Assessment of potential interaction between simvastatin and clarithromycin in healthy adult male subjects

Cardiac patients with weak immune system are susceptible to bacterial infections. Their prescriptions frequently contain simvastatin and clarithromycin together. The objective of present project was to assess the potential interaction between simvastatin and clarithromycin by evaluating the clarithromycin effects on the pharmacokinetics of simvastatin in healthy adult male subjects. The study design comprised of two phases, used at interval of one week. In first phase simvastatin 20 mg alone was administered to each volunteer. In second phase, co-administration of simvastatin 20 mg with clarithromycin 250 mg was made under similar specified conditions. Blood samples were collected at specified time intervals. Simvastatin plasma concentrations were analyzed through High Performance Liquid Chromatography with UV detector at 238 nm wavelength. Using one compartment open model, MW/PHARM version 3.02 software program was used by F. Rombut for pharmacokinetic parameters calculation. Clarithromycin co-treatment resulted in 2.3 fold increase in maximum plasma concentration Cmax [from 2.47 +/- 0.34 ng.mL-1 to 5.66 +/- 1.18 ng.mL-1; p<0.05] and 3.9 fold increase in area under time versus concentration curve from 0 to 10 hours AUC0-10 [from 15.10 +/- 3.73 ng.hr.mL-1 to 58.49 +/- 15.73 ng.hr.mL-1; p<0.05] of simvastatin. These results suggest that co-prescription of simvastatin and clarithromycin should be avoided to minimize the adverse events resulting from high simvastatin concentration, without sacrificing therapeutic worth of simvastatin

Comparison of functional outcome in Mayo Elbow performance score in Olecranon Fractures after treatment with Tension band wiring and locking compression plate

Objective: To compare mean change in the Mayo Elbow Performance Score in olecranon fracture after treatment with tension band wiring and locking compression plate

Study Design: Randomized controlled trial

Place and Duration of Study: Department of Orthopaedics, Benazir Bhutto Hospital Rawalpindi, from Aug 2015 to Aug 2016

Material and Methods: Sixty patients were included in the study. Patients were divided into two groups, A and B. For group A, Locking compression plate while in group B tension band wiring was used. Follow-up was carried out at the end of 1st week and then at the end of 6th week post-operatively. Functional outcome was assessed by mean change in Mayo Elbow Performance Score

Results: Mean age in the study was 43.62 +/- 12.187 years. There were 32 [53 percent] male patients and 28 [47 percent] female patients, while 34 [57 percent] patients had Mayo IIB fractures and 26 [43 percent] had mayo IIA fractures. Twenty five patients [42 percent] belonged to ASA class II while 35 [58 percent] belonged to ASA class I. Twenty Six patients [43 percent] presented within 24 hours of the injury while 34 [57 percent] presented within 48 hours. Mean change in the Mayo Elbow Performance Score in TBW group was 8.77 +/- 3.54 versus 10.63 +/- 3.479 for the LCP group [p=0.044]

Conclusion: Locking Compression plate is superior to Tension Band Wiring in patients with olecranon fracture in terms of Mayo Elbow Performance Score

Antimicrobial activity of prunella vulgaris extracts against multi-drug resistant escherichia coli from patients of urinary tract infection

Background and Objective: Escherichia Coli is the most common etiological agent of UTI and accounts for more then 100, 0000 hospitalization annually. The objective of this study was to investigate the antimicrobial activity of aqueous and ethanolic extracts of Prunella vulgaris against E. coli from urinary tract infection patients

Methods: Urine samples of forty four suspected patients from Tertiary Care Hospital Faisalabad were used in this study. Ethanolic and aqueous extracts of Prunella vulgris [PV], a medicinal plant was evaluated for its ability to inhibit the growth of 38 resistant isolates of Escherichia coli strains and compared to Ciprofloxacin, Ofloxacin, Cefixime and Tobramycin by well diffusion method. Minimum inhibitory concentration was measured by using broth micro dilution method

Results: PV showed antibacterial activity against Escherichia coli strains, however Tobramycin at 10 microgram [10?g] inhibited the resistant E. coli to a greater extent as compared to other antibiotics and was resistant to twice less number of strains, about 82% of E. coli isolates have MDR pattern

Conclusion: Ciprofloxacin has more efficacy than PV and no synergistic effect with extracts of PV. Cefixime is least efficacious against resistant E. coli, however it has synergistic effect with extracts of PV

