Thinking out of the box: alternative career choices for young doctors in Pakistan

The number of young medical graduates in Pakistan is increasing every year. Most of whom wish to specialize in a particular clinical field. Considering the competition faced for specialty training selection and later on for job placement, it is suggested that these young graduates should explore some alternative careers as well. Opportunities can be availed and decision made based on graduates' personal interest, preference to work in Pakistan or abroad, and availability of suitable employment in local and international hospitals among other factors. Careers in the basic medical sciences, medical education, medical research, medical writing and bioethics can be considered, too. There are very few trained professionals in these fields in Pakistan and once trained, these young doctors will hopefully find rewarding employment

Evaluation of outcome of totally extra peritoneal laparoscopic inguinal hernia repair with Lichtenstein open repair

The objective of this study was to evaluate outcome of total extraperitoneal laparoscopic inguinal hernia repair with Lichtenstein open repair in terms of postoperative pain. Quasi experimental study. Surgical unit 1 Rawalpindi and Allied hospitals from January to June 2012. Sixty patients, with unilateral, primary, inguinal hernia were alternately allocated to undergo either total extraperitoneal [TEP] laparoscopic repair of inguinal hernia or Lichtenstein tension free, mesh repair of inguinal hernia. Pain scores at 12, 24, and 48 hours and at 7 days of follow up were noted using a visual analogue scale. Total number of intravenous injections of Diclofenac Sodium requested by the patient for pain relief was also noted. At 12 hours after surgery, the mean pain scores in the TEP group were 3.1 +/- 1.8 and in the Lichtenstein group they were 4.2 +/- 2.1 [p 0.031]. At 24 hours after surgery, the scores were 2.3 +/- 1.5 and 3.1 +/- 1.9 for the TEP and Lichtenstein groups, respectively [p = 0.026]. At 48 hours after surgery, the mean pain scores in the TEP group were 1.5 +/- 1.1 while in the Lichtenstein group they were 2.0 +/- 1.6 [p = 0.041]. At 7 days after surgery, the scores were 0.3 +/- 0.5 in the TEP group and 0.4 +/- 0.8 in the Lichtenstein group [0.137]. The mean number of injection of Diclofenac Sodium required by the TEP and Lichtenstein groups was 3.1 +/- 1.6 and 5.8 +/- 2.2, respectively [p = 0.011]. Less postoperative pain and requirement for analgesics were reported by patients who underwent total extraperitoneal laparoscopic repair of inguinal hernia as compared to those who underwent inguinal hernia repair by Lichtenstein tension free mesh hernioplasty

Functional outcomes following lower extremity amputation at the armed forces institute of rehabilitation medicine using lower extremity functional scale

To assess improvement in functional outcomes following prosthetic fitting after lower limb amputation using a lower extremity functional scale in a cohort of the Pakistani population. Quasi experimental Study. Amputee rehabilitation ward [indoor] / OPD [out patient department] at Armed Forces Institute of Rehabilitation Medicine Rawalpindi. From August 2009 to August 2010. Study was carried out in the amputee rehabilitation ward of the Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan. Fifty two consenting lower limb amputees fulfilling the inclusion criteria were enrolled. All patients were provided with modular prosthesis followed by gait training and integrated amputee rehabilitation program. An assessment was done at 0, 4 and 12 weeks after the provision of prosthesis. Results were analyzed by SPSS Version 15. Most of the patients were males [98.1%]. Mean age was 30.17 +/- 9 years. Trauma was the main etiology [99%] followed by tumor [in only 1 patient who had osteosarcoma]. Transtibial amputation level was the commonest [53.8%] followed by transfemoral in 32.7% patients and Syme's [7.7%]. Lower extremity functional scale [LEFS] mean score in the first week was 35.56 [44.5% of maximum function], which improved to 49.40 [61.8% of maximum function] at week 4, and 59.27 [74.09% of maximum function] at the end of week 12. The p-value for each was 0.000. Early and multidisciplinary amputee rehabilitation improves the functional ambulation level, quality of life and satisfaction level of the individual

Role of anterior decompression with internal fixation in dorsal spine tuberculosis

