Pattern of rubber bullet injuries in the lower limbs: A report from Kashmir / 中华创伤杂志(英文版)

<p><b>PURPOSE</b>Rubber bullets are considered a non-lethal method of crowd control and are being used over the world. However the literature regarding the pattern and management of these injuries is scarce for the forensic pathologist as well as for the traumatologist. The objective of this report was to add our experience to the existing literature.</p><p><b>METHODS</b>From June 2008 to August 2010 the Government Hospital for Bone and Joint Surgery Barzulla and the Department of Orthopaedics, SKIMS Medical College/Hospital Bemina Srinagar received 28 patients for management of their orthopaedic injuries caused by rubber bullets. We documented all injuries and also recorded the management issues and complications that we encountered.</p><p><b>RESULTS</b>All patients weremales with an age range of 11e32 years and were civilians who had been hit by rubber bullets fired by the police and the paramilitary forces. Among them, 19 patients had injuries of the lower limbs and 9 patients had injuries of the upper limbs. All patients were received within 6 h of being shot.</p><p><b>CONCLUSION</b>Our findings suggest that these weapons are capable of causing significant injuries including fractures and it is important for the surgeon to be well versed with the management of such injuries especially in areas of unrest. The report is also supportive of the opinion that these weapons are lethal and should hence be reclassified.</p>

Management of humeral fracture nonunion in severe osteoporosis by a combination of locking plating and intramedullary fibular grafting / 中华创伤杂志(英文版)

Nonunion of the humerus in a severely osteoporotic bone is a likely event especially if the fracture is transverse. The management of such a combination is a challenge. Most of the conventional fixation methods are unlikely to succeed as the bone failure precedes implant failure in osteoporosis. The challenge is further compounded in severe osteoporosis when the cortical thickness is affected more severely. We used a combination of an intramedullary fibula with a locking plate in 5 cases. The results show that it may be a good combination in such situations as the bone strength is augmented and the plate pullout is less likely.

HLA- DR Alleles in Pakistani Patients of Pemphigus Vulgaris

Objective: To determine frequency of HLA-DR alleles in Pakistani patients of pemphigus vulgaris in comparison with local healthy controls. Study Design: Cross-sectional, comparative study. Place and Duration of Study: Department of Immunology, Armed Forces Institute of Pathology [AFIP], Rawalpindi, from January 2011 to January 2014. Methodology: Twenty eight patients with biopsy proven diagnosis of pemphigus vulgaris referred from Department of Dermatology, Military Hospital, Rawalpindi were included. Patients were compared with a group of 150 unrelated local healthy subjects. DNA was extracted from peripheral blood collected in Tri-potassium EDTA. HLA-DRB1 typing was carried out on allele level [DRB1*01 - DRB1*16] using SSP [sequence specific primers]. HLA type was determined by agarose gel electrophoresis and results recorded. Phenotype frequency of various alleles among patient group and control group was calculated by direct counting and significance of their association was determined by Fisher's exact test/ Chi square test. Results: A total of 12 male and 16 female patients, with age ranging from 21 to 34 [mean 23.4 years] were genotyped for HLA-DRB1 loci. A statistically significant association of the disease with HLA-DRB1*04 was observed [50% versus 20.7% in controls, p < 0.05]. Conclusion: There is a strong association of HLA-DRB1*04 with pemphigus vulgaris in Pakistani population. Key Words: Pemphigus vulgaris. Human leukocyte antigen. Pakistan. Haplotype.

Fracture of the humerus caused by a slingshot projectile / 中华创伤杂志(英文版)

Unconventional and 'non-lethal' weapons are being used in crowd control regularly nowadays. The use of these arms is not risk-free. The paramilitary forces in 2010 used the old fashioned slingshots for crowd control in Kashmir. A young male suffered from a fracture of the distal humerus due to a marble from a slingshot. He was managed by debridement and plaster splintage. Use of apparently innocuous weapons for crowd control is not without risk, as the projectiles fired from them can achieve high velocities and cause significant damage.

