pulmonary embolism, pleural effusion/hemothorax, etc.], cardiac [arrhythmias, myocardial infarction, and congestive cardiac failure], and surgical complications [wound infections, anastomotic leak, and fistula formation]. The patients were also followed-up for survival at 1[st], 6[th], and 12[th] month

Results: There were 18 males and 7 females [mean age: 53 +/- 14 years]. Majority presented with T4N2M0-stage disease. The operation lasted for a mean time of 7.7 +/- 1.3 hours [range: 6.3-11 hours] and a mean 1218 +/- 338 ml [range: 590-2020 ml] blood was lost during the operation. The patients remained in the hospital for a mean 26 +/- 16 days [range: 1-56 days]. The commonest complication following operation was pleural effusion/hemothorax present in 72% of the patients. The perioperative mortality was 12% and one-year survival rate was 36%

Conclusion: Majority of our sampled patients presented with T4N2M0-stage disease. The mean operation time in our sample was longer with an increased incidence of anastomotic leaks when compared to the international data. The other complications and perioperative mortality were comparatively similar while one-year survival rate was lower

Bilateral spontaneous anterior shoulder dislocation: A missed orthopedic injury mistaken as proximal neuropathy / 中华创伤杂志(英文版)

A number of orthopedic injuries can occur during epileptic seizures. Anterior shoulder dislocation is one such orthopedic injury that is quite rare. The shoulder dislocation may injure the brachial plexus. Besides seizures, the nerves can also be damaged by anticonvulsive therapy. Muscle wasting following a seizure can misguide a clinician to investigate only neural or muscular pathologies. We report here an individual with epilepsy who was referred to us for electrodiagnostic evaluation of proximal muscle wasting related to a suspected proximal neuropathy. He was found to have a normal electrodiagnostic evaluation and later on discovered to have had bilateral shoulder dislocation on X-rays. This report advocates a thorough clinical appraisal, radiographs, and electrodiagnostic evaluation in a case with muscle wasting following a seizure.

Congenital anonychia totalis: a rare occurrence in a Pakistani family

Anonychia totalis is a rare disease characterized by complete absence of finger and toe nails. Possible associations include anomalies of bones, teeth, skull, hair, skin and sweat glands besides hearing and intelligence impairments. We report here a 60-year-old woman with low back pain and tenderness at the lumbosacral spine who was found to have complete absence of all nails, abnormal teeth, dry skin and left ectropion. She was educated about the disease and managed for the backache on rehabilitation guidelines. Gene mapping of her whole family was planned, but she was lost to follow up. This case provides evidence of the presence of this condition in Pakistani population. There is a need for further investigation and pooling of cases to build clinical data about phenotypes and the inheritance patterns of this disorder in our population

Objective structured clinical examination [OSCE] - a better dimension to measure clinical competencies

The teaching and learning of medical students has always been a demanding perspective. The best teachers at times may strive in conveying medical knowledge and assessing yield of the effort. The traditional written and practical instruments of assessment have many limitations in their practicality and fair judgment. Since its introduction in the 70s, objective structured clinical examination [OSCE] has gained worldwide recognition and appreciation as a fair and standardized format to assess the clinical competencies of medical students and residents. It is an approach in which all the three aspects of clinical competence namely knowledge, skills, and attitude are evaluated in a comprehensive, consistent, and structured manner with close attention to the objectivity of the procedure. OSCE demands excellent communication, time management, and organizational skills. Not only the examiners but also the examinees have widely appreciated OSCE. Therefore, it should be recommended as a standard procedure for a student's evaluation. The aim of this paper was to review and recommend OSCE as a learning tool

Frequency and intensity of shoulder pain after stroke A hospital based study

Objective: To determine the frequency and intensity of shoulder pain in stroke patients and explore any relation of shoulder pain with the side of involvement and the primary etiology of stroke

Study Design: A cross-sectional descriptive study

Place and Duration of Study: Armed Forces Institute of Rehabilitation Medicine [AFIRM], Rawalpindi from January 2012 to June 2012

