Aggressive behavior and prognosis in patients with mild cognitive impairment / Comportamento agressivo e prognóstico em pacientes com comprometimento cognitivo

ABSTRACT The diagnosis of mild cognitive impairment (MCI) is associated with an increased risk of developing dementia. When evaluating the further prognosis of MCI, the occurrence of neuropsychiatric symptoms, particularly aggressive and impulsive behavior, may play an important role. Objective: The aim of this study was to evaluate the relationship between aggressive behavior and cognitive dysfunction in patients diagnosed with MCI. Methods: The results are based on a 7-year prospective study. At the time of inclusion in the study, participants, recruited from an outpatient clinic, were assessed with Mini-Mental State Examination (MMSE) and the Cohen-Mansfield Agitation Inventory (CMAI). A reassessment was performed after 1 year using the MMSE scale in all patients. The time of next MMSE administration was depended on the clinical condition of patients took place at the end of follow-up, that is, at the time of diagnosis of the dementia or after 7 years from inclusion when the criteria for dementia were not met. Results: Of the 193 patients enrolled in the study, 75 were included in the final analysis. Patients who converted to dementia during the observation period exhibited a greater severity of symptoms in each of the assessed CMAI categories. Moreover, there was a significant correlation between the global result of CMAI and the results of the physical nonaggressive and verbal aggressive subscales with cognitive decline during the first year of observation. Conclusions: Despite several limitations to the study, aggressive and impulsive behaviors seem to be an unfavorable prognostic factor in the course of MCI.

RESUMO O diagnóstico de comprometimento cognitivo leve (CCL) está associado a um risco aumentado de desenvolver demência. Ao avaliar o prognóstico adicional do CCL, a ocorrência de sintomas neuropsiquiátricos, particularmente o comportamento agressivo e impulsivo, pode desempenhar um papel importante. Objetivo: Avaliar a relação entre comportamento agressivo e disfunção cognitiva em indivíduos com diagnóstico de CCL. Métodos: Nossos resultados são baseados em um estudo prospectivo de sete anos. No momento da inclusão no estudo, os participantes, recrutados em um ambulatório, foram avaliados com o Mini-Exame do Estado Mental (MEEM) e o Inventário de Agitação de Cohen-Mansfield (CMAI). A reavaliação foi realizada após um ano com a escala MEEM em todos os pacientes. O momento da próxima administração do MEEM dependeu da condição clínica dos indivíduos e ocorreu no final do acompanhamento, ou seja, no momento do diagnóstico da demência ou após sete anos da inclusão, quando os critérios para demência não foram atendidos. Resultados: Dos 193 pacientes incluídos no estudo, 75 foram incluídos na análise final. Os indivíduos que converteram para demência durante o período de observação exibiram uma maior gravidade dos sintomas em cada uma das categorias avaliadas pelo CMAI. Além disso, houve uma correlação significativa entre o resultado global do CMAI e os resultados das subescalas de agressão física e verbal com declínio cognitivo durante o primeiro ano de observação. Conclusões: Apesar das várias limitações do estudo, os comportamentos agressivos e impulsivos parecem ser um fator prognóstico desfavorável no curso do CCL.

Comparative results of repair of ischemic mitral regurgitation [IMR]: conventional against trans-septal approach

Objective Ischemic mitral regurgitation is common and increases mortality, even when mild. [American Heart Association] AHA and European association have both stressed the need of mitral valve repair in patients with moderate or more regurgitation. The aim of this study was to compare the results with the conventional and right atrial trans-septal approach of mitral valve repair in Ischemic Mitral Regurgitation [IMR]

Methodology A total of 308 consecutive patients underwent mitral valve repair for IMR, between January 2012 and December 2013 at Tabba Heart Institute. Patients who had at least moderate mitral regurgitation or more mitral regurgitation underwent mitral regurgitation repair. The final decision of mitral valve repair was taken after the intra operative trans-esophageal echocardiography [TEE]

