Intra-articular corticosteroids versus physiotherapy in the management of adhesive capsulitis

Objective: To compare the intra-articular corticosteroid versus physiotherapy in the management of adhesive capsulitis in terms of mean pain score. Study Design: Randomized controlled trial. Place and Duration of Study: Outpatient department, at Armed Forces Institute of Rehabilitation Medicine, from Jul 2013 to Jul 2015

Material and Methods: A total of 90 patients with adhesive capsulitis were enrolled as per inclusion criteria by non probability consecutive sampling. Forty five patients were assigned to group "A" and were given intra-articular injection of triamcinolone 40mg [2ml] and bupivacain 2ml into the shoulder joint. Group "B", having forty five patients received eight session of physiotherapy on alternate day. Outcome measure included mean pain score using visual analogue scale at six week follow-up

Results: Statistically significant improvement in pain score on visual analogue scale was found in patients with group "A", with improvement in score from 7.2 +/- 0.91 at the start of the study to 5.6 +/- 0.18 at six week follow-up [p<0.001]. Whereas no statistically significant results were obtained in patients with group "B" having pain score on visual analogue scale of 7.4 +/- 0.14 at the start of the study to 7.3 +/- 0.14 at six week follow-up [p=0.54]

Conclusion: The use of intra-articular corticosteroid injection in shoulder joint potentially offers a significantly greater clinical improvement in pain relief over the use of supervised physiotherapy in the management of patients suffering from adhesive capsulitis

Bone Mineral Density in patients with Chronic low back pain

Objective: To determine mean bone mineral density in patients with chronic low back pain presenting at Armed Forces Institute of Rehabilitation Medicine Rawalpindi based on dual energy x-ray absorptiometry studies

Study Design: Cross sectional study

Place and Duration of Study: Armed Forces Institute of Rehabilitation Medicine [AFIRM], Rawalpindi from Apr 2015 to Mar 2016

Patients and Methods: Two hundred and forty patients having low back pain of more than 6 months duration fulfilling the inclusion criteria were included both from indoor and outdoor departments through non-probability consecutive sampling. Bone mineral density was measured at lumbar spine by dual energy x-ray absorptiometry studies by the same technical staff using the same equipment. A written informed consent was taken from each patient. Data were collected and recorded on specialized proforma by the principal investigator

Results: Spine BMD on DXA scan ranged from 0.90 to 0.98 g/cm2 with a mean of 0.95 +/- 0.02 as shown in. When stratified, the mean BMD decreased significantly with increasing age and severity of LBP; 20-30 years vs. 31-40 years [0.95 +/- 0.01 vs. 0.92 +/- 0.02; p=0.001]. However, there was no significant difference in mean BMD across genders; male vs. female [0.94 +/- 0.01 vs. 0.94 +/- 0.02; p=0.680]. Similarly there was no significant difference in mean BMD across various durations of low back pain; 7-10 vs. 11-14 months [0.94 +/- 0.03 vs. 0.93 +/- 0.01; p=0.617]

Conclusion: The mean bone mineral density at spine was found to be lower in patients with chronic low back pain. It was significantly lower in older patients and those with severe low back pain. However, it didn't change significantly with various durations of low back pain or gender

Effect of delayed post-stroke rehabilitation program on patient's functional outcome

Objective: To examine the effects of delayed admission to rehabilitation on functional outcomes in post stroke patients

Study Design: Observational study

Place and Duration of Study: Department of Physical Medicine and Rehabilitation of Combined Military Hospital Kohat, from Sep 2016 to Sep 2017

Material and Methods: A total of 55 patients with age ranging from 20-80 years who were diagnosed with first ever stroke and reported within 150 days of the onset of stroke to rehabilitation setup were selected through non-probability purposive sampling. The patients were divided into 2 groups as early [group-A ?30 days] and delayed admission group [group-B=30-150 days] based on the length of time from stroke onset to admission to inpatient rehabilitation facility. Reasons for delay admission were identified and noted. Functional independence measure [FIM] score was used to assess functional status of the patient at admission. Patients in both groups underwent identical eight weeks of regular rehabilitation program with therapy sessions 3 hours a day, 5 days a week. Functional independence measure score was noted again at eight week of indoor rehabilitation

