Thrombotic Thrombocytopenic Purpura: our clinical experience

Objectives: To assess clinical presentation and outcome of patients with thrombotic thrombocytopenic purpura [TTP] in our setup

Study Design: Descriptive study

Place and Duration of Study: Combined Military Hospital [CMH] Peshawar, from Feb 2016 to Aug 2017

Patients and Methods: In a prospective design, patients diagnosed to be suffering from TTP, were included in this study. Detailed history along with physical examination and thorough investigation of all cases was carried out and collected on proformas. The diagnosis of TTP in our study was done by demonstration of significant schistocytes [more than 1 percent] on peripheral blood film. The patients were treated with steroids and plasma pheresis and in some cases with weekly Rituximab for 4 weeks. The patients were followed up in outdoor clinic on monthly basis

Results: Being a very rare disease, only 11 patients suffering from TTP reported during the study period. They were followed prospectively with a mean duration of follow-up of 11.23 months [ +/- SD 5.57]. All patients [100 percent] had anaemia, thrombocytopenia and acute kidney injury. Fever was seen in 54.4 percent patients and 63.6 percent patients had neurological involvement. A likely secondary cause of precipitation of TTP was found in 54.5 percent cases. The mortality rate was 18.2 percent

Conclusion: TTP is a challenging disease for intensive care specialists and can be fatal without effective treatment. A high index of suspicion followed by early diagnosis and prompt treatment can save life. Documentation of deficiency of plasma ADAMTS13 activity is not essential for the diagnosis of TTP and plasmapheresis is the treatment of choice

Percutaneous tracheostomy by physician intensivists

Objective: To assess the safety of percutaneous tracheostomy when performed by physician intensivists

Study Design: Descriptive study

Place and Duration of Study: Adult Medical ICU in the Department of Critical Care Medicine, Military Hospital, Rawalpindi, Pakistan, from September 2013 to August 2016

Methodology: Departmental record for percutaneous tracheostomies, performed by physician intensivifts, was evaluated. Variables studied were underlying primary diagnosis, details of the operating doctors, presence of immediate complications, departmental protocol for the procedure, pre-procedure safety checklist, written instructions on procedure steps, use of ultrasound and bronchoscopy. Portex Percutaneous Dilation Tracheostomy Kit with Single-Stage Dilator was used in all the patients

Results: Fifty-six percutaneous tracheostomy procedures were performed with a male to female ratio 3:1; more than 2/3[rd] [80%] had an underlying neurological illness. All doctors performing the procedures were physicians having minimum qualification of Fellowship with at least one year experience in intensive care and had observed at least five procedures. Departmental protocol for the procedure was followed in all the cases. Minor complications were observed in three patients [5.35%]. These included para-tracheal misplacement, accidental de-cannulation, and endotracheal tube cuff puncture. None of the patient died due to direct complications of the procedure

Conclusion: Percutaneous tracheostomy is safe in Medical ICUs of developing countries, when performed by experienced physician intensivists under defined protocols

Analysis of orbital malignancies presenting in a tertiary care hospital in Pakistan

Objective: To determine the frequencies of various orbital malignancies amongst orbital lesions in patients presenting in a tertiary care hospital in Pakistan

Methods: A retrospective analysis of 666 orbital cases with an established histopathological diagnosis of malignant tumors treated in Mayo Hospital Lahore from 1996 to 2015 [20 years]

Results: About 66% of the malignant tumors were primary, 25% secondary, 8% haematopoietic and 1% metastatic. Almost 50% of the cases were children. Retinoblastoma is the commonest tumor [43% overall and 87% among children]. Squamous cell carcinoma is the second commonest [15.6% overall and 31% among adults]. These are then followed by Adenoid cystic carcinoma of Lacrimal Gland [9%], Lymphoma/Leukaemia [8%] and Rhabdomyosarcoma [6.3%]

Conclusion: Frequencies of various orbital malignancies show geographical variation in both paediatric and adult population

