randomized controlled trial of intermittent cervical traction in sitting Vs. supine position for the management of cervical radiculopathy

Objective: To compare the effectiveness of intermittent cervical Traction in sitting vs. supine position for the management of cervical radiculopathy

Methods: A randomized clinical trial was done to compare pain and disability modification of cervical radiculopathy patients by using cervical traction in sitting and supine positions. Forty patients [males and females aged between 18-60 years with chronic cervical radiculopathy] were recruited for the trial. Participants were randomized into two homogeneous groups by dice method. The Group-A [n=20] received 3-weeks of intermittent cervical traction in sitting position along with Transcutaneous Electric Nerve Stimulation [TENS] and hot pack. The Group-B [n=20] received the same treatment except the intermittent cervical traction that was applied in supine position. Participants were assessed two times: at baseline [week 0] and at the termination of rehabilitation [week 3]. Neck disability index was used to collect the data before and after the treatment

Results: The mean age of the patients was 43.15+/-8.99 vs. 48.80+/-6.89 years in Group-A vs. Group-B respectively. Mean [+/-S.D.] weight of the patients was 74.75+/-12.11 vs. 74.60+/-11.24 kg in Group-A vs. Group-B respectively. Mean Neck Disability Index score at start of treatment was 30.30+/-7.46 vs. 30.75+/-7.85 in Group-A and Group-B respectively. There was a significant difference in Group-A and Group-B regarding aggregate NDI score at the end of treatment [19.45+/-7.12 vs. 11.05+/-4.40; p<0.0001]

Conclusion: Supine position is better choice for applying cervical traction as compared to sitting position for the management of cervical radiculopathy comparing post interventional NDI score

Effectiveness of stretching exercises in symptomatic and asymptomatic phase in primary dysmenorrhoea

Background: Primary dysmenorrhoea is health related problem within females with high prevalence affecting different aspects of their life and their productivity. The objective of the study was to compare the effectiveness of stretching exercises done during symptomatic and asymptomatic phase of menstrual cycle in primary dysmenorrhea

Methods: Randomized controlled trial [RCT] [double blinded] study was carried out at Royal group of colleges Gujranwala, Pakistan. Sixty six students with confirmed diagnosis of primary dysmenorrhoea were included through non-probability convenience sampling. The students were randomly assigned to two equal [n=33] groups: Asymptomatic [A] and Symptomatic [B]. Each student was assessed for pain and associated symptoms of dysmenorrhoea by using numeric pain rating scale and Daily record of severity of problems [DRSP]. Stretching exercises were performed thrice per week for group A which did exercises during asymptomatic phase and same exercises were done twice a day for group B only in symptomatic days. Both groups did exercises for three months. Data was taken at baseline and post menstrual phase of three successive menstrual cycles. The data was analyzed using SPSS 20. An independent samples t test was used to compare both groups and repeated measures ANOVA was used to find the intervention-based effects within each group

Results: Mean age of students was 21.29+/-2.60 [Year], mean weight was 52.70+/-4.81 [Kg], mean age at menarche was 13.18+/-1.11 [Year] and mean BMI was 16.87+/-0.81 [Kg/m2 ]. Both groups were comparable at baseline for age, weight, BMI and age at menarche as p>0.05. Significant changes for pain and associated symptoms were found within each group [p>0.05]

Conclusion: It is concluded that stretching exercises in symptomatic phase and asymptomatic phase are equally effective to relieve pain and associated symptoms of Primary Dysmenorrhoea

Fibrodysplasia ossificans progressiva

Fibrodysplasia Ossificans Progressiva [FOP] is a rare autosomal dominant disorder characterized by postnatal progressive heterotopic ossification of connective tissue and congenital malformation of big toes. We report a 3-year male toddler with clinical and radiological features of FOP. He was born with bilateral hallux valgus and at the age of 3 years presented with hard swellings over back, scapular region and forehead that were initially inflammatory and then became bony hard. There is also tilting of neck towards the left due to calcification in neck region. The radiographs showed heterotopic ossification in thoracic region, neck, spine and region of hip joint

Versatality of supraclavicular flap in neck, face, and upper chest region coverage

