Significance of the Association between Disc Degeneration Changes on Imaging and Low Back Pain: A Review Article

Low back pain (LBP) is a major health issue resulting in a huge economic burden on the community. It not only increases the medical costs directly, but also raises the disability and loss of productivity in the general population. Symptoms include local pain over the spinal area, pain radiating to the lower leg, stiffness, and muscle tension. LBP is strongly linked with intervertebral disc degeneration that is further associated with the disruption of the complex anatomy of nucleus pulposus, annulus fibrosus, and adjacent supporting structures of the spine. Change in the shape and intensity of nucleus pulposus, decreased disc height, disc herniation, vertebral endplate changes, presence of osteophyte, and posterior high intensity zones are degenerative changes found in imaging studies. Every feature is considered while grading the severity score. Modic changes, DEBIT (disc extension beyond interspace) score, and Pfirrmann criteria are some of the scoring criteria used for evaluating disc degeneration severity. Moreover, the total number and contiguous pattern of affected discs play a crucial role in symptom generation of back pain. Many studies have reported asymptomatic patients. Thus, the correlation between degeneration severity found in imaging study and symptom severity of LBP remain unclear. This review discusses and summarizes the available literature on the significance of the association between the severity of degenerative changes found in imaging study with the presence and intensity of LBP.

Molecular occurrence of canine babesiosis in rural dog population in Pakistan

@#Canine babesiosis is an important tick-borne protozoal disease of dogs that poses major health problem worldwide. Farm dogs in rural areas are the companion animals, that not only watch the livestock herds but also guard the house of the owners. Each farmer keeps his companion dog to get all the services. In our study, a total of 450 blood samples of farm dogs from three different ecological zones (Southern, Central and Northern regions of the province; Punjab) of Pakistan, were collected to examine through microscopy and PCR. Examination of thin blood smears revealed an overall prevalence of 12.8% (58/450) of canine babesisal parasites. However, PCR analysis revealed 46.8% (211/450) and 7.3% (33/450) samples positive for B. gibsoni and B. vogeli, respectively. The amplicons of 671 bp and 590 bp were amplified for the detection of B. gibsoni and B. vogeli, respectively through PCR. The results of multivariate analysis showed that the occurrence of canine babesiosis is higher in the Central Punjab and younger age of the dogs, while breed and sex of the host were not significantly associated with the occurrence of the disease. Mixed infection of B. gibsoni and B. vogeli was observed only in 3 dogs each in district Kasur and Rawalpindi. Our study is the first report to observe the occurrence of canine babesiosis in rural dogs in Pakistan through PCR.

Impact of constructive feedback on the undergraduate medical students' attitude towards psychiatry

To determine the impact of constructive feedback, during clinical attachment, on the undergraduate medical students' attitude towards psychiatry. Quasi-experimental study. CMH Lahore Medical College, Lahore, Pakistan from December 2012 to October 2013. Participants were 107 students of final year MBBS. They were divided into study and control groups. Demographic data was recorded and attitude towards psychiatry [ATP-30] questionnaire was administered to all the students before the clinical attachment. Both the groups underwent 3 weeks clinical attachment. However, only the students in study group received constructive feedback. ATP-30 was re-administered to students of both groups soon after completion of attachment. Because of errors and omissions in data, forms of two students were excluded. Statistical analysis was carried out on data of 105 students, which consisted of 53 students in the study group and 52 in control groups. The mean age of study group was 22.21 years [SD=0.885], while that of control group was 22.19 years [SD=0.886]; with 32.1% and 34.6% males in the study and control group respectively. Both the groups had comparable demographic features. Pre-attachment ATP30 scores of both groups were comparable i.e. 84.47 +/- 5.29 versus 84.56 +/- 5.30 [p-value < 0.934]. However, post-attachment scores of both groups increased i.e. 103.11 +/- 5.98 versus 85.85 +/- 4.31 [p-value < 0.001]. This increase in score was statistically highly significant in the study group. Constructive feedback during clinical attachment has a significantly positive impact on the undergraduate medical students' attitude towards psychiatry

Relationship of academic success of medical students with motivation and pre-admission grades

