Atypical chest pain in soldiers serving in hard areas: a cardiovascular and psychodiagnostic assessment

Objective: To assess the relationship between psychological illnesses and atypical chest pain in reported cases of soldiers serving in hard areas

Study Design: A cross-sectional study

Place and Duration of Study: Armed Forces Institute of Cardiology [AFIC] and National Institute of Heart Diseases [NIHD] Rawalpindi from Nov 2012 to Oct 2013

Patients and Methods: Forty patients through non-probability convenience sampling were studied with complaints of chest pain besides no evidence of heart disease once assessed by ECHO, computerized tomography [CT] Angio, Thallium Scan and echocardiography [ECG], they were subjected to psychometric assessment

Results: Out of 40 patients 72.5% [n=29] were found to have psychiatric illnesses including, depressive disorder [n=26], adjustment disorder [n=2], and malingering [n=1]. Of these 29 patients, 42.5% [n=17] appeared with mild [acute] symptoms of depression and 15% [n=6.6] with moderate and severe depression respectively

Conclusion: Psychiatric illnesses mostly go unrecognized and in order to over come the current stressor generally an individual tries to display it in socially acceptable organic disorders to avoid stigmatization

Heart and kidney patients; correlational patterns of social support with coping strategies and subjective well-being

The prevalence of chronic diseases is exceptionally high [37.9%] among the adult population of Pakistan. Social support could play a significant role in shaping the coping strategies and determining the subjective wellbeing of chronically ill patients. This research documents the correlation patterns of social support with coping strategies and subjective well-being among Heart and Kidney Patients. The primary data was collected from four major hospitals in Lahore by using purposive sampling method. For the collection of quantitative data, a hospital-based, cross-sectional survey was conducted with 275 admitted patients [131-heart and 144-kidney]184 male and 91 female [20 to 110 years of age] by using a structured interview schedule. Pearson Product-moment Correlation and Multiple Regression Analysis were performed on the data set. Strongest correlation was found between emotional and informational social support [r=.853]. Instrumental social support also indicates strong relationship with the emotional social support [r=.838]. There was a moderate positive correlation [r=.339] between behavioral coping, emotional social support and informational social support [r=.424]. Data show a negative relationship between physical coping and subjective well-being [r=.381]. Results of the study suggest that emotional [beta=.230] and informational [beta=.217] social support affect the patients' ability to actively engage in behavioral and physical coping for the subjective well-being; however, physical coping indicated negative effects [beta =-.225] on the subjective feelings of well-being. A strong correlations among four types of social support exists and behavioral coping has the strongest impact on the subjective well-being [beta=.629]

Knowledge and conception of tuberculosis; among reproductive aged women: a quantitative analysis based on Pakistan demographic and health survey

With the very high incident of tuberculosis, Pakistan ranks fifth globally among the 22 high tuberculosis risk countries. Amongst other factors, socio-demographic factors play a significant role in determining "knowledge of tuberculosis". This study used secondary data from the Pakistan Demographic and Health Survey to estimate the impact of socio-demographic factors determining the knowledge of tuberculosis and conception on how it is spread. The relevant variables and the other parameters were extracted from the both pdf and SPSS files of PDHS. Bi-variant cross tabulation was used to determine the level of association between the hypothesized variables using the Pearson chi-square statistic. Age and wealth index showed a highly significant relationship [p<0.0001] in determining the knowledge of tuberculosis. Moreover, the increasing level of education showed a decreasing trend of misconception about the spread of TB. Though the results of the study indicated a highly significant relationship between the socio-demographic factors and knowledge of tuberculosis, there is a dire need to launch awareness campaigns by the public and private sector organizations to enhance the level of correct knowledge and conception of large masses

Comparison of dietary intake and dietary requirement in post operative adult cardiac surgical patients in ICU