Material and Methods: Through non-probability convenience sampling 100 patients of both genders satisfying the World Health Organization clinical definition of stroke and reporting within one year of stroke development were included and those with cognitive dysfunction and rheumatic diseases or a history of chronic pain prior to the stroke were excluded. Shoulder pain was defined as pain in the shoulder area requiring analgesia for two or more consecutive days and its intensity was graded on visual analogue scale [VAS]

Results: Of 100 patients [mean age: 63 +/- 18 years], majority were males [76%], diagnosed with ischemic stroke [80%] and had a right sided pain [44%]. Patients with moderate to severe pain were more common [83.3%]. On comparison with the type of stroke, the pain was more prevalent on left side [72.7%] and in patients of ischemic stroke [62.5%]. However, these relations were statistically insignificant [p=0.061 and p=0.197 respectively]

Conclusion: More than half of the stroke patients reporting to our institute developed shoulder pain in first year after stroke the majority of whom had moderate to severe pain. The shoulder pain is not related to the primary etiology of stroke and side of involvement

Searching the research or re-searching the search: where to start from? a post-graduate medical trainees perspective from rawalpindy lslamabad

To explore the post-graduate medical trainees perceptions and practices towards research and to investigate potential barriers to perform research. Cross sectional descriptive study. Military hospital, Combined Military hospital, Rawalpindi and Pakistan institute of medical sciences Islamabad, from Jan 2013-Dec 2013. A pretested, structured and validated questionnaire was used to collect data from 114 final year post-graduate medical trainees [PGMTs]. SPSS version 17 was used for descriptive data analysis. One hundred and fourteen [n=114] final year post-graduate medical trainees [PGMTs] of fellowship program of College of Physician and Surgeons of Pakistan gave their written consent to participate in this study. Among them 68 [59.6%] were males while 46 [40.3%] were female. One hundred and twelve [98.2%] trainees agreed that research is an important and healthy activity and have a great impact on their future carriers. 63 [55.2%] PGMTs had worked as data collector in various studies conducted at their institutions while only 21[18.4%] PGMTs had published their manuscript. Obstacles that prevented the PGMTs from conducting research included: lack of professional supervisors: 103 [90.3%], poor research training: 98 [86.0%], and lack of resources: 84 [73.6%]. Although the majority of the PG trainees believe that research is important in medical field, only about 55.2% of them have participated in the research activities other than mandatory dissertation during their training. Measures should be taken at postgraduate level to involve and support the PGMTs in health research with formal training programs and good mentorship

diagnostic dilemma of progressive muscular atrophy

Progressive muscle atrophy is a rare subtype of motor neuron disease that affects only the lower motor neurons and presents as asymmetrical rapidly progressive muscle weakness, atrophy and normal sensations. The diagnostic electrophysiological findings are denervation potentials in three out of four body segments [bulbar, cervical, thoracic and lumbosacral]. The disease is fatal and the management is supportive. We present the report of a 45-year-old female patient who presented with unilateral foot drop and rapidly progressed to profound weakness in muscles of all limbs, neck and back along with dysarthria and dysphagia. She had been operated twice for suspected cervical and lumbosacral intervertebral disc herniations and ultimately guided in right direction after muscle biopsy, nerve conduction studies and electromyography

Frequency and the related socio-demographic and clinical factors of phantom limb pain in traumatic amputees presenting at a tertiary care rehabilitation setup

Objective: To find out the frequency of phantom limb pain [PLP] in a sample of Pakistani amputee population presenting with amputation due to trauma and to investigate its relationship with different sociodemographic and clinical factors

Study Design: A cross-sectional descriptive study

Place and Duration of Study: Armed Forces Institute of Rehabilitation Medicine, Rawalpindi from August 2010 to October 2013

Material and Methods: Through non-probability purposive sampling, patients of both genders and all ages having a traumatic etiology of amputation were sampled from the outdoor amputee clinic and the indoor amputee ward. Patients having diabetes mellitus, polyneuropathy, memory loss, cognitive deficits and established history of psychiatric disorders were excluded. Through face to face semi structured interviews, information was obtained about presence of PLP, gender, location [urban or rural], ethnicity based on Pakistani provinces [Punjab, Sindh, Khyber Pakhtunkhwa, Balochistan, Azad Jammu and Kashmir], monthly income in Pakistani Rupees [PKR] [<10,000, 10,000 - <50,000 and >50,000], level of education [grade <5, grade 5 - 10, and grade >10], level of amputation and cause of trauma [fall from height, motor vehicle accident, blast injury, bullet injury or others]