To determine predictive validity of pre-admission scores of medical students, evaluate correlation between level of motivation and later on academic success in a medical college. Analytical study. Foundation University Medical College, Islamabad, from June to August 2011. A non-probability convenience sampling of students of 1[st] to final year MBBS classes was done after obtaining informed consent. These students filled out 'Strength of Motivation for Medical School' [SMMS] questionnaire. The data of pre-admission grades of these students along with academic success in college according to examination results in different years were collected. The correlation between the pre-admission grades and score of SMMS questionnaire with their academic success in medical college was found by applying Pearson co-efficient of correlation in order to determine the predictive validity. Only 46% students revealed strong motivation. A significant, moderate correlation was found between preadmission scores and academic success in 1[st] year modular examination [0.52] which became weaker in various professional examinations in higher classes. However, no significant correlation was observed between motivation and academic success of medical students in college. Selecting medical students by pre-admission scores or motivation level alone may not be desirable. A combination of measures of cognitive ability criteria [FSc/pre-admission test scores] and non-cognitive skills [personality traits] is recommended to be employed with the use of right tools for selection of students in medical schools

Multiple myeloma presenting at unusual sites

To report unusual presentations of multiple myeloma and to highlight that early detection of these unusual features will encourage early investigation, diagnosis and appropriate management and consequently better prognosis of this difficult disease. Three consecutive cases of plasmacytoma reported at histopathology department of Foundation University Medical College which were later on diagnosed as multiple myeloma are presented. The clinical features and lab investigations were extracted from the patients' files. The hematoxylin and eosin stained slides were retrieved and reviewed. Three cases comprising a surgically excised chest wall mass [presternal], trucut biopsy of a mediastinal mass and a surgically excised extra dural mass along D7-D8 vertebrae were received in histopathology lab. All the patients were females. The ages of the patients were 63, 55 and 47 years respectively. On initial view of slides the diagnosis of plasma cell tumor, plasmacytoma and non-Hodgkin's lymphoma [lymphoplasmacytic type] was made respectively although the differential of large cell lymphoma with plasmacytic differentiation was also kepi in mind. Surprisingly all three cases turned out to be multiple myeloma after bone marrow aspiration, serum protein electrophoresis and skeletal x- rays. Plasmacytoma with coexistent multiple myeloma must be kept in the differential of mediastinal and vertebral masses and further lab and radiologic assessment must be done before starting the treatment.

Effect of intravitreal bevacizumab injection on visual acuity in patients with proliferative diabetic retinopathy

To determine the effect of intravitreal bevacizumab injection on visual acuity in patients with proliferative diabetic retinopathy. Seventy eyes of 52 patients of proliferative diabetic retinopathy with visual acuity of <6/36 were selected from 26-02-2009 to 25-08-2009, at Retina Clinic of Layton Rehmatulla Benevolent Trust Eye and Cancer Hospital, Lahore, for this case series study. After taking aseptic measures intravitreal [1.25mg/0.05ml] Bevacizumab injection was injected. Post injection follow up was done for best corrected visual acuity with snellen visual acuity chart on 1st week, 6th week and 12th week. Efficacy was considered as gain of one or more snellen visual acuity chart line after 12 weeks. Effect modifiers like age and duration of diabetes mellitus [10 years] were addressed through stratification. The mean+Standard Deviation [SD] of patients' age was 47.2 +/- 7.9 years. Females 42 [60%] outnumbered the males. Majority of patients 38 [54.3%] had diabetes for more than 10 years. Overall improvement rate was 11 [15.7%] with significant improvement from 1.028 log MAR at baseline to 0.99 at 12 weeks [Paired t test p=0.0014, 95% Confidence interval of mean difference=0.016-0.062]. Intravitreal bevacizumab injection is effective in patients of proliferative diabetic retinopathy for short term results

Percutaneous intervention for coronary bifurcations-our experience on 133 patients at army cardiac centre Lahore

To study the safety and efficacy [pre and post procedure outcomes] of stenting the main vessel [MV] with or without stenting the side branch [SB] in the treatment of coronary bifurcation lesions. In this retrospective analysis of 133 patients, operated between Oct 2009 and Sept 2010, true coronary bifurcation lesions using the registry at Army Cardiac Centre were analyzed. All angiograms and case notes were reviewed for sites of lesions, MADINA classification, angle of bifurcation, size of MV and of SB, number and type of stents used, total procedure and radiation time, and patient characteristics. In-hospital MACE events were recorded for all patients. Of the 133 cases, 120 [90.2%] underwent MV stenting alone, while 13[9.8%] underwent SB stenting as well. Drug Eluting Stent [DES] with minicrash technique was deployed in the majority of the latter cases. In hospital clinical follow up showed 2 NSTEMI in the SB stents [p=0.009] whereas no MACE event was recorded for MV stents alone. Stenting of only MV is safer, effective and economical than stenting of both MV and SB. Moreover contrast related risks and risks of radiation are much less with stenting the MV in the treatment of coronary bifurcation as compared to stenting of both MV and SB

