Predisposing factors, clinical assessment, management andoutcomes of agitation in the trauma intensive care unit / 世界急诊医学杂志（英文）

BACKGROUND: Agitation occurs frequently among criticaly il patients admitted to the intensive care unit (ICU). We aimed to evaluate the frequency, predisposing factors and outcomes of agitation in trauma ICU. METHODS: A retrospective analysis was conducted to include patients who were admitted to the trauma ICU between April 2014 and March 2015. Data included patient's demographics, initial vitals, associated injuries, Ramsey Sedation Scale, Glasgow Coma Scale, head injury lesions, use of sedatives and analgesics, head interventions, ventilator days, and ICU length of stay. Patients were divided into two groups based on the agitation status. RESULTS: A total of 102 intubated patients were enrolled; of which 46 (45％) experienced agitation. Patients in the agitation group were 7 years younger, had significantly lower GCS and sustained higher frequency of head injuries (P<0.05). Patients who developed agitation were more likely to be prescribed propofol alone or in combination with midazolam and to have frequent ICP catheter insertion, longer ventilatory days and higher incidence of pneumonia (P<0.05). On multivariate analysis, use of propofol alone (OR=4.97; 95％CI=1.35–18.27), subarachnoid hemorrhage (OR=5.11; 95％CI=1.38–18.91) and ICP catheter insertion for severe head injury (OR=4.23; 95％CI=1.16–15.35) were independent predictors for agitation (P<0.01). CONCLUSION: Agitation is a frequent problem in trauma ICU and is mainly related to the type of sedation and poor outcomes in terms of prolonged mechanical ventilation and development of nosocomial pneumonia. Therefore, understanding the main predictors of agitation facilitates early risk-stratification and development of better therapeutic strategies in trauma patients.

Primary Hyperparathyroidism and Cardiac Arrest: Case report.

Hyperparathyroidism is a common endocrine disorder characterized by hypersecretion of parathyroid hormones due to abnormal activity of one or more parathyroid glands. Several cardiac abnormalities have been reported due to hyperparathyroidism. In this case report, a case of cardiac arrest due to hyperparathyroidism and hypercalcemia is presented and discussed. A female patient, 73 years old, was admitted to surgical ward (SICU) with malignant goiter extending to the retrosternum. She was a known case of hyperparathyroidism and hypercalcemia. After the operation, the patient was shifted to SICU for further management. Suddenly, the patient had sudden cardiac arrest and was successfully resuscitated within 2 minutes. The ECG showed a new Right Bundle Branch Block (RBBB) changes. Patient remained on ventilator, not obeying commands, and opened her eyes spontaneously with cough reflex. A week after, percutaneous tracheostomy was performed, and patient became hemodynamically stable, weaned from ventilator and allowed to breathe spontaneously. Although cardiac arrest is a rare complication, it should be expected by health care providers when dealing with patients with hyperparathyroidism and hypercalcemia.

Fundus findings and visual functions in Pathological Myopia

Background: Visual function is a group of specific properties of eye which are essential for comprehensive vision of an individual. Pathological myopia is the condition of eye in which axial length of eye is more than 24mm and refractive error is more than -6 D

Objectives: To evaluate the visual functions in patients with high myopia and to find the most common finding of fundus in pathological myopia

