Neonatal Cerebral Air Embolism

Background: Vascular air embolism (VAE) is rare but potentially lethal condition, andsurvival is rarely reported in newborn. Case Characteristics: A preterm (27+1 weeks)neonate on Continuous positive airway pressure developed sudden cardiac asystole on day3 of life and required 30 minutes of cardiopulmonary resuscitation. Observation: Infant hadair embolism in liver and brain. He survived but developed cystic encephalomalcia requiringextensive neuro-rehabilitation. Message: Air embolism should be considered as differentialdiagnosis of sudden unexplained cardiac deterioration in well neonate.

Evaluation of carotid artery dynamics & correlation with cardiac & hepatic iron in β-thalassaemia patients.

Background & objectives: Early atherosclerosis and vascular complication have been described in thalassaemia patients. There is lack of data or guidelines regarding monitoring of vascular health in thalassaemia. This study was conducted to compare carotid artery structural and functional indices such as carotid artery intima-media thickness (CIMT), stiffness index (SI) and Young’s elastic modulus (YEM) in β-thalassemia patients with age and sex matched controls, and to correlate these parameters with serum ferritin, cardiac iron, and hepatic iron. Methods: This cross-sectional study included 53 β-thalassaemia patients receiving regular blood transfusions. Carotid artery indices such as CIMT, SI, and YEM were calculated by duplex ultrasound and colour Doppler. Serum ferritin levels were measured by chemiluminescence. Cardiac and hepatic iron estimation were done using MRI T2* sequences analyzed by a special thalassaemia software. Results: Mean CIMT of cases and controls were 0.48 ± 0.04 and 0.44±0.02 mm, respectively and these were significantly different (P<0.001). Similarly significant differences were noted in SI and YEM of cases (2.45±0.79 and 96.12±34.85, respectively) as compared to controls (1.98±0.54 and 68.60±24.29, respectively) (P<0.001). There was significant inverse correlation between stiffness index and cardiac iron overload assessed by MRI cardiac T2* (P=0.03). Mean SI and YEM of cases were (2.1736 ± 0.2986 and 107.3± 41.6, respectively) significantly higher among non-splenectomized patients compared to splenectomized patients (2.0136 ± 0.263 and 86.9 ± 25.2, respectively) (P<0.05). Interpretation & conclusions: CIMT and arterial stiffness indices were significantly increased in β-thalassaemia patients compared to controls which was indicative of early atherogenic changes. This study supports the hypothesis that iron overload is a risk factor for early atherosclerosis and cardiovascular disease.

Study of orthopedic morbidities among outdoor patients in a medical college in District Ambedkarnagar, India.

Introduction: Congenital bone diseases, nutritional disorders like rickets, infective or metabolic conditions and trauma of bones and joints are most common orthopedic problems encountered among outdoor patients. This study was conducted to find out the prevalence of different orthopedic morbidities amongst outdoor patients of the Department of Orthopedics, Government Medical College, and District Ambedkarnagar. Material and Methods: These six months, observational, outdoor department study was carried out in Department of Orthopedics, Government Medical College, Ambedkarnagar, India. A total of 1000 individuals gave their consent and participated in the study. A structured, pretested schedule was used to collect the data on the demographic characteristics (age, gender, religion) and orthopedic problems. The data was analyzed using SPSS software. Results: A higher proportion of the outdoor patients was aged between 16-60 years (82.6%) and was females (50.1%). A higher percentage of orthopedic problems encountered were regional conditions of limbs (23.7%), followed by traumatic (23.0%) and degenerative (22.7%).Traumatic causes and neuromuscular disorders were more common among the males while degenerative, regional and rheumatic conditions were more common among the females. Conclusion: Larger nationwide community based studies are required to know the extent of the orthopedic problems and formulate better health policies.