Protective effect of melatonin against methotrexate induced hepatotoxicity in mice

Objective: To evaluate protective role of melatonin against methotrexate induced hepatotoxicity

Study Design: Randomized controlled trial

Place and Duration of Study: Department of Pharmacology Army Medical College, duration of the study was, from Apr to Aug 2016

Material and Methods: Eighteen mice were randomly divided into three groups [n=6]. Group [Gp]-1 received normal saline. Gp-2 received single intraperitoneal injection of methotrexate [MTX] while Gp-3 received melatonin along with MTX. Blood samples for measuring serum alanine amino transferase [ALT], aspartate amino transferase [AST] and alkaline phosphatase [ALP] along with liver samples for hepatic histological examination were taken after 24 hours of last dose

Results: In Gp-2 MTX there was significant rise in serum ALT, AST and ALP as compared to its control gp [p<0.05]. There was significant attenuation of serum ALT, AST and ALP with protective Gp-3 [MTX + Melatonin] when compared with Gp-2 [p<0.05]. The histopathological findings in the liver of mice of Gp-2 MTX showed mild fatty changes which were markedly reduced in mice treated with melatonin along with MTX though minimal inflammation was seen

Conclusion: Melatonin has hepatoprotective potential when administered along with methotrexate

Diaphragmatic excursion: does it predict successful weaning from mechanical ventilation?

Objective: To measure the diaphragmatic excursion and its outcome on weaning from mechanical ventilation

Study Design: Cross-sectional comparative study

Place and Duration of Study: Medical Intensive Care Unit [ICU], Military Hospital [MH], Rawalpindi, Pakistan, from January to December 2014

Methodology: Diaphragmatic excursion [DE] in cm was measured through ultrasound by marking liver and spleen displacement in patients who fulfilled the criteria of removal from ventilatory support. The patients were followed up for 48 hours and classified according to the outcome as successful weaning and weaning failure

Results: Out of 100 cases, 76 patients had a successful weaning while 24 had a failed weaning outcome. At a diaphragmatic excursion of 1.2 cm and more, out of 67 cases, 60 had a successful weaning [89.55%] while 7 cases [10.45%] had a weaning failure. At an excursion of less than 1.2 cm, 17 out of 33 cases [51.5%] had successful weaning while 16 [48.48%] had weaning failure. At this cut off point [1.2 cm], the sensitivity and specificity for successful weaning were 78.95% and 70.83%, respectively. The positive and negative likelihood ratio [LR] for these values being 2.70 and 0.29, respectively. The positive predictive value was 82.35% and negative predictive value 60.00%

Conclusion: Ultrasonographic measurement of diaphragmatic excursion is a good method for predicting weaning outcome from mechanical ventilation

Endobronchial ultrasound guided transbronchial needle aspiration [EBUS-TBNA] for diagnosis of mediastinal and hilar masses

Objective: To determine the sensitivity, specificity, negative and positive predictive values, and diagnostic accuracy of Endobronchial Ultrasound Guided Transbronchial Needle Aspiration [EBUS-TBNA]

Study Design: A cross-sectional validation study

Place and Duration of Study: Department of Histopathology, Army Medical College, in collaboration with Department of Pulmonology, Military Hospital Rawalpindi, from March 2014 to March 2015

Methodology: Cases of EBUS-TBNA comprised of both TBNAs and cell block/biopsy of the same patients. Diagnosis was made on the TBNA slides and cell block/biopsy material. Taking biopsy/cell block as the gold standard, the data was analysed to calculate the sensitivity, specificity, negative and positive predictive values, and diagnostic accuracy of EBUSTBNA

Results: The sensitivity of EBUS-TBNA was found to be 96.5%; whereas, specificity and positive predictive values were 100%. The negative predictive value was calculated at 50%. Diagnostic accuracy of the procedure was found to be 96.67%

Conclusion: EBUS-TBNA is a sensitive and a specific test and is accurate in diagnosing mediastinal and hilar pathologies