audit of length of bone marrow trephine biopsies at a tertiary care hospital

Bone marrow trephine biopsy is a well established minor surgical procedure for the inspection of bone marrow usually done along with bone marrow aspiration. The objective of this study was to evaluate the length of trephine biopsies and the rate of positivity for diagnosis as well as unfit biopsies in various length ranges. This retrospective study was conducted at Fauji Foundation Hospital and Foundation University Medical College Rawalpindi from Jan 2007 to Dec 2009. A total of 394 trephine biopsy reports were collected and reviewed. The criterion for adequate trephine biopsy was >/= 1.5 Cm. The biopsies were divided into four groups according to length, i.e., group-1: >/= 1.5 Cm, group-2: 1-1.4 Cm, group-3: 0.5-0.9 Cm, and group-4: <0.5 Cm. The adequacy of trephine biopsy length and rate of positive diagnosis as well as unfit biopsies were compared. Total 394 trephine biopsies were reviewed. Group-1 included 88 biopsies and 87 [98.9%] had positive diagnosis. Group-2 included 137 biopsies and 133 [97.1%] had positive diagnosis. Group-3 included 99 biopsies and 91 [92%] had positive diagnosis. Group-4 included 70 biopsies and 57 [81.4%] had positive diagnosis. There was no significant difference between group-1 and group-2 for the rate of positivity of diagnosis [p=0.65]. In group-1, 1 [1.1%] was unfit for evaluation, in group-2, 4 [2.9%] were unfit, in group-3, 8 [8%] were unfit, and in group-4, 13 [18.5%] were unfit for evaluation. Total 26 trephine biopsies were unfit for evaluation, out of which 13 [50%] belonged to group-4. Trephine biopsies that were unfit for evaluation were 4 [4.9%] in 2007, 17 [10.5%] in 2008, and 5 [3.3%] in 2009. Although 22.3% biopsies were of recommended length there was no significant difference in rate of positive diagnosis between biopsies of >/= 1.5 Cm and 1-1.4 Cm

Labour Induction With Randomized Comparison Of Oral And Intravaginal Misoprostol In Post Date Multigravida Women

The efficacy and safety of oral versus vaginal misoprostol for elective induction of labor in post date multigravida with an unfavourable cervix was compared over a period of one year in the Bahawal Victoria Hospital, Bahawalpur, Pakistan. Eightyeight multigravida post date women were divided into two groups and given 50 mg misoprostol orally and 50 mg intravaginally, respectively. The induction to onset of significant uterine contractions and delivery intervals were lower in the first group (7.8 h vs. 8.9 h) when compared to (10.4 h vs. 12 h). The first group had a higher rate of Caesarean section (7% vs. 4%; p>0.05), uterine hyperstimulation (9% vs. 5%; p>0.05), uterine tachysystole (23% vs. 14%; p>0.05) and neonatal admissions to intensive care unit (12% vs. 4%; p>0.05) when compared to second group. Fifty mg oral misoprostol has the potential to induce labor as safely and effectively as the intravaginal route.

Morphological spectrum of chronic hepatitis [C] infection: experience at foundation university medical college and Fauji foundation hospital Rawalpindi

To determine the morphological patterns of HCV related liver disease in our set up. 164 routinely processed liver biopsies were assessed and scored for grading [necro-inflammatory changes] and staging [fibrosis] using modified Knodell HAI scoring system. Our patients were mostly females and maximum cases were in 4[th] and 5[th] decades. Mild portal inflammation was seen in 78% and moderate in 20% cases. Piecemeal necrosis was mild in 76% while moderate in 15% cases. HAI grades ranged from mild [161 cases] to moderate [03 cases]. Fibrous portal expansion/short fibrous septae were seen in 35[21.3%] cases. HCV related lived disease is mild in our set up and a long term follow up of these cases is required to assess the progression of disease

Cytomorphological spectrum of neurosurgical lesions by crush smears cytology

To study the cyto-pathological appearance of intraoperative crush smears of neurosurgical biopsies after subsequent comparison with paraffin sections. Place and duration of study: The study was conducted at Armed Forces Institute of Pathology, Rawalpindi, for one year from February 2002 to February 2003. One hundred, neurosurgical biopsies were received for intraoperative consultation over a period of one year. Clinical information like age, gender, history, and CT scan or MRI findings were recorded. Crush smears were prepared, fixed in 95% alcohol and stained with rapid haematoxylin and eosin stains. Diagnosis was categorised into inflammatory, benign and malignant tumours considering the cyto-pathological features. Remaining tissue was fixed overnight in 10% formalin for histological sections. Permanent Haematoxylin and Eosin [H and E] sections were used as the "gold standard" for comparison. Out of 100 neurosurgical biopsies, crush smears of 94 were considered suitable for interpretation. The smears were categorised as, 8 inflammatory, 41 benign and 41 malignant tumours. Four cases were labelled as inconclusive. Eighty four of the crush smears diagnosis agreed with the histological diagnosis, cyto-morphology of the lesions on crush smear is discussed. Crush smears are useful in the intraoperative diagnosis of space occupying lesions of central nervous system as majority of the cases have typical diagnostic yield and cyto-morphology. We found crush smear cytology highly reliable, rapid and inexpensive mode of intraoperative diagnosis