Results: Out of 268 patients [mean age 28 +/- 6 years], 266 [99.3%] were male and 2 [0.7%] were female. Majority [79.1%] were rural based, Punjabis [44.8%], had a monthly income <10,000 PKR [85.4%], education from grade 5 - 10 [80.2%] and a lower limb amputation [86.9%]. The commonest cause was blast injuries [72.8%]. PLP was present in 42.5% [n=114] of the individuals and it was not significantly related to gender, living location, ethnicity based on Pakistani provinces, level of education, monthly income, cause of traumatic amputation and level of amputation

Conclusion: PLP was found in 42.5% of our sample of Pakistani traumatic amputees. The frequency was not related to gender, monthly income, ethnicity based on provinces, education, rural or urban based living and etiology or level of amputation

Frequency, character, intensity and impact of neuropathic pain in a cohort of spinal cord injury patients

The purpose of this study was to determine frequency, character, approximate location and intensity of neuropathic pain in spinal cord injury and its impact on the quality of life. A cross-sectional survey. Armed Forces Institute of Rehabilitation Medicine [AFIRM], Rawalpindi from Feb 2009 to Feb 2010. Through non-probability convenience sampling 87 patients of both genders diagnosed with spinal cord injury based on American Spinal Injury Association criteria and admitted within a year of injury were included. Those in spinal shock, having poor cognition, inability to communicate, concurrent brain injury and history of chronic pain before injury were excluded. The history, localization and characteristics of the pain and interference with life activities were recorded. Neuropathic pain of patients was evaluated with Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale. Visual analogue scale was used to measure the severity of pain. Out 87 [mean age 36.9 years] seventy four were male and 13 were female. Seventy patients [80%] were AIS-A, 6 [7%] were AIS-B and 11 [13%] were AIS-C. Neuropathic pain was present in 57.5% [n=50]. Most of the patients localized their pain below the neurological Ievel of injury [78%] and rated pain intensity as [moderate pain] [54%]. Majority [48%] described the pain as burning fallowed by electric shock like [42%], stabbing [8%] and pricking [2%]. 48% patients reported that their quality of life was affected due to pain. 52% required two analgesics of different groups to relieve pain followed by 40% requiring three Analgesics and 8% requiring one analgesic. Neuropathic pain is prevalent in people with spinal cord injury and adversely affects life quality. Neuropathic pain is primarily described as a burning sensation of moderate intensity mostly referred to below the neurological level of injury

Diacerein: a treatment option in painful primary knee osteoarthritis

To identify the efficacy and side effects of Diacerein in patients with mild to moderate knee mteoarthritis. Quasi experimental study. Outpatient Department of Armed Forces Institute of Rehabilitation Medicine, Rawalpindi from June 2012 to June 2013. Ninety cases fulfilling American College of Rheumatology criteria for diagnosis of Knee Osteoarthritis and falling in Grades I-III of Kellgren-Lawrence Radiological Classification for Knee Osteoarthritis were included. Pre-treatment associated symptoms, complete blood count, renal and liver function tests were documented. After a baseline pain assessment on a 10-Point Visual Analogue Scale, 50 mg of Diacerein was given orally for 4 months followed by pain assessment and inquiry about adverse effects at 6[th] week, 3[rd] and 6[th] months. Post-treatment labs were repeated. Reduction in pain was analyzed by paired-sample t-test using SPSS version 17. Chi-Square test was used to assess the frequency of adverse effects. A p-value < 0.05 was considered sigruficant. Mean age was 61.5 +/- 7.8 years. Majority 77 [85.6%] were females. Mean Visual Analogue Scale at start was 6.1 +/- 0.87. Sigruficant pain reduction measured on Visual Analogue Scale was observed at six weeks [4.6 +/- 1.2] [p < 0.001], three months [2.37 +/- 0.91] [p < 0.001] and six months [2.2 +/- 0.85] [p < 0.001]. Very few patients developed diarrhea 3.3% and nausea 4.4%. Diacerein is effective drug with minimal side effects for treatment of mild to moderate painful Knee Osteoarthritis