To determine the comparative values of lipid profile between ischemic and hemorrhagic stroke

Objectives: To determine the relationship of total cholesterol, HDL-C and their ratio among ischemic and hemorrhagic stroke

Study Design: An observational prospective comparative study

Place and duration: This research work was carried out from 1[st] June 2014 to 31[st] December 2014 at department of medicine Bahawal Victoria Hospital Bahawalpur

Methedology: Hundred patients between 30 to 90 years of age, who were admitted by the department of general medicine BVH Bahawalpur with first ever stroke and verified by CT scan brain, were included in the study. Patients who had history of coronary heart disease or lipid lowering drugs, neurological deficits secondary to epilepsy, infective or metastatic disorder, or pre-existing severe cognitive disorder were excluded from this study. A detailed history and physical examination details along with fasting lipid profile were collected from patient records in the hospital medical department. Mean values of quantitative data were presented as mean SD [standard deviation].Frequency percentage of total cholesterol, high density lipoproteins and triglycerides in both groups of ischemic and hemorrhagic stroke, were determined and compared using proportion test for any significant difference taking p-value of < 0.05 as significant

Results: Quantitative data of CVA, comprising [50 each of ischemic and hemorrhagic cases] was analyzed. Mean age of presentation was 56 years. In 50 ischemic patients mean total cholesterol was raised above normal reference range. It was 218.30 +/- 79mg/dl in ischemic stroke while it was 194 +/- 26.7mg/dl in hemorrhagic cases and it was highly significant at P value of < 0.001.The mean HDL concentration was 33.10 -7.33 in patients of ischemic stroke while it was 39.02-4.22 in hemorrhagic cases with p value of o.oo2 [highly significant]. Serum triglycerides levels turned out to be normal in both groups

Conclusion: Hypercholesterolemia and low HDLC was seen significantly in ischemic CVA group as compared to hemorrhagic counterpart

Efficacy of intra-vitreal bevacizumab combined with phaco-emulsification in the prophylaxis of macular edema in patients with non-proliferative diabetic retinopathy

Objective: This study was designed to evaluate the prophylactic efficiency of intra-vitreal Bevacizumab combined with cataract surgery in patients of non-proliferative diabetic retinopathy without macular edema for the prevention of macular edema by assessing the visual outcome

Methodology: This was interventional, randomized, open-label and control study of two parallel groups of already diagnosed patients with pre-proliferative diabetic retinopathy without macular edema. The study included sixty eyes of sixty patients, having non-proliferative diabetic retinopathy without macular edema and lens opacity [grade 1 to 3]. One group [n=30] received intra-vitreal injection of Bevacizumab and the control group [n= 30] did not received intra-vitreal injection of Bevacizumab at the time of standard phaco-emulsification. Main outcome measure was best-corrected visual acuity [BCVA] at the end of two months compared with the baseline visual acuity recorded along with central macular thickness [CMT] measured on optical coherence tomography [OCT] as required

Results: The outcome was an improvement of BCVA at the end of 8[th] week compared with that at baseline in the Bevacizumab group and a worsening of visual acuity in the control group [p = 0.005]

Conclusions: Prophylactic use of intravitreal Bevacizumab combined with phacoemulsification appears to be beneficial in preventing post-surgical visual loss in eyes with NPDR by preventing the chance of macular edema

Profile of ocular trauma in patients under the age of sixteen years in allied hospital, Faisalabad

Aims and Objectives: Evaluation of epidemiological contributing factors in occurrence of ocular trauma in patients under the age of 16 years. Study Design: Descriptive and analytical study carried on 216 children. Period: 13-02-2014 to 26-12-2015. Setting: At Ophthalmological Department, Allied Hospital, PMC, Faisalabad

Patients and Methods: The patients with eye injury who presented to the ophthalmological Department of Allied Hospital, PMC, FSD from 13-02-2014 to 26-12-2015 were included in the study. The Activity at the time of injury, place of injury, identifiable objects causing trauma, age 1-16 years, any sex, use of eye protectors, were noted

