Granulomatous interstitial nephritis: a rare cause of acute kidney injury

Acute granulomatous interstitial nephritis [GIN] is a rare cause of acute kidney injury [AKI] but treatable. It is present in 0.5 to 0.9% of native renal biopsies. Treatment with moderate dosage of steroids is associated with good prognosis. We herein review a case of a 48-year lady having AKI following drug-induced damage [non-steroidal anti-inflammatory drugs [NSAIDs] and antibiotics]. Her renal functions did not improve after one month of drug withdrawal, so renal biopsy was done that showed acute GIN. She was treated with intravenous then oral steroids that completely resolved AKI

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

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

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

Clinicopathological study of solid pseudopapillary tumor of pancreas

Objective: To study the morphological and immunohistochemical features of solid pseudopapillary tumor of pancreas. Study Design: Retrospective study. Place and Duration of Study: Shaukat Khanum Memorial Cancer Hospital and Research Centre from Jun 2016 to Mar 2017

Material and Methods: Sixty-four patients [n=64] including 61 females and 3 males with pathological diagnosis of solid pseudopapillary tumor were selected from archives of Shaukat Khanum Memorial Cancer Hospital and Research Center for the period of 2000-2017. For the sample selected, their morphological features and immunohistochemical profile were reviewed and analyzed. The morphological features are considered as gold standard for the diagnosis

Results: The mean age was 33 years [range 8-50 years]. Immunohistochemical stains were performed on formalin fixed paraffin embedded section of 55 cases. Pancytokeratin was performed on 8 cases, out of which only 2 cases showed positivity. CD10 was performed on 14 cases, out of which only 12 cases showed positivity. Neuron specific enolase [NSE], CD56, vimentin, progesterone receptor [PR] and beta catenin were performed on 8, 5, 3, 13 and 16 cases respectively and showed positivity in majority of cases. Neuroendocrine markers [chromogranin and synaptophysin] were performed on 25 and 6 cases, from which it showed weak positivity in 3 cases. CD99 was performed on 19 cases and showed characteristic dot like staining

Conclusion: Among the immunohistochemical stains, CD99 had a specific dot like staining pattern and was used as a first line marker in diagnosis

Frequency and intensity of shoulder pain after stroke A hospital based study

Objective: To determine the frequency and intensity of shoulder pain in stroke patients and explore any relation of shoulder pain with the side of involvement and the primary etiology of stroke

Study Design: A cross-sectional descriptive study

Place and Duration of Study: Armed Forces Institute of Rehabilitation Medicine [AFIRM], Rawalpindi from January 2012 to June 2012

Material and Methods: Through non-probability convenience sampling 100 patients of both genders satisfying the World Health Organization clinical definition of stroke and reporting within one year of stroke development were included and those with cognitive dysfunction and rheumatic diseases or a history of chronic pain prior to the stroke were excluded. Shoulder pain was defined as pain in the shoulder area requiring analgesia for two or more consecutive days and its intensity was graded on visual analogue scale [VAS]

Results: Of 100 patients [mean age: 63 +/- 18 years], majority were males [76%], diagnosed with ischemic stroke [80%] and had a right sided pain [44%]. Patients with moderate to severe pain were more common [83.3%]. On comparison with the type of stroke, the pain was more prevalent on left side [72.7%] and in patients of ischemic stroke [62.5%]. However, these relations were statistically insignificant [p=0.061 and p=0.197 respectively]

Conclusion: More than half of the stroke patients reporting to our institute developed shoulder pain in first year after stroke the majority of whom had moderate to severe pain. The shoulder pain is not related to the primary etiology of stroke and side of involvement