C-reactive protein in patients with acute coronary syndrome: association with coronary markers, lipid profile and markers of coagulation

To determine levels of C-reactive protein [CRP] and its association with coronary markers, lipid profile and markers of coagulation in patients of acute coronary syndrome [ACS]. Case control study. The study was conducted at Shifa college of Medicine and Shifa international hospital for a period of one year [November 2005-December 2006]. Sixty nine age matched controls and 133 consecutive patients of ACS were included in the study. CRP were measured by immunoturbidometric method, MB fraction of creatine kinase [CK-MB] and Troponin-I by micro-particle enzyme immunoassay, lipid levels by Colorimetric Enzymatic methods, platelets by celldyn and coagulation markers were measured by CA-50 Sysmax. At admission mean CRP levels, cardiac biomarkers, lipid profile and coagulation markers were significantly increased in patients of ACS versus controls. Within the patients of ACS the mean levels of CRP, CK-MB, Trop I, prothrombin time [PT] and activated partial thromboplastin time [APTT] were significantly raised in patients with ST-elevation myocardial infarction [STEMI] and non STEMI [NSTEMI] versus patients of unstable angina [UA]. Association between CRP levels and coronary markers, coagulation markers and lipid profile was found to be non significant. The CRP levels were increased in patients with ACS as compared to controls. The CRP levels were insignificantly correlated with coronary markers [CK-MB, Trop I], coagulation markers [platelet count, PT, APTT], and lipid profile [cholesterol, triglyceride, HDL and LDL cholesterol] in patients with ACS

Platelet count / splenic size ratio: a parameter to predict the presence of oesophageal varices in cirrhotics

350 million people are infected with Hepatitis B virus [HBV] and 60 million people with Hepatitis C virus [HCV]. Chronic infection by these viruses leads to cirrhosis of liver and hepato-cellular carcinoma [HCC]. Esophageal varices develop in cirrhotic patients which can be demonstrated by invasive methods or predicted by non-invasive methods. An observational, Cross sectional study was conducted in Medical Unit-IV, Liver Center of District Head Quarters Hospital and Medical units of Allied Hospital, Faisalabad for 6 months from 23 May 2007 to 22 November 2007. The study was conducted on 100 patients diagnosed as post viral cirrhosis of liver of either sex between 25 -70 years of age. The ratio between platelet count and spleen size was calculated .The mean ratio for those with esophageal varices was found to be 650 [100 -1614] and for those without esophageal varices, the mean value of the ratio was calculated to be 2453 [1600-3483], which was significantly different [p<0.05]. Non-invasive markers have been used to predict varices in cirrhotic patients. Cirrhotics with esophageal varices have a significantly lower platelet count and a significantly greater ultrasonographic spleen size as compared to those patients of liver cirrhosis without esophageal varices [13,14] a fact also consistant with our study [p < 0.05]

Diagnostic application of smooth muscle antibodies in autoimmune hepatitis

To measure the level of C-reactive protein and find its association with the glycaemic status [fasting plasma glucose, glycosylated haemoglobin] of metabolically normal and diabetic albino rats. Total 60 Albino rats were included [normal n=30; diabetic n=30]. Plasma glucose levels were determined by using glucose oxidase method while determination of total Hb and glycosylated hemoglobin [HbA[1]c] was done by diagnostic kit that uses weak cation-exchange resin to bind Hb. The% HbA[1]c was determined by measuring the absorbance at 415 nm of the glycosylated hemoglobin fraction and the total hemoglobin fraction. The ratio of the two absorbances gave the% of HbA[1]c. C-reactive protein was measured by the ELISA kit. Significant difference was found in the values of fasting glucose, of the normal and diabetic groups [p<0.05] but no significant difference was present in the values of HbA[1]c of both groups. There was no significant difference in the values of C-reactive protein of the normal and diabetic groups. Short duration hyperglycemia has no role in producing inflammation and raising the levels of bioinflammatory marker C-reactive protein

