Melcmotic neuroectodermal tumour of infancy: a rare brain tumour of childhood

Melanotic neuroectodermal tumour of infancy is a rare, mostly benign but locally aggressive tumour of neural crest cell origin occurring in infants. The most commonly affected anatomic site is the maxilla. Such tumours of the brain and skull are very rare. We present the case of an 8 months old baby girl whose presenting complaint was a swelling in the scalp for 6 months. She was otherwise asymptomatic. CT imaging confirmed the presence of an osteolytic tumour in the anterior parasagittal skull with dural involvement. The tumour was surgically excised enbloc. The patient has been well at 2 years follow-up without any evidence of recurrence

High altitude headache - an etiological based study

To determine the various causes of headache in patients evacuated from high altitude. Descriptive study An observational hospital based study carried out on 50 soldiers evacuated from Northern Areas to Military Hospital Rawalpindi between Sep 2009 to Mar 2010 for evaluation of headache as their major complaint. Necessary investigations including neuroimaging were carried out in coordination with Department of Neurology, Military Hospital and an appropriate diagnosis was made in each case. The data was analyzed accordingly. A total of 50 patients were analyzed .They were all males and the mean age was 25 years. 52% patients had Acute Mountain Sickness, 12% hypertension, 10% High altitude cerebral edema, 8% Tension type headaches, 6% Dural venous sinus thrombosis, 6% migraine, 2% encephalitis, 2% were of Subarachnoid hemorrhage and 2% patients Hydrocephalus. Acute mountain sickness and high altitude cerebral edema accounts for a significant number of patients with high altitude headache

Wheat pill: clinical characterisitcs and outcome

To determine the clinical characteristics and outcome in patients presenting with wheat pill poisoning. Retrospective study. Department of medicine, Combined Military Hospital, Kharian from 1st July 2009 to 30 December 2010. Fifty two patients with wheat pill ingestion were included in the study. All patients' history, symptoms, signs and management data was collected on a pre-designed data collection form. Mean age was 25.10 +/- 5.35 years with 51.9% females. Time interval between ingestion of pills and presentation to hospital was 2.5 +/- 1.27 hours. Numbers of pills consumed were 2.73 +/- 20. Most common symptom seen in patients was vomiting seen in 88.5% of the patients. Other common symptoms were irritability in 63.5% and confusion in 55.8% patients. Most common clinical sign hypoxia in 75% patients. Overall mortality was 86.5 percent. Wheat pills are highly toxic with rapid and high mortality rate. These patients develop refractory hypotension and metabolic acidosis which progresses to death. More research is required to develop antidote and to minimize toxicity. Strict legislations are required to control sale of aluminium phosphide over the counter

Frequency of axonal variants of guillain-barre syndrome in Pakistan

To determine the frequency of axonal variants in our patients of Guillain-Barre Syndrome. Descriptive study. Department of Neurology, Military Hospital, Rawalpindi and Armed Forces Institute of Rehabilitation Medicine [AFIRM] from 01 Jan 2009 to 30 Jul 2010. Forty adult patients meeting the National Institute of Neurological Disorders and Stroke criteria for Guillain-Barre Syndrome [GBS] were consecutively enrolled in the study. Patient's data, detailed history, examination and electrophysiological studies were carried out and recorded on predesigned proforma. All patients were examined and reviewed by Consultant Physicians and neurologists. Electromyography and Nerve conduction study testing was done by experienced electro-physiologists. Axonal variants of Guillain-Barre Syndrome constituted 16[40%] in our study. The variants of Guillain-Barre syndrome were acute inflammatory polyradiculoneuropathy [AIDP] in 24[60%] patients followed by acute motor axonal neuropathy [AMAN] in 12[30%] and acute motor sensory axonal neuropathy [AMSAN] in 4[10%] patients. We report a high frequency of the axonal variants of Guillain-Barre Syndrome in Pakistan

Risk factors associated with childhood asthma among children aged 1-12 years in Rawalpindi