Methodology: This was a descriptive cross sectional study which was conducted on seventy five subjects. Samples were selected by using non probability purposive sampling technique. Visual functions were assessed by using i.e visual acuity by Snellen chart, contrast sensitivity by lea numbers, visual field by confrontation method, color vision by D-15, glare by BAT [brightness acuity test], funds finding by indirect ophthalmoscope. Results: Study was conducted on 75 subjects [150] eyes. Best corrected visual acuity [BCV] was 6/6 to 6/9, 6/9 to 6/12 and 6/9 to 6/18 in myopes with -6.00DS to -8.00DS, - 8.00DS to - 10.00DS,-11.00DS and in -15.00DS respectively. Visual field in myopes from -6.00DS to -8.00DS was normal, it was constricted in myopes more than -9.00DS. Contrast sensitivity [CS] of Myopes having refractive error of -6.00DS to -8.0DS, - 9.00DS to -14.00DS and ? -14.00 DS had 1.25%, 1.25%-2.50% and 5% contrast respectively. 55 subjects having refractive errors from -6.00 DS to -12.00 DS had normal color vision for more than -12.00DS refractive errors. Color vision was defective in 45% subjects specially for blue color. Glare was present in 15 myopes with refractive error more than -14.00DS. The most common fundus findings in pathological myopes were myopic crescent, temporal tilting of optic disc and posterior staphyloma in severe pathological myopes. Conclusion: Visual functions were reduced in high degree of myopia. Myopic crescent, temporal displacement of disc and posterior staphyloma are most common fundus findings in pathological myopes

Astigmatism and early academic readiness in school children

Background: Astigmatism may effect schooling among children

Objective: To determine the effect of uncorrected astigmatism on the readiness of child to go to school

Methodology: This cross-sectional study was conducted on 61 children and vision screening was performed on these children admitted in nursery and prep class of Government Paisa and Akhbar School Lahore from 1 October to 30 November 2015. A questionnaire was asked from the in-charge of each class. The questions represented the different scales of academic readiness. These questions included physical health, personal and social development, academic performance, reluctance while coming to school, attention, language and literacy. The children with astigmatism [defined as >o.5 or equal to 0.5 in either eye] were compared with children who had no astigmatism. Association between the astigmatism and each scale of academic readiness was measured by applying qualitative chi square test. The effect of age and spherical refractive error was ignored. The data was entered and analyzed by using SPSS version 13

Results: A total of 61 students participated in this study. 21 students were of age 4 years and 40 children were of age 5 years. 35 children were non-astigmatic and 25 children were astigmatic. There was no significant effect of uncorrected astigmatism on health and development [P=0.2], reluctance to go to school [p=0.08] and school attendance [p=0.3]. This may be due to the fact that our schools are not that efficient to record theacademic performance across the developing years. There was a significant effect of astigmatism on academic readiness [p=0.02], language and literacy [0.05]

Conclusion: The study showed that there was significant effect of astigmatism on academic readiness, language and literacy whereas there was no significant effect on health and development, reluctance to go to school and school attendance. This study emphasized on the importance of early vision screening in preschoolers so that children can see clearly in early years of their visual development and academic learning

Frequency of visual disorders in school children of district Rahim Yar Khan

Background: Low vision is defined as visual acuity of less than 6/18, but equal to or better than 3/60, or a corresponding visual field loss to less than 20 degrees in the better eye with best possible correction

Objective: To determine the frequency of visual disorders in school children

Subjects and Methods: In this cross sectional study, 5360 students of different age groups and of both sexes from the urban and rural government schools of all the tehsils of district Rahim Yar Khan, were selected and screened out. Schools were selected in clusters through random sampling. Visual acuity of all the children was checked by using Snellen's Chart and children with refractive errors were refracted at the same place and prescribed the required number for glasses. The children with organic lesion or not improved with refraction were referred to Sh. Zayed Hospital, Rahim Yar Khan [SZH] for thorough assessment and management. The data was entered and analyzed by using SPSS 15

Results: Out of total 5360 children 256 [4.77%] have refractive errors and 33 subjects [0.61%] comprising 23 [69.69%] males and 10 [30.30%] females have low vision. The major cause of low vision was found to be Retinitis Pigmentosa [RP] which accounted 13 cases [39.39%] of the total low vision patients while 7 cases [21.21%] of congenital cataract, 4 [12.12%] Buphthalmos, 3 [9.09%] Optic Atrophy, 3 [9.09%] Albinism, 2 [6.06%] Maculopathy and 1 [3.03%] high Myopia [Chorioretinal degeneration]