Frequency of low bone mass in a cohort of mixed pakistani population

To determine the frequency of low bone mass in a multiethnic group of Pakistani population at Armed Forces Institute of Rehabilitation Medicine [AFIRM], Rawalpindi. Cross-sectional comparative study. Outpatient Department of Armed Forces Institute of Rehabilitation Medicine [AFIRM], Rawalpindi from October 2010 to March 2011. A total of 400 patients, both male and female, were sampled according to inclusion criteria by non-probability purposive sampling. Bone density was measured by DXA scan model Hologic [Discovery A], focused at neck of femur and spine. Four hundred patients were included in the study. Average age of the patients was 59.24 years [SD = 10.38] with 258 [64.5%] females. Two hundred and thirty two [58%] were Punjabi, 77 [19.3%] were Pathan, 64 [16%] were Kashmiri, 20 [5%] were Sindhi and 7 [1.8%] were Balochi. Average BMI was 26.45 [SD = 5.31]. Average T-score was -2.037 [SD = 1.40]. Out of 400 patients, 134 [33.5%] patients had normal BMD, 140 [35%] had osteopenia and 126 [31.5%] patients had osteoporosis. Frequency of osteopenia was higher in males than females i.e. 40.8% vs. 31.8% whereas frequency of osteoporosis was higher in females than males i.e. 32.9% vs. 28.9% [p = 0.191]. Similarly association between ethnicity and BMD was also observed to be insignificant [p =0.714]. The study showed high prevalence of low bone mass in Pakistani population in females as well as in males. The results in various ethnic groups are comparable, however, due to availability of smaller number of Sindhi and Balochi people, further multicentre studies at larger scale are recommended

Frequency, character, intensity and impact of neuropathic pain in a cohort of spinal cord injury patients

The purpose of this study was to determine frequency, character, approximate location and intensity of neuropathic pain in spinal cord injury and its impact on the quality of life. A cross-sectional survey. Armed Forces Institute of Rehabilitation Medicine [AFIRM], Rawalpindi from Feb 2009 to Feb 2010. Through non-probability convenience sampling 87 patients of both genders diagnosed with spinal cord injury based on American Spinal Injury Association criteria and admitted within a year of injury were included. Those in spinal shock, having poor cognition, inability to communicate, concurrent brain injury and history of chronic pain before injury were excluded. The history, localization and characteristics of the pain and interference with life activities were recorded. Neuropathic pain of patients was evaluated with Leeds Assessment of Neuropathic Symptoms and Signs Pain Scale. Visual analogue scale was used to measure the severity of pain. Out 87 [mean age 36.9 years] seventy four were male and 13 were female. Seventy patients [80%] were AIS-A, 6 [7%] were AIS-B and 11 [13%] were AIS-C. Neuropathic pain was present in 57.5% [n=50]. Most of the patients localized their pain below the neurological Ievel of injury [78%] and rated pain intensity as [moderate pain] [54%]. Majority [48%] described the pain as burning fallowed by electric shock like [42%], stabbing [8%] and pricking [2%]. 48% patients reported that their quality of life was affected due to pain. 52% required two analgesics of different groups to relieve pain followed by 40% requiring three Analgesics and 8% requiring one analgesic. Neuropathic pain is prevalent in people with spinal cord injury and adversely affects life quality. Neuropathic pain is primarily described as a burning sensation of moderate intensity mostly referred to below the neurological level of injury

pattern of peripheral nerve injuries among Pakistani soldiers in the War against terror

To determine the pattern of peripheral nerve injuries in Pakistani soldiers in the War against terror. Case series. Department of Electrodiagnosis at Armed Forces Institute of Rehabilitation Medicine [AFIRM], Rawalpindi, Pakistan, from June 2008 to June 2011. All new cases of war wounded soldiers with peripheral nerve injuries were consecutively enrolled. Physical examination and electrodiagnostic study was carried out by experienced physiatrists. Data was entered in pretested especially designed questionnaire which was analysed using SPSS version 17.0. Seddon's classification system was used to assess the severity of injury. There were 418 cases of peripheral nerve injuries with 504 different nerve segments. Mean age was 29.41 +/- 8 years. Blast was the main cause of nerve injury in 244 [48.5%] cases followed by gunshot in 215 [42.7%] and 45 [8.9%] cases had nerve injuries secondary to fall, burial under debris and motor vehicle accidents. Eighty six [17%] cases had multiple nerve injuries. Most commonly injured nerve was ulnar [20.6%] followed by sciatic [16.7%], median [16.5%], radial [16.3%], peroneal [8.7%], brachial plexus [8.5%], axillary [4.8%], tibial [2%], femoral [1.8%], long thoracic [0.4%] and others [3.8%]. Axonotmesis was seen in 459 [91.1%] cases, 44 [8.7%] cases revealed neurotmesis and 1 [0.2%] case had neuropraxia. Peripheral nerve injuries are a major component of war related injuries mainly involving the upper limbs. Electrodiagnostic studies help in assessing severity and determining prognosis. Precise documentation of severity of nerve injuries is important to estimate the burden on our resources and to extend rehabilitation services

