effective technique of obturator nerve block to prevent adductor reflex during transurethral resection of bladder tumor

Objective: To observe the efficacy of blind obturator nerve block by Labat technique for prevention of obturator jerk during transurethral resection of bladder tumor performed under spinal anesthesia

Study Design: Descriptive Study

Material and Methods: This was a single center based study conducted at tertiary care military hospital for a period of thirty months. Fifty five patients were recruited in the study, after identifying the location of bladder growth in the lateral wall on ultrasound USG and confirming its exact site on cystoscopic examination. Those eliciting obturator jerk during transurethral resection of bladder tumor [TURBT] were included and ONB was performed using 2% lidocaine via blind technique of Labat. TURBT was restarted and presence of obturator jerk was recorded if evoked [primary outcome]

Results: Median age was 67.3 +/- 8 years with majority [72.7%] in the age group between 61 to 80 years. Male female ratio was 7:1. Fifty [90%] patients presented with solitary growth. Mean operating time was 28.8 +/- 12 minutes. ONB was successful in 52 [94.54%] of the cases while failure in 3 [5.45%] resulted in conversion to general anesthesia for the completion of TURBT

Conclusion: Blind obturator nerve block [ONB] by using Labat technique for obturator nerve block has proven to be simple, reliable and easily replicable in any set up and it does not require any time consuming steps or sophisticated equipment

Frequencies of acute intra-dialytic complications: a single centre experience

Objective: To determine frequencies of various acute complications in patients undergoing hemodialysis

Study Design: Descriptive cross-sectional study

Place and Duration of Study: Department of Nephrology Military Hospital [MH] Rawalpindi, from Jan 2016 till Mar 2016

Material and Methods: A total of 150 patients who underwent haemodialysis at MH were enrolled in the study after informed consent on justification of inclusion and exclusion criteria. The patients were evaluated for the frequency of various intra-dialytic complications and data were analysed using SPSS version 19

Results: Out of the 150 enrolled patients, males were 125 [83.33%] and females were 25 [16.67%]. A total of 2520 haemodialysis session were performed. Hypotension was the most frequently observed complication during 318 [12.62%] dialysis sessions, followed by hypertension in 208 [8.25%] and fever in 193 [7.66%] sessions. Other complications were muscle cramps in 116 [4.60%], shivering in 94 [3.73%], headache in 70 [2.78%], nausea/vomiting 60 [2.38%], itching 41 [1.62%], chest pain 37 [1.47%], hypoglycaemia 31 [1.23%], seizures 23 [0.91%] and arrhythmias in 13 [0.52%] dialysis sessions

Conclusion: Haemodialysis, one of the renal replacement therapies, is a life-saving treatment modality but it is not without complications despite the advances in technology. However frequency with which they occur is low and majority are not life threatening

Effect of computer based animations on learning of physiology

Objective: To find out the effect of computer based animations on learning of Physiology

Study Design: Randomized control trial

Place and Duration of Study: Army Medical College Rawalpindi, from Jan to Sep 2016

Material and Methods: Sixty students of first year MBBS class were selected through simple random sampling and then randomly assigned into two groups of 30 each; group I and II. A pre-test was given to both the groups to assess their basal knowledge about the systems to be taught. In 1st teaching session, experimental group was taught with and control without animations. In 2nd teaching session, control group became experimental and previously experimental group became control. After both the teaching sessions MCQ tests of C2, C3 and C4 level were given to the groups and marks obtained were compared

Results: There were 20 [33.3%] male and 40 [66.7%] female students with mean age of 18.92 +/- 0.56 years. Comparison of pre-test scores confirmed that basal level of knowledge was equal between the two groups [p-value=0.19]. Post-test score comparison showed that experimental group scored significantly higher marks as compared to the controls [p-value=0.001 for post-test I and 0.02 for post-test II]

Conclusion: Level of understanding of student increases if they are shown computer based animations during the physiology lectures. Hence, animations have positive effect on student's academic performance

Experience with renal cell carcinoma- a single centre study from Khyber Pakhtunkhwa

Objective: To analyze the clinical characteristics, management and outcome of renal cell carcinoma [RCC] and its variants in patients treated at CMH Peshawar, from Aug 2011 to Aug 2014