To assess efficacy of anterior decompression and internal fixation using mesh cage and rod with screws in patients with dorsal spine tuberculosis This observational study was conducted in the Department of Neurosurgery Lady Reading Hospital Peshawar from July 2010 to June 2012 [2 years]. There were 38 patients with dorsal spine tuberculosis who underwent anterior decompression and fusion using anterior spinal instrumentation and allograft replacement. We included those patients in our study, who undergone anterior decompression with internal fixation for dorsal spine tuberculosis, of both genders irrespective of their age. We excluded those patients who were unfit for surgery, treated conservatively, involved spine other than dorsal spine or undergone procedure other than anterior approach for Carrie's spine. Clinical outcome of the patients was assessed using the frankle grade. The patients were observed for post-operative complications, neurological improvement and bony fusion. We had total of 38 patients who undergone the procedure in whom23 [60.5%] were males and 15 [39.5%] females with male / female ratio of 1.5: 1. Their age ranged from 4-70 years [mean 37years]. The most common level involved were between D5-D12 for which thoracotomy was needed. Preoperative neurodeficit was observed in 76.3% patients of whom 89.7% showed improvement after surgery. Our patients had 7.9% complications after surgery. We had wound infection in 5.3% and dyspnea in 2.6% cases. There were no graft related complications and bony fusion was observed in all the patients. It is concluded from our study that anterior decompression with internal fixation using cage and rod with screws is an effective procedure in dorsal spine tuberculosis. It has few complications and yields good results

Stercolith Perforation

A 62-year-old diabetic bed ridden woman, presented to the emergency department with symptoms suggestive of peritonitis. She had been taking oral laxatives and enemas to relieve her chronic constipation for last 6 years. Hard impacted stools and pelvic tenderness were found on digital rectal examination. Her X-ray abdomen showed soft tissue shadows in the colon but there was no gas under the diaphragm on chest X-ray. Sonography found free fluid in pelvis. She was resuscitated, and her hyperglycemia was controlled by use of regular insulin as per sliding scale. Operative findings revealed free fluid in pelvis and very hard faecalomas lying free in peritoneal cavity. There was a 2 x 3 cm perforation at the anterior wall of the recto-sigmoid junction. Peritoneal toilet was carried out followed by Hartmann's procedure. Histopathology of perforation side showed no evidence of malignancy

Lateral epicondylitis; steroid injections for the management

To find out effectiveness of steroid injection for early management of lateral epicondylitis. One hundred and twenty Patients of both genders presenting with unilateral lateral epicondylitis of less than two weeks duration reporting at Outpatient Department at Armed Forces Institute of Rehabilitation Medicine, Rawalpindi. Quasi experimental study. Out patient department of Armed Forces Institute of Rehabilitation Medicine, which is the largest rehabilitation facility in the country at present offering a multidisciplinary approach in the management of disability and musculoskeletal disorders17. 01 yrs. Both groups had sixty cases each with a mean age of 35.1 +/- 6.22 and 36.08 +/- 5.98 respectively. There were 54[45%] males and 66[55%] females. At four weeks and three months follow up assessments there was significant improvement in pain relief and pain free grip strength in the Group A[steroids] as compared to Group B [NSAIDs]. Local steroid injection is an effective treatment with an advantage over nonsteroidal anti-inflammatory drugs [Diclofenac]. It results in a rapid and better relief of symptoms, which is sustained over a period of three months

Microvascular decompression in patients with intractable idiopathic trigeminal neuralgia