To compare the relapse rate of artesunate with tetracycline and quinine with tetracycline in uncomplicated falciparum malaria

To determine the relapse rate of falciparum malaria treated with artesunate plus tetracycline [AT] versus quinine plus tetracycline [QT] in uncomplicated patients of malaria. A cross sectional comparative study was carried out at Combined Military Hospital, Quetta from 01 May to 30 November 2006. Ninety patients of age-sex matched group with uncomplicated falciparum malaria having parasitemia >1%, age between 14-65 yrs, either sex and with no previous malaria treatment related to the present attack were recruited from emergency department, medical wards, included in the study. One group was given quinine along with tetracycline [QT] and the other group was given artemesinin and tetracycline [AT]. The patient was discharged from the hospital when three negative blood smears were obtained. Thereafter, blood smears were taken at days 7, 14, 21 and 28 after the start of the treatment, as outdoor patients. Parasitological response was regarded as radical cure with parasite clearance by day 7 without recrudescence up to day 28. Fever and parasite clearance times were noted as the time from the initiation of treatment to the first of three consecutive normal axillary temperature readings [<37°C] or negative blood peripheral film slides, respectively. Out of 90 patients of falciparum malaria, treatment was completed in 85 patients. The cure rates using treatment with AT was effective in 35 of 45 [77.7%] while QT was effective in 34 of 45 [75.5%] of the patients without any statistically significant difference [p = 0.68]. Poor compliance with the treatment schedule was observed in 2 of 45 [4.4%] in the AT group and 4 of 45 [8.8%] QT group of patients. Cure rates of 95.5% and 91.1% would have been obtained in the AT and QT groups if only compliant patients [n = 69] were considered. Parasitemia at day two cleared faster in the AT group than the QT group [91.1% versus 44.4%, respectively; p-value <0.001]. Combination of artesunate plus tetracycline is effective in the treatment of uncomplicated falciparum malaria and may provide a useful alternative to other treatment regimens

Clinician's responsibility in pre-analytical quality assurance of histopathology

To ascertain the adequacy of information provided by clinicians when requesting a histopathology investigation and to study the quality control parameters of the specimen containers. This is an observational descriptive study which was carried out at Armed Forces Institute of Pathology in December 2006 on 500 specimen requests for histopathology. Out of 500 specimens, age was not mentioned in 29 [5.8%] cases. No clinical history or differential diagnosis was given in 170 [34%] cases. Site of biopsy was absent in 65 [13%] cases and the name of requesting clinician or any contact information was present in only 115 [23%] of request forms. One hundred forty three [28.7%] containers were inadequate relative to the size of the specimen. Adequate volume of fixative was absent in 176 [38.2%] samples. There were 22 [4.3%] samples which did not have any sort of label mentioning either patient's name or type of specimen. Injection bottles constituted the highest number of containers [n=204; 40.8%] used to submit the histopathology specimen. Clinicians of all grades and specialties must be educated and made aware of their primary responsibility to request the service appropriately for the benefit of the patient and patient care

Urothelial neoplasia of the urinary bladder - comparison of interobserver variability for WHO classification 1972 with WHO/ISUP consensus classification 1998

Classification of urothelial bladder tumours is an important factor in the treatment and prognosis of these lesions. Over the years many classifications have been proposed for this purpose. The objective of this study was to classify urothelial neoplasms of the urinary bladder using the latest WHO/ ISUP Consensus Classification 1998 and WHO Classification 1972 and compare the two regarding interobserver variability. This study included 100 consecutive biopsy specimens of urothelial neoplasms of the urinary bladder diagnosed at the department of Histopathology, Armed Forces Institute of Pathology, Rawalpindi. These were classified according to WHO Classification 1972 and WHO/ISUP Consensus Classification 1998 by 2 groups of pathologists independently. The tumour categories for WHO classification 1972; papilloma, and transitional cell carcinoma [TCC] grades I, II and III were compared with the WHO/ISUP Consensus Classification entities of papilloma, papillary neoplasm of low malignant potential, low grade and high grade papillary carcinomas. Kappa statistics were used to evaluate interobserver variability. Chi square test was used to calculate significance. There was agreement on 80 tumours between the two groups of histopathologists when using WHO classification 1972 while there was agreement on 95 tumours using WHO/ISUP consensus classification. The value of Kappa for WHO Classification was 0.68 [good agreement] whereas for WHO/ISUP Consensus Classification it was 0.91 [excellent agreement]. The difference between the two systems was statistically significant [p<0.001]. Kappa values were less for benign and borderline lesions using both systems. WHO/ISUP Consensus Classification 1998 showed less interobserver variability than WHO Classification 1972 in the evaluation of bladder tumours. It was found easier to apply by both groups. There was less agreement on the benign and borderline lesions using both the classifications