Results: Total 52 patients completed the study with 27 [51.9 percent] male and 25 [48.1 percent] female. Lack of awareness of Rehabilitation was the most common patient related factor found in 11 [34.4 percent] while Lack of care giver support was most common external factor reported in 6 [18.7 percent]. The patients with early admission to inpatient rehabilitation facility had a better functional independent measurement scores gain than the patients with delayed admission to inpatient rehabilitation facility [40.4 +/- 11.4 vs. 11.9 +/- 8.4, p=0.01]. However, FIM scores at admission in both groups were not statistically significant

Conclusion: Delayed admission to inpatient rehabilitation facility after stroke event caused poorer functional outcomes in stroke patients

Urodynamic bladder patterns in spinal cord injury patients

Objective: To determine the frequency of various neurogenic bladder patterns in patients with traumatic spinal cord injury presenting at Armed Forces Institute of Rehabilitation Medicine Rawalpindi based on urodynamic studies

Study Design: Descriptive cross sectional study

Place and Duration of Study: Armed Forces Institute of Rehabilitation Medicine [AFIRM] Rawalpindi, from Jul 2014 to Jun 2016

Material and Methods: One hundred and forty traumatic spinal cord injury patients fulfilling the inclusion criteria were included both from indoor and outdoor departments through non-probability purposive sampling. Urodynamic studies were performed using the urodynamic equipment at urodynamic laboratory. Data were collected and recorded on specialized proforma by the principal investigator

Results: Among 140 study participants detrusor overactivity was found in 100 patients out of which 76 [76%] had thoracic level of injury, 20 [20%] had cervical level and 4 [4%] had lumbar level of injury. Detrusor areflexia was the bladder pattern in 40 patients out of which 26 [65%] had thoracic level of injury, 10 [25%] had cervical level, and 4 [10%] had lumbar level of injury

Conclusion: Detrusor overactivity was the commonest neurogenic bladder pattern among the traumatic spinal cord injury patients

Objective structured clinical examination [OSCE] - a better dimension to measure clinical competencies

The teaching and learning of medical students has always been a demanding perspective. The best teachers at times may strive in conveying medical knowledge and assessing yield of the effort. The traditional written and practical instruments of assessment have many limitations in their practicality and fair judgment. Since its introduction in the 70s, objective structured clinical examination [OSCE] has gained worldwide recognition and appreciation as a fair and standardized format to assess the clinical competencies of medical students and residents. It is an approach in which all the three aspects of clinical competence namely knowledge, skills, and attitude are evaluated in a comprehensive, consistent, and structured manner with close attention to the objectivity of the procedure. OSCE demands excellent communication, time management, and organizational skills. Not only the examiners but also the examinees have widely appreciated OSCE. Therefore, it should be recommended as a standard procedure for a student's evaluation. The aim of this paper was to review and recommend OSCE as a learning tool

Simultaneous quantitation of Ofloxacin, Fexofenadine HCl and Diclofenac Potassium in affixed dose combinative formulation by HPLC-UV method

A high-pressure liquid chromatography [HPLC-UV] based simple and specific method for simultaneous quantitative determination of Ofloxacin, Fexofenadine HCl and Diclofenac Potassium has been developed and validated according to ICH guidelines. Chromatographic separation of the three drugs was carried out on 4.6 x 250mm x 5micro Licrospher RP Select B Column, using mobile phase constituted of methanol and phosphate buffer pH 3.5 [650: 350], pH adjusted to 3.5 +/- 0.05 with dilute ortho-phosphoric acid and delivered at a flow rate of 1ml/min. The eluents were detected at UV wavelength of 220nm and the retention times for Ofloxacin, Fexofenadine HCl and Diclofenac Potassium were 2.5 minutes, 4 minutes and 11.5 minutes, respectively. This method is suitable and specific for the three drugs and was found to be linear [R2>0.996], accurate, specific, reproducible and robust over a concentration range of 0.05 to 0.15mg/ml for Ofloxacin, 0.015 to 0.045mg/ml for Fexofenadine HCl and 0.0125 to 0.0375mg/ml for Diclofenac Potassium. The proposed method is simple and convenient, hence easily utilized for the characterization and quantitation of the three drugs in a single formulation for combination therapy of rheumatoid arthritis, sepsis, infection with fever and flu

Laparoscopic repair of massive inguinal hernia containing the urinary bladder

Inguinal herniation of the urinary bladder is an extremely rare occurrence involving less than 5% of inguinal hernias reported in literature. These hernias require a high index of suspicion for their diagnosis and pose significant challenges to the operating surgeon. The majority of these hernias have been repaired by an open technique. We report two cases managed laparoscopically