Disaster management in combined military hospital Quetta

Objective: To review the mass casualty management at Combined Military Hospital Quetta [CMH QTA], from 2012 to 2015 and to recommend measures for enhancement of capabilities in order to handle major mass casualty events

Study Design: Descriptive, cross sectional

Place and Duration of Study: Combined military hospital Quetta, from Jan 2012 to Dec 2015

Material and Methods: This study is a review of the patients brought to CMH QTA, in different types of mass casualty events from 2012 to 2015. The type of trauma, the procedure carried out and the patient outcome in each case was recorded. The data were analyzed and based upon the mortality and morbidity of casualties, the evaluation of facilities available and required was carried out as per Joint Commission on Accreditation of Healthcare Organizations [JCAHO] standards

Results: Over a period of four years, out of 3507, the highest number of casualties [42%] were received in year 2013. Civilians represented the commonest victims [79%] followed by army personnel [13%] and frontier corps [8%]. The gunshot wounds and Improved Explosive Device [IED] blasts were on the top [53.5%] as a cause of mass casualty followed by road traffic accidents [37.5%]. The highest number of patients [89%] underwent minor procedures like debridement, stitching and aseptic dressing. Twenty five percent of patients required a team work of various surgical specialists

Conclusion: The existing resources are sufficient for managing minor and moderate mass casualty scenarios but proper planning and enhancement of resources [equipment, infrastructure and personnel] is essential to cope with any probable major mass casualty event. We recommend training of paramedical staff for receiving, triage, resuscitation and definitive management of casualties

Frequency and antibiogram of isolates from surgical units of a tertiary care hospital in Quetta

Objective: To determine the frequency and antibiogram of the isolates from infected patients in surgical units of a tertiary care hospital

Study Design: Cross-sectional, descriptive study

Place and Duration of Study: Department of Microbiology, Combined Military Hospital, Quetta, from March to October 2015

Methodology: Clinical samples from the surgical units received in Department of Microbiology for culture and sensitivity were analyzed by Gram stain, culture and biochemical tests for identification of the isolates; and the antibiotic susceptibility was determined by modified Kirby Bauer disc diffusion method. Data was analyzed by Statistical Package for Social Sciences [SPSS] version 19

Results: The commonest isolate was Acinetobacter baumannii [22%] followed by Escherichia coli [20%], Pseudomonas spp. [15%] and Methicillin-resistant Staphylococcus aureus [MRSA] [11%]. Acinetobacter baumannii showed highest susceptibility to doxycycline [41%], Enterobacteriaceae to meropenem [96%], Pseudomonas spp. to polymyxin-B [100%] and Gram positive bacteria to linezolid [100%]. Seventy-two percent of the isolates were found to be multi-drug resistant

Conclusion: There was a high infection rate in surgical patients with Acinetobacter baumannii, Eschericia coli, Pseudomonas spp. and MRSA being the commonest isolates. Acinetobacter baumannii showed highest susceptibility to doxycycline, Enetrobacteriaceae to meropenem, Pseudomonas spp. to polymyxin-B and Gram positive bacteria to linezolid

Pharmacokinetic behavior of montelukast in indigenous healthy male volunteers

Aim of present study was to investigate the pharmacokinetic behavior of Montelukast in the healthy male volunteers under indigenous conditions. One tablet of montelukast 10 mg was administered in each subject and blood at different time intervals. Concentration of montelukast in plasma samples was analyzed by high performance liquid chromatography method to calculate pharmacokinetic parameters. The plasma concentration of montelukast was in the range of 1.31-1.76 micro g/mL at 0.5-12 hours with C[max] value of 1.59+/-0.16 micro g/mL at 3.71+/-0.64 hours. These values of plasma drug concentrations were above the minimum effective concentration of montelukast during the entire study hours. Absorption and elimination half-lives of the montelukast were evaluated as 2.52+/-0.54 hours and 2.63+/-0.35 hours, respectively. The volume of distribution and total body clearance of montelukast were investigated as 0.34+/-0.01 L/kg and 0.01+/-0.00 L/hr/kg, respectively. The pharmacokinetic parameters i.e. Cmax, AUC, t1/2, Vd and ClB of montelukast calculated in present study were found different as compared to that of the previous literature values which was due to genetic and environmental variation