Study Design: Retrospective descriptive

Place and Duration of Study: Combined Military Hospital [CMH] Peshawar, from Aug 2011 to Aug 2014

Material and Methods: All patients who underwent nephrectomy for renal masses at our institution between Aug 2011 and Aug 2014 were included in the study. The demographic distribution, symptoms, tumour characteristics, operative findings and histopathology reports were extracted from the hospital records and analysed via SPSS version 20.0

Results: Among 27 patients male to female ratio was 1.25:1. Mean age was 55.5 +/- 11.7 years. Flank pain was the commonest symptom reported. Mean maximum diameter of the tumour was 13.6 +/- 4.6 cm. All the tumours were malignant and most common histopathological type was conventional/clear cell RCC. All patients were treated by radical nephrectomy through transperitoneal approach. One patient developed post operative thrombosis of inferior vena cava. Two patients developed metastatic deposit during follow up

Conclusion: Renal tumours in the study population of Khyber Pakhtunkhwa at our centre presented late with large sizes, and incidental diagnosis is rare. Health education and availability of advanced diagnostic facilities will improve outcomes

Diagnostic accuracy of alvarado score in acute appendicitis in low resource setting

Background: Acute appendicitis is one of the most common causes of acute abdomen in surgical patients

Objective: To assess the diagnostic accuracy of the Alvarado score [AS] in determining acute appendicitis

Methodology: A total of 180 patients of suspected acute appendicitis were included in this study. Patients of both sexes and age groups 12 years and above were included in the study and their Alvarado scores were calculated. Patients were divided into three groups according to the AS, as AS 1-4, AS 5-6 and AS 7-10. Acute appendicitis [AA] and normal appendix [non AA] rates were compared according to the different parameters. The signs, symptoms, laboratory values, surgical interventions, and pathology reports of each patient were evaluated. Diagnosis was confirmed by histopathological examination. Sensitivity, specificity, positive and negative predictive values and diagnostic accuracy were calculated. SPSS version 16 was used for data analysis

Results: This study included 180 patients which comprised of 72 males [40%] and 108 females [60%]. 129[76.6%] patients were less than 30 years of age. Acute appendicitis rate diagnosed on histopathology reports, was 20% in patients with Alvarado score 1-4. 35.29% in Alvarado score 5-6 and 96% in Alvarado score 7-10. The negative appendicectomy rate decreased with the increase of AS. The overall diagnostic accuracy of AS in detecting acute appendicitis was 90%. The present study found no significant difference between genders, age and BMI in terms of the reliability of the AS

Conclusion: Alvarado scoring system is a useful tool in pre operative diagnosis of acute appendicitis and can work effectively in routine practice especially in resource limited settings

Perceptions of medical students in preventing medical errors and patient safety

To evaluate under graduate medical students' perceptions on medical errors and patient safety. Descriptive cross sectional study. Army Medical College from Dec 2014 to Jan 2015. The 4x simulation role play patient safety sessions of 15 minutes each took place in the lecture hall conducted on fourth-year medical students selected during a whole-class academic sessions in Dec 2014 and Jan 2015. Participants in these sessions were given clinical scenario after taking the informed written consent. After the role play, students were given the same questionnaire. Responses to each item were added using a like rt scale. Most of the students agreed after the role play sessions that they had a good understanding of common medical errors. Medical students in Army Medical College had knowledge of medical errors as being a barrier between what is thought better and what is being available

Evidence based dentistry - a review

To provide awareness to the dental practitioners regarding Evidence Based Dentistry [EBD] which is a new paradigm shift in the field of medical science. This paper is a review of literature written after thoroughly searching Pub Med for relevant articles as well as evidence based medicine and dentistry books. EBD is practiced to validate our dental decision making in the best interest of patients

Impact on healthcare professionals after a workshop in first two steps of evidence based medicine

