Modulatory effects of rutin and vitamin A on hyperglycemia induced glycation, oxidative stress and inflammation in high-fat-fructose diet animal model.

In the current study we investigated the impact of combination of rutin and vitamin A on glycated products, the glyoxalase system, oxidative markers, and inflammation in animals fed a high-fat high-fructose (HFFD) diet. Thirty rats were randomly divided into six groups (n = 5). The treatments, metformin (120 mg/kg), rutin (100 mg/kg), vitamin A (43 IU/kg), and a combination of rutin (100 mg/kg) and vitamin A (43 IU/kg) were given to relevant groups of rats along with high-fructose high-fat diet for 42 days. HbA1c, D-lactate, Glyoxylase-1, Hexokinase 2, malondialdehyde (MDA), glutathione peroxidase (GPx), catalase (CAT), nuclear transcription factor-B (NF-κB), interleukin-6 (IL-6), interleukin-8 (IL-8) and histological examinations were performed after 42 days. The docking simulations were conducted using Auto Dock package. The combined effects of rutin and vitamin A in treated rats significantly (p < 0.001) reduced HbA1c, hexokinase 2, and D-lactate levels while preventing cellular damage. The combination dramatically (p < 0.001) decreased MDA, CAT, and GPx in treated rats and decreased the expression of inflammatory cytokines such as IL-6 andIL-8, as well as the transcription factor NF-κB. The molecular docking investigations revealed that rutin had a strong affinity for several important biomolecules, including as NF-κB, Catalase, MDA, IL-6, hexokinase 2, and GPx. The results propose beneficial impact of rutin and vitamin A as a convincing treatment strategy to treat AGE-related disorders, such as diabetes, autism, alzheimer's, atherosclerosis.

Passivity-based Rieman Liouville fractional order sliding mode control of three phase inverter in a grid-connected photovoltaic system.

Photovoltaic (PV) system parameters are always non-linear due to variable environmental conditions. The Maximum power point tracking (MPPT) is difficult under multiple uncertainties, disruptions and the occurrence of time-varying stochastic conditions. Therefore, Passivity based Fractional order Sliding-Mode controller (PBSMC) is proposed to examine and develop a storage function in error tracking for PV power and direct voltage in this research work. A unique sliding surface for Fractional Order Sliding Mode Control (FOSMC) framework is proposed and its stability and finite time convergence is proved by implementing Lyapunov stability method. An additional input of sliding mode control (SMC) is also added to a passive system to boost the controller performance by removing the rapid uncertainties and disturbances. Therefore, PBSMC, along with globally consistent control efficiency under varying operating conditions is implemented with enhanced system damping and substantial robustness. The novelty of the proposed technique lies in a unique sliding surface for FOSMC framework based on Riemann Liouville (R-L) fractional calculus. Results have shown that the proposed control technique reduces the tracking error in PV output power, under variable irradiance conditions, by 81%, compared to fractional order proportional integral derivative (FOPID) controller. It is reduced by 39%, when compared to passivity based control (PBC) and 28%, when compared to passivity based FOPID (EPBFOPID). The proposed technique led to the least total harmonic distortion in the grid side voltage and current. The tracking time of PV output power is 0.025 seconds in PBSMC under varying solar irradiance, however FOPID, PBC, EPBFOPID, have failed to converge fully. Similarly the dc link voltage has tracked the reference voltage in 0.05 seconds however the rest of the methods either could not converge, or converged after significant amount of time. During solar irradiance and temperature change, the photovoltaic output power has converged in 0.018 seconds using PBSMC, however remaining methods failed to converge or track fully and the dc link voltage has minimum tracking error due to PBSMC as compared to the other methods. Furthermore, the photovoltaic output power converges to the reference power in 0.1 seconds in power grid voltage drop, whereas other methods failed to converge fully. In addition power is also injected from the PV inverter into the grid at unity power factor.