To explore various risk factors associated with childhood asthma in Rawalpindi garrison and city among children 1-12 years old. Case Control study. Pediatric departments of Military Hospital [MH] and Combined Military Hospital [CMH] Rawalpindi from 1st Aug to 30th Nov 2009. A total of 128 children with diagnosis of asthma presenting in outpatient and indoor pediatric departments of MH and CMH Rawalpindi between ages of 1-12 years were included. Age, gender and socioeconomically matched 112 children without diagnosis of asthma were included as controls. A predesigned questionnaire containing various factors associated with childhood asthma was filled by the researcher by detailed interview with either of parents. Data was analyzed by SPSS version 15 and chi-square test was applied to determine significance. p value <0.005 was considered significant. Out of 15 risk factors studied 8 were found significantly associated with childhood asthma. Significant factors were education of any of the parents more than matric, history of fever at least three times in last year, use of antibiotics, history of hay fever, raised IgE levels, exposure to passive smoking, living in urban areas and family history of asthma [p value<0.005]. Non significant factors were mode of delivery, exclusive breast feeding for more than 3 months, partial breastfeeding for more than 6 months, history of eczema, atopy, history of viral respiratory infections in infancy and less than three number of rooms at home. Male preponderance was noted amongst cases. Education of parents, fever, antibiotics, hay fever, raised IgE levels, exposure to passive smoking, living in urban areas and family history of asthma proved to be significant factors which are similar to those reported in other studies. However, difference was found in other factors. Recognition of these factors can help to optimize management of asthma in children in this area

Frequency of headache with stress in adolescent and young adults

Objective of this study was to establish a link between stress as a cause of headache in young adults. Cross sectional study. Department of Neurology Military Hospital [MH] Rawalpindi from September 2009 to March 2010. Thirty young patients, referred for the complaints of headache to the Neurology out patient department, were included in this study. A detailed especially designed, pre tested headache questionnaire was devised which was filled for every patient individually included in the study. Twenty One [70%] of the patients in the study group did have the feeling of stress preceding the headache which sometimes persisted during the episode. Nine [30%] did not report any such feeling of stress before or during the episode. Out of the patients reporting stress 71% [15] were female patients and 29% [6] were males. These key findings suggest that stress and headaches may be related for adolescents and young adults and that this relationship may be reinforced over time. Moreover female patients were far more susceptible to this stressful stimulus as compared to the males

Frequency and risk factors for chronic HCV infection: a community based study

It was a community based, cross-sectional study undertaken to assess the frequency of HCV infection and to find out the risk factors associated with its spread. Study was carried out from Oct 2004 to Mar 2005. One hundred and twenty five apparently healthy consecutive subjects not known to be infected with HBV or HCV, between the ages 13 and 60 years with equal sex distribution were selected from the population of the Village Mera Kalan near Rawalpindi. They were screened for Anti HCV antibodies using ELISA and interviewed in detail. Subjects found positive for Anti HCV Ab were tested for ALT [Alanine aminotransferase] levels and HCV RNA by PCR. The frequency of HCV was found to be 53.6%. The most important risk factor associated with the transmission of HCV infection was unsafe injection therapy with contaminated equipment. Other risk factors include ear and nose piercing by unsterilized means in females and sharing of razors in males. The prevalence of HCV infection in our population is significantly higher than in the developed world. Public awareness programs should target the identified risk factors to prevent HCV transmission

Comparative efficacy of amlodipine and hydrochlorthiazide-amiloride in cases of mild essential hypertension in outdoor patients at combined Military Hospital Multan

To compare antihypertensive effect of fixed dose combination Hydrochlorothiazide-Amiloride and Amlodipine in patients of mild essential hypertension. Randomized controlled trial [RTC]. Department of Medicine Combined Military Hospital Multan Cantt from 29 January 2007 to 29 June 2007. After fulfilling the inclusion criteria of mild essential hypertension, defined as per recommendations of Seventh Joint National Committee [JNC 7] for treatment of Hypertension as stage 1 hypertension, systolic blood pressure [SBP] >/= 140-159-mmHg and Diastolic blood pressure[DBP] >/= 90-99-mmHg, 100 patients were randomized into two study groups using a table of random numbers. Group 1 received tab amlodipine [5 mg] and Group 2 received tab hydrochlorothiazide-amiloride [25 mg-2.5mg]. Informed written consent was taken. The patients were followed on subsequent visits [6 in total] for five months and systolic and diastolic blood pressure was recorded carefully. All the data thus obtained were processed and analyzed using SPSS version 10.0. Mean and standard deviation [SD] were calculated for age, diastolic and systolic blood pressure. In group 1 the drop in mean SBP between first and last visit was 15.42 mm Hg. In group 2 the drop in mean SBP between first and last visit was 18.34 mm Hg. In group 1, the drop in mean DBP between first and last visit was 10.08 mm Hg. In group 2 the drop in mean DBP between first and last visit was 14.65 mmHg. Mean drop in SBP of both the groups were compared with each other and found to be significantly different [P=0.003]. Similarly mean drop in DBP of both the groups were compared with each other and found to be significant statistically [P=0.001]. Hydrochlorothiazide-Amiloride had significantly better antihypertensive effect than Amlodipine in patients of mild essential hypertension at the end of five months therapy

Montelukast as add-on therapy to inhaled beclomethasone in persistent bronchial asthma