To estimate optimum energy and protein intake and to examine the differences in actual intake versus optimum protein and energy requirement during first three days of patients at surgical ITC of AFIC. A descriptive, cross sectional study was conducted by using purposive sampling technique. One hundred patients admitted in adult ITC of Armed Forces Institute of Cardiology and National Institute of Cardiovascular Diseases between periods of 10[th] July to 10[th] December 2013, fulfilling study criteria were included in study sample. Data was collected from hospital records [bedside charts] and food frequency questionnaire [FFQ]. Protein and energy intake on 1[st], 2[nd] and 3[rd] post operative day was calculated and compared with pre- calculated optimum protein and caloric requirement. Mean caloric intake on 1[st] post operative day was 583 k/cal, on 2[nd] post operative day 679 kcal and on 3[rd] post operative day was 820 k/cal which were 70%, 65% and 68% respectively less than the optimum requirement. Whereas mean protein intake was 13 grams on the 1[st] post operative day and 13.2 and 22.3 grams on the 2[nd] and 3[rd] day respectively which was 85%, 83% and 72% less respectively on first, second and third post operative day. The results suggest that the energy and protein intake of patients was below estimated requirements. Attention must be paid to malnutrition and nutrition in general in the hospital wards

Frequency of dysnatremia and dyskalemia in cardiac surgical intensive care unit

To determine the frequency of dysnatremia and dyskalemiain cardiac surgical intensive care unit patients and to identify the factors associated with the changes in potassium and sodium levels. Cross Sectional study. Cardiac surgical intensive care unit [ICU] of Armed Forces Institute of Cardiology / National Institute of Heart Diseases [AFIC/NIHD] from July 2013 to November 2013. Post-operative patients in cardiac surgical intensive care unit were selected through non probability convenient sampling. Demographic and clinical data was collected for all patients including: age, sex etc. Additionally, laboratory data such as potassium and sodium serum concentrations were recorded of day one of the first five post operative days. Out of 100 patients, 51% had dyskalemia, 33% had episodes of hypokalemia, and 19% had hyperkalemia. On the other hand 79% patients had dysnatremia, among them 71%had hyponatremia, and 8% had hypernatremia. Dyskalemia and dysnatremia are common problems in cardiac surgical ICU with higher frequency of hyponatremia as compared to hypernatremia, and hypokalemia as compared to hyperkalemia

Reduction in platelet count in post CABG patients with or without IABP- an experience at AFIC/NIHD Rawalpindi

To study the reduction in platelet count in patients after coronary artery bypass grafting having IABP placed peri operatively with and without IABP placed. Descriptive Study. Armed Forces Institute of Cardiology/National Institute of Heart Diseases [AFIC/NIHD] from Jan 2012 to Dec 2013. All cases with intra-aortic balloon pump [IABP] placed peri operatively [coronary artery bypass grafting, CABG] during this time period were examined in detail. Only those patients who had a platelet count of 150,000 or more pre operatively were included in the study. Patients taking medicines pre operatively that lead to decrease in platelet count were excluded. Platelet counts of each patient were analyzed till the third post-operative day. One hundred and fifty patients were divided into two equal groups, group A without IABP and group B with IABP. Patients without IABP [group A] pre operatively had mean platelet count of 223.57 +/- 83.02, on first post op day the mean platelet count was 171.0 +/- 59.0 which was 76.48% of preoperative level, on second post op day the mean platelet count was 168.1 +/- 59.4 which was 75.20% of preoperative level and on third post op day the mean platelet count was 167.5 +/- 60.0 which was 74.95% of pre-operative level. Patients with IABP [group B], pre operatively had mean platelet count of 205.32 +/- 50.257, on first post op day the mean platelet count of 152.71 +/- 43.77 which was 74.37% of preoperative level, on second post op day the mean platelet count was 112.11 +/- 42.571 which was 54.60% of preoperative level and on third post op day the platelet count was 90.87 +/- 41.538 which was 44.25% of preoperative level. There was significant reduction in platelet count from the pre-operative level in both the groups. Reduction in platelet count in post CABG patients is similar in both the groups i.e. in whom IABP is and those patients who are not treated with IABP

Should we routinely expose recurrent laryngeal nerve[s] during thyroid surgery?