To determine the effectiveness of delivering a single workshop in evidence based medicine by comparing the pre and post workshop scores to ascertain level of knowledge and skills of formulating an answerable question and EBM literature searching skills among healthcare professionals. Single center quasi-experimental study. PNS SHIFA Karachi, Pakistan Navy Medical Training School. Volunteers in four groups including postgraduates group 1, undergraduate group 2, nursing student group 3 and medical technician group 4. Intervention: Eight workshops [two per group] of EBM literature searching skills were carried out with pre and post evaluation through first two questions of Fresno tool. A total of 102 participants were enrolled with 17 [16.6%] postgraduates, 34 [33.33%] undergraduates, 31 [30.4%] nursing students and 20 [19.6%] medical technicians. There was statistically significant improvement after the workshop in mean Fresno scores of individual groups. Mean pre and post workshop scores of different groups were nursing students 0.68 and 2.89, medical technicians 0.80 and 3.55, postgraduates 2 and 4.17, undergraduates 1 and 4.97 respectively. A single EBM brief workshop has a statistically significant impact on the competence level of healthcare professionals in first two EBM steps

Variations in thyroid stimulating hormone levels in various non-thyroidal illnesses

To find out the pattern of variations in thyroid stimulating hormone [TSH] levels in hospitalized patients with major Non-Thyroidal Illnesses [NTIs] leading to stressful state. A cross-sectional study was carried out in the Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology [AFIP] and the Department of Pathology, Army Medical College Rawalpindi in collaboration with Department of Internal Medicine MH, Rawalpindi. Two hundred patients, were selected by convenience sampling, who were suffering from acute febrile illness, acute psychiatric illness, acute myocardial infarction and surgical trauma [50 each]. Fifty age and sex matched subjects without present or previous history of thyroid disorders were also included as controls to neutralise the confounding variables affecting TSH estimation. Serum TSH, triidothyronine [T[3] and free tetraidothyronine [fT[4] were measured during the course of these illnesses and after complete recovery. Serum TSH, T[3] and fT[4] were estimated in the laboratory by chemiluminescence method using auto-analysers lmmulite-2000 [DPC-USA] and LIA-Mat [Sangtech-Germany] at AFIP and Army Medical College, respectively. Tests related to the concurrent illnesses e.g. liver and renal function tests and cardiac enzymes were assayed by routine end-point and kinetic methods using commercial kits manufactured by M/S Linear Chemicals [Spain] on Selectra 2 Chemistry Auto-analyser. [Mecrk-Germany]. In patients of acute febrile illness there was no statistically significant difference in serum TSH levels in patients [mean: 2.03 mlU/L] and control group [mean 1.99 mlU/L] [P>0.05]. Serum TSH was significantly higher in patients of surgical trauma [mean 3.87 mlU/L [J/L] acute myocardial infarction [mean 5.55 mlU/L] and in patients with acute psychiatric illness [mean: 3.94 mlU/L] as compared to controls [P<0.05]. The transient abnormalities in serum TSH levels can mimic or at times mask the biochemical changes observed in patients with intrinsic thyroid disease, so realisation and recognition of these responses help in avoiding misdiagnosis

Bilateral emphysematous pyelonephritis

A 63 year old male, known diabetic for 10 years and a known case of Ischemic Heart Disease for almost same duration, on regular treatment presented in a peripheral hospital with 4 days history of jerky movement of left half of body, fever, cough and urinary incontinence. Examination revealed bibasal crackles in chest; tenderness in right lumber region and upper motor neuron type weakness in left half of body. Investigations revealed Hb 15.1, TLC 17.8, platelet count of 28,000, numerous RBCs and Pus cells in urine. LFTs were normal. There was no ketonuria and DIC screen was negative. Serum urea and creatinine done on alternate days showed a rising trend with max serum urea 34.8 mmol/L and serum creatinine 1138 umol/L five days following admission. Hepatitis serology was negative. Culture of urine showed growth of Escherichia coli as well as candida species. CT scan Brain revealed right Parietal lobe infarct. USG Abdomen revealed air lucencies in subcapsular and cortical region of both kidneys suggesting bilateral emphysematous pyelonephritis. CT scan abdomen confirmed bilateral emphysematous pyelonephritis [R>L] with extension of air lucencies in perinephric spaces and prominence of gerota's fascia bilaterally. Right kidney was at the verge of bursting. Case was discussed with Urologist and Anesthetist but patient was unfit for surgery because of existing comorbid conditions. Aggressive conservative management was started including antibiotics [intravenous Tazocin] based on urine c/s and intravenous Fluconazole alongwith alternate