To evaluate etiology and implications of microvascular decompression [MVD] in patients with intractable idiopathic trigeminal neuralgia. Descriptive case series. Neurosurgery department of Hayatabad Medical Complex, Peshawar from January 2007 to December 2009. Patients with idiopathic trigeminal neuralgia [ITN] irrespective of age and sex, were included in the study. Patients responding to medical treatment were excluded. MRI brain was done for all patients to exclude secondary causes. Microvascular decompression was performed in all patients under general anesthesia. Patients were examined on seventh postoperative day and the clinical findings were documented. Outcome of surgery was declared as successful when there was a commensurate relief of neuralgia paroxysms and deep background pain along with total withdrawal of medications. Fifty two patients were operated for trigeminal neuralgia. There were 23 [44%] males and 29 [56%] females [M:F 1:1.26]. Age ranged between 20-70 years [Mean 56 years]. Right sided neuralgia was present in 34 [65%] cases. In 50 cases [96%] a neurovascular conflict was found. The superior cerebellar artery [SCA] was the cause of compression in 45 [86.53%] patients, anterior inferior cerebellar artery [AICA] in two patients, and one patient each, the vessel involved was posterior inferior cerebellar artery [PICA], basilar artery, and petrosal vein. In 2 patients trigeminal nerve was found encased by tight arachnid adhesions. Trigeminal nerve entry zone was the point of conflict in 38 cases [73.07%]. The mandibular division [V3] was involved in 30 cases [57.7%] followed by maxillary division [V2] in 18 cases [34.61%] and ophthalmic division [V1] in 4 cases [94.23%]. Cerebrospinal fluid [CSF] leakage occurred in 3 cases [5.76%]. One patient developed wound infection. One patient [1.92%] expired in the postoperative period due to mid brain stroke. The main etiological factor of trigeminal neuralgia was vascular compression, especially by SCA, of the 5[th] nerve roots at brain stem. Microvascular decompression is safe and effective therapy for all ages

Frequency of peripheral polyneuropathy in a cohort of diabetic patients having symptoms of polyneuropathy using electrodiagnostic procedure

To determine the frequency of peripheral polyneuropathy in patients having diabetes mellitus with symptoms of polyneuropathy using electrodiagnostic procedure. Observational descriptive study. Armed Forces Institute of Rehabilitation Medicine [AFIRM], Rawalpindi. June 2008 to June 2009 [one year]. Sixty three patients of diabetes mellitus having symptoms of peripheral polyneuropathy fulfilling the inclusion criteria were sampled by purposive sampling. Informed consent was taken. Their demographic data and common symptoms were recorded. All patients underwent Electrodiagnostic procedures for the presence or absence of polyneuropathy, using nerve conduction studies by recording amplitudes, velocities and latencies of minimal two [sural, peroneal] and maximum six nerves. Electromyography was performed only in patients with abnormalities in nerve conduction findings or conditions other than polyneuropathy. Frequencies as percentages were calculated for the presence or absence of polyneuropathy, type of polyneuropathy, associated symptoms and other related diagnosis [if any]. There were thirty three males [52.4%] and thirty female [47.6%]. Forty one [65%] patients had confirmed polyneuropathy on electrodiagnosis, out of which forty patients [97.6%] had axonal polyneuropathy, only one patient [2.4%] had demyelinating polyneuropathy. Twenty two had no polyneuropathy [35%], out of which 65% had other diagnosis like Carpal Tunnel Syndrome [CTS], Radiculopathy and other Compression neuropathies. Majority of symptomatic diabetic patients actually had polyneuropathy. Electrodiagnostic studies are a sensitive tool for early detection of peripheral polyneuropathy, its types and extent

Review of prescriber approach towards rational drug practice in hospitalised patients

The rational drug prescribing practice is an important health concern around the globe that not only interferes patient's life but also the socioeconomic issues. The aim of current study was to evaluate the rational use of drug, prescribing behaviour of consultant physicians, role of medical team members in irrational therapy and form the basis for providing necessary information to the policy makers. This cross-sectional study was conducted involving a set of 340 medication orders containing about 1,755 medications prescribed to patients in DHQ Teaching Hospital DI Khan, Pakistan from March to July 2009. The WHO operational package for monitoring and assessing country pharmaceutical situations indicators were used for data collection. Among drugs prescribed per average encounter, 75% were dispensed from hospital pharmacy. Generally about 22.3% encounters of overdosing, 16.16% drug duplication, 24.25% drugdrug interactions, 3.5% adverse drug effects and 3.8% cases of contraindications were recorded. The proportion of consultations with antibiotics and injectables prescribed was 80% and 57% respectively. Likewise not less than 70% patients were prescribed NSAIDS, 67% steroids, 55% vitamin supplements, and 34% oral re-hydration solutions. Minimum 5 drugs per prescription were recorded and 70% of prescriptions were reported with high cost of therapy. The drug practice among hospitalised patients was clearly irrational accompanied by high levels of medication error. An accurate prescribing decision, appropriate treatment, and rational use of drugs are major needs of the day to ensure safe medication practice

