Intrathecal tramadol as an adjuvant in subarachnoid block to prolong the duration of analgesia

Objective: To assess the effect of intrathecal tramadol added to bupivacaine to prolong the duration of analgesia in subarachnoid block for lower limb orthopedic surgeries

Study Design: Randomized controlled trial

Place and Duration of Study: Anesthesia department of Combined Military Hospital Sialkot, from Nov 2015 to Apr 2016

Material and Methods: Patients were selected by non-probability consecutive sampling. One hundred and fifty patients from American Society of Anesthesiologists [ASA] I, II and III category fulfilling inclusion criteria undergoing various lower limb orthopedic surgeries were divided into two groups by lottery system. Group tramadol bupivacaine [TB] received 25mg [1 ml] of tramadol plus 2ml [10mg] of 0.5% bupivacaine while group bupivacaine alone [SB] received 1 ml normal saline plus 2ml [10mg] of 0.5% bupivacaine. Time to first analgesia request was noted as a measure of duration of analgesia. Time of onset of sensory block level and peak sensory block level and time to reach the peak sensory block level were also noted. Quality of anesthesia was compared among two groups. Data were analyzed by using SPSS version 22

Results: Four patients were excluded from the study. The duration of anesthesia was effectively prolonged in group TB 181.56 +/- 12.42 mins as compared to group SB 120.93 +/- 15.54 mins. VAS score was significantly lower in group TB. Higher peak sensory block levels [T6] were achieved in group TB as compared to group SB. However time to reach the peak sensory block levels were significantly longer in group TB. [4.5 +/- 0.47mins vs 3.09 +/- 0.54 mins]

Conclusion: This study showed that intrathecal tramadol [25mg] can safely be used along with bupivacaine in subarachnoid blockade to prolong the duration of analgesia and improve the quality of anesthesia as well

Surgical treatment in lumbar spondylolisthesis: experience with 45 patients

Spondylolithesis is forward slipping of upper vertebra in relation to its lower one, which at times requires surgery. The objective of present study is to document the outcome of surgical treatment in spondylolisthesis of lumbosacral region. We reviewed outcome of surgery in 45 patients with spondylolisthesis. Improvement in pain intensity, neurological status and union achieved after surgery was studied. All patients requiring surgical treatment were included in the study. The patients were operated by single spine surgeon. A Performa was made for each patient and records were kept in a custom built Microsoft access database. Majority of our patient were in 4[th] and 5[th] decade with some male domination. Pain was main indication for surgery which was excruciating in 6, severe in 33, and moderate in 6 cases. The neurological status was normal in 34 cases while 11 patients had some deficit. L5-S1 was affected in 26, L4-L5 in 13 and multi or high level was found in rest of cases. Slip grade was measured with Meyerding grades, 18 had grade II, 15 had I, 9 had III and 3 had IV spondylolisthesis. Posterior lumbar inter body fusion [PLIF] was done in 24 patients, posterolateral, transforaminal lumbar inter body and anterior inter body fusion in others. Translaminar screw fixation, transpedicular transdiscal transcorporial and Delta fixation in some cases. Pedicle screw fixation was done in most cases, AO fixator internae and 4.5 mm screw in others. Average follow up was 2 years and 5 months, max 5 years and minimum 6 months. Pain relief was achieved in 82%, neurological improvement 60% and union in 91% cases. There was no deterioration of neurological status, two implant failure and one wound infection. Surgical procedure for Spondylolisthesis must be individualised. Young patients with spondylolysis can be treated with osteosynthesis and sparing of motion segment. PLIF provides satisfactory results in majority of low to moderate cases with some reduction. Transpedicular transdiscal transcorprial and delta fixation is good procedure for severe slips in adult.

pharmacoeconomic study in two tertiary care hospitals in Abbottabad

Pharmacoeconomics has been defined as: the description and analysis of the cost of drug therapy to health care systems and society. Aim was to observe the Medication Therapy on the basis of Phamacoeconomics Analysis and to save the economic resources. This Descriptive Cross sectional study was conducted at Ayub Teaching Hospital and Combined Military Hospital, Abbottabad, from May-August 2011. The case histories of 100 patients were scrutinized thoroughly specially with reference to socioeconomic history, Clinical laboratory tests, Medication history and treatment at hospital and discharge medications. After their collection, these case histories were analyzed with respect to Phamacoeconomics and compared with the world literature. A total of 100 patients were studied. Pharmacoeconomic analysis shows that in 49 Patients' medications were according to international standards while in 51 patients' medications prescribed were irrational. Mutual interaction between physician, surgeon, other healthcare professionals, and clinical pharmacist is necessary to assure rational medication therapy and positive response to therapy of each patient.