Supervisors' perspective on electronic logbook system for postgraduate medical residents of CPSP

Objective: To find out the perspective of the supervisors about the role of electronic logbook [E-Logbook] of College of Physicians and Surgeons, Pakistan [CPSP] in monitoring the training of postgraduate medical residents of CPSP

Study Design: Descriptive cross-sectional study

Place and Duration of Study: College of Physicians and Surgeons Pakistan [CPSP], Karachi, from May to October 2015

Methodology: An electronic computer-based questionnaire designed in Hypertext Preprocessor [PHP] language was distributed to the registered CPSP supervisors through the e-log system. The questionnaire comprised of seven close ended questions. The data were entered and analyzed by SPSS version 20. Descriptive statistics were determined

Results: A total of 1,825 supervisors responded to the questionnaire. Fifteen hundred and ninety-eight [87.6%] supervisors gave regular feedback for their trainees, 88.2% considered it a better monitoring tool than conventional logbook, 92.5% responded that e-logbook helped in the regular assessment of the trainees, 87.8% believe that quality of training will improve after introduction of e-logbook, 89.2% found e-logbook useful in implementation of outcome-based learning and 88.4% considered e-logbook user-friendly. The main reasons for not providing regular feedback included the supervisors not familiar to e-logbook interface, internet access problems, and busy schedules of supervisors

Conclusion: There was a wide acceptability of the e-log system among the supervisors with positive perception about its usefulness. The common reasons that hinder the provision of regular feedback include not being familiar to e-log interface, internet access problem, busy schedule and some consider using e-logbook a cumbersome task. These reasons can be alleviated to provide a better training monitoring system for the residents

Frequency of different causes of upper gastrointestinal bleeding using endoscopic procedure at a tertiary care hospital

To assess the outcome of early endoscopy in terms of frequency of different causes of upper gastrointestinal bleeding at a tertiary care hospital. Cross sectional descriptive study. Outpatients / indoor patients, Department of Medicine Military Hospital Rawalpindi from 1[st] Jan 2010 to 30[th] June 2010. Study was carried out in department of medicine Military Hospital Rawalpindi. Two hundred and forty four after cosen. Patients of upper gastrointestinal bleeding fulfilling the inclusion criteria were included in the study. Haemodynamically stable patients were kept empty stomach for at least 6-8 hours before procedure. A detailed history and thorough physical examination was carried out. Protocols for endoscopic examination were followed. Mandatory baseline investigations were obtained. Endoscopic findings were documented on a proforma. p value of less than 0.05 was considered statistically significant. There were 174 males [71.3%] and 70 females [28.7%]. The age of the patients ranged from 15 years to 75 years, mean age was 52.23 years [SD = 14.78]. The most common cause of upper GI bleed was varices in 176 [72.1%] patients; followed by gastric ulcer in 24 [9.8%] patients. Other causes in order of decreasing frequency included gastritis 16[6.55%], duodenal ulcer 14[5.73%], esophagitis 6[2.45%], Mallory Weiss tear 2[0.81%] and miscellaneous 6[2.45%]. Esophageal varices is the most common cause of upper GI bleed in our set up reflecting high prevalence of liver cirrhosis secondary to chronic HBV and HCV infection

Diabetes mellitus prediction; Serum lipids, ALT and fasting blood glucose: using serum lipids and ALT