Distal Femur Replacement: An Option for Osteoporotic Fractures in the Elderly.

Background A distal femur fracture (DFF) around the native or prosthetic knee is commonly seen in the osteoporotic elderly population. Surgical management is required to restore the function. Fracture fixation requires a period of restricted weight-bearing; however, distal femoral replacement (DFR) allows immediate weight-bearing and quicker recovery. Methods All patients who underwent distal femur replacement from 2020 to 2023 at our hospital were retrospectively reviewed. Data related to the patient's demographics, medical comorbidities, preinjury mobility status, perioperative management and length of stay were collected. Results Eleven patients with 13 distal femoral replacements were included. There were 10 periprosthetic and 3 native fractures around the distal femur. Two patients had bilateral periprosthetic fractures. The median age was 84 years (range 62-95) with all patients being females. Eight patients were living in their homes while three were care home residents. The median duration of surgery was 120 min. The mean blood loss was 350 ml. Patients were mobilised out of bed at a median of three days and were able to walk for 2 meters with a frame at a mean of 10 days (range 3-15) except for two patients whose mobility was limited to the chair. The mean length of hospital stay was 32 days (range 8-54). All patients were discharged back to their original destination except for one who was shifted to a care home instead of her own home. Conclusion In our opinion, distal femur replacement provided a more favourable outcome with respect to pain management, early rehabilitation with full weight-bearing immediately following the surgery and fewer complications. Furthermore, in our hands, the surgical time was short with limited blood loss.

Role of platelet-rich plasma in early osteoarthritis of knee joint: Experience from a tertiary care center in Pakistan.

PURPOSE: Osteoarthritis is the most common articular disease. The aim of this study was to observe the outcome after intra-articular platelet-rich plasma (PRP) injection in our patients presenting with knee osteoarthritis. METHODS: This study was conducted in Dow University of Health Sciences, Karachi, Pakistan, from December 2014 to December 2015. All patients between 35 years and 60 years of age diagnosed with grade I and II arthritis were included in the study. Three PRP injections were injected in the knees at 4-week interval. Patients were followed up in outpatient department (OPD) and were assessed for pain and physical activity associated with arthritis using the Western Ontario and McMaster University Arthritis Index (WOMAC) score at the time of induction in the study and at 6 months interval. RESULTS: Two hundred fourteen patients with the mean age of 55.15 (±6.93) years were studied. Female to male ratio was 3:1. One hundred fifty-five patients were classified as having Kellgren-Lawrence grade 1 osteoarthritis, while 59 were grade 2. One hundred eighty-nine patients had clinical symptoms for less than 2 years and 25 for more than 2 years. Mean WOMAC score before the start of treatment was 83.05, and after 6 months, it was reduced to 38.84 which was statistically significant ( p = 0.000). WOMAC score was improved more in the subgroup with patients having symptoms less than 2 years ( p = 0.005). Three patients developed minor hyperemia which was managed conservatively with activity limitation and ice application, but none of the patient developed gross infection. CONCLUSION: The sequential use of PRP injection for the treatment of early osteoarthritis proved to be effective in our study.

Use of fibular bone graft and cancellous screw fixation in the management of neglected femur neck fractures in young patients.

OBJECTIVE: To present the clinical outcome of patients with neglected femur neck fracture treated with fibular bone graft. METHODS: During May 2010-February 2013, 15 patients younger than 35 years of age with neglected fracture neck of femur were managed with non-vascularized fibular graft and cannulated screws. Fractures were classified according to Sandhu Classification. Hip function was assessed using Harris hip score. RESULTS: Fifteen patients with mean age of 28.67 years were managed. Mean period of delay from injury to presentation was 3.07 months. Mean follow-up was 18.5 months. Union was achieved in 13 cases. 2 patients developed nonunion with progression of avascular necrosis (AVN). Patients with healed fracture did not show radiological signs of AVN till the past follow-up. Functional status was evaluated at 6 months according to Harris hip score and was poor in 2 patients, fair in 2 patients, good in 6 patients, and excellent in 5 patients. CONCLUSION: Fibular graft along with two cancellous screws proved to be an effective technique in our cases with neglected femur neck fractures.

