Cardiac manifestations in patients of rehumatoid arthritis

Abstracts: Cardiovascular manifestations of Rheumatoid arthritis have never been studied before therefore this study was designed to evaluate cardiac disease in patients suffering from rheumatoid arthritis

Methodology: Fifty patients of Rheumatoid Arthritis presenting in Out Patient, Emergency and Rheumatology Clinic of Mayo Hospital Lahore from March 1998 till January 1999 were studied. All of them full filled the criteria for the diagnosis of Rheumatoid Arthritis as described by the American Rheumatism Association. After history and physical examination, a clinical assessment of the patient was made of whether he / she had Cardiac Manifestations of Rheumatoid Arthritis or not

Results: Out of 50 patients seen 35 were female, and 15 were male. Giving a female to male ratio of 2.3 to 1. Maximum number of patients seen were between 26 45 years i.e 31[62%] In which 19 [38%] were between 26 to 35 years and 12 [24%] were between 36-45 years. Next most frequent group was of 8 [16%] patients, between 15-25 years of age. Short systolic murmurs were heard in four patients. One patient showed pulsus paradoxus while in the rest no rhythm irregularity was felt. Myocarditis or Coronary Rheumatoid disease was not noticed in any patient. No heart block of any degree was seen. In 4 E.C.G's low voltage was demonstrated in the limb leads. Out of 50 Patients only 3 had pericardial effusion. In one patient it was only a thin rim more prominent posteriorly than anteriorly

Conclusion: Cardiac manifestations of Rheumatoid Arthritis also occur in Pakistani Population, although not with the same frequency as in the Western world. It is also concluded that in Pakistani population, like in the West, the most common Cardiac complication is Pericardial Effusion

Technique of syndesmotic screw insertion in weber type C ankle fractures

To find out impact of the position of the ankle during tightening of the syndesmotic screw used to fix syndesmotic disruption in bimalleolar Weber type C ankle fracture. A randomised controlled clinical trial. Orthopaedic Department at Combined Military Hospital Malir Karachi, from October 2002 to December 2005. We hypothesized that syndesmotic screw tightening with ankle in plantigrade position rather than 200 dorsiflexion would result in reduced range of dorsiflexion of the ankle joint postoperatively. Twenty-one consecutive young active patients with Weber type C bimalleolar ankle fractures having syndesmotic injuries treated with open reduction and internal fixation were randomly allocated to two groups. In group I [n=10] syndesmotic screw was inserted with ankle in 200 dorsiflexion and in group II [n=11] syndesmotic screw was inserted with ankle in plantigrade position. Patients were followed up for 12 months. Study end point was healing of the fracture. Subjective and objective assessment with Olerud-Molander Ankle [OMA] scores and bi-planar radiography was done. The range of ankle dorsiflexion postoperatively, hardware failure and need to remove the screw were the outcome measures. Comparing two groups using paired sample t-test, we did not find a statistically significant difference in postoperative range of ankle dorsiflexion between the two groups [p values > 0.05]. Differences between the two groups as regard the OMA scores, hardware failure and need to remove the screws were not significant either. Syndesmotic screw can be tightened with ankle in plantigrade or dorsiflexed positions without resulting in reduced range of ankle dorsiflexion postoperatively

Syndesmosis fixation in bimalleolar weber C ankle fractures; comparison of 3.5 and 4.5-mm screws

To study the influence of size of screws for syndesmosis fixation in bimalleolar Weber C ankle fracture. A prospective randomised controlled clinical trial. Orthopaedic Department at Combined Military Hospital Malir. From October 2002 to September 2005. 17 consecutive young active patients with Weber type C bimalleolar ankle fractures having syndesmotic injuries treated with open reduction and internal fixation were randomly allocated to two groups. In group I [n[1] = 9] 3.5mm small fragment and in group II [n[2]=8] 4.5mm large fragment AO cortical screws were used for syndesmotic fixation. All patients were followed up for 12 months. Fracture healing or loss of reduction of syndesmosis was taken as the study end point. Hardware loosening or breakage and need for hardware removal were the outcome measures. Subjective and objective assessment with Olerud-Molander Ankle [OMA] scores1, range of motion and radiographic criteria was done. Loss of reduction was not seen in any patient in both groups. Comparing two groups using paired sample t-test, there was no difference in screw loosening and breakage [p values > 0.05]. We did not find a statistically significant difference between range of motion [p = 1.08] and OMA score [p-value = 0.805]. Size of the syndesmotic screw does not appear to influence healing of syndesmotic injury. Screw loosening, which can result in reduced range of ankle motion postoperatively was more common in smaller screw group though the difference was not significant

comparison of early echocardiographic findings in patients having first acute myocardial Infarction with or without pre-infarct angina

Background: Acute myocardial infarction [AMI] is the most common cause of morbidity and mortality. In order to reduce myocardial infarct size, a new technique i.e. ischemic pre-conditioning has evolved. The brief periods of ischemia followed by reperfusion appear to pre-condition the heart and make it more resistant to a subsequent longer period of ischemia. Pre-conditioning is defined as "a rapid, adaptive response to a brief ischemic insult, which slows the rate of cell death during a subsequent, prolonged period of ischemia"

Material and Methods: A comparative study was conducted to identify the patients of AMI with or without pre-infarction angina, to find out the differences in their in-hospital course and to assess the prognostic value of pre-infarction angina in first episode of AMI during hospital stay