Results: Out of 216 patients, there were 166 male [76.85 %] while female were 50 [23.15 %]. There were 76 patients having age between 0-5 years while 78 [36.11 %] were between 6-10 years of age. Out of 216 only 62 [28.7 %] patients were of age between 11 years to 16 years. The injuries due to knife and scissors, occurred in home and were the commonest [17.59 %]. The injuries occurring due to fire cracker and vegetable matter outside home were also common 16.20% and 13.89 % respectively. The fist and hand bite injuries in this group were least common [0.93 %]. In our setting commonest eye injuries involving corneo-scleral were [35+25] [27.78 %]. The frequency of subconjuctival hemorrhage was 11.11 %. The cases having lid tear and canicular cut were 6.48 %

Conclusion: Ocular trauma is an important cause of preventable visual morbidity particularly among younger people who are at the lower risk for chronic ocular diseases. Pediatric ocular trauma is a common cause of ophthalmic consultation

Enteral paracetamol or Intravenous Indomethacin for Closure of Patent Ductus Arteriosus in Preterm Neonates: A Randomized Controlled Trial.

Objective: To compare the efficacy of enteral paracetamol and intravenous indomethacin for closure of patent ductus arteriosus (PDA) in preterm neonates. Design: Randomized controlled trial. Setting: Level III neonatal intensive care unit. Participants: 77 preterm neonates with birth weight ≤1500 g and PDA size ≥1.5 mm, with left to right ductal flow with left atrium to aortic root ratio >1.5:1; diagnosed by 2D-Echo within first 48 hours of life. Intervention: Paracetamol drops through the infant feeding tube (15mg/kg/dose 6 hourly for 7 days) or intravenous indomethacin (0.2 mg/kg/dose once daily for 3 days). Outcome measures: Primary: PDA closure rate assessed by echocardiography. Secondary: need for surgical closure of PDA, renal impairment, gastrointestinal bleed, necrotising enterocolitis, hepatotoxicity, pulmonary hemorrhage, sepsis, hypothermia, retinopathy of prematurity, intraventricular hemorrhage, bronchopulmonary dysplasia and mortality. Results: PDA closure rate was 100% (36/36) in enteral paracetamol group as compared to 94.6% (35/37) in intravenous indomethacin group (P=0.13). The secondary outcomes were also similar between the two groups. There was no occurrence of hepatotoxicity. Conclusions: Enteral paracetamol is safe but not superior to intravenous indomethacin in the treatment of PDA in preterm neonates.

Effectiveness of incentive spirometry in preventing postoperative pulmonary complications after laparotomy

Objective: To compare the effectiveness of incentive spirometry with deep breathing exercises in preventing post operative pulmonary complications after laparotomy

Study Design: Observational Analytic study

Place and Duration of Study: This study was conducted in the Department of General Surgery, CMH Abbotabad from Jan 2014 to Mar 2015

Materials and Methods: Total of 100 patients fulfilled the inclusion criteria. Patients of both sex and different age groups were included in the study.50 patients underwent deep breathing exercises and 50 patients underwent incentive spirometry postoperatively in addition to deep breathing exercises for five days. ABGs and the temperature was monitored for five days postoperatively. The findings were recorded and analyzed on SPSS 20

Results: The mean age for deep breathing exercises was 40 + 13.34 and for IS was 43 +12.76..the male :female ratio was 1.34:1 for deep breathing exercises and 1.8:1 for incentive spirometry. In group A 52% had no post pulmonary complications while incidence of PPC varied with grade 01 [30%] ,grade 2 [10%] and grade 3[6%] .In group B 74% had no post operative pulmonary complication while incidence of PPC varied with grade 01[18%] ,grade 02[6%] and grade 3[2%]

Conclusion: Our study showed that the use of incentive spirometry along with deep breathing exercises decreases the incidence of postoperative pulmonary complications as compared to deep breathing exercises alone

Glycerin Suppository for Promoting Feeding Tolerance in Preterm Very Low Birthweight Neonates: A Randomized Controlled Trial.