Pattern of bony injuries among civilian gunshot victims at tertiary care hospital in Karachi, Pakistan.

PURPOSE: Firearm injuries impose a continuous economic burden on society and hospital resources. The aim of this study was to assess the pattern of bony injuries among victims of gunshots. METHODS: A retrospective study was conducted in the Department of Orthopedics, Dow University of Health Sciences and Civil Hospital Karachi from January 2011 to December 2012. Patients with isolated bony injuries were included while patients with other systemic injuries were excluded. RESULTS: There were 90 cases and the majority of them were male (84.4%). Mean age was (32.52 ± 10.27) years. Most of the patients (72.2%) belong to the younger age group. A low velocity weapon was used in 61 (67.8%) cases and a high velocity weapon was used in 29 (32.2%) cases. Armed robbery (64.4%) was the cause of conflict in more than half of the cases. Lower limb was involved in 72.2%. Fifty eight (64.4%) patients remained hospitalized for 15-20 days and others for more than 20 days. Internal fixation with intramedullary nailing was done in 35 patients while K-wire was used in 5 patients. Fifty patients were managed with external fixation, either uniplanar or multiplanar ilizarov. Deep wound infection and nonunion were observed more often in high velocity injuries. CONCLUSION: Armed robbery was the leading cause of gunshot bony injuries in our hospital. Young males were victimized in a majority of cases. High velocity injuries were associated with more complications.

Vacuum Assisted Closure- utilization as home based therapy in the management of complex diabetic extremity wounds.

OBJECTIVE: Vacuum assisted closure is a reported technique to manage complex wounds. We have utilized this technique by using simple locally available material in the management of our patients on outpatient basis. The objective of this study is to present our experience. METHODS: This study was conducted from June 2011 to June 2013 at Dow University Hospital and Aga Khan University Hospital, Karachi. There were 38 patients managed with vacuum assisted closure. Mean age was 56±7.8 years. Twenty three patients presented with necrotizing fasciitis and 15 patients with gangrene. Lower limbs were involved in majority of the patients. Debridement or amputations were done. Vacuum dressing was changed twice weekly in outpatient department. Wounds were closed secondarily if possible or covered with split thickness skin graft in another admission. RESULTS: All the wounds were successfully granulated at the end of vacuum therapy. Mean hospital stay was 7.5 days. Vacuum dressing was applied for a mean of 20 days. There was reduction in the size of the wound. Thirteen patients underwent secondary closure of the wound under local anesthesia, 18 patients required coverage with split thickness skin graft and 7 patients healed with secondary intention. CONCLUSION: Vacuum assisted closure appeared to be an effective method to manage complex diabetic wounds requiring sterile wound environment.

Salvage of infected non-union of the tibia with an Ilizarov ring fixator.

PURPOSE: To review outcomes of 24 patients who underwent Ilizarov ring fixation for infected nonunion of the tibia. METHODS: Medical records of 21 men and 3 women aged 13 to 74 (mean, 38) years who underwent Ilizarov ring fixation for infected non-union of the tibia were reviewed. The mean bone defect was 3.3 (range, 2-5) cm. The mean time from injury to presentation was 11.9 (range, 1-36) months. The mean number of previous surgeries was 2 (range, 0-14). A local flap was used in 2 patients and a free flap was used in one patient. Nine of the patients underwent Ilizarov ring fixation without soft tissue and bony resection, as inadequate stability was the reason for non-union. Patients were assessed using the Association for the Study and Application of the Method of Ilizarov criteria. RESULTS: Patients were followed up for a mean of 11 (range, 8-46) months. Functional outcome was excellent in 8 patients, good in 12, fair in 2, and failure in one