The objective is to analyze the utility of theisland supraclavicular flap in a region where skin graft cannot be used and free flap is not feasible. We assessed complications and functional outcomes. Prospective descriptive study. The study was done at plastic and reconstructive surgery department CMH Rawalpindi during the period of 03 year from October 2011 to October 2014. An island supraclavicular artery flap was used to reconstruct oncologic, and post burn neck contractures release defects. 30 patients were included in the study. Doppler probe was used to help with localization of vascular pedicle. All the patients with scarring in both shoulder regions, history of radiation to neck and undergoing radical neck dissection were excluded. Atotal of 30 patients were included 20 [66.6%] male and 10 [33.3%] were female. Oncologicre section was followed by immediate reconstruction with island supraclavicular artery flap. Post burn contractures were released and covered by a pedicled supraclavicular artery flap. The recipient sites were neck, face, oral and upper chest region. The average harvest time was 1 and half hour. Donor site was closed primarily in 22 [73.3%] while 8 [26.6%] require skin grafting. Post burn contractures needed scar management with intralesional steroid, pressure garments and scar revision with Z-plasty in 4[13.3%] cases. 1 [3.3%] flap failed completely and the defect was covered with a skin graft. We had 01 [3.3%] mortality due to respiratory obstruction, despite adequate flap perfusion for 24 hours. Minor complications included, partial flap loss, seroma, and haematoma formation. In addition hypertrophied scar, spreading scar and keloid formation occurred at the donor site 18 [60%]. Island supraclavicular artery flap with an easy learning curve is a reliable flap. It has a good colour and texture match with minimal donor site morbidity. It is an excellent choice for neck coverage after post burns contracture release and an attractive alternative to free flap for oral/ facial defects

Juvenile rheumatoid arthritis

To determine the spectrum of clinical presentation, laboratory parameters and drug therapy in patients with Juvenile Rheumatoid Arthritis [JRA]. Case series. The Children's Hospital and The Institute of Child Health, Lahore, from October 2008 to October 2011. All patients who fulfilled the American College of Rheumatology criteria for JRA were enrolled. Their clinical features, investigations done and treatment received for JRA were noted. Statistical analysis of data was done on SPSS version 16.0 for obtaining descriptive statistics. Out of 185 patients, 50.3% [n = 93] were females; 54% [n = 100] were between 10 - 15 years of age. Polyarthritis was found in 71.9% [n = 133] followed by oligoarthritis [22.7%, n = 42] and systemic onset disease [5.4%, n = 10]. Morning stiffness [78%] and fever [68%] were the most common clinical presentations. All patients with systemic onset disease had fever [n = 10] followed by skin rash, hepatosplenomegaly and lymphadenopathy. Uveitis was found in 2 patients, and both belonged to the oligoarticular group. Rheumatoid factor was found in 10.27% [n = 19] of all patients. All patients were given non-steroidal anti-inflammatory drugs [NSAIDs]. Disease modifying agents [methotrexate] were given to 43.8% [n = 81]. Steroids were used in 61% [n = 113] of patients either with NSAIDs alone or NSAIDs plus methotrexate. Disease profile of JRA at the study centre showed that polyarthritis is the commonest type. Recognition of subtypes will help in planning the management of these patients

Utility of medium thickness plantar skin grafts in palmar defects

To assess the utility of medium thickness plantar skin grafts in palmar defects. Case series. Department of Plastic Surgery Combined Military Hospital, Peshawar, from January 2006 to February 2009. Total 16 patients with palmar defects resulting from post-burn contractures, syndactyly release and tumor resection were included. All patients were treated with release of contractures and excision of scar tissue. Post release the palmar defects were covered primarily using medium thickness plantar skin graft from foot instep. First dressing was changed after two weeks with advice to splint the fingers for six months. Donor site was covered with calcium sodium alginate dressing which was removed after two weeks. Graft was assessed with regards to rate of graft take, colour and texture match, recurrence of contracture, mobility of the graft and the nature of donor site healing. All the patients operated had a complete take of the medium thickness plantar skin grafts, which were judged by their epithelialisation. The color match and the texture match were excellent. Three patients had mild infection at recipient site which healed with debridement and dressings. Hypertrophic scarring and mild hyper pigmentation at the donor site was seen in 4 cases but ultimately all wounds healed completely by the end of three months. In our study the excellent color, texture match and the functional advantages offered by the medium thickness plantar graft far exceeded the expected outcome of conventional techniques