Epithelial ingrowth after penetrating trauma

This is a case report about the anterior segment findings of epithelial ingrowth in a young female patient after penetrating trauma. The patient underwent multiple surgeries after penetrating trauma and epithelial ingrowth was noted on regular follow-up. Epithelial ingrowth was noted along the inner surface of corneal endothelium along with the presence of cysts. These findings suggest that epithelium penetrated through the site of perforation and grew along endothelium. Although epithelial ingrowth is a commonly reported complication of photorefractive surgery, it is rarely reported after trauma to eye. To authors' knowledge, this is the first reported case of epithelial ingrowth in Pakistan

Correlation of inferior vena cava [IVC] diameter and central venous pressure [CVP] for fluid monitoring in ICU

To determine intravdar fluid status in mitidy ill patients using inferior vena cava diameter and correlating it with central venous pressure. Cross sectional study. Intensive care dement, h4Xitary Hospital Rawalpindi from Jan 2013 to Aug 2013. We included 115 adult patients af both genders in age range of 18 to 87 years by consecutive sampling admitted in intensive care unit. U1txasound guided IVC diameter was assessed in supine patients. Data was simultaneously collected from the CVP catheter. Variables included in study were age, gender, CVP, IVC diameter. CVP ranged from 4 to 26 an H20 with mean of 8 cxn H20 [SD = 6.24]. Mean IVC diameter; increased with increase in CVP. Correlation between CVP and max IVC diameter was moderate and significant [r = 0.53, p < 0.001]. Correlation between CVP and min IVC diameter was also moderate and significant [r = 0.58, p < 0.001]. A simple bedside sonography of inferior vena cava diameter correlates well with extremes of CVP values and can be helpkd in assessing intravascular fluid status in these patients

Developing local guidelines for management of sepsis in adults: sepsis guidelines for Pakistan [SGp] endorsed by global sepsis alliance

The purpose of developing [Sepsis Guidelines for Pakistan] [SGP] is to provide clinicians practicing in local hospitals with a framework to aid timely recognition and management of adult patients in sepsis by adopting evidence-based recommendations of Surviving Sepsis Campaign [SSC] tailored to available resources. These recommendations are not meant to replace the SSC Guidelines. SGP is an initiative of Pakistan Society of Critical Care Medicine [PSCCM]. Four key decision points to be addressed in the guidelines were identified by a thirteen member multidisciplinary committeei.e., grading the hospitals in the country, recognition of sepsis and associated organ dysfunction, essential interventions to manage sepsis, and general measures for provision of a comprehensive care to patients in sepsis according to the level of education and training of healthcare providers and facilities and resources available in different levels of hospitals. The draft was presented at the 3[rd] Sepsis Symposium held on13[th] September, 2014 in Karachi. The final document was approved by a panel of experts from across the country, representatives of relevant societies and Global Sepsis Alliance [GSA]. Hospitals are divided into basic, intermediate and tertiary depending on the availability of diagnostic facilities and training of the medical personnel. Modified definitions of sepsis,severe sepsis, and septic shock are used given the lack of facilities to diagnose sepsis according to international definitions and criteria in Pakistan. Essential interventions include fluid resuscitation,vasopressors to support the circulation, maintaining oxygen saturation >/= 90% with oxygen, non-invasive ventilation or mechanical ventilation with lung protective strategies, prompt administration of antibiotics as recommended by the Medical Microbiology and Infectious Diseases Society of Pakistan [MMIDSP] and early source control. It is recommended to avoid starvation, keep an upper blood glucose 7.20, avoid fresh frozen plasma in the absence of bleeding, transfuse platelets if indicated, not use intravenous immunoglobulins and avoid neuromuscular blocking agents [NMBAs] in the absence of ARDS, target specific titration endpoints when continuous or intermittent sedation is required in mechanically ventilated patients and use continuous renal replacement therapy [CRRT] to facilitate management of fluid balance in hemodynamically unstable septic patients in tertiary care centers. In addition a comprehensive, meticulous and multidisciplinary general care is required to improve outcome of sepsis by reinforcing hand hygiene and other infection control measures, adequate monitoring and documentation tailored to the available resources. Goals of care and prognosis should be discussed with patients and families early and either shifting the patient to a hospital with better facilities or limiting or withdrawing therapy in case of poor prognosis should be considered