The rapid change in lifestyles and dietary has led to a pandemic of diabetes mellitus. The diagnosis of diabetes mellitus sometimes requires 2 hr OGTT sampling. Recent evidence has shown that there are lipid related abnormalities associated with diabetes mellitus, so a consideration comes in fortheir utilization as a marker to support diabetes mellitus. [1] To correlate serum total cholesterol, triglycerides and ALT with fasting blood glucose [2]. To predict diagnosis of diabetes mellitus using above serum markers. Cross-sectional analysis, descriptive study. This study was carried out between Mar-2010 to Jan-2011 at the department of pathology, PNS RAHAT in collaboration with PNS SHIFA. A total of 251 subjects were screened for presence of glucose dysregulation. Based upon the results of fasting blood glucose, subjects were grouped as having normal glucose tolerance [NGT], impaired fasting glucose [IFG], and newly diagnosed diabetes mellitus [NDDM]. A comparison of lipids including triglycerides, total cholesterol and alanine aminotransferase [ALT] were made in the above groups to measure the differences between the above mentioned three groups. ALT, triglyceride and total cholesterol were correlated with results of fasting blood glucose through pearson's correlation. Later the performance of different cut-offs of triglycerides, total cholesterol and two mathematical models [[Factor-l=FBG [mmol/L] + triglycerides [mmol/L]] and [Factor-ll=FBG [mmol/L] + triglycerides [mmol/L] + total cholesterol [mmol/L]]] were evaluated for detecting diabetes mellitus against the gold standard 2 hr OGTT in 71 subjects. The results of triglycerides, total cholesterol and serum ALT between the three groups were as: [[Triglycerides: NGT =1.91, IFG =2, 10, NDDM= 2.75, p=0.003] [total cholesterol: NGT=5.03, IFG=5.19, NDDM=5.74, p=0.056] [ALT:NGT=28.47, IFG=27.95, NDDM=25.78, p=0.846]]. Most correlation was found between serum triglycerides and fasting blood glucose [r2=0.235, p<0.001]; while serum total cholesterol and ALT showed lesser correlations [[total cholesterol:r2= 0.172, P=0.007], [ALT:r2= 0.010, p= 0.877]]. While triglycerides demonstrated superiority in terms of sensitivity to total cholesterol for detection of diabetes mellitus, the factors incorporating lipids and glucose had the highest overall diagnostic efficiency. Triglycerides and total cholesterol levels rise from normoglycemic individuals to subjects having impaired fasting glucose and newly diagnosed diabetics. The inclusion of triglycerides and total cholesterol for diagnosis of diabetes mellitus improves the chances of for detection of diabetes mellitus

Medical professionalism: a panoramic view through the kaleidoscope of stakeholder perspectives

Background: Recently, over the last couple of decades, great emphasis is being placed on the role of professionalism in medical education. This interest has intensified following the positive relationship identified between unprofessional behaviour in medical schools and subsequent practice. This paper aims to develop an understanding of the perceptions of various stakeholders regarding the subject in the local setting and tries to relate it to the global context. Methods: This was a qualitative study conducted in 2011 involving the faculty and students of the University of Health Sciences Lahore. An open-ended questionnaire was fashioned following brainstorming and utilising Delphi technique involving representatives of the students, faculty and the public. Responses from all the respondents were entered into Microsoft Excel data sheet and then imported into Qualitative Data Analysis Software 'NVIVO 9'. Themes were extracted from the responses. Results: Overall 650 questionnaires were distributed amongst the faculty, students and general public. Response rates were 74%, 68% and 59% respectively. Commonalities and differences in the perceptions of the various stakeholders of medical profession including the medical practitioner, public and the medical students were identified. Conclusion: The product of the healthcare professional education system needs to conform to the global standards applied within local settings. It is the identification of the local setting that is critical to devising a costeffective and efficient curriculum, which amongst others includes teaching/training/learning and practice of professionalism

Surgical management and outcome analysis of extradural hematoma at combined military hospital Rawalpindi

The aim of this study is to see the frequency of extradural hematomas [EDH] at neurosurgical centre CMH Rawalpindi. Descriptive study. Department of Neurosurgery CMH Rawalpindi over a period of 2 years [Jan 2001 to Jan 2003]. All patients with head injury reporting to trauma center CMH Rawalpindi from 2001 to 2003 were reviewed. Using non-probability convenient sampling, patients with closed head trauma were included in the study. A total of 1215 patients were reviewed during the study period. Maximum patients were under 12 years of age. Extradural haematoma was found in 23 [2%] patients. Out of 23 patients, 18 [78%] were males and 5 [22%] were females, the male to female ratio was 3.5:1. Alteration of consciousness was the most common presentation [61%]. Location of EDH was temporoparietal in majority of patients. Bilateral EDH was found in 1 patient only. At 6 months follow up, good recovery was observed in 15 [65%] patients. Level of consciousness at the time of surgery is the single most important decisive factor in the outcome hence early diagnosis and surgical intervention is essential

