Frequency of co-morbidities associated with spinal cord injury

To determine the frequencies of comorbidities [dyslipidemias, diabetes mellitus, and hypertension] in patients with spinal cord injury [SCI] of duration > 1 year. Spinal Cord Injury Department, Armed Forces Institute of Rehabilitation Medicine [AFIRM] Rawalpindi and Department of Chemical Pathology, Army Medical College, National University of Sciences and Technology [NUST], from October 2013 to March 2014. Thirty six patients with complete spinal cord injury [SCI], level C5 to T12 were included by non-probability, convenience sampling. Control group consisted of age and sex matched healthy individuals. A detailed medical history was obtained. Anthropometric measurements and blood pressure were recorded. Fasting blood samples were obtained and analyzed for plasma glucose and serum lipid profile. Out of thirty six patients, 31 [86.1%] were male and 5 [13.9%] were females; their mean age was 36.6 +/- 11 years. Mean duration of injury was 6.04 +/- 3.35 years. Among cases, dyslipidemias were detected in 25 [69.4%] patients while 7 [19.4%] patients had diabetes mellitus. Whereas in control group, frequency of dyslipidemias and diabetes mellitus were significantly lower than cases i.e 13.8% and 5.5% respectively. Also no significant difference was found between blood pressures of study group when compared with control group. Individuals with chronic SCI had more frequent associated co-morbid conditions like dyslipidemias and diabetes mellitus than normal individuals. Early screening is recommended in patients having SCI >6 months for better patient care and reduction in long term comorbidities in such patients

Recombinant factor VII [rFVII] can be useful for massive hemorrhage during radical nephrectomy

Radical nephrectomy for renal tumors can be associated with serious complications, e.g. massive bleeding or even table deaths. Various regimens like normovolemic hemodilution, autologous transfusion, hypotensive anesthesia, etc have been used in anticipation of hemorrhage in these operations. In our case there was not only massive hemorrhage but also a failure to clot and disseminated intravascular coagulation. All the routine regimens failed to stop bleeding and the generalized ooze. Recombinant Factor VII [rFVIIa] was used and it saved the day

Frequency of low bone mass in a cohort of mixed pakistani population

To determine the frequency of low bone mass in a multiethnic group of Pakistani population at Armed Forces Institute of Rehabilitation Medicine [AFIRM], Rawalpindi. Cross-sectional comparative study. Outpatient Department of Armed Forces Institute of Rehabilitation Medicine [AFIRM], Rawalpindi from October 2010 to March 2011. A total of 400 patients, both male and female, were sampled according to inclusion criteria by non-probability purposive sampling. Bone density was measured by DXA scan model Hologic [Discovery A], focused at neck of femur and spine. Four hundred patients were included in the study. Average age of the patients was 59.24 years [SD = 10.38] with 258 [64.5%] females. Two hundred and thirty two [58%] were Punjabi, 77 [19.3%] were Pathan, 64 [16%] were Kashmiri, 20 [5%] were Sindhi and 7 [1.8%] were Balochi. Average BMI was 26.45 [SD = 5.31]. Average T-score was -2.037 [SD = 1.40]. Out of 400 patients, 134 [33.5%] patients had normal BMD, 140 [35%] had osteopenia and 126 [31.5%] patients had osteoporosis. Frequency of osteopenia was higher in males than females i.e. 40.8% vs. 31.8% whereas frequency of osteoporosis was higher in females than males i.e. 32.9% vs. 28.9% [p = 0.191]. Similarly association between ethnicity and BMD was also observed to be insignificant [p =0.714]. The study showed high prevalence of low bone mass in Pakistani population in females as well as in males. The results in various ethnic groups are comparable, however, due to availability of smaller number of Sindhi and Balochi people, further multicentre studies at larger scale are recommended

Role of pulsed electromagnetic therapy in the management of backache: a study conducted at armed forces institute of rehabilitation medicine, Rawalpindi

To determine the role of pulsed electromagnetic therapy in providing pain relief for backache. This was a quasi experimental study. This study was conducted at Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan from Jan 2012 to June 2012. This study included 65 consecutive patients with backache. The pain was assessed on 11 points [0-10] Numeric Rating Scale [NRS] and patients with score >1 were included in the study. Detailed history was obtained and examination was performed. All patients were subjected to pulsed electromagnetic therapy. The pain was assessed at first week, 2nd week, third week and six week after start of the pulsed electromagnetic therapy. Data was compiled and analysed using SPSS version 17. A p-value < 0.05 was considered as significant. There was marked reduction in pain of patients with backache after treatment with pulsed electromagnetic therapy. Reduction in pain as calculated by the NRS [numeric rating scale] value after 1[st] week was 25.35% [p=0.002], after 2[nd] week was 43.66% [p=0.001], after 3[rd] week was 50.7% [p=0.001] and after 6 weeks was 71.83%[p=0.001]. Pulsed electromagnetic therapy is very effective in relieving pain in patients with backache