Characterization and Metal Detoxification Potential of Moderately Thermophilic Bacillus cereus from Geothermal Springs of Himalaya

Two thermophilic Bacillus cereus strains (B. cereus-TA2 and B. cereus-TA4) used in the present study were isolated from the geothermal spring of Hunza valley, Gilgit, Pakistan. They showed the ability to withstand and grow at high temperature (85°C). Both these strains could resist multiple metals (copper, cadmium, mercury, manganese, zinc, arsenic, chromium and selenium). Strain B. cereus-TA4 reduced Cr (VI) at pH 5.0 to 9.0 but maximum reduction (83%) was observed at pH 7.0 after 48 h when initially supplied with 200 µg mL-1 of K2CrO4. Lower initial concentrations such as 100 µg mL-1 supported higher reduction (90 to 95%) than that of high concentration such as 500 µg mL-1 (20 to 30%). Both the strains reduced nearly 70% of Se (IV) after 48 h of growth at pH 7.0 when initially supplied with 200 µg mL-1 of Na2SeO3. The optimum temperature for maximum Se (IV) reduction was 45°C for both the strains.

Association of vitamin d deficiency with tuberculosis in adult patients reporting to a tertiary care hospital of Rawalpindi

To compare the mean vitamin D levels in pulmonary tuberculosis patients and healthy controls and to find out the frequency and association of vitamin D deficiency in patients with tuberculosis. Study Design: Case control study. Pulmonology department, Military Hospital Rawalpindi from Jan 2013 to Dec 2013. Patients and Methods: Fifty two incident outdoor pulmonary tuberculosis patients were selected with 52 age and gender matched controls. Tuberculosis was diagnosed by the sputum examination through gene Xpert technique from National Institute of Health [NIH], Islamabad. Serum 25-hydroxvitamin D level <50 nmol/1 [electrochemiluminescene assay] was taken as vitamin D deficiency. Mean vitamin D was much lower [20.688 +/- 14.065 nmol/1] in cases as compared to the controls [57.917 +/- 18.197 nmol/1] which was statistically significant [p<0.001]. Forty nine [94%] cases and 18 [34.6%] controls were found to be vitamin D deficient. [Odd's Ratio = 3.8, 95% CI = 2.423-5.999, p>0.00l]. Sensitive tuberculosis patients had mean vit D levels of 18.55 +/- 9.99 nmol/1 while multi-drug resistant tuberculosis patients had the mean serum vitamin D levels of 22.38 +/- 16.60 nmol/1 but the difference was statistically insignificant [p > 0.05]. Significant vitamin D deficiency was seen in newly diagnosed TB patients. It was found that vitamin D deficiency is associated with tuberculosis, but its causal role has not been established

Correlation of global registry of acute coronary events [GRACE] with the angiographic severity and extent of coronary artery disease in patients with non- ST elevation acute coronary syndrome

To determine whether the GRACE risk score correlates with the angiographic extent and severity of coronary artery disease in patients with NSTE-ACS undergoing cardiac catheterization. We conducted a cross sectional descriptive study in 154 patients with NSTE-ACS admitted at AFIC-NIHD from 1[st] April to 30[th] September 2011. For each patient the GRACE risk score was calculated by using specific variables collected at admission. The extent and severity of coronary artery disease was evaluated on angiography for each patient. A total of 154 patients were included in the study. The average age of the patients was 55.81years. Majority [75%] of the patients was male and 25% were females. The mean GRACE score was 132.85. Overall 40 patients had low, 54 had intermediate, and 60 had high GRACE risk score. Among patients with low score 28 had SVCAD, 4 patients had DVCAD and none of the patients had TVCAD. In the intermediate group 24 patients had SVCAD, 18 had DVCAD and 6 had TVCAD whereas among the high GRACE risk score 4 patients had SVCAD, 24 had DVCAD and 32 had TVCAD. Regarding the severity of coronary artery disease; among the low GRACE risk score patients; 8 had subcritical and 32 had critical CAD. In the intermediate GRACE risk score subset of patients, 6 had subcritical and 48 had critical CAD and none of the patients of high GRACE risk score had subcritical CAD and all 60 patients had critical CAD. GRACE risk score is a valuable noninvasive tool in predicting the extent and severity of CAD