Ventilator-associated pneumonia in children

To determine the frequency of Ventilator-Associated Pneumonia [VAP] and to identify the associated factors, causative organisms and outcome of VAP in children admitted to ICU. Cross-sectional, observational study. Medical ICU [MICU] of the Children/'s Hospital and Institute of Child Health, Lahore, from August 2008 to March 2009. All children admitted to MICU and requiring ventilation during the study period were included and monitored for any features suggestive of VAP. Partial septic screen was done in all suspected cases. VAP was labelled when any patient on the ventilator for more than 48 hours had at least 2 of the following features of nosocomial infection - fever > 101'F, TLC < 4000 or > 15000 per mm[3], neutrophils > 85%, CRP > 48 mg/L or new findings on chest examination suggestive of pneumonia' and radiological evidence of new or progressive and persistent infiltrates. Percentages were compared using chi-square test with the significance at p-value less than 0.05. Of the 93 children requiring mechanical ventilation during the study period, 16 developed VAP [17%]. Almost half [46%] were younger than 1 year with male to female ratio of 1.2:1. Children developing VAP required ventilation for 13.5 [+ 10.1] days compared to 7.7 [+ 5.5] days in those who did not develop VAP. The common organisms isolated were Pseudomonas, Klebsiella and E. coli. Factors associated with increased frequency of VAP included age less than 1 year, unplanned emergency intubation and use of continuous intravenous sedation. Features that strongly suggested underlying VAP included purulent tracheal secretions compared to increased secretions alone, CRP > 48 mg/L, positive radiological findings and positive tracheal aspirate culture. Overall mortality was 23% among the ventilated cohort. Thirty two percent of them had VAP compared to only 13% among those who survived to discharge [p = 0.03]. The frequency of VAP was 17% in this series. Factors significantly associated with VAP were age less than 1 year, unplanned intubation and continuous sedation. The important predictors of VAP included purulent tracheal secretions, high CRP and persistent new radiological findings

neonate with Poland-Mobius syndrome

Poland-Mobius syndrome is a combination of two rare congenital syndromes characterized by congenital facial weakness, loss of abduction of eyes, limb defects, and absence or hypoplasia of the pectoral muscles. A patient with features of both the Mobius syndrome and the Poland syndrome is presented in this case report

Socioeconomic risk factors for asthma in child

The purpose of the study was to explore and explain different socioeconomic conditions and factors related to childhood asthma, Cross sectional descriptive study, This study was conducted at the Children's Hospital and the Institute of Child Health, Lahore for a period of three month. This is a descriptive study done at the asthma clinic of the Children's Hospital and the Institute of Child Health, Lahore. Total 110 patients were included in the study between 2-16 years, An objectively designed structured questionnaire was used and data was collected after taking consent from the parents. Out of 110 patients, the commonest age was 2-8 years for both males and females. The disease was most common in boys [63.6%] and urban area [57.3%] had higher frequency than patients from semi urban [24.5%] or rural areas [18.2%]. Asthma was more common in lower and middle class than upper. Different socioeconomic risk factors involved in the increased frequency of asthma were smoking, animals at home and environmental dust. Allergic reactions to food, change in weather and preceding upper respiratory tract infections also play an important role. Poor socioeconomic class, uneducated families, urban life and environmental allergen exposure are responsible for increase frequency of asthma and by investing resources in to community based education and support services we can provide a better control of asthma to our community

case of polyglandular autoimmune syndrome type I with unusual presentation

Eight years old girl presented with mucocutaneous candidiasis, nail dystrophy, twitching left half of face, progressively increasing generalized skin hyperpigmentation and hypopigmented patches over both shins. Her investigations revealed low intact PTH level, low serum cortisol, high ACTH, impaired glucose tolerance test and candidal onycomycosis. She was diagnosed as Polyglandular Autoimmune Syndrome [PGA] type I. She also developed idiopathic generalized epileptiform seizures and Alcaligenes faecalis septicemia not previously reported with PGA type I. The patient responded well to alphacalcidol, hydrocortisone, valproate sodium, topical antifungal and systemic antibiotic

child with roberts syndrome

Roberts syndrome Is a genetically determined rare birth defect causing, skeletal deformities, particularly symmetrical limb reduction and craniofacial anomalies. For any child with limb and craniofacial bony malformations, this syndrome should be considered in the differentials. Although this syndrome represents only a small proportion of the total number of individuals with limb deficiency, it is important to be identified in order to give accurate genetic counselling including recurrence risk in siblings and possible prenatal diagnosis. This is the case report of a 22 days old male infant who presented with defective development of all four extremities and craniofacial abnormalities. The overall clinical and radiological features were suggestive of Roberts syndrome