Helicobacter pylori infection in patients with calcular cholecystitis: a hospital based study

Helicobacter pylori, a gram negative bacillus has been recognised as a public health problem and approximately half of the world population has H. pylori infection causes chronic gastritis, peptic ulcer disease and gastric malignancies. Objective of this study was to determine the frequency of H. pylori infection in patients of chronic calcular cholecystitis. This cross-sectional descriptive study was conducted at Liaquat University Hospital, Hyderabad, Pakistan from April 2010 to September 2010. All patients with history of gallstone presented with acute abdominal pain, dyspepsia, bloating and epigastric discomfort and diagnosed as calcular cholecystitis were further evaluated for the detection of H. pylori by serology and histopathology. Frequency and percentage of H. pylori infection in patients with calcular cholecystitis was calculated. Total 100 patients of cholelithiasis underwent laparoscopic cholecystectomy were recruited. The pain in upper right part of the abdomen was observed in all 100 patients, fever in 75%, nausea and vomiting in 68%, loss of appetite in 45%, feeling of tiredness or weakness in 22%, headache in 38%, chills in 52%, backache in 58%, pain under the right shoulder in 45%, heartburn in 67%, belching in 54%, indigestion in 80%, dyspepsia in 90%, bloating in 88%, and epigastric discomfort in 85% patients. Eighty-two percent patients had family history of gallstones. The mean age of overall study population was 48.72 +/- 8.78 years and mean age of H. pylori infected calcular cholecystitis patients was 47.98 +/- 5.43 years in male and 48.76 +/- 6.68 years in females. The H. pylori infection was identified in 55% patients with calcular cholecystitis, of which 32.7% were males and 67.3% were females [p=0.03, statistically significant]. Majority of females [60%] had >/= 40 U/ml antibody titre [p=0.917, non-significant]. A possible relationship was identified between Helicobacter pylori and calcular cholecystitis

Acute pancreatitis; evaluation of modified glasgow scoring system [IMRIE]

To determine whether in our setup the Modified Glasgow Scoring System is still an accurate marker for the assessment of severity in acute pancreatitis. Observational study. Surgical Unit, CMH Peshawar. January 2005 to January 2008. It is an observational study of 50 male and female patients between ages of 1 5-75 years [Mean 43.3]. Male to female ratio was 1:1.3. They were graded mild, moderate and severe using the 8 variables / markers of Modified Glasgow Scoring System. Exclusion from this study were the patients with acute pancreatitis who were treated at the same institution but not admitted to the surgical ICU, those admitted after inter institutional transfer for tertiary care and patients admitted as sick transfer from other hospitals after 24 hours. On the basis of variables in the Modified Glasgow scoring system [Imrie], 18 patients were predicted with the severe outcome, but only 15 [83%] cases had an actual severe outcome. Whereas 3 cases [17%] did not follow the prediction and behaved as moderate pancreatitis. Similarly, 16 cases predicted as moderate pancreatitis, 14 [88%] followed the prediction and only 2 [12%] cases behaved as mild cases.16 cases were predicted mild, but 13 [81%] followed the prediction and only 3 [19%] switched to moderately severe group. Thus the overall accuracy of Modified Glasgow Scoring System was found in 42 [84%] cases. Bililary pathology remained the main aetiological factor. Two of the variables were significantly deranged in severe cases. These were age over 50 [4 cases], and WBC count > 20x 10[9]/l [12 cases]. Hospital stay varied between 4-21 days [Mean 9 days]. Conclusion: The Modified Glasgow Scoring System remains a valid predicting system for the outcome in patients with acute pancreatitis. It is simple, easy to apply with good predictive value and can be used in all hospital settings

Clavicle fractures; incidence a two years study

To emphasize upon the frequency of fractures of clavicle due to indirect blunt trauma caused by road traffic accidents and falls from heights and their sequalae. Observational descriptive study. Combined Military Hospital Bannu during a period of two years from June 2003 to May 2005. Patients included in the study were the trauma patients brought to Combined Military Hospital Bannu during a civil -military conflict in tribal areas of North and South Waziristan. Patients had sustained multiple injuries mostly due to road traffic accidents in hilly terrain, falls from heights and combat scuffles. Out of these trauma victims, 746 patients fractures of the clavicle were grouped, analyzed, treated with standard treatment methods and patients were followed up for the varying periods of time. Out of 746 patients treated at our hospital, 84 were having fracture of clavicle [10.8%]. 53 patients [63.1%] with clavicle fracture had fracture involving middle third of the clavicle, 20 patients [23.8%] had fracture of lateral third, and 11 patients [13.1%] had fractures involving medial third of the clavicle. Clavicle is a bone which is at risk of fracture in cases of indirect blunt trauma because the first human reaction in any violence or assault is to protect oneself by using the upper limbs. Its peculiar development and anatomical shape makes it vulnerable to fracture in most physical insults. However, it usually unites by conservative methods and even considerable non-union does not significantly affect function