Result Total number of patients included in study was222, out of those 153 [69.9%] patients underwent conventional approach and 69 [31.1] patients underwent trans-septal approach. Total 88.2% patients got off bypass in normal sinus rhythm in conventional approach group, as compared to 82.1% in transseptal group. 11.8% and 17.9% patients got off by pass on pacing in conventional and transseptal approach respectively. 3 patients developed junctional rhythm and 5 patients developed complete heart block in post-operative period in trans-septal approach

Conclusion Right Atrial Trans-septal technique is a good alternative approach that can be used in relatively small atria. It not only provides an excellent exposure to the mitral valve, there also seems to be no associated rhythm disturbances encountered as well

Radiological mean age of fusion of medial end of the clavicle: a parameter of age

Objective: To determine the mean age of fusion of medial end of clavicle by radiography

Study Design: Cross-sectional study

Place and Duration of Study: Departments of Forensic Medicine, Dow Medical College and Ziauddin University, Karachi, from June 2010 to May 2011

Methodology: The subjects for this study were selected from various government colleges of Karachi. The subjects were analyzed for age and further confirmation was done by interviews where birth records and other physical parameters of age were also assessed. X-rays chest PA view was taken focusing on the medial end of clavicle; and were examined by a consultant radiologist and complete fusion of the medial end was noted. P-value less than 0.05 was considered significant

Results: The mean age of fusion of medial end of the clavicle was found to be 21 +/- 1.43 years. Significant difference was observed in male to female age of fusion 21.14 +/- 1.41 years versus 20.65 +/- 1.94 years [p > 0.05]. Similarly, statistically significant differences were observed between lower to middle income class and higher income class of all society. No difference was observed among various ethnic groups

Conclusion: Socio-economic factors, such as diet and nutrition, directly affect bone growth and hence bones' age. The results of fusion of the medial end of the clavicle are not affected by ethnicity; however, it is significantly affected by gender. More studies should be conducted in various parts of the country to make a natural standard in setting up uniform criteria for assessing age at or above 21 years

Ultrasound guided internal jugular venous cannulation: comparison with land-mark technique

To compare real-time ultrasonography-guided technique versus the traditional land-mark technique for internal Jugular venous cannulation. Randomized controlled trial. Department of Anaesthesia, Combined Military Hospital, Rawalpindi, from September 2013 to July 2014. A total of 200 patients who required internal jugular vein cannulation were randomly assigned using either real-time ultrasound-guided technique or land-mark technique. Access time, number of attempts until successful cannulation, complications and the demographics of each patient were recorded. Access time was significantly less in real-time ultrasound group [34.95 +/- 11.47 vs. 146.59 +/- 40.20 seconds, p < 0.001]. Cannulation was performed in first attempt in 99% of patients in ultrasound group as compared to 89% of landmark group. Complication rate was significantly higher in the land-mark group than in the ultrasound-guided group. Carotid artery puncture rate [9% vs. 1%] and haematoma formation [7% vs. 0%] were more frequent in the land-mark group than in the ultrasound-guided group. Brachial plexus irritation was also more in land-mark group [6% vs. 0%]. Access time, failure rate and procedure related complications are reduced when real-time ultrasonography is used to cannulate internal Jugular vein

Complications in laparoscopic cholecystectomy

Objective: to list and understand the types and the rate of complications associated with laparoscopic cholecystectomy done by a small group of surgeons over a decade at four military hospitals PNS Shifa Karachi, CMH Rawalpindi, MH Rawalpindi and PNS Hafeez Islamabad

Study Design: observational and descriptive study

Place and Period of study: CMH Rawalpindi from January 2003 to December 2012 [10 years]

Patients and Methods: case records of all patients [both genders and all age groups] undergoing laparoscopic cholecystectomy over a period of ten years were reviewed. Fifteen hundred patients with a clinical follow up record of at least six months were included in the study. Complications were grouped into three main categories, per operative, early post-operative and late post-operative. They were further sub-grouped into major and minor categories. A major complication was regarded as one causing significant morbidity or likely to be potentially fatal if not treated expeditiously. Data analysis included calculation of the number of patients, rate and percentage of different types of complications