Monitoring of progression in diabetic nephropathy by use of protein: Creatinine index

To assess the progression of nephropathy in diabetic patients by using protein: creatinine index in spot urine sample as compared to 24 hours urinary protein excretion rate. Comparative cross-sectional study. One hundred and fourteen patients, 45 male and 69 female, aged 18 to 67 years having proteinuria of more than 150 mg/day were included this study. Quantitative measurement of protein in the spot and 24h urine specimens were carried out by a method based on the formation of a red complex of protein with pyrogallal red in acidic medium, on Microlab 200 [R] [Merck]. Estimation of creatinine was done on Selectra [R]-2 [Merck] by Jaffe's reaction. The urine protein: creatinine index was calculated by dividing the urine protein concentration [mg/L] by urine creatinine concentration [mmol/L] and multiplying by 10. The protein: creatinine index in spot urine sample showed a reliable method of monitoring of progressive diabetic nephropathy as compared to 24 hours urine protein excretion rate. A significant correlation [r = 94] was found between the protein creatinine index and standard 24 hours urinary protein excretion in these patients [p< 0.001]. The index showed a significant negative correlation [r = 0.46] with glomerular filtration rate in progressive renal insufficiency in poorly controlled diabetics. The protein: creatinine index is quick and reliable method of estimation of proteinuria, to be used for monitoring of nephropathy leading to renal insufficiency in poorly controlled diabetics

Diagnosis of detrusor instability and detrusor hyperr eflexia by urodynamic studies

Urodynamic testing is relatively a newer field of urology but an important tool for reaching definitive diagnosis. Two such cases referred to urodynamic laboratory of Armed Forces Institute of Urology are described here. An elderly man with clinical diagnosis of bladder outlet obstruction found to be suffering from bladder instability in addition on the basis of Water/voiding cystometry. The second case a young paraplegic whose upper urinary tracts were at risk despite treatment advised by neurosurgeon, was diagnosed to be suffering from detrusor hyperreflexia with DESD. Treatment of both the patients was directed appropriately on the basis of urodynamic testing which otherwise would not have been possible by any other modality. These cases are the first to be reported from any army urology department and underscores its importance

Aetiology and outcome of acute upper gastrointestinal haemorrhage cases admitted to military hospital, Rawalpindi

Acute upper gastrointestinal bleeding remains one of the most commonly encountered presentation in the emergency department of hospitals world wide. It has multifactorial aetiology which varies widely between different geographical areas of the world. Incidence in America ranges from 50-150 cases/100,000/year and in United Kingdom it varies from 100-107/100,000/year. The epidemiological analysis of such cases in Pakistan is yet to be formulated. In the last two decades the advent of state-of-the-art upper gastrointestinal endoscopy has considerably improved the diagnostic and therapeutic modalities in the management of upper gastrointestinal bleeding. This study design included thirty seven patients admitted to Military Hospital Rawalpindi with manifestations of acute upper gastrointestinal haemorrhage between August 1996 and August 1997. Endoscopy was done within seventy-two hours of admission. Male to female ratio was 8:1 and mean age at presentation was 42 years. At admission 48.6% had hematemesis whereas only 5.4% presented with melena alone. Major causes of bleeding were esophageal varices [35.2%], duodenal ulcer [21.6%] and reflux esophagitis [8.1%]. One case of Boerhave's syndrome was also seen. Prior history of NSAIDs intake was obtained in 10.8% and 5.4% gave history of previous episode of bleeding whereas 21.6% had suffered from jaundice. At presentation, haemorrhage was hemodynamically severe in 21.6% who also had Hb of <6 gm/dl with a raised urea level as well. This contributed to the overall mortality of 13.2% being highest with massively bleeding esophageal varices. Out of the 13 cirrhotic patients, 5 had hepatitis B and 3 had hepatitis C. This study signifies predominance of the esophageal varices in incurring morbidity and somewhat higher mortality rate in our population as compared to other studies. These observations necessitate proper multicentre epidemiological survey in order to adequately prevent and effectively combat the adverse outcome of upper gastrointestinal haemorrhage