Posterior capsular rupture during phacoemulsification

To find out the reasons for Posterior Capsular Rupture during Phacoemulsification in our cases. Retrospective study from 2001 to 2005. Setting: Hamdard University Hospital and Nisar Eye Hospital, Karachi. A total of 300 patients who underwent Phacoemulsification were included in the study. Cases with +4 nuclei and those operated in camps were not included in this study. After thorough examination and investigations the patients were operated, mostly under retrobulbar anaesthesia. First follow up was on the first post operative day and then after one week, three weeks and eight weeks. Posterior capsular rupture was the most common intra-operative complication, seen in around 16% of our initial phacoemulsification cases. In most [43%] cases it was caused by the sharp and heated phaco tip. In every stage of the phacoemulsification we have to be very careful. Fluid dynamics change during phacoemulsification that may lead to rupture of the thin posterior capsule, and we should be alert to save it

Corneal problems during and after phacoemulsification by beginner phacoemulsification surgeon

To determine the corneal problems faced during and after phacoemulsification [phaco] as a beginner of phaco surgeries Corneal problems in 100 cases of phaco were retrospectively analysed. Those cases with nuclei+3/above and those who were operated in camps were excluded. Phaco-chop technique was used in 80% of cases. Average duration of surgery was 20 minutes Corneal problems were analysed during and after phaco procedures. During phaco corneal abrasion was developed in 40% of cases, detachment of Descemet's membrane was developed in 03% of cases. After phaco on first few days the main corneal problem was corneal edema and striate keratopathy which was in 53% of cases. To reduce corneal problems one has to reduce phaco time and power. We have done phaco in the anterior chamber in most of cases which have increases the chances of corneal endothelial damage and resulted in more corneal edema and striate in early postoperative period so one should try to do phaco in bag. Sharp instruments should be used. Phaco should be done in selected cases rather does "do phaco in all cases" strategy

Honey compared with 1% silver sulfadiazine cream in the treatment of superficial and partial thickness burns

To assess the efficacy of honey compared with 1% silver sulfadiazine cream as a burn dressing for the treatment of superficial and partial thickness burns covering less than 15% of the body surface. In a randomized comparative clinical trial, carried out at the Surgical Department, of Combined Military Hospital, Bahawalpur, from September, 2002 to August, 2003, 50 patients were selected for the study. They were randomly assigned to two groups. Each group contained 25 patients. Patients in group-I were treated with pure honey which was applied once daily after the wound was cleaned with normal saline. Patients in group-II were similarly dressed with a layer of 1% silver sulfadiazine cream once daily. The effectiveness of the two modalities of treatment was judged on the basis of time taken for the wounds to heal, to be relieved of pain and to get sterile. In group-I [treated with honey], 52% of the patients had all the burns healed after 2 weeks and 100% got cured after 4 weeks. In group II [treated with 1% silver sulfadiazine], 20% of the patients had their burns healed after 2 weeks, 60% after 4 weeks and 100% by the end of 6 weeks of the treatment. As regards pain relief, all the patients of group-I were relieved of pain after 3 weeks of the treatment. On the contrary it took 4 weeks for all the patients of group-II to be free of pain. Lastly, it took 3 weeks and 5 weeks for positive swab culture from the wound to get sterile with honey and 1% silver sulfadiazine cream, respectively. With all the three criteria used to compare the effectiveness of the two modes of burn wound treatment, honey was found superior to silver sulfadiazine

'Sore throat' - a commonly misinterpreted symptom

'Sore Throat' is a very common presenting complaint. However, it is misinterpreted very often. In our set-up where English is not the mother language patients use the sentence 'Gala kharab hai' for any problem in throat; it carries meaning ranging from pain in throat to hoarseness to cough. This is erroneously translated as 'sore throat' when effort is not made to elaborate the above complaint. We carried out a study at Combined Military Hospital [CMH] Rawalpindi to analyze the above symptom and see what it meant from patient to patient. We found that though some patients use this term in the context of pain, others use it for completely different meanings. Serious errors in management can take place, if presenting complaint of the patient is not properly analyzed