Objective: To compare the efficacy of glycerin suppository versus no suppository in preterm very-low-birthweight neonates for improving feeding tolerance. Design: Randomized controlled trial. Setting: Level III neonatal unit from Mumbai, India. Participants: 50 very-low-birthweight (birth weight between 1000 to 1500 grams) preterm (gestational age between 28 to 32 weeks) neonates randomized to glycerine suppository (n=25) or no intervention (n=26). Intervention: Glycerin suppository (1g) once a day from day-2 to day-14 of life or no suppository, along with intermittent oral feeds and standardized care. Primary outcome: Time required to achieve full enteral feeds (180 mL/kg/d). Results: Baseline characteristics of neonates like gestational age, birthweight, gender and age at the time of introduction of feeds were comparable in both groups. The mean (SD) duration to reach full enteral feed was 11.90 (3.1) days in glycerin suppository group and was not significantly different (P=0.58) from control group, [11.33 (3.57) days]. Glycerin suppository group regained birth weight 2 days earlier than control group but this difference was not significant (P=0.16). There was no significant difference in duration of hospital stay or occurrence of necrotizing enterocolitis amongst the two study groups. Conclusion: Once daily application of glycerin suppository does not accelerate the achievement of full feeds in preterm very-lowbirthweight neonates.

Efficacy and Safety of Deferasirox for Reducing Total Body and Cardiac Iron in Thalassemia.

Objective: To assess the efficacy of deferasirox as an iron chelator, with specific reference to reducing cardiac iron overload. Design: Prospective, open label, single arm study between 2008- 2010. Setup: Thalassemia center at a teaching hospital. Participants: 30 multitransfused Thalassemia Major (TM) patients receiving deferasirox (DFX) therapy. Methods: All patients had MRI T2*evaluation for cardiac iron load before starting DFX therapy. MRI T2* was performed on a 1.5 tesla Siemens sonata machine using thalassemia tools software and the ejection fraction measured using standard cardiac magnetic resonance sequence. Quantification of cardiac iron deposit was categorized into T2* <10 ms as high cardiac risk, 10- 20 ms as intermediate risk, and >20 ms as low risk. We also estimated left ventricular ejection fraction (LVEF), end systolic volume (ESV) and end diastolic volume (EDV) using standard sequence. EF <56 % was considered to be significant cardiac dysfunction. DFX was administered in an initial dose of 20mg/kg/ day and increased to a maximum of 35mg/kg/day. Serum ferritin level was estimated in pretransfusion samples at 1-3 monthly intervals. The primary end point of the study was change in serum ferritin level and cardiac MRI T2* value after 12-18 months therapy. Results: Of the 30 patients, cardiac iron value of >20 ms was seen in 15 (50%), whereas 9 (30% ) had 20-10 ms, and 6 (20% ) had ≤10 ms. The mean serum ferritin pre DFX therapy of all cases was 3859.8 ± 1690.70 ng/mL (1066 – 6725 ng/mL) and mean cardiac T2* was 23.8±15.2 ms (6.24-69.2 ms). After 12 to 18 months of DFX therapy on a mean dose of 33 mg/kg/day, the mean serum ferritin was 2693.4 ±1831.5 ng/mL (drop by 30.2%, P<0.001) and mean cardiac T2* was 24.2±12.9 ms (increase of 1.6 %, P=0.87). Percentage change in cardiac iron was greater in high risk (24.8%) and intermediate risk (33.4%) patients than low risk patients (8.4%), though these values were not statistically significant. LVEF was 62.0 (±7.0%) before treatment and changed to 58.9 (± 4.8%) after 18 months of therapy but the values remained within normal range and this change was not significant (P=0.061). Adverse effect of DFX included diarrhea, maculopapular skin rash and transient proteinuria that necessitated temporary stoppage of medication. Conclusion: Deferasirox monotherapy has a good safety profile and effectively chelates total body iron. It is also a good myocardial iron chelator, more efficacious in moderate to severe cardiac iron overloaded patients.