Pattern of injuries inflicted on troops fighting, on the western front

To determine the pattern of fatal and non fatal injuries in soldiers and officers during the present war on Western front. Descriptive study with partly retrospective data collection. The study was carried out at Combined Military Hospital [CMH] Peshawar, the tertiary care centre for Pakistan Armed Forces serving FATA and NWFP from March 2004 to May 2009. Data of non-fatal injuries was collected by noting down the wounds inflicted on injured soldiers and officers evacuated from forward areas while the record of non-fatal injuries was noted from the hospital papers prepared for each patient. Due to reasons of confidentiality the analyses is based on percentages only, while actual figures can be provided by the authors on appropriate security cleared requests. The Lethality Index [LI] of wounds, calculated by dividing the fatal injuries by the total injuries, was 18% during these six years. Out of the total fatal injuries in all six years highest number occurred in 2008 [40%] while LI was highest in 2005 [25%]. Only a small number of patients [1.86%], who were evacuated alive, died in the hospital. Fifty one percent soldiers received multiple [>two] fatal injuries. Head [46%] and Chest [44%] were the commonest sites of fatal injuries while limbs were the commonest sites of non-fatal injuries. Gun shot wounds were the commonest [68%] mode of fatal and non-fatal injuries. Head and chest injuries are the commonest sites of fatal injuries, while limbs injuries constituted the major portion of the non-fatal injuries indicating potential areas in need of improved protective

Relationship of joint hypermobility and musculoskeletal problems and frequency of benign joint hypermobility syndrome in children

The majority of individuals with joint hypermobility remain asymptomatic. However, those associated with Benign Joint Hypermobility Syndrome [BJHS], develop a number of systemic manifestations. Our objective was to determine the relationship between joint hypermobility and musculoskeletal problems, and frequency of BJHS in children and adolescents. This crosssectional observational descriptive study was conducted at Outpatient Department, The Children's Hospital, Lahore, Pakistan. A total of 872 individuals [4-18 year] were examined for hypermobile joints using Beighton score >/= 4. A questionnaire was implied to get data regarding demographic profile, musculoskeletal and extra-articular complaints, family history of joint problems and daily activity. Brighton's criteria were implied for diagnosis of BJHS. The frequency of joint hypermobility was 37.0%; male 39.5%, and female 34.2% [p=0.1]. There was a gradual decline in mean Beighton score with age. The female population showed increase in mean Beighton score around 16-17 year age. Arthralgias and back pains 7.7% vs. 1.6%, [p<0.001], and hernias 2.5% [p=0.03] were significantly higher in individuals with joint hypermobility. History of joint problems in the family was also significantly higher in children with joint hypermobility [p=0.01]. BJHS was detected in 4.8% children [male 3.6% and female 6.3%, p=0.06]. Arthralgias [51.0%], hernias [16.3%], joint dislocations [8.2%] and varicose veins [8.2%] were the most common presentations. BJHS is common among children. Arthralgias, back pains and hernias are significantly higher in these individuals

Johanson-blizzarci syndrome with diamond-blackfan anemia

Johanson Blizzard syndrome [JBS] is a rare multi-system disorder characterized by congenital aplasia or hypoplasia of alae nasi, exocrine pancreatic insufficiency, hypothyroidism, deafness, growth retardation, varying degree of mental retardation, alopecia, wide open fontanels, anti-mongoloid slant, cafe-au-lait spots and absent of permanent teeth. We report a 3 months old male child having Johanson Blizzard syndrome with classical clinical features, pancreatic insufficiency and Diamond-Blackfan anemia

Comparison of diagnostic accuracy of core biopsy for breast lesions with fine needle aspiration cytology