Total thyroidectomy as primary elective procedure in multinodular thyroid disease

Multinodular goitre is one of the commonest thyroid diseases encountered in the practice of surgery. The most common surgery being performed for multinodular goitre is subtotal thyroidectomy. Total thyroidectomy is designed to remove all of the thyroid tissue. The objective of this study was to evaluate total thyroidectomy as a primary elective procedure for treatment of multinodular thyroid disease. This descriptive study was carried out at Combined Military Hospital Rawalpindi from June 2003 to September 2006. 88 patients of multinodular thyroid disease were included. Patients having evidence of recurrent laryngeal nerve damage, recurrent goitre, evidence of altered parathyroid functions or evidence of malignancy were excluded. All patients underwent total thyroidectomy by the same team of surgeons and the patients were closely followed up for postoperative complications especially in terms of recurrent laryngeal nerve damage and hypocalcaemic tetany. No major postoperative complication was noted. Only 1 patient [1.14%] developed unilateral recurrent laryngeal nerve damage and 2 patients [2.27%] developed transient hypocalcaemia that recovered quickly. Total thyroidectomy as a primary elective procedure in multinodular thyroid disease is a safe option and it removes the disease process completely, lowers local recurrence rates and avoids the substantial risks of reoperative surgery

Treatment of acute lumbago; low dose diclofenac sodium with vitamin-B complex compared with diclofenac alone

To determine whether concomitant use of vitamins B1, B6, B12 along with low dose of diclofenac sodium causes quicker pain relief in patients of acute lumbago compared with diclofenac sodium alone. A randomized clinical trial. Surgical Department of C M H Attock. From September 2004 to August 2005. A total of 50 patients were selected for the study. The patients complaints were of acute lumbago of less than 3 days duration with severe impairments of movements. The age group of patients was between 20 and 65 years. The patients were randomly assigned into two groups. Group I was prescribed tablet diclofenac sodium 25mg along with vitamin B-complex containing combination of 100mg thiamine nitrate [B1], 100mg pyridoxine hydrochloride [B6], and 200mcg cyanocobalmine [B12] three times a day. Group II patients were prescribed 25mg of tablet diclofenac sodium alone. Improvement in the intensity of pain at rest and during movements [as assessed by the patients] was noted in accordance to visual analogue scale 1 to 10. The effectiveness of diclofenac sodium in combination with vitamin-B complex with diclofenac sodium alone was judged on the basis of extent of pain relief after 7 days of treatment. A total of 25 patients were treated with combination of diclofenac sodium and vitamin-B complex [Group I] and 25 were treated with diclofenac sodium alone [Group II]. As far as the extent of pain relief in first 7 days is considered, 22 patients [88%] belonging to group I and 10 patients [12%] belonging to group II had an excellent pain relief and were able to carry on with their normal routine activities. Remaining 3 patients in group I were completely relieved of pain in next 3 days while 15 patients in group II had to complete another 10 days for complete cure. To test the statistical significance of the result chi-square test was applied and the result showed that patients of Group I responded significantly well to the treatment as compared to those in Group II. Using the parameters of pain relief and movements of vertebral column, the combination of diclofenac sodium and vitamin-B complex was found to be more effective mode of treatment as the duration of treatment and the dosage of diclofenac sodium was less and also relief of pain was more rapid

Borrelia recurrentis as a cause of high grade fever in Rawalakot, Azad Kashmir

A descriptive study was conducted at Combined Military Hospital Rawalakot, Azad Kashmir to determine the frequency of Borrelia recurrentis. Both out door and indoor cases were included. A total of 80 febrile patients with temperature above 1000C were studied. Cases showing any other cause of fever on routine / available tests were excluded. Borrelia recurrentis was sought by Giemsa stain. All positive cases were treated with Doxycycline. Nine cases were positive [11.25%]. Treatment response was 100%. Borrelia recurrentis is found in a significant number of febrile cases at Rawalakot Azad Kashmir