To evaluate the efficacy of Montelukast as add-on therapy in moderate persistent asthma with inadequate control on high dose inhaled beclomethasone. A quasi experimental study. The study is carried out at the Combined Military Hospital Multan, from 1st Nov 2006 to 30th May 2007. One hundred nonsmoking symptomatic asthmatics with one year history of moderate persistent bronchial asthma being treated with high dose inhaled beclomethasone dipropionate for at least 6 weeks before the study were selected as per inclusion criteria. Group-I [47 cases] was given inhaled beclomethasone [1000 µg daily in two divided doses] alone for 12 weeks. While Group-II [48 cases] received both inhaled beclomethasone [1000ug daily in two divided doses] and Montelukast Sodium 10 mg at bed time for 12 weeks. Seven-point global evaluation score and Pulmonary function test [PFTs] were done at 0, 6 and 12 weeks; and the need for use of rescue 2-agonist was also calculated in both groups. Mean age of patients was 29.30 years [SD +/- 7.04] with 64.22% males. There was significant difference in episodes of dyspnea and wheeze among group I and group II at 6 weeks while all four parameters including cough and nocturnal awakenings were significantly less at 12 weeks in group II. Similar comparative improvement in mean FEV1 was seen at 12 weeks in group II. Combined therapy also reduced the use of rescue inhaled 2-agonist treatment. Montelukast sodium as add-on therapy to high dose inhaled beclomethasone provides significant complementary clinical benefits in symptomatic moderate persistent asthmatics

Radial nerve injuries; presenting as wrist drop-analysis of 100 patients

To highlight etiological factors leading to radial nerve injury resulting in wrist drop, with particular reference to iatrogenic causes. Retrospection and Descriptive. One hundred patients of all ages and both sexes with wrist drop. Data of clinical assessment after detailed history and examination as well as electro diagnostic studies was recorded on pre-designed assessment proforma. The outcome was charted down for frequency of etiology of the wrist drop. Rehabilitation Medicine Department of Combined Military Hospital [CMH] Multan and Armed Forces Institute of Rehabilitation Medicine [AFIRM]. The major cause of injury was splinter/gun shot injury 31%, mis-placed injection at mid-arm 21%fracture of humerus was 21%, compression neuropathy 16%, and stab wound 11% caused wrist drop. Electro-physiological studies revealed that 85% patients had injury to radial nerve at mid-arm, 9% had injury to posterior interosseous nerve while 4% had injury to superficial branch of radial nerve and only 2% had normal study. Electrodiagnostic studies also revealed that majority of the patients suffered from axonotmesis [44%] and neurapraxia [38%], whereas [16%] were neurotmesis. The most common cause of radial nerve injury is trauma. It is also found that the frequency of radial nerve palsy due to iatrogenic causes is quite high. In addition to the clinical examination, the nerve conduction studies and electromyography proved to be the better investigation technique in the assessment of the location, severity and extent of the peripheral nerve injury and subsequently guides in starting the proper treatment option due to early referral of patient to the concerned fields

Errors in the diagnosis and treatment of pulmonary tuberculosis

The objective of this study was to evaluate the causes of treatment failures in patients diagnosed as pulmonary tuberculosis and started on ATT by general practitioners and general physicians. This was a descriptive observational study conducted at CMH Multan from 1st August 2004 till 31st July 2006. It included patients of all ages and both sexes. All of these patients received ATT for more than 2 months but failed to respond. All relevant investigations including sputum microscopy/culture sensitivity, bronchoscopy and CT scan chest were carried out. Total numbers of patients registered were 48. There were 27 males and 21 females and the mean age of patients was 42.75 years. Of these, 58.33% [n=28] were wrongly diagnosed. 25.02% [n=12] did not show proper compliance. 10.41% [n=5] were prescribed inadequate dosage. While 6.25 [3] were suffering from MDR-tuberculosis. Chronic bronchitis/ COPD, bronchiestasis and bronchogenic carcinoma were the commonest disease found in this series. All TB suspects should have a sputum microscopy done at the earlier stage. AFB culture/ sensitivity should be carried out whenever considered necessary. In Sputum smear negative patients high index of suspicion for non tubercular pulmonary diseases should be maintained. DOTS needs to be employed in all patients with active pulmonary tuberculosis

Dermatological disorders related to cultural practices in black africans of Sierra Leone