Evaluation of Cardiac Iron Load by Cardiac Magnetic Resonance in Thalassemia.

Objective: To quantify myocardial iron stores by Cardiac Magnetic Resonance (CMR) . Design: Prospective cohort study. Setting: Thalassemia center in a teaching hospital. Participants: 60 transfusion dependant thalassemia major patients and 10 controls during 2008-2009. Methods: MRI T2* for cardiac iron load and cardiac functions was performed on a 1.5 Tesla Siemens Sonata machine using the thalassemia tools software. Ejection fraction (EF) was measured using standard CMR sequence and EF <56% considered as cardiac dysfunction. Quantification of iron deposition was categorized as T2* <10 milliseconds (ms) as high risk, 10-20 ms as intermediate risk and >20 ms as low risk. Simultaneous liver iron T2* values were categorized into normal i.e. >6.3 ms, mild iron overload 6.3 - 2.7 ms , moderate iron overload 2.7- 1.4 ms and severe iron overload <1.4 ms. Pretransfusion serum ferritin levels were simultaneously determined. Data was analyzed by paired and unpaired t test of mean. Results: Of 60 patients, 50% had no cardiac siderosis; 33.3% had mild to moderate and while 16.7% had severe cardiac siderosis . In contrast, only 8.3% had normal liver iron values, 55.7% had mild to moderate and 36% had severe iron stores. The mean serum ferritin of all 60 cases was 3528.6 ± 1958.6 ng/mL. There was a statistically significant difference in the mean cardiac T2* of patients (23.45 ± 13.4 ms) as compared to controls (32.67 ± 2.68 ms) (P<0.01). Conclusions: Thalassemia patients had significantly higher cardiac iron stores as compared to controls. Serum ferritin and liver iron values did not correlate with cardiac iron values. Three of 10 patients <10 years showed evidence of myocardial siderosis.

study of diabetic foot syndrome

This study was carried out to determine the number and predisposing factor of foot infection in the adult onset diabetes mellitus. An observational study. The study was carried out at PAF Hospital Islamabad, from June 2003 to June 2005. A total of 130 patients with adult onset diabetes mellitus were included in this study. The population was mixed. Clinical profile and investigations were recorded. Patients were managed as indoor cases. Plain insulin was used to control the diabetes. Broad-spectrum antibiotics and serial debridments, where required, were carried out. A total of 18.5% of the hospitalized diabetic population was due to foot infection. Males were affected 1.5 times more than the females. The disease was bilateral in 4% cases. Poor control of diabetes, bad foot hygiene, peripheral neuropathy, trauma, ingrowing toenails, callosities and corns were implicated as predisposing factors in majority of cases. Foot infection in diabetics is a common occurrence and both sexes are involved though males more commonly than females. Majority of the patients were elderly and have poor knowledge and insight of their disease

phase II study of gemcitabine concurrent with radiation in locally advanced squamous cell carcinoma of head and neck: a trial of the cancer research group Pakistan

To evaluate the efficacy and toxicity of weekly gemcitabine as a radiosensitizer concurrent with radical radiotherapy in locally advanced carcinoma of head and neck. From August 2001 to January 2002, thirty-nine patients with stage III or IV B inoperable carcinoma of head and neck were enrolled. Patients with histopathologically confirmed squamous cell carcinoma with at least one bidimensionally measurable lesion, no prior chemotherapy or radiotherapy, and a KPS of 60 or above were included. Patients with nasopharyngeal, glottic or sub-glottic cancer were excluded. Gemcitabine 150mg/m2 or a total dose not exceeding 200 mg was given on day 1, 8, 15, 22, 29, and 36 during radiation treatment. Radiation was delivered with conventional fractionation to a total dose of 66-70Gy. Miller's criteria was used for response evaluation. RTOG/EORTC acute radiation [and chemotherapy] morbidity scoring system and WHO grading of acute and sub acute toxicity criteria were used for documentation of toxicity. All 39 patients were evaluable for toxicity but only 35 patients were evaluable for response. An overall response rate of 94.3% [95% CI; 80.8-99.3] was seen with a partial response rate of 71.4% and complete response rate of 22.9% [95%CI; 10.4-40.1]. Grade 3 mucositis was seen in 28 patients [71.8%]. Grade 4 mucositis was seen in 2 patients [5.1%]. Pharyngeal toxicity was the second-most common toxicity. Grade 2 toxicity was seen in 12 patients [30.8%] and grade 3 in 6 patients [15.4%]. Despite vigorous symptomatic and supportive care acute toxicities led to treatment interruption in 40% of patients. A high overall response rate and a high rate of acute toxicity are seen at a weekly gemcitabine dose of 150mg/m2 concurrent with radiation. This shows that gemcitabine is a potent radiosensitizer with a marked tumor and normal tissue radio sensitization