Usefulness of crush smears in intraopertive consultation of neurosurrgical biopsies

To evaluate accuracy of intraoperative crush smears diagnosis of neurosurgical biopsies. Cross-sectional study. The Armed Forces Institute of Pathology, Rawalpindi, from February 2002 to February 2003. One hundred, neurosurgical biopsies were received for intraoperative consultation over a period of one year. Clinical information regarding age, gender, history, and CT scan or MRI findings were recorded. Crush smears were prepared, fixed in 95% alcohol and stained with rapid haemotoxylin and eosin [H and E] stains. Diagnosis was categorized into inflammatory, benign and malignant tumours. Remaining tissue was fixed overnight in 10% formalin for histological sections. Permanent H and E sections were used as the gold standard. The average time required for intraoperative cytological diagnosis was 8 minutes. Out of 100 neurosurgical biopsies, crush smears of 94 were considered suitable for interpretation. There were 8 inflammatory, 41 benign and 41 malignant tumours, including 4 inconclusive. Eightyfour of the crush smears diagnosis agreed with the histological diagnosis. Overall diagnostic accuracy of crush smears was 93.3%. Diagnosis of inflammatory, benign and malignant tumours showed specificity of 98.7%, 96% and 94%, and a sensitivity of 70%, 97.5% and 95% respectively. Crush smears are useful in the intraoperative diagnosis of space occupying lesions of central nervous system. The crush smears cytology was found highly reliable, rapid and inexpensive mode of intraoperative diagnosis

pattern of malignant tumours: Tumour registry data analysis, AFIP, Rawalpindi, Pakistan [1922-2001]

To provide information regarding frequency of malignant tumours through data retrieved from pathology based tumour registry of AFIP, Rawalpindi, Pakistan. All malignant tumours recorded with the AFIP tumour registry over a period of 10 years [1992-2001] were analysed in terms of age group, gender and type of tumour with relation to site. A comparison with the previously published material from same setting, national and international studies were also done. The total malignant tumours in the 10 years period were 21,168. Out of these, 12584 [59.5%] were seen in male patients while 8584 [40.5%] were in females. Total malignant tumours in pediatric age group were 927 [4.4%]. The common malignant tumours in males in order of decreasing frequency were, those of prostate, skin, lymph node, leukaemia, urinary bladder, colorectum, bone, lung, stomach and liver. In females, breast carcinoma was on top followed by skin, leukaemia, ovary, coloretum, lymph node, bone, liver, cervix and gall bladder. In females, contrary to the Western studies and India, ovarian tumours were more frequent than cervical cancers. Comparison of this analysis with our previous analysis, national and international studies showed some interesting features. It was found that in males, tumours of the prostate were the most frequent as compared to the previous study, which showed lymphomas and leukemias to be the most common. On the other hand in females, tumours of the breast remained to be consistently most frequent

Acute ascending hypokalaemic paralysis

A fifty-year-old male presented with weakness, difficulty in talking and breathing along with ascending paralysis. He gave prior history of excessive sweating in hot weather and had been administered many intravenous drips of dextrose solutions over the last three days. On clinical examination he was fully conscious, but was restless and tachycardiac. Motor power was 1/5, there was no obvious muscle wasting or fasciculation and the tendon reflexes along with abdominals and plantars were absent. Fundoscopy was unremarkable. Blood biochemistry revealed marked hypokalemia of 2.2 mmol along with an elevated blood and CSF sugar. Electrocardiography revealed flattened T waves and non-specific ST changes. His ventilation was supported and he was given I/V fluids with potassium supplementation and hyperglycaemia was managed with appropriate doses of insulin. The patient rapidly improved over the following few days with serum levels of potassium and ECG changes reverting to normal. The patient was discharged home in an ambulant state and he did not report back with any recurrence of symptoms