To compare the frequency of recurrent laryngeal nerve[s] [RLNs] palsy after various thyroid procedures with and without identification of recurrent laryngeal nerve during the operation. Randomized controlled trial. Department of Surgery, Military Hospital, Rawalpindi, from August 2008 to April 2010. Patients undergoing indirect laryngoscopy with normal vocal cords and those with carcinoma and re-do surgery having normal vocal cord were included in the study. Patients with hoarseness of voice, abnormal vocal cord movements and with solitary nodule in the isthmus were excluded. These patients were randomly divided into 2 groups of 50 each using random number tables. RLN was identified by exposing the inferior thyroid artery and traced along its entire course in group-A. Whereas, in group-B, nerves were not identified during the operations. Immediate postoperative direct laryngoscopy was performed by a surgeon with the help of an anaesthesiologist for the assessment of vocal cords. Patients with persistent hoarseness of voice were followed-up with indirect laryngoscopy at 3 and 6 months. Temporary unilateral recurrent laryngeal nerve palsies occurred in 2 [4%] patients in group-A where the voice and cord movements returned to normal in 6 months. In group-B, it occurred in 8 [16%] patients, 2 bilateral [4%] injuries requiring tracheostomy and 6 unilateral injuries [12%]. Among the 2 bilateral recurrent laryngeal nerve injuries, the tracheostomy was removed in one case after 6 months with persistent hoarseness of voice but no respiratory difficulty during routine activities. Tracheostomy was permanent in the other case. Among the 6 cases of unilateral nerve injuries, the voice improved considerably in 4 cases within 6 months but in 2 cases hoarseness persisted even after 6 months. Frequency of recurrent laryngeal nerve palsies was significantly lower in group-A as compared to group-B [p = 0.046]. For safe thyroid surgery, recurrent laryngeal nerve[s] should be routinely exposed in its entire course

Awareness during coronary artery bypass grafting surgery

To determine the frequency of awareness in patients undergoing coronary artery bypass grafting [CABG] with cardiopulmonary bypass [CPB]. Cross-sectional Survey. Armed Forces Institute of Cardiology, Rawalpindi - Pakistan. A total of 100 patients [both males and females] of age > 18 years, undergoing elective CABG, were interviewed 24-72 hours after anesthesia using a modified Brice questionnaire. Patient's anesthesia record was consulted and the drugs and doses used at induction and maintenance of Anesthesia at different stages of the surgery were noted down. Overall frequency of awareness was found to be 5%. It was found to be less in patients who received propofol infusion during CPB compared to the patients who did not. Regular use of sedation with propofol infusion during CPB can reduce the frequency of awareness. Bispectral index [BIS] monitoring can prove to be a helpful monitor of the depth of anesthesia during CPB

Modified ultrafiltration in adult cardiac surgery is it really beneficial? A pospective randomized clinical trial