To assess and compare the diagnostic usefulness of fine needle aspiration cytology [FNAC] of trucut biopsy of breast lesion. A comparative cross sectional study. The study was conducted in the surgical and pathology department of CMH Peshawar from February to August 2007. The first eighty two consenting female patients presenting with palpable breast lumps were subjected to FNAC then Trucut biopsy under local anaesthesia and later excision biopsy. Finally the results of FNAC and Trucut biopsy were compared in the light of excision biopsy results. There were 18 malignant and 64 benign cases on histopathology. On FNAC there were 5 in C5 category [confirmed on histopathology], 12 in C4 category [10 malignant on histopathology], 22 in C3 category [1 malignant on histopathology], 27 in C2 category [confirmed on histopathology] and 16 in C1 category [2 malignant on histopathology]. On Trucut 60 were benign and 17 malignant all of which were confirmed on histopathology. Five specimens were inadequate on Trucut [1 malignant on histopathology]. Sensitivities of FNAC and Trucut biopsy were 93.75-% and 100% and specificities were 96% and 100% respectively. Area under Receiver Operating Characteristic [ROC] curve for Trucut biopsy was found to be more than that of FNAC, showing that Trucut biopsy was more accurate than FNAC. Trucut biopsy has significantly higher diagnostic accuracy as compared to FNAC

Predictors of intractable childhood epilepsy

To determine the prognosis of seizures in epileptic children and identify early predictors of intractable childhood epilepsy. Case-control study. The Epilepsy Centre of the Children's Hospital Lahore, from February 2005 to April 2007. All children [aged 1 month to 16 years] with idiopathic or cryptogenic epilepsy who were treated and followed at the centre during the study period were included. The patients who had marked seizures even after two years of adequate treatment were labeled as intractable epileptics [cases]. Children who had no seizure for more than one year at last follow-up visit were the controls. Adequate treatment was described as using at least three anti-epileptic agents either alone or in combination with proper compliance and dosage. Records of these patients were reviewed to identify the variables that may be associated with seizure intractability. Of 442 epileptic children, 325 [74%] intractable and 117 [26%] control epileptics were included in the study. Male gender [OR=3.92], seizures onset in infancy [OR=5.27], >/= 10 seizures before starting treatment [OR=3.76], myoclonic seizures [OR=1.37], neonatal seizures [OR=3.69], abnormal EEG [OR=7.28] and cryptogenic epilepsy [OR=9.69] and head trauma [OR=4.07] were the factors associated with intractable epilepsy. Seizure onset between 5-7 years of age, idiopathic epilepsy, and absence seizures were associated with favourable prognosis in childhood epilepsy. Intractable childhood epilepsy is expected if certain risk factors such as type, age of onset, gender and cause of epilepsy are found. Early referral of such patients to the specialized centres is recommended for prompt and optimal management

Comparison of three prognostic scores [PRISM, PELOD and PIM 2] at pediatric intensive care unit under Pakistani circumstances

To compare the performance of the Pediatric Risk of Mortality [PRISM], the Pediatric Index of Mortality 2 [PIM 2] and Pediatric Logistic Organ Dysfunction [PELOD] scores at general pediatric intensive care unit in a developing country setting, investigating the relation between observed and predicted mortality. A contemporary cohort study was undertaken at Pediatric Intensive Care Unit [PICU], Children's Hospital, Institute of Child Health, Lahore, Pakistan. 131 consecutive admissions fulfilling the inclusion criteria were enrolled in the study. PRISM, PIM 2 and PELOD calculations were performed as set out by original articles, using the published formulae. Statistical analysis included Standardized Mortality Rate [SMR], Hosmer Lemeshow goodness of fit test, receiver operating curve [ROC] characteristics and Spearman's correlation test. 139 patients were admitted to PICU. 38 presented exclusion criteria. 29 [28.7%] patients died. Estimated mortality was; PRISM: 19.7[19.5%], PIM: 21.01[20.5%] and PELOD: 18.4[18.3%]. SMR was 1.47 [SD +/- 0.19], 1.4 [SD +/- 0.19] and 1.57 [SD +/- 0.19], respectively. PRISM had better calibration [x[2] = 7.49, p = 0.49] followed by PIM 2 [x[2] = 9.65, p = 0.29]. PIM 2 showed best discrimination with area under ROC = 0.88 [0.81-0.94] followed by PRISM 0.78 [0.67-0.89] and PELOD 0.77 [0.68-0.87]. Spearman's correlation r between PRISM and PIM 2 returned 0.74 [p < 0.001]. PRISM as well as PIM 2 is validated for PICU setting in Pakistani circumstances. PELOD performed poorly. PIM 2 has advantages over PRISM for stratification of patients in clinical trials