Total inferior turbinectomy for hypertrophied inferior turbinates: postoperative results in 135 patients

The surgical treatment of hypertrophied inferior turbinate remains controversial. A wide variety of surgical procedures have been performed with universally unsatisfactory results. The objective of our study was to evaluate the efficacy and safety of total inferior turbinectomy in relieving nasal obstruction caused by hypertrophied inferior turbinates. The study was conducted at the Departments of Otolaryngology Combined Military Hospital Kharian and Peshawar, over a period of 5 years [January 1997 to December 2001]. Three hundred and twenty two patients suffering from chronic nasal obstruction due to enlarged inferior turbinates underwent total inferior turbinectomy. Out of these, 135 were followed for one year postoperatively and included in the study. Postoperative evaluation was done by formal questionnaire and clinical examination. One hundred and twenty eight patients described marked improvement in their nasal breathing, 4 had mild improvement, and 3 had no change. Three patients developed postoperative bleeding which was controlled by anterior nasal packing only. No blood transfusion was required. Asymptomatic adhesions were found in 8 patients and none developed atrophic rhinitis. We conclude that total inferior turbinectomy is safe and very effective in relieving chronic nasal obstruction caused by hypertrophied inferior turbinates and does not require expensive instrumentation

Leech in the hypopharynx: an unusual cause of bleeding from throat

Combined Military Hospital, Peshawar and Army Medical College, Rawalpindi. This paper presents as a case of a 22 year-old young man who presented with a 4-day history of bleeding from throat. Indirect laryngoscopy revealed a blackish living foreign body in the right laryngo-pharynx. Pharyngo-laryngoscopy under general anaesthesia showed a leech, which was removed by forceps. We conclude that a high index of suspicion of leech infestation is required when faced with bleeding from throat

Modified Epley's maneuver for treatment of benign positional vertigo: an experience with over 100 cases

Treatment for Benign positional vertigo has traditionally been pharmacological. However, physical methods of treatments are gradually replacing the former. Particle repositioning maneuver as described by Epley, has gained wide acceptance over the last decade. We present our experience with more than 100 cases treated with modified Epley's maneuver [no sedation given, nor mastoid vibrator applied]. The study was conducted at CMH Rawalpindi from Jun-2002 to May-2003. All patients with features typical of benign positional vertigo, confirmed by positive Dix-Hallpike test, were included. The patients were followed-up for 3 months. The success rate in our series was around 66%. We conclude that modified Epley's maneuver is indeed an effective method for treatment of BPV, but success rate is less than generally reported

Otological manifestations of bomb blast injury

The study was conducted to assess the spectrum and pattern of otological injuries in bomb blast. Observational/non-interfering descriptive study of the trauma to the auditory system in a bomb blast in a bus was explored. This study was conducted from 28 to 30 Oct. 2001 in a tertiary care hospital, following a bomb blast in a bus on 28'h October 2001. An explosive charge detonated under a seat in a local urban transport bus on 28th October 2001, killing 3 passengers on the spot. All the survivors who required medical treatment were transferred to a major medical facility located about 100 metres from the scene of the incident. All those, admitted or reporting to ENT Department, were examined for any ear nose or throat injury. In the otological evaluation the audiological and vestibular symptoms were recorded and tuning fork tests, pure tone audiometery and Hallpike manoeuvre were also performed. The otological manifestation of blast trauma were hearing loss, tinnitus, ear discharge and pain. Vertigo was not a symptom of blast trauma. Perforation of tympanic membrane was a common sign in blast trauma. Sensorineural hearing loss was also one feature of bomb blast injury. Typical noise induced deafness was found in 36% of total ears tested on PTA. The 256 Hz tuning fork was more sensitive in detecting conductive deafness as compared to 512 Hz tuning fork in Rinne test. The results of the study call for the necessity of early ENT observation of all the patients who are subjected to explosive trauma because the ear is particularly susceptible to damage