Conclusion: Hereditary diseases have been found to be the major cause of low vision leading to blindness. The study also revealed that low vision is more common in males. There is high prevalence of refractive errors found in this study, giving the picture of the increased burden of eye problems in district Rahim yar Khan

Atypical spectrum of fundus fluorescein angiography features in central serous chorioretinopathy

Background: Central serous retinopathy [CSR] is an idiopathic disorder of the macula characterized by serous elevation of the neurosensory retina at the posterior pole caused primarily by leaky choriocapillaries. On fundus fluorescein angiography [FFA], two typical patterns of this leakage are defined as inkblot and smoke stalk appearance. But atypical and unusual patterns also occur that can produce difficulty in diagnosis

Objective: To determine the spectrum of atypical presentations of CSR on FFA

Patients and Methods: All patients presenting with a clinical diagnosis of CSR and referred for FFA were included in this descriptive study. After taking consent, FFA was performed and the results were analyzed for atypical features of this disorder. Where FFA features were not conclusive an optical coherence tomography [OCT] was also performed to aid further evaluation

Result: 12 out of 23 patients had atypical FFAfeatures. These include multiple inkblots in one eye, multiple inkblots in both eyes, ink blot and smoke stalk in the same eye, CSR with pigment epithelial detachment in which only the pigment epithelial detachment shows up on FFA, CSR with choroidal eovascularisation in which the CNV only shows on FFA and CSR with no leakage on FFA

Conclusion: Atypical presentations of CSR can cause diagnostic problems. The ophthalmologist must be aware of these features. Furthermore, these cases should be worked up for associated systemic / ocular disease

Atypical spectrum of fundus fluorescein angiography features in central serous chorioretinopathy

Background: Central serous retinopathy [CSR] is an idiopathic disorder of the macula characterized by serous elevation of the neurosensory retina at the posterior pole caused primarily by leaky choriocapillaries. On fundus fluorescein angiography [FFA], two typical patterns of this leakage are defined as inkblot and smoke stalk appearance. But atypical and unusual patterns also occur that can produce difficulty in diagnosis

Objective: To determine the spectrum of atypical presentations of CSR on FFA

Patients and Methods: All patients presenting with a clinical diagnosis of CSR and referred for FFA were included in this descriptive study. After taking consent, FFA was performed and the results were analyzed for atypical features of this disorder. Where FFA features were not conclusive an optical coherence tomography [OCT] was also performed to aid further evaluation

Result: 12 out of 23 patients had atypical FFA features. These include multiple inkblots in one eye, multiple inkblots in both eyes, ink blot and smoke stalk in the same eye, CSR with pigment epithelial detachment in which only the pigment epithelial detachment shows up on FFA, CSR with choroidal eovascularisation in which the CNV only shows on FFA and CSR with no leakage on FFA

Conclusion: Atypical presentations of CSR can cause diagnostic problems. The ophthalmologist must be aware of these features. Furthermore, these cases should be worked up for associated systemic / ocular disease

Nasolacrimal duct obstruction in infants: a simple technique of silicon intubation

Background: The obstruction of the nasolacrimal duct leads to the blockage of lacrimal drainage. Congenital duct obstruction occurs in approximately 5% of normal newborn infants. There are many surgical techniques for its management

Objective: To study the efficacy of a new technique in the management of childhood nasolacrimal duct obstruction epiphora

Subjects and Method: Quasi experimental, interventional study, conducted from December 2001 to December 2008 at Eye department of Jinnah Postgraduate Medical Centre, Karachi and Eye Department Sheikh Zayed Medical College, Rahim Yar Khan. Fifty children between one to three years of age with epiphora due to nasolacrimal duct obstruction, in which at least previous one probing was done not less than three months back, were registered. Silicon intubation was done under general anaesthesia