Management of multilevel lumbar disc herniation

To identify and document more then one level symptomatic lumbar disc herniation and to find its frequency presentation and outcome. Descriptive study Combined Military Hospital Rawalpindi from 2001 to 2002. A total number of 260 male patients were selected from out patient department over a period of 1 year. After clinical evaluation, confirmation was done by nonenhanced Electro-resonance imaging [MRI] of the lumbar spine. All the patients with multilevel disc herniation on MRI underwent never conductions [NCS] electromyography [EMG] studies. All the patients were males. Maximum number of patients was between 32 - 40 years of age; mean age was 35 with a standard deviation of 2. 48 belonged to military setup and 82 were civilians. Out of all, 14 had multilevel lumbar disc herniations, the frequency being 5.8 in our study. All the patients with multilevel disc herniations underwent surgery. Only 4 patients had multilevel discectomy where 10 had discectomy at single level. Mortality was nil and there were no postoperative neurological deficits. All the patients were back to work at 6 weeks. Data was analyzed using the descriptive SPSS package. The identification of symptomatic multilevel disc herniation is extremely important in order to manage the patients with multilevel disc herniation as single level discectomy in such patients will not ameliorate the symptoms and may require another difficult surgery

Head trauma due to earthquake October 2005 - experience of 300 cases at the combined military hospital Rawalpindi

To assess the spectrum and management of he ad injuries among earthquake victims. Case series. The study was conducted at Surgical Ward II, Combined Military Hospital, Rawalpindi, from October 2005 to December 2006. Three hundred consecutive cases of head injury, secondary to earthquake were included in the study. Plain X-rays of skulls were undertaken in clinically stable patients with head injuries. Cases with altered level of consciousness and compound depressed fractures were advised CT scan of head. Pus swabs were taken from open wounds. Proformas were maintained for every patient. Head injury was classified as mild, moderate and severe, and each patient was treated accordingly. One hundred and twenty three [41%] patients were children under 10 years of age. Adults below 55 years were 69 [23%] and above 55 years were 108 [36%]. Mean age was 32.2 years [SD + 6.7]. Female to male ratio was 1.1:1. One hundred and sixty five [55%] cases were of mild head injury, 103 [34.3%] patients had moderate head injury and 32 [10.7%] patients had severe head injury. Majority [48.7%] of patients was managed conservatively. Minor surgeries were done in 17% of patients and major surgeries were done in 34.3% of patients. Glasgow Outcome Scale assessment was made at the end of 6 months and 1 year. Mortality increased from 3.3% to 7% in one year time. Patients at the extremes of age are more vulnerable to trauma and should be given timely attention in disaster management plans. General and trauma surgeons should be well-versed with the techniques and indications of burr hole evacuation of life threatening intracranial haematomas in situations, where early evacuation is unattainable

Peripheral vascular trauma an experience of two years

The incidence of vascular trauma has increased considerably during last 40 years. The study was carried out to describe the causes of injury, presentations, surgical approaches, outcome and complication of vascular trauma of the upper and lower limbs. This was a descriptive study. Surgical Department CMH Kharian, in which this study lasted from Oct 1997 to Oct 1999. In the study, 30 patients were operated for peripheral vascular injuries. Diagnosis was made by physical examination and hand Doppler alone. Primary vascular repair was carried out where possible; if not interposition vein graft was placed. Early liberal fasciotomy was considered as and when required. Patients with isolated venous trauma and patients with obviously unsalvageable lower extremity injury requiring primary amputation were excluded from the study. The limb salvage rate was 93.3%. A total no of 30 patients were included in this study. Out of these 24 [80%] were males and 6 [20%] were females, all were young adults with age ranging from 14 to 52 years, a mean age of 22 years and a standard deviation of. Gun shot wound [GSW] constituted the major cause of trauma and was present in 18 [60%] Patients, road traffic accident [RTA] in 6 [20%] patients and stab wound in 6 [20%] patients which are comparable to international studies. Primary end-to-end anastomosis was done in 20 [66.07%] patients and graft interposition was done in 10 [33.3%] patients. Vein graft was used in 20 [66.07%] patients lateral repair was done in 7 [23.3%] patients while in 3 [10%] patients ligation was performed. Early complications included bleeding in 2 [6.7%], thrombosis in 4 [13.3%] and wound infection in 3 [10%] patients respectively. Late complications are amputation in 2 [6.7%] patients and muscle ischaemia in 2 [6.7%] patients. Decisive management of peripheral vascular trauma will maximize patient survival and limb salvage. Priorities must be established in the management of associated injuries, and delay must be avoided when ischemic changes are present. Early fasciotomy is warranted if there is any suspicion of occurrence of compartment syndrome