Results: Twenty-five patients with [Group A] and 25 patients without [Group B] pre-infarction angina were compared for their in-hospital course. Mean age +/- SD in Group A was 55 +/- 7 years and in Group B 54 +/- 8 years. There were 18 [72%] males and 7 [28%] females in Group A, and 17 [68%] males and 8 [32%] females in Group B. As far as the baseline risk factors in two groups were concerned, 5 vs 7 patients had diabetes mellitus, 7 vs 8 had hypertension, 16 [64%] vs 13 [52%] were smoker, 3 vs 4 had obesity, 4 vs 5 had family history of IHD and 5 vs 6 had hyperlipidemia in Group A and Group B respectively. Regarding the intake of anti-anginal medication like calcium channel blockers, beta-blockers and nitrates in the two groups, there were more patients in Group A as compared to B who were taking them [p<0.05]. Similarly there were also 10 [40%] vs 2 patients in Group A and B respectively who were taking aspirin [p<0.05]. In-hospital complications like cardiogenic shock, CCF, LVF, RVF, recurrent ischemic pain, infarct extension and rhythm abnormalities were more in Group B as compared to Group A [p<0.05]. When echocardiography was performed, the data showed that the ejection fraction percentage [mean +/- SD] in Group A was 55% +/- 7.8 versus 44% +/- 7.9 in Group B [p<0.001]. There were 3 in Group A vs 13 patients in Group B who had developed aneurysm [p<0.05], 2 in Group A vs 1 in Group B who had papillary muscle rupture, 1 in Group A vs 5 in Group B who developed VSD and 4 in Group A vs 10 in Group B who had clot in left ventricle. While in-hospital mortality between two groups was observed, there was only 1 in-hospital death in Group A vs 6 [24%] in Group B [p<0.05]

Conclusion: The presence of pre-infarction angina had a favorable effect on in-hospital course after AMI i.e. a lower incidence of in-hospital mortality, a lower incidence of in-hospital complications, development of significantly smaller infarct size with a higher ejection fraction and a lower incidence of aneurysmal formation

Comparison of in-hospital course of patients having first acute myocardial infarction with or without pre-infarct angina

Background: Acute myocardial infarction [AMI] is the most common cause of morbidity and mortality and to reduce myocardial infarct size a new technique i.e. ischemic pre-conditioning has evolved. The brief periods of ischemia followed by re-perfusion appear to pre-condition the heart and make it more resistant to a subsequent longer period of ischemia. Pre-conditioning is defined as "a rapid, adaptive response to a brief ischemic insult, which slows the rate of cell death during a subsequent, prolonged period of ischemia"

Material and Methods: A comparative study was conducted to identify the patients of AMI with or without pre-infarction angina, to find out the differences in their in-hospital course and to assess the prognostic value of pre-infarction angina in first episode of AMI during hospital stay

Results: Twenty-five patients with [Group A] and 25 patients without [Group B] pre-infarction angina were compared for their in-hospital course. Mean age+/- SD in Group A was 55 +/- 7 years and in Group B 54 +/- 8 years. There were 18 [72%] males and 7 [28%] females in Group A, and 17 [68%] males and 8 [32%] females in Group B. As far as the baseline risk factors in two groups were concerned, 5 vs 7 patients had diabetes mellitus, 7 vs 8 had hypertension, 16 [64%] vs 13 [52%] were smokers, 3 vs 4 had obesity, 4 vs 5 had family history of IHD and 5 vs 6 had hyperlipidemia in Group A and Group B respectively. Regarding the intake of anti-anginal medication like calcium channel blockers, beta-blockers and nitrates in the two groups, there were more patients in Groups A as compared to B who were taking them [p<0.05]. Similarly there were 10 [40%] vs 2 [8%] patients in Groups A and B respectively who were taking aspirin [p<0.05]. In-hospital complications like cardiogenic shock, CCF, LVF, RVF, recurrent ischemic pain, infarct extension and rhythm abnormalities were more in Group B as compared to Group A [p<0.05]

Conclusion: The presence of pre-infarction angina had a favorable effect on in-hospital course after AMI i.e. a lower incidence of in-hospital mortality, a lower incidence of in-hospital complications, development of significantly smaller infarct size

Spinal surgery in earthquake victims

Objective of present paper is to document the operations performed in earthquake spinal injury patients and to analyze the results of surgery. This is a quasi-experimental study. This study was conducted at the department of Orthopaedic and Spinal surgery at Combined Military Hospital [CMH], Rawalpindi. Study started after earthquake in Pakistan on 8[th] of October 2005 and ended in August 2006. 250 patients with spinal injury were admitted at the three main army hospitals at Rawalpindi [CMH, MH and AFIRM] after earthquake on 8[th] October 2005. Out of these, 110 patients underwent 120 major spinal operations. 12 patients were received from other units for revision surgery. 75% of the patients were civilians and 25% were army personnel and their families. Average age was 28 years and range was 8-65 years. 56% patients were females and 44% were males. 46% patients had complete neurological deficit and 54% had incomplete neurological deficit. Most common associated injuries were fractures of tibia and fibula. Most common level of injury was at T12/L1 [55%]. After surgery almost all patients had rehabilitation at AFIRM. Post-operatively excellent [>75%] or good [50-75%] correction of deformity was achieved in 90% of patients. 92% patients had mild or no pain, post-operatively. Neurological improvement was seen in all patients with incomplete deficit except four. Some patients with complete deficit also showed improvement. Overall there was 1.5 AIS improvement per patient. At last follow up 46% patients were walking independently and 51% were independent in wheel chair. Spinal surgery in patients with unstable spines after major disaster should be carried out by properly trained surgeons as soon as possible and in a setup where facilities for proper rehabilitation are available as it carries best prognosis for these high risk and at times paralyzed patients