Delayed referral of lower limb amputees for rehabilitation; an audit study

To determine the causes of delayed referral of lower limb amputees for rehabilitation. Study Design: Descriptive study. Armed Forces Institute of Rehabilitation Medicine Rawalpindi, from April 2012 to July 2012. Thirty two patient cases of lower limb amputation were included. They were referred cases to AFIRM from operational areas and CMHs all over Pakistan for provision of prosthesis and rehabilitation. A total of 32 lower limb amputees7 male patients with mean age 29 years were included in the study. Transtibial level was the most common amputation 19[57.6%]. Improvised Explosive Device [IED] was the most common mode of injury 19[57.6%]. 34.37% patients were delayed due to leave granted to them at local set ups before referral to AFIRM for rehabilitation. Delayed referral for rehabiltation has poor impact on rehabilitation of an amputee

Low serum HDL-c levels: a hidden threat to patients with spinal cord injury

To determine the serum lipid profile in patients with traumatic spinal cord injury [SCI] of duration >1 year and to compare the serum HDL-c levels of SCI patients undergoing regular physiotherapy for >60 minutes daily with those who did not undergo physiotherapy. Cross-sectional, comparative study. Spinal Cord Injury Department, AFIRM Rawalpindi and Department of Chemical Pathology, Army Medical College, Rawalpindi, from January 2013 to June 2013. Forty six patients suffering from traumatic spinal cord injury [SCI] wore included. After recording the detailed medical history, fasting blood samples were obtained and analyzed for serum lipid profile. Dyslipidemias were assessed using guidelines from the National Cholesterol Education Project Adult Treatment Panel III [ATP III]. Serum high-density lipoprotein cholesterol [HDL-c] < 0.9 mmol/1 [40 mg/dl] was considered as low HDL-c level. Out of total 46 patients, 33 [71.7%] were male and 13 [28.3%] were females with mean age of 34.9 +/- 9.55 years. Low levels of serum HDL-c were found in 21 [45.7%] SCI patients [mean serum HDL-c levels: 0.97 +/- 0.23]. SCI patients were further categorized in two groups depending upon the status of regular physiotherapy. Statistically significant difference was found in mean serum HDL-c levels of 22]47.82%] SCI patients undergoing regular physiotherapy as compared to 24 [52.18%] SCI patients who did not underwent physiotherapy [p < 0.05]. Patients with SCI have decreased levels of serum HDL-c, imparting an increased risk of cardiovascular disease [CVD] in these disabled persons. SCI individuals following regular physiotherapy, have better serum HDL-c levels as compared to bed-ridden SCI patients, suggesting the physical activity as an important factor to elevate the serum HDL-c in such patients. Knowledge of relative risk of CVD in persons with SCI is important for appropriate interventional strategies, including planned physical activities or exercises and therapeutic intervention

Comparison of electromyography / nerve conduction studies and magnetic resonance imaging in diagnosis of lumbosacral radiculopathy

To compare EMG/NCS with MRI in diagnosis of lumbosacral radiculopathy. Cross-sectional comparative. The study was carried out at Armed Forces Institute of Rehabilitation Medicine, for a period of six months, from January 2007 to June 2007. Fifty consenting patients with clinical lumbosacral radiculopathy were included, they underwent MRI and NCS/EMG, and then both procedures were compared for diagnosis of radiculopathy. MRI and NCS/EMG had comparable sensitivity but MRI was less accurately correlated with clinical estimated level of radiculopathy. Both NCS/EMG and MRI are time sensitive investigations which provide different information regarding the pathology. NCS/EMG reveal physiological etiology of radiculopathy, compared to MRI, which gives the anatomical information. Every patient with clinical lumbosacral radiculopathy should undergo NCS/EMG for confirmation of diagnosis. However, when anatomical lesion is suspected, or surgical intervention is planned, MRI should complement it