Results: complications occurred in 495 [33%] cases. Major complications occurred in 199 [13.27%] cases. In the remaining 296 [19.73%], the complications were labeled as minor. Conversion to open surgery occurred in 147 [9.8%]. Post-cholecystectomy laparoscopic re-intervention within 48 hours was done in 3 [0.2%] cases. There was one mortality due to septicemia following bowel injury

Conclusion: the risk of complications is a possibility in any patient undergoing laparoscopic cholecystectomy despite remarkable advances in instrumentation and video systems. Most common complication is hemorrhage [1.3%] followed by CBD injuries [.13%]. Due attention to risk assessment, patient and family counseling, importance of valid consent and a flexible approach to conversion to open surgery is stressed

Comparison of ropivacaine and bupivacaine as single-shot epidural anaesthesia for orthopaedic surgery

To compare the efficacy and side-effects of 0.5% ropivacaine with that of 0.5% bupivacaine when used for single-shot epidural anaesthesia for orthopaedic surgery. Randomized controlled trial. Department of Anesthesiology, Combined Military Hospital Rawalpindi, over a period of eight months from June 2013 to January 2014. The study was carried out in 60 ASA physical status I, II or III patients undergoing elective lower extremity orthopedic surgery. Two groups of 30 patients each received single-shot epidural anaesthesia either with ropivacaine 0.5% [ropivacaine group] or bupivacaine 0.5% [bupivacaine group]. Onset, time for maximum height and median height of sensory block was assessed as well as time to two segment recession. Modified Bromage scale was used for motor blockade. Total duration of motor block and common side effects were also recorded. The patients in both groups were similar in age, height, weight, gender and ASA status. There was no significant difference in onset of sensory block and time for maximum height of sensory block. The median heighest level of sensory block was T6 [T5-T8] for ropivacaine group and T5 [T4-T7] for bupivacaine group. Time for two segment regression and duration of sensory block were also comparable for both groups. The total duration of motor block was significantly more in bupivacaine group [159 min vs 134.2 min, p< 0.001]. Modified Bromage scale was also significantly higher in bupivacaine group [2.86 vs 1.96 min, p<0.001]. Side effects like hypotension, bradycardia, nausea, vomiting and shivering were similar in both groups. Epidural administration of 0.5% ropivacaine provided effective and good quality anaesthesia. Motor blockade was of less duration as compared to equivalent dose of 0.5% bupivacaine, which may offer potential benefit of early patient mobilization after orthopaedic surgery

Zolmitriptan is effective in relieving post-dura! puncture headache in young parturients

This comparative study was designed to assess the efficacy of zolmitriptan, a triptan widely employed as first-line therapy for migraine, in relieving post-dural puncture headache in parturients who were operated for cesarian section under spinal anesthesia. The study was carried out at department of Anesthesiology, Combined Military Hospital Rawalpindi, over a period of twelve months from August 2012 to July 2013. We enrolled 60 adult parturients who complained of post-dural puncture headache in post-partum period. They were divided into two equal groups of 30 each; Group-1 [Z-group] received zolmitriptan along with other supportive treatment for spinal headache and Group-2, control group [C-group] was given only supportive treatment. Efficacy of zolmitriptan in relieving post-dural puncture headache [PDPH] was studied and frequency of complications of the drug were noted. After 6 hours, 60% patients of Z-group got relief from headache. While in control group only 36.66% patients were pain free [p 0.016]. After 12 hours, relief from headache was noted in 70% patients of zolmitriptan-group while in C-group only 46.66% were relieved [p 0.015]. After a period of 24 hours results were 86.66% vs. 63.33% [p 0.006]. After 48 hours, in Z-group 96.66% patients were pain free, while in C-group 63.33% were free from headache [p 0.001]. There was no change in results for Z-group after 72 hours. In contrast, in C-group 80% were pain free and 20% patients were still symptomatic. Borderline statistical significance was present [p 0.046]. The study revealed that anti-migraine drug zolmitriptan in combination with supportive treatment is effective in relieving PDPH in parturients