Results: Forty [80%] cases were cured by the intubation in six months to one year follow up. Recurrent infection was noted in ten [20%] cases, which was managed medically. The severity of infection was much less than the one before intubation. All of the ten cases were planned for future dacryocystorhinostomy. Only a few treatable or insignificant complications were noted

Conclusion: This simple, easy and cost-effective technique of silicon intubation in nasolacrimal duct obstruction can be done in any operation theatre with general anaesthesia facilities

Scleral buckling procedure; an experience with Rhegmatogenous retinal detachment patients

Background: rhegmatogenous Retinal Detachment [RDD] is the most common type of Retinal Detachment, secondary to break in neurosensory layer of retina

Objective: to determine anatomical and functional improvement and complications, in patients with RDD, treated by scleral buckling procedure

Patients and Methods: this descriptive study was conducted in Department of Ophthalmology, Jinnah Post Graduate Medical Centre, Karachi, during July 2004 to December 2005. A total of 40 patients of RRD with proliferative vitreoretinopathy [PVR] grade A and B, underwent scleral buckling procedure [SBP]. The patients from 5 to 55 years of age and of either sex were included in this study. In addition, patients with diabetes mellitus, coronary vascular disease and other known risk factors for surgery were excluded from the study. All of the patients had uncomplicated RRD with duration of less than three months. Patients were followed up for up to three years for anatomical and functional improvement and complications

Results: a three year follow up showed anatomical reattachment after first surgery in 77.5% [31] of the cases and after second surgery in all of the cases. Visual improvement was observed in 75% [30] of the cases while 7.5% [3] cases had worsening of vison and 17.5% [7] cases showed no improvement in their vision. Per operative complication of iatrogenic break, choroidal hemorrhage was also noticed and draining of sub-retinal fluid [SRF] in a total of 7.5% [3] cases, RD in early post-operative period were encountered in 7.5% [3] cases, due to inadequate buckling, whereas in 15% [6] cases, RD developed in late-post operative period. In two of the cases, plumb was exposed. Out of these, one developed endophthalmitis. Causes of RD in early post-operative period was missed hole in two cases, which was dealt with successfully by application of additional plumb

Conclusion: observing the basic surgical principles and thorough pre and post-operative examination of the patients, scleral buckling procedure is a safe and effective technique for uncomplicated patients of RRD

Visual outcome after penetrating keratoplasty

Background: penetrating keratoplasty [PKP] is a surgical procedure in which surgical replacement of the host cornea with a donor cornea is performed. The term "allograft " is used if the donor is another person, and "autograft" if the tissue is taken from same subject. The important optical indications include keratoconus, corneal dystrophies, corneal degenerations, pseudophakic bullous keratopathy, corneal scarring and corneal opacities resulting from infective and non-infective causes

Objectives: to evaluate visual outcome after penetrating keratoplasty [PKP]

Patients and methods: this interventional, quasi-experimental study was conducted at corneal unit of Lyton Rehmatullah Benevolent Trust [LRBT] Eye Hospital Lahore from March 21st 2005 to January 21st 2007. 50 eyes of 50 patients were selected. Best corrected Visual acuity [BCVA] was checked and compared preoperatively and postoperatively with Snellen acuity charts

Results: 11 [22 %] treated eyes had visual acuity >/= 6/18, 32[64%] eyes had between 6/60 to 6/24 and 7[14%] eyes had

Conclusion: PKP is a good surgical procedure to restore visual acuity of selected patients with corneal opacities utilizing proper material and optimal surgical techniques