Short duration medical education workshops - analysis of participants' response

The aim of present study was to assess the response of the participants of short duration medical education workshops [one day, approximate 4-5 hours duration] conducted by the faculty of department of medical education. A descriptive study. Study was carried out by the Department of Medical Education [DME], Army Medical College, Rawalpindi, Pakistan from 2008 to 2010. Between 2008-2010, five teacher educational workshops were arranged by the department of medical education [DME], Army Medical College, Rawalpindi, Pakistan. Both clinical and pre-clinical teachers attended the workshop. Considering the very busy schedule, particularly of the clinical teachers the workshops were planned as short duration [one day] and contents of workshop were therefore very carefully selected. A total of 120 teachers participated in five workshops and at the end of workshop a questionnaire was filled by each participant. A total of 120 participants attended the five different workshops. The duration of workshop, which was our main concern, was regarded adequate by most of the participants, 53-96% and rest responded the duration as short particularly case base learning [CBL] workshop. Surprisingly one participant of assessment technique and 2 participants of OSCE, OSPE workshop, thought the duration to be long. The handouts were regarded as useful [55-70%] very useful [30-45%]. Computer presentations and transparencies were regarded as above average by majority [52-78%]. The facilitation by the facilitators was well appreciated with >80% responding as top scale, majority of the participants regarded these as very useful activity and stressed to continue such activities. Majority of the participants responded the short duration workshops in very positive way and found them useful for teachers training

clinical account of hospitalized 2009 pandemic influenza A [H1N1] cases

To determine the clinical characteristics in adults with confirmed pandemic influenza A [H1N1] infection 2009. A case series. The study was carried out at the Department of Pulmonology and Critical Care, Military Hospital, Rawalpindi, from 1st December 2009 to 30th May 2010. Thirty six adults with confirmed 2009 pandemic H1N1 infection by reverse transcriptase polymerase chain reaction [RT-PCR] were included in the study. All patients were followed in-hospital and clinical features, laboratory and radiological investigations and management data was collected on a pre-designed patient data collection form. Mean age was 34.24 +/- 13.92 years with 61.1% females. Seventeen [47.2%] had at least one risk factor for complications with 2009 H1N1 infection; namely obesity in 19.4%, pregnancy in 8.3%, COPD in 5.6%, cardiac failure in 5.6%, chronic liver disease in 5.6%, Diabetes mellitus in 5.6%, immunosuppression in 2.3%, smoking in 25%. Fever [97.2%], cough [97.2%], rhinnorhea [80.6%], and shortness of breath [58.3%] were the commonest symptoms. Radiographic abnormalities were interstial/reticular infiltrates [30.6%], patchy consolidations [11.1%] and reticular shadows with areas of consolidation [25%]. PaO2/FiO2 ratio was less than 200 in 27.8% cases. Thirty six percent cases had creatinine kinase [CK] levels greater than 400 U/L and lactate dehydrogenase [LDH] levels higher than 1000 U/L. Twenty seven percent cases were managed in ICU and 16.7% cases died during hospital stay. The 2009 pandemic H1N1 virus infection had a wide clinical spectrum with a potential to cause high morbidity and mortality. Early empirical antiviral therapy for hospitalized suspected influenza A [H1N1] is vital to prevent the rapid disease progression

Refractive errors among children aged 6-15 years playing video games

Background: A refractive error is an error in the focusing of light by the eye and a frequent reason for reduced visual acuity. The burden of uncorrected refractive errors among our population is large and as effective interventions are available, prompt identification can improve quality of life