Frequency of axonal variants of guillain-barre syndrome in Pakistan

To determine the frequency of axonal variants in our patients of Guillain-Barre Syndrome. Descriptive study. Department of Neurology, Military Hospital, Rawalpindi and Armed Forces Institute of Rehabilitation Medicine [AFIRM] from 01 Jan 2009 to 30 Jul 2010. Forty adult patients meeting the National Institute of Neurological Disorders and Stroke criteria for Guillain-Barre Syndrome [GBS] were consecutively enrolled in the study. Patient's data, detailed history, examination and electrophysiological studies were carried out and recorded on predesigned proforma. All patients were examined and reviewed by Consultant Physicians and neurologists. Electromyography and Nerve conduction study testing was done by experienced electro-physiologists. Axonal variants of Guillain-Barre Syndrome constituted 16[40%] in our study. The variants of Guillain-Barre syndrome were acute inflammatory polyradiculoneuropathy [AIDP] in 24[60%] patients followed by acute motor axonal neuropathy [AMAN] in 12[30%] and acute motor sensory axonal neuropathy [AMSAN] in 4[10%] patients. We report a high frequency of the axonal variants of Guillain-Barre Syndrome in Pakistan

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

Uro-dynamic evaluation

drsaqii1711@hotmail.com To describe the pattern of Urodynamic evaluation at Armed Forces Institute of Rehab Medicine, Rawalpindi. Descriptive study. This study was conducted on 466 patients reporting for urodynamic evaluation at Urodynamic/Incontinence Clinic at A F Institute of Rehab Medicine from Feb 2003 to Dec 2006. We considered the age, gender, etiology, reason for referral, and presenting complaints whereas results were formulated according to Classification of voiding disorders by International society of Incontinence. Data was analyzed using statistical package for Social Science version 10. In all [466] patients, 58% were males and 42% were females. Mean age was 46.8 years. Increased frequency [61%] and incontinence [52%] were the most common presenting complaints, 158[34%] had spinal cord injuries, 58 were cases of myelodysplasias and 128 reported with stress incontinence. Urodynamic studies showed that 152[33%] had hyperactive bladders, 110[24%] had a contractile/hypo-contractile bladders, 104[22%] had stress incontinence and 56[12%] cases had normal results. Urodynamics helps in diagnosis of potentially life threatening urinary problems. The availability of this equipment and trained staff must be encouraged at tertiary care hospital. More research is required in this regard in Pakistan, which shall help in formulating better management protocols in future

Role of therapeutic exercises in neurogenic thoracic outlet syndrome

Neurogenic Thoracic Outlet Syndrome [TOS] is a set of signs and symptoms existing due to compression of brachial plexus in the cervical area. We performed the study to highlight the role of therapeutic exercises on patients with neurogenic thoracic Outlet Syndrome. This quasi-experimental study was carried out at Armed Forces Institute of Rehabilitation Medicine [AFIRM], Rawalpindi. Fifty consecutive patients of neurogenic TOS of both genders and all ages were selected. Patients were diagnosed clinically and the diagnosis was confirmed by electrodiagnosis. These patients were asked to follow a therapeutic exercises program for 6 months. Outcome measures included Visual Analogue Scale [VAS] and Ulnar Nerve Conduction Velocity across neck. Results were compared by applying relevant tests of significance on follow up visits at 3 and 6 months. Mean age was 39.1 +/- 7.79 years. Thirty seven [74%] cases were females and thirteen [26%] were males. On each visit, statistical analysis showed significant improvement with therapeutic exercises. After 6 months of conservative treatment, 17 [34%] of patients showed full recovery, 14 [28%] had marked improvement, 16 [32%] had partial improvement while 3 [6%] patients reported with persistent severe symptoms. Current study shows that a trial of therapeutic exercises provides relief of symptoms of Neurogenic Thoracic Outlet Syndrome in majority of patients