Pit falls in stroke rehabilitation: a Pakistani perspective

To identify short comings in the stroke rehabilitation referral and consultation in Pakistan. Observational study. Stroke Clinic at Armed Forces Institute of Rehabilitation Medicine [AFIRM] Rawalpindi from March 2005 to September 2005. 171 patients of stroke fulfilling the inclusion criteria were enrolled in the study. Detailed history was obtained and a thorough examination with emphasis on neurological and musculoskeletal system was performed. Medical records and radiological investigations were reviewed. There were 132 [77.2%] males and 39 [22.8%] female patients. Radiological investigations were not available in some patients. In the remaining patients the frequency of Ischemic vs Hemorrhagic was 82% and 18% respectively .Involvement of right and left cerebral hemisphere was almost equal with 53% and 47% respectively. Majority, i.e 153 [89.5%] of the patients were referred as OPD cases while indoor rehabilitation consultation was made only for 18 [10.5%] patients. Only 04 [2.3%] patients were seen within 48 hours of stroke onset. In 39 [22.8%] cases consultation was made between one week to one month and for 116 [67.8%] between one to six months, while it was delayed beyond six months in 12 [7%] patients. Important shortcomings identified were non availability of physicians in rehabilitation medicine, late/ no referrals, inadequate referrals, long term placement of indwelling catheters and lack of patient and family education. Stroke is an important cause of long-term disability. Timely and comprehensive stroke rehabilitation minimizes the impairments and leads to successful reintegration of individual into the society. It is a poorly understood concept in Pakistan. Physicians are either not aware of the concept and significance of stroke rehabilitation or often confuse it with physiotherapy alone. There is a need to improve the stroke rehabilitation services in the country

Role of radiology in pancreatic disorders

To find out mode of presentation and role of image modalities in pancreatic lesions in patients referred to radiology department. Prospective study. Radiology departments of CMH Muzaffarabad and CMH Sialkot from Jan 2003 to Jan 2006. This study was conducted at CMH Muzaffarabad in collaboration with Kashmir CT Scan installed at CMH Muzaffarabad and CMH Sialkot in collaboration with PVT-CT Scans. Radiology departments of CMH Muzaffarabad and CMH Sialkot are equipped with ultrasound and fluoroscopic facilities. We evaluated 50 patients of different pancreatic lesions referred to our radiology department. Pancreatic lesions were more common in men [70%] than women [30%]. Large group of patients [90%] belong to old age group. Out of 50 cases, 60% patients presented with jaundice, 20% with acute abdomen, 10% with mass abdomen and 10% with mixed symptoms. Ultrasonograph [USG] has been the main imaging modality in our study. All patients initially scanned with USG, patients diagnosed as mass pancreas on USG were advised CT scan, percutaneous transhepatic cholangiogram [PTC]/endoscopic retrograde cholangiopancreatogram [ERCP], and USG guided FNAC. In 15 [30%] cases ultrasound was inconclusive, in 10 patients pancreas was not clearly visualized and in 05 cases pancreas was normal looking. CT scan is more sensitive in picking up pancreatic lesions. CT scan was done in 24 [48%] patients. The results are shows in table. In our study 26 [52%] patients were of pancreatitis [Acute/chronic] and 20 [40%] of growth pancreas, 04 [8%] misc. cases [Divisum pancreas 02, annular pancreas 01, retropancreatic haemangioma 01]. It is concluded that pancreatic lesions present as acute abdomen, mass epigastrium and jaundice. In our set up USG is the main imaging modality to diagnose the pancreatic lesions. CT scan, PTC and ultrasound guided FNAC used as complementary tool

Comparison of three antibiotics regimens in the treatment of acute pyogenic meningitis

Aim of this study is to compare various antibiotics in setting of acute pyogenic meningitis. A quasi-experimental study. CMH Kohat from Dec 1999 to March 2002. Study was conducted in department of medicine Combined Military Hospital Kohat from Dec 1999 to March 2002. A total of sixty patients with provisional diagnosis of acute pyogenic meningitis between 13 - 50 years age belonging to heterogenous group of population mainly recruits from various military training centers were included in the study. Ten patients were excluded from study because of negative cerebro spinal fluid findings. These patients were started on group A antibiotics [Ceftriaxone, Ampicillin plus Chloramphenicol], group B [Ampicillin plus Chloramphenicol] and group C [Ceftrixone] at random. The analysis of results of treatment with three different treatment regimens was done by noting complete recovery, complications and death. Twenty patients who were given group A regimen showed 90% complete recovery, one patient developed fulminant menigococcemia recovered fully and another patient developed deafness with gradual recovery [10% complications]. Amongst fifteen patients in group B regimen 87% patients showed complete recovery, one patient developed seizure finally controlled, another patient developed hydrocephalus and was referred for shunt procedures [13% complications]. Fifteen patients who were started group C regimen 93.33% patients fully recovered and one patient developed fulminant meningococcemia completely recovered but developed gangrene of toes for which amputation was done at a later stage [7% complications]. The results of three treatment regimens were compared by using chi square test and were almost comparable [p-value > 0.05]. In the empirical treatment of acute pyogenic meningitis, ceftriaxone alone cheap, safe and is as effective as combination of ceftriaxone plus ampicillin plus chloromphenicol or combination ampicillin plus chloromphenicol