To describe various skin manifestations directly or indirectly related to the prevalent cultural practices in the local community of black Africans of Sierra Leone. Eastern province [Kenema] of Sierra Leone from November 2004 to October 2005. Local black patients of all age groups presenting in Dermatology Outpatient department of Pak Field Hospital [established as a part of UN peacekeeping mission in Sierra Leone] were included. After clinical history and physical examination, lesions were photographed. Laboratory investigations were carried out when indicated. Skin diseases were broadly classified into two major categories i.e. related to cultural practices and not related to cultural practices. Non-black settlers in the area and UN troops were excluded. Data was recorded and analyzed by Microsoft Excel. A total of 3011 patients belonging to different local tribes having a variety of skin disorders were seen during the study period. Patients ranged from 1 month to 73 years of age with almost equal gender ratio. Vast majority were from very low socioeconomic group. Skin manifestations related to cultural practices were seen in more than 20% patients and most prevalent were alopecia and hypertrophic scars followed by pomade acne, pseudofolliculitis and contact dermatitis. Prevalent cultural practices in black Africans do play a role in causation of various skin disorders. For a dermatologist, it becomes imperative to be cognizant of the signs and symptoms associated with these practices for proper diagnosis and appropriate treatment

Role of sonourethrography in evaluation of anterior urethral stricture and its comparison with retrograde urethrography

The aim of this study was to compare retro grade urethrography [RUG] and sonourethrography [SUG] for assessment of urethral strictures and to evaluate whether RUG underestimates stricture length, as has been reported. Quasiexperimental study. The study was performed in the department of Radiology PNS Shifa Karachi from January 2004 till December 2004. Forty male patients diagnosed with anterior urethral stricture were assessed for presence of strictures and their length by conventional contrast urethrography and sonourethrography. Contrast urethrography was carried out by retrograde injection of Urograffin 76% under fluoroscopic guidance. Sonourethrography was done with a 7.5 MHz small parts transducer. Stricture lengths were recorded and compared. Analysis of the results showed that the estimation of stricture length measured by contrast urethrography was under-estimated as compared to sonourethrography. The difference between the two tests was significant [P < 0.001] and the correlation coefficient was poor [r = 0.493]. When the strictures were grouped into penile and bulbar anatomical locations the results remained highly significant in the bulbar region [P = 0.0001] however no significant difference was found in the estimated length for penile strictures [P = 0.25]. Sonourethrography is a good adjunct investigation before definitive surgical therapy particularly in the bulbar region where conventional contrast urethrography was shown to underestimate stricture length significantly

Frostbite in gangrene; role of classification

The objective of this study is to determine if classification of cases of frost bite in 1st, 2nd, 3rd and 4th degree have any predictive value on the future complications e.g. skin necrosis and gangrene. A non-interventional and descriptive study. The study was carried out at the Surgical Department, of Combined Military Hospital Gilgit from January 2002 to February 2005. All the patients who reported to the hospital with frost bite were admitted and enrolled in the study. The local examination of wound was done and all the physical signs were recorded, The frost bite was labeled according to the severity from 1st to 4th degree in accordance to the specified criteria. All the patients were placed on a standard treatment protocol comprising of injection of Benzyl Penicillin 10 lac U x 6 hourly, injection of Heparin 5000 IU s/c x 6 hourly and tablets Ibuprofen 400mg x 8 hourly for 5-7 days. The condition of wound was assessed daily till 8 weeks after admission. The end point of medical treatment was a clear demarcation of dry gangrenous and viable tissue, or the formation of moist gangrene or infection in frost bitten area which was spreading proximally. Once this condition was reached the patients were planned for amputation surgery. Total numbers of patients included were 96. Among them 33 had 1st degree, 37 had 2nd degree, 16 had 3rd degree and 10 had 4th degree frost bite. All the 33 patients of 1st degree frost bite recovered well and were discharged from the hospital without any surgical intervention. 16 patients among the total 37 who sustained 2nd degree frost bite developed superficial ulcers over the skin. These patients required regular wound dressings and recovered well by 6 weeks of treatment without any limb loss. 7 out of total 16 patients of 3rd degree and all the 10 patients of 4th degree frost bite developed gangrenes. They were observed till 8 weeks and after that they underwent amputations. In accordance to the results it is concluded that most of the patients who had r degree of frostbite and all the patients who sustained 4th degree frost bite developed gangrene by 8 weeks of hospitalization despite of the treatment. None of the patient of 1st and 2nd degree frostbite developed gangrene. Hence the initial assessment of a patient was very useful in predicting the chances of development of gangrene

Recent advances in the management of tuberculosis

The importance of tuberculosis in Pakistan and other underdeveloped countries cannot be over emphasized. Despite inclusion of BCG vaccination in the EPI program and availability of the anti-tuberculosis medicines at affordable prices, tuberculosis is still the number one cause of prolonged morbidity. The emergence of Human Immunodeficiency Virus and multidrug resistant tuberculosis has added another dimension to an already complicated situation of tuberculosis globally. In response, vigorous efforts have been made to stratify the patient population and streamline the treatment of various categories of tuberculosis patients