Penile amputation due to improvised explosive device [IED] blast injury in a pakistani soldier

Penile amputation is a catastrophe and the goal should be to restore adequate mass, sensation and functionality of penis considering penile prosthesis where necessary. A case of a 25 year soldier who had penile amputation due to improvised explosive device blast injury is reported

Spinal cord injury without radiographic abnormalities [SCIWORA] in a preschool child: a case report

A 3, 1/2 year old boy presented at the Soldiers' Family Rehabilitation Unit, Armed Forces Institute of Rehabilitation Medicine, Rawalpindi with 2, 1/2 years' history of weakness and numbness in legs and loss of control over bowel and bladder following run over by a vehicle. At presentation, the child was unable to stand without support with power of 2/5 in iliopsoas, 3/5 in extensor hallucis longus and 0/5 in ankle plantar flexors on both sides. The power in quadriceps was0/5 on right and 2/5 on left side. The knee and ankle jerks were absent bilaterally. Sensations to both light touch and pin prick were impaired below T9 level on both sides. Perianal sensations were intact but voluntary anal contraction was absent. He was categorized as a case of Spinal Cord Injury T9 as classified by American Spinal Injury Association [ASIA] with impairment Scale C. X-Rays and Magnetic Resonance Imaging Scans were normal. These investigations aided by relevant clinical features qualified him as a case of Spinal Cord Injury without Radiographic Abnormalities

Quality of referrals for nerve conduction studies and electromyography to a tertiary care rehabilitation center

To perform an audit of quality of referrals for Electrodiagnosis [EDX]/Nerve conduction studies and Electromyography [NCS/EMG] to a tertiary care rehabilitation center. A detailed referral proforma covering all the prerequisites for EDX studies had already been distributed among the dependent Defense Forces hospitals. The data was taken from that proformas and the patients were asked if the referring physician had explained them about the test and if they had gone through the instructions. Frequencies and percentages were calculated for provision of clinical information, query, reading of instructions by the patients and punctuality of the patients. The reporting time of the patient, if they were late than the appointment time was calculated in minutes. Physician's explanation about the procedure to the patient and provision of information about precautions and contraindications was also included Of the total 130 registered patients, 85 were males and 45 females. 86 [66.2%] referrals were made by consultants, 42 [32.3%] by residents and 2 [1.5%] by General Practitioners. 41 out of total were from consultants and residents in Physical Medicine and rehabilitation followed by 22 from Orthopedics. Regarding institutions, largest number of referrals were from Combined Military Hospital Rawalpindi [43] and Armed Forces Institute of Rehabilitation medicine [40]. By large, the clinicians neither provided clinical notes [62%] nor mentioned the query and provisional diagnosis [53%]. Majority [92%] did not provide information about the test to the patient and did not cue the patient about any precaution to be taken [92%].The patients on the other hand generally read the instructions provided in the request pro forma [54%] and reported well in time for the appointment of procedure [86%]. An inappropriate practice in referring patients uncritically to the EDX studies. Adopting good referral practices seemed crucial for meaningful usefulness of NCS/EMG. Instructions for proper referrals were sent to the concerned hospitals and a repeat audit was planned after one year

Congenital insensitivity to pain with anhidrosis: a case report from Pakistan and literature review

Congenital insensitivity to pain with anhidrosis is a rare disease with an autosomal recessive inheritance. The patients present in early childhood with frequent episodes of fever and absence of sweating. Painless fractures, bruises and cuts are quite common. Defective lacrimation and mental retardation are strongly diagnostic. Repeated injuries often lead to a reduced life expectancy. The diagnosis depends on relevant clinical features, abnormal sensory response on nerve conduction studies and nerve biopsy showing loss of the unmyelinated and small myelinated fibers. We report here a 5 year old female child who presented for electrodiagnostic evaluation and was found to have this disease