Objective: To determine association between duration of playing video games and different types of refractive errors among children between age 06 to 15 Years

Patients and Methods: In this cross sectional study 100 children [95 Male and 05 Female] were registered and vision of all the subjects were checked using a distance Snellens visual acuity chart. Retinoscopy and subjective refraction were done in the subjects having visual acuity less than 06/12 in one or both eyes. Questions regarding their habits of playing video games along with its duration were asked, with demographic features of each study subject

Results: Out of the 100 subjects, 18 were found to have refractive errors, mainly; myopia [72.22%], hyperopia [16.7%] and astigmatism [11.1%]. Our study showed no significant relation of refractive error with their habit of playing different types of video games. However, there was significant relation between refractive error and duration of playing video games

Conclusion: It is concluded that there is a significant association between refractive errors and duration of playing video games in children, and this relation needs to be further explored on large scale

Depression, anxiety and their associated factors among medical students

To determine the frequency of anxiety and depression among medical students of Wah Medical College and their associations with sociodemographic and educational characteristics if any. Cross-sectional survey. Wah Medical College, from September 2007 to March 2008. A sample of 279 students was included in the study after excluding first year medical students because they were admitted for less than 6 months. A self administered Encounter Form was administered. Sociodemographic and educational characteristics included age, gender, birth order, number of siblings, monthly income, monthly expenditure on education, academic performance in professional examination, past medical and past psychiatric history, substance abuse and family history of psychiatric illness. Beck depression inventory and beck anxiety inventory were used to assess the level of depression and anxiety. The chi-square test was applied at 5% level of significance to determine associated factors for anxiety and depression respectively. The mean age of students was 21.4 +/- 1.41 years with female preponderance i.e. 202 [72.4%]. Anxiety was present in 133 [47.7%] students and depression in 98 [35.1%] students. Both were found concomitantly in 68 [24.37%] students. Age [p=0.013], gender [p=0.016], examination criteria dissatisfaction [p=0.002] and overburden with test schedule [p=0.002] were significantly associated with depression. Anxiety was significantly associated with gender [p=0.007], birth order [p=0.049], year of study [p=0.001], examination criteria dissatisfaction [p=0.010] and overburden with test schedule [p=0.006]. One third of students were found to have anxiety and depression which was associated with the sociodemographic and educational factors as stated above

Health professionals in armed forces and their continuing professional development [CPD]

Biomedical knowledge is rapidly changing with nearly a million new citations in MEDLINE alone every year. There is currently no structured or systematic Continuing Professional Development [CPD] program for health professionals in the Armed Forces of Pakistan. The overall aim is to develop a system of continually updating our knowledge, skills and attitudes that will promote heightened professionalism, both in peace time and war. All health professionals need to be offered opportunities and facilities for their professional growth. Such systems are already in place all over the world. To achieve these objectives careful regulatory mechanism and implementation strategies have to be instituted. Target populations in the order of priority and dedicated providers have to be identified, trained and motivated. With proper monitoring and facilitation a culture of self improvement can easily be created and propagated. Armed forces can easily take the lead in Pakistan. The ultimate beneficiaries will be the armed forces personnel and their families

Frequencies of anaemia and thrombocytopenia in patients of malaria: a hospital based study

To determine the frequencies of anaemia and thrombocytopenia in patients of malaria. Descriptive study. Study was conducted from June 2008 to February 2009 at the Combined Military Hospital Quetta, a tertiary care hospital. Study included all the patients presenting with blood film proven malaria. Their hematological parameters including hemoglobin, total white cell count and platelets were studied. Anemia was seen in 61% [120 patients] of the patients with malaria and thrombocytopenia in 74% [146 patients] of cases. Frequency of anemia and thrombocytopenia in patients of malaria was quite high. It is suggested that the index of suspicion for malaria should be kept high in patients presenting with fever associated with anemia and/or thrombocytopenia