Cardiopulmonary bypass initiates systemic inflammatory response syndrome [SIRS] causing deleterious effects on various body systems with increased morbidity. Modified ultrafiltration [MUF] is a technique that removes excess water and inflammatory mediators from the circulation in the post-bypass period resulting in reduced bleeding, less blood transfusion requirements and overall reduced morbidity. 96 patients were randomly selected and divided into two groups. In Group I called MUF group [n=50], modified ultrafiltration was carried out for 15 min in the post bypass period. Group II called NON-MUF group [n=46], MUF was not carried out. Clinical assessment was based on ASA class. Mean cardiopulmonary bypass and aortic cross clamp times were 95.42 and56.94 min and 77.98 and 43.64 min in the MUF and NON-MUF groups respectively. Variables were expressed as mean and percentage. In the MUF group, there was increase in Hb by more than 2g/dl in 32 patients [64%] whereas in the NON-MU F group, this increase was only in 12 patients [20%] Mean postoperative chest drainage was far less [422 ml] in MUF group as compared to NON-MUF group [842.50 ml]. Transfusion [449.12ml Vs 996.58 ml] and postoperative ventilatory requirements [40% Vs 47.8%] were also less in MUF group than NON-MUF group. Inotropic support was nearly comparable in both the groups but overall morbidity [Low cardiac output state, sepsis, reopening] was less in the MUF group [18%] as compared to NON-MUF group [30%]. Mean ICU stay was also less in MUF group [mean 51.52 hrs] than in NON-MUF group [mean 55.43 hrs]. One patient in each group died. Modified Ultrafiltration is associated with improved hemoglobin, less postoperative bleeding, reopening and transfusion requirements with overall reduced morbidity and ICU stay. However, the need for inotropes were not significantly different in the two groups

Mechanical ventilation in snake bite

A reversible neuromuscular blockade occurring after envenomation by a neurotoxic snake may lead to respiratory and bulbar paralysis. We present our experience in managing such a case in which all modalities of treatment including anti-snake venom [polyvalent antiserum], anticholinesterases and assisted ventilation were used. An 18 years old boy was admitted in Intensive Care Unit of Pakistan Ordinance Factories Hospital Wah Cantt with two hours history of snake bite on the dorsal aspect of left thumb. At the time of admission he was conscious with normal muscle power and breathing. The bleeding profile did not reveal any abnormality. Three hours later he developed blurring of vision, slurred speech and muscle weakness followed by difficulty in breathing and became tachypnoeic and cyanosed. He was immediately intubated and placed on ventilator after initial ventilatory support with Ambu bag. Polyvalent anti-snake venom, neostigmine and atropine were administered. Meticulous nursing care was provided with continuous monitoring of haemodynamic and respiratory variables. The clinical condition started improving on 4[th] day with spontaneous opening of eyes but on 6[th] day he developed pneumonia which was aggressively treated with antibiotics. Respiratory effort appeared on 9th day and gradually increased to adequate level on 14[th] day. He was removed from ventilator on 15[th] day. We suggest that mechanical ventilation is a helpful modality in case of respiratory failure occurring due to snake envenomation and its timely institution results in better prognosis

Organophosphorus poisoning leading to respiratory failure

Organic insecticide poisoning [suicidal, accidental or occupational exposure] is quite prevalent in the rural areas of Pakistan. Presentation is variable, ranging from GIT symptoms to severe neurological manifestations of paralysis and cardiovascular instability. Such patients need careful thorough assessment, vigilant monitoring and aggressive supportive management. We present a case of such poisoning who went into respiratory failure

Is mechanical bowel preparation really necessary in colorectal surgery?

To determine the outcome of colorectal surgery without mechanical bowel preparation. Design: A descriptive, analytical and observational study. Place and Duration of Study: Combined Military Hospital, Kharian and Pano Aqil, from September 1998 to April 2003. Subjects and Forty-seven patients underwent debridement/resection and repair/ primary anastomosis of colon and upper rectum without bowel preparation. Of these,16 patients were operated in emergency. The anastomosis was carried out with polyglactin [vicryl] interrupted, full thickness single layer and no patient had defunctioning colostomy. Third generation cephalosporin, cefotaxime or ceftazidime and metronidazole were given perioperatively, repeated during surgery if lasted for more than 2 hours and continued for 3-5 days postoperatively. Anastomoses were ileocolic in 29.7%, colicocolic in 61.7% and colorectal in 14.8% cases. Anastomotic failure was seen in 4.2% and wound infection in 8.5% cases. There was one mortality [2.1%] due to unrelated cause. Mechanical bowel preparation is not necessary for safe colorectal surgery