Frequency of common bacteria and their antibiotic sensitivity in patients with symptomatic cholelithiasis

To determine the frequency of common bacteria and their antibiotic sensitivity in patients with symptomatic cholelithiasis This cross sectional descriptive study was conducted at Department of Surgery, Lady reading hospital, Peshawar for 6 months i.e., from December 2012 to May 2013. The total number of patients were 126. They presented with symptomatic cholelithiasis. Bile was aspirated preoperatively before cholecystectomy from gall bladder and was sent for culture and sensitivity test. The data was analyzed using Statistical Package for Social Sciences[SPSS] version 10.0. On culture and sensitivity test, 74 [58.73%] have positive growth while 52 [41.27%] have no growth. The most common bacteria was E. Coli isolated in 28 [22.22%] patients followed by Klebseilla in 22 [17.46%], Salmonellain 16 [12.70%] and Shigella in 8 [6.35%] patients. On culture and sensitivity test, all the 4 isolated bacteria showed sensitivity to Cefuroxime, Ceftriaxone and Ciprofloxacin in more than 50 % cases, while all the four bacteria showed resistance to amoxicillin in more than 50 % cases. The most common bacteria of symptomatic cholelithiasis are E. coli and Klebseilla followed by Salmonella and Shigella. These bacteria showed maximum sensitive to cefuroxime and ceftriaxone

Routine preoperative chest X-ray and its impact on decision making in patients undergoing elective surgical procedures

It is the routine of our hospital that all patients undergoing any kind of surgery in any specialty are subjected to routine pre-op chest x-ray [CXR]. However there is increasing evidence that this practice does not have much influence on patient management and thus could be limited to a very small number of patients in whom it is justified. We conducted this study to know the significance of routine pre-op x-rays chest in patients admitted in a surgical unit for elective surgery and to what extent such routine x-ray affected our surgical intervention. It is a cross sectional study in which 500 consecutive adult patients admitted in surgical 'C' unit of Lady Reading Hospital Peshawar, for elective surgical procedures were included. The age, gender, co-morbidity, delay in operation if any was recorded and CXR were reported upon by a qualified radiologist. The influence on decision making regarding fitness of patients for general anaesthesia/surgery was also determined. Data were analysed using SPSS- 20. Out of total of 500 chest x-rays 109 [21.8%] were reported to have some abnormality in the film. Out of these 109, 58 were male 51 were female patients. The percentages of abnormal CXR according to age were 13.6%, 35.8%, and 50% in the 16-39 years, 40-69 years and 70 year age groups respectively. Amongst the patients with abnormal CXR, 30 had their surgery delayed. However in only one patient out of the 30 the delay was on the basis of significant finding on the CXR. Good medical history and clinical examination can save many patients from unnecessary CXR. Preoperative CXR may only be done in patients who have a clear indication for this investigation

Assessment of Clavien-Dindo classification in patients >75 years undergoing nephroureterectomy nephrectomy/

There is a paucity of a standardized post-operative complications grading system in urology especially in the elderly population. Studies show satisfactory survival and oncological outcomes albeit with a slight increase in post-operative morbidity compared to younger patients. The Clavien-Dindo classification for post-operative complications is established as a valid system worldwide and applicable in many fields of surgery. Retrospective assessment of post-operative complications in patients >75 years who underwent open/laparoscopic nephrectomy/nephroureterectomy for renal diseases and grading the post-operative complications according to the Clavien-Dindo classification. Retrospective review of case notes was performed in patients >75 years who underwent a laparoscopic/open nephrectomy/nephroureterectomy between 2000 and 2008. Post-operative complications were graded according to the Clavien-Dindo classification. A total of 54 patients >75 years underwent nephrectomy/nephroureterectomy. 29 patients had laparoscopy and 25 had open surgery. Fifty one patients had a malignancy and 3 had benign diseases. Grade I, II, IlIb, lllb and IVa were 25.6%, 41.1%, 7.7%, 7.7% and 17.9% respectively. No significant difference was noted in the 2 groups. We believe that in elderly patients, laparoscopic surgery can be offered safely without significantly increasing the surgical risks. The Clavien-Dindo classification is easy to use and effectively applied to categorize post-operative complications associated with nephrectomy/nephroureterectomy in elderly population. However, this system needs slight modification to incorporate intra-operative complications and large studies are needed to validate and standardize this classification for all urological procedures