Short term Neurodevelopmental outcome of asphyxiated newborns at tertiary care unit

To find out the short term neurodevelopmental outcome of asphyxiated newborns. Cross-sectional study using prospective data. Neonatal unit of Children's Hospital, Lahore from August, 2000 to July, 2001. We included 150 cases of birth asphyxia and survivors were followed till the age of six months and neurodevelopmental status was assessed by Denver developmental screening test II [DDST-II]. Severity of asphyxia was categorized as no encephalopathy, three different stages of HIE. During follow up visits, normal to delayed developmental status was expected. Infants were divided into two groups. Group A included neonates without HIE and group B with encephlopathy. Among group B, newborns developmental delay was found in 9 neonates and 48 neonates died while in group A neonates there was no child who had developmental delay and only six newborns died.[P value<0.05] There were 117 [78%] males, 35 mothers [23%] had antenatal visits to trained medical professionals. Majority of mothers [76%] had their visits to non doctor personnel like midwives, lady health visitors or nurse. Majority [61%] of study population were home delivered, 24% at private clinics and maternity homes while only 14% came from hospitals. Different stages of HIE have strong correlation with the outcome of these neonates. More effort and resources should be directed to this preventable community problem

Management of thoracic injuries: our experience at military hospitals

Thoracic trauma is a major health care problem accounting for a significant percentage of the morbidity and mortality associated with the management of trauma patients. We performed a prospective study with the purpose to review our experience of the management of thoracic injuries at military hospitals having no proper thoracic surgical set up. The study was conducted at Combined Military Hospital Quetta and Combined Military Hospital Peshawar from January 2001 to September 2005 and a total of 84 cases of thoracic trauma with blunt and penetrating injury were managed. Mean age of patients was 36.5 years and female to male ratio was 1:13. Penetrating trauma was more common cause, 51 [61.7%] cases of chest injuries as compared to the blunt trauma 33 [39.3%] cases. The clinical conditions resulting ribs fractures in 73 cases [86.9%], flail chest in 3 patients [3.57%], haemothorax in 24 [28.57%] cases, pneumothorax in 8 [9.52%] cases, haemo-pneumothorax in 43 [51.19%] cases, pulmonary contusions in 5 [5.95%] cases, bronchial injury in 1 patient [1.19%], ruptured left diaphragm in 5 [5.95%] with herniation of abdominal contents in the left chest in 2 patients. Bilateral thoracic involvement was seen in 3 cases [3.57%]. Right chest was involved in 48 patients [57.14%] while the left in 36 patients [42.86%]. Extra-thoracic associated injuries were seen in 33 [39.3%] cases. Cardiac, great vessels, thoracic duct and esophageal injuries were not encountered during the course of this study. Seventy seven patients [91.66%] were treated initially with tube thoracostomy and it alone was effective in 69 patients [89.61%]. Overall thoracotomy rate was 9.52% [8 cases]. Emergency thoracotomy was performed in 3 [3.57%] cases and delayed thoracotomy in 5 [5.95%] cases. Empyema thoracic was seen in 3 patients [3.9%] with tube thoracostomy. Overall percentage of empyema was 3.57%. Seven patients [8.33%] were managed without the need of either tube thoracostomy or thoracotomy. Minor complications of tube thoracostomy were seen in 10 cases [12.99%]. Overall mortality rate was 3.57% [3 deaths]. Tube thoracostomy remains the most effective treatment modality in the management of most of the cases of chest trauma

Management of periorbital defects with local flaps after resection of basal cell carcinoma eye lids

Basal cell carcinoma [BCC] is the most common malignant tumour of eyelids. In this study management of periorbital defects of patients treated for BCC is described. A prospective study. This study was done from June 2001 to October 2003 at CMH Quetta. This study included all the patients suffering from BCC who were treated for periorbital defects resulting from resection of BCC. Fifteen patients with periorbital BCC were included in this study. Eight were males and seven were females. Ages varied from forty to seventy years. These patients were treated by cheek flap, muscular flap, Glabellar flap and Tenzel flap. An early detection and timely management of eyelid BCC give excellent results and prevent disfigurement and morbidity