Deep vein thrombosis above 17000 FT

A young soldier performing his duties at 17000 ft in northern areas of Pakistan developed progressive painless swelling of his right leg. He was a smoker but not on any drug. Examination revealed swelling of right leg up to knee joint with pitting edema. There was slight increase in temperature of the affected limb. Rest of the systemic examination was unremarkable. He was descended within next forty-eight hours of incidence to Rawalpindi at less than 2000 ft above sea level. His Doppler duplex ultrasound and radioisotope [Tc labeled] scanning of right leg revealed a large thrombous in right popliteal vein non-modifiable extending up to femoral vein. He was thoroughly investigated for inherited and acquired non-modifiable causes of thromopophilia including, anti-phospholipids syndrome, Protein C and S deficiency, APC [Factor V Leiden] resistance, which were unremarkable before and after 4 weeks of cessation of anticoagulant therapy. He was managed on the standard lines and recovered completely

Combined thoracic epidural and light general anaesthesia for upper abdominal surgery in high risk patients

The goal of the study was to assess the safety and effectiveness of the thoracic epidural anesthesia [TEA] in high risk patients undergoing upper abdominal surgery. Quasi Experimental. Department of anaesthesia, Liaquat National Hospital, Karachi from August 2002 - July 2003. 20 adult patients aged between 50 - 70 years were selected with ASA status III and IV. TEA was performed in sitting position at the level of T7 -T8 using hanging drop method. Titrated doses of 0.25%. Bupivacaine and 1% Xylocaine was injected 1 ml / dermatome through the catheter, anesthetic levels achieved were found to be T4 - T10. Light general anesthesia was instituted by using I/V propofol 50 - 60 mg, I/V Nalbuphine 5 - 7.5 mg and Midazolam 1.5 - 2 mg I/V. Total dose of local anesthetic varied from 12 -18 ml [mean 16 ml]. Two patients had bradycardia with heart rate less than 60 beats/min treated with atropine. Two patients had hypotension treated with titrated doses of ephedrine and I/V Ringer's solution. Our results were very promising and we can state confidently that thoracic epidural is a viable option and safe alternative, reducing morbidity in high risk patients

To compare changes in serum electrolytes during turp, while using 5% dextrose water and glycine as irrigation fluids in two groups

To compare changes in serum electrolytes during TURP, while using 5% dextrose water and gly-cine as irrigation fluids in two groups. Experimental study design. Department of Anaesthesiology, Liaquat National Hospital, Karachi, from January 2004 to Jun 2004. 60 ASA I and II patients who presented for TURP under spinal anaesthesia were divided in two groups. 30 patients were included in each group. Patients in group A received 5% dextrose water as irrigation fluid while patients in group B received 1.5% glycine as irrigation fluid. Serum electrolytes were checked preoperatively, intraoperatively at every 15 minutes interval and postoperatively every hour for 2 hours. Serum Na+ level was decreased in both groups, but it was more marked in group A, maximum change being recorded at 45 minutes interval. These changes returned towards baseline with in 2 hours. Serum K[+], Cl and HCO[3] were also decreased in both the groups with more marked changes in group A. However, these changes were statistically insignificant. After comparing 1.5% glycine with 5% dextrose water as irrigation fluids during TURP, we concluded that glycine was found to be better irrigation fluid as dextrose water causes more evident hyperv-olemia, hyponatremia and hemodilution than glycine

Endoscopic assessment of dyspepsia

This study was conducted to identify the spectrum of diseases causing dyspepsia and to find out relative prevalence of individual diseases in our society. A number of 510 patients between ages of 10-70 years with dyspepsia were selected after fulfilling a definite criterion for the study. The results indicated that 261 [51.17%] had no endoscopic abnormality suggesting that a large majority of patients suffer from non-ulcer dyspepsia. The prevalence of peptic ulcer was 10%. About 20% had esophagitis and 13% suffered from gastritis/duodenitis. It was concluded that majority of patients with dyspepsia had no peptic ulceration, though they may present with ulcer like symptoms