Management of periocular post burn scarring in the epileptics

To assess the clinical presentation and management of patients with epilepsy presenting with periocular post burn scarring. Design: Prospective and descriptive study. Place and Duration of Study: Department of Ophthalmology, Jinnah Postgraduate Medical Centre, Karachi from September 1999 to September 2002. Subjects and This study included 23 patients who had epilepsy and presented with periocular post-burn scarring to the eye department for management. All patients had contractures of their lids with variable amounts of corneal scarring and damaged to the eye ball. The surgical procedure performed consisted of release of contracture, horizontal lid shortening and application of free skin graft. There were 18 [78.26%] female and 5 [21.73%] male patients. The age range was from 18 to 45 years with a mean of 28 years. In 17 [73.91%] patients, lid contracture was released to cover their eyeballs. In 6[26.08%] patients the eyeball was lost due to late presentation. There should be a high index of suspicion in facial burns for ophthalmic damage and early referral to an ophthalmologist should be made to prevent complications. Early release of contracture with application of full or partial thickness skin grafts is advisable

Squamous cell carinoma eye lis presentin as unilateral: Blepharoconjunctivitis

Two rare cases of squamous cell carcinoma [Scc] of eyelid presented with chronic unilateral blepharoconjunctivitis are jointly reported by Ophthalmology and Histopathology Departments of Jinnah Postgraduate Medical Centre, Karachi. Histopathological examination of resected tumor and reconstruction of eyelids with different surgical techniques was carried out in both the cases. No local recurrence was seen in 10 and 2 years of follow-up. Both of them, however, developed dry eyes with its complications. It was concluded that unilateral chronic blepharoconjunctivitis, not responding to medical treatment, should be subjected to histopathological examination to find out the cryptogenic cause of inflammation and extensive eyelids surgery in oculoplastic procedures may ultimately end up in dry eye. Case I. Sixty-five years old lady with unilateral blepharoconjunctivitis of five years standing reported out to be SCC on incision biopsy. Both of her right upper and lower lids were resected with 0.5 to 1.0 cm apparently healthy margin. Reconstruction of anterior lamina was done by glabellar and forehead flap for upper lid and Mastarde's flap for lower lid. Inner lamina was reconstructed with buccal mucosa. Ten years of follow-up showed no evidence of recurrence, though, she did developed complications of dry eye. She was kept on local lubricants but despite of her regular use of artificial tears she developed total corneal opacity. Case II. Sixty-two years old male presented with right chronic blepharoconjunctivitis of 3 years standing. SCC was found to be underlying cause on incision of biopsy. Total right upper lid resection followed by reconstruction of upper lid was done. Skin [by local flap] used for outer lamina, while donor sclera for inner lamina. Due to shrinkage of sclera, root of the upper lid gave way. This defect was filled with Cuttler Beard lid sharing technique successfully. Upper lid was mobile and functional and patient did not had any evidence of recurrence in two years of follow-up. This patient developed dry eye and is being managed on lubricants

Surgical treatment of anophthalmic socket - an experience with 42 intra orbital implants

We operated upon 42 eyes of 42 patients of different age groups [six-month to sixty-seven years] from December, 1995 to December, 1998. Intra orbital implant used were of Allen type in 24 eyes and Lowa type in 18 eyes. Fifteen, out of forty-two, were primary while remaining twenty-seven were secondary Implantations. Six months to three years follow-up [average being one year and eight months] showed excellent results in primary except one, which migrated inferiorly. Four, out of twenty-seven, secondary implants extruded out while six migrated from their normal position. Thirty-three [78.8%] had moderate to severe non-infective orbital cellulitis in early postoperative period which subsided with short course of systemic steroids. Prosthetic motility was much better in Allen type as compared to Lowa type implant. Improper dissection of extra ocular muscles, early absorbable suture [catgut], large size implant, severe postoperative orbital cellulitis [aseptic], excessive use of local steroids appear to be important causes of extrusion and migration. Implantation, in the patients whose eye were enucleated in early childhood, is another important cause of implant extrusion and migration. Primary orbital implant with adequate size Allen type acrylic mould after proper dissection and repair of all the six extra ocular muscles, using nonabsorbable sutures [6/0 prolene], tension-free closure of Tenon and conjunctiva give fairly acceptable cosmetic result