Lichtenstein repair versus darning repair in direct inguinal hernia

To compare the merits of Lichtenstein repair with Darning repair in Army soldiers having direct inguinal hernia. Study Design and A comparative, interventional clinical study in 100 cases, carried out in Combined Military Hospital, Malir, Karachi and Pakistan Air Force Hospital Faisal Base, Karachi from March 2002 to March 2004. During the study period, serving soldiers reporting to the surgical outdoor department of both hospitals were selected according to the inclusion criteria and randomly assigned to either group A [Lichtenstein repair] or group B [Darning repair]. Written informed consent was obtained from all the patients before induction in the study groups. 50 patients each were assigned to both the groups. Thorough clinical examination and laboratory profile was done to assess pro operative fitness for general anesthesia. The parameters used to assess the results were duration of stay in hospital, patient comfort and fitness, complications and recurrence. After the respective procedure, as per the group of the patients, they were followed up on day 7, 1 month, 3 months, 6 months and 1 year. On each visit thorough history and clinical examination was done to assess the condition of the patient. Physical efficiency requirements for serving soldiers were also assessed and complications noted. Overall 58% patients presented with right inguinal hernia and 39% with a left, while 3% patients had bilateral hernia. The overall incidence of postoperative complications was 10.4%. Scrotal hematoma occurred in 3% in group A and 6% in group B. The wound infection occurred in 1% of patients in group A and 3% in group B. 10% of group A and 15% of group B had postoperative pain, which required oral NSAIDS for 4-7 days. 2% patients of group B and none of group A developed urinary retention post operatively. The incidence of complications and recurrence is lower in Lichtenstein repair as compared to Darning repair, therefore, we recommend Lichtenstein hernial repair for direct inguinal hernia

Anesthesia crisis resource management

The critical scenario in which rapid response is needed, for example. Malignant Hyperthermia, occurs rarely. Hence conducting training about such clinical events leaves no alternative but to use simulation. The aims of anesthesia crisis resources management [ACRM] training are to learn principles of complex problem solving, decision making, resource management and team work behavior to improve medical and technical skills. In medical training, simulator can substitute for actual patients and recreate actual clinical environment for anesthesiologists, surgeons, radiologists, cardiologists, gynecologists, etc. for their training. Simulators range from simple mannequin to high fidelity simulators. Mannequin represents the patient, and the participants act as surgeons, anesthetists and operating room assistants in a replica of operation theatre. The high fidelity simulators are programmed to create a special situation which the trainees are required to diagnose and manage the situation and resources accordingly. A panel consisting of consultants and instructors trained in this field are observing and recording all the details on the video tape which is used later on for the debriefing sessions. Simulators have high face validity because they ease trainees' transition to actual patient. Simulators can effectively identify errors and appropriateness of decision making. There is a risk that clinician might acquire inappropriate behavior or develop a false sense of security in their skills that could theoretically lead to harm the patient. The trainees develop an underst and ing that how stresses contribute to the occurrence of error. The ACRM training is an effort to improve our underst and ing about the crisis management aiming at reducing error and ultimately improve patient safety