Searching the research or re-searching the search: where to start from? a post-graduate medical trainees perspective from rawalpindy lslamabad

To explore the post-graduate medical trainees perceptions and practices towards research and to investigate potential barriers to perform research. Cross sectional descriptive study. Military hospital, Combined Military hospital, Rawalpindi and Pakistan institute of medical sciences Islamabad, from Jan 2013-Dec 2013. A pretested, structured and validated questionnaire was used to collect data from 114 final year post-graduate medical trainees [PGMTs]. SPSS version 17 was used for descriptive data analysis. One hundred and fourteen [n=114] final year post-graduate medical trainees [PGMTs] of fellowship program of College of Physician and Surgeons of Pakistan gave their written consent to participate in this study. Among them 68 [59.6%] were males while 46 [40.3%] were female. One hundred and twelve [98.2%] trainees agreed that research is an important and healthy activity and have a great impact on their future carriers. 63 [55.2%] PGMTs had worked as data collector in various studies conducted at their institutions while only 21[18.4%] PGMTs had published their manuscript. Obstacles that prevented the PGMTs from conducting research included: lack of professional supervisors: 103 [90.3%], poor research training: 98 [86.0%], and lack of resources: 84 [73.6%]. Although the majority of the PG trainees believe that research is important in medical field, only about 55.2% of them have participated in the research activities other than mandatory dissertation during their training. Measures should be taken at postgraduate level to involve and support the PGMTs in health research with formal training programs and good mentorship

Functional outcomes following lower extremity amputation at the armed forces institute of rehabilitation medicine using lower extremity functional scale

To assess improvement in functional outcomes following prosthetic fitting after lower limb amputation using a lower extremity functional scale in a cohort of the Pakistani population. Quasi experimental Study. Amputee rehabilitation ward [indoor] / OPD [out patient department] at Armed Forces Institute of Rehabilitation Medicine Rawalpindi. From August 2009 to August 2010. Study was carried out in the amputee rehabilitation ward of the Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan. Fifty two consenting lower limb amputees fulfilling the inclusion criteria were enrolled. All patients were provided with modular prosthesis followed by gait training and integrated amputee rehabilitation program. An assessment was done at 0, 4 and 12 weeks after the provision of prosthesis. Results were analyzed by SPSS Version 15. Most of the patients were males [98.1%]. Mean age was 30.17 +/- 9 years. Trauma was the main etiology [99%] followed by tumor [in only 1 patient who had osteosarcoma]. Transtibial amputation level was the commonest [53.8%] followed by transfemoral in 32.7% patients and Syme's [7.7%]. Lower extremity functional scale [LEFS] mean score in the first week was 35.56 [44.5% of maximum function], which improved to 49.40 [61.8% of maximum function] at week 4, and 59.27 [74.09% of maximum function] at the end of week 12. The p-value for each was 0.000. Early and multidisciplinary amputee rehabilitation improves the functional ambulation level, quality of life and satisfaction level of the individual

Role of physical medicine and rehabilitation intervention for plantar fasciitis

To highlight the role of early physical medicine and rehabilitation. Randomized case control study. Armed Forces Institute of Rehabilitation Medicine Rawalpindi from March 2002 to March 2003. Eighty patients of both sexes between 25-45 years of age were randomly divided into Study and Control group. Group 1 [study] was given standard physiatric therapeutic intervention and Group 2 [control] was given conventional treatment with heel cup and Non Steroid anti inflammatory drugs [NSAIDs]. They were followed up for three months. Pain was assessed by Visual Analog Scale [VAS] and Heel Tenderness Index [HTI]. Mean age of the patients was 35.7 years.Forty percentage cases were male and 60% were female. After three months of treatment, 75% of group 1 and 20% of group 2 showed marked improvement [VAS < 30mm]. On HTI index, 72.5% of patients were in Grade 0 [no pain] and 22.5% were in Grade I while 30% of patients in group 2 were in grade 1 [painful]. Difference was found to be statistically significant i.e. P- value < 0.05. Comprehensive rehabilitation management has shown promising results in the treatment of plantar fasciitis especially when initiated in early stages and may prove to be the mainstay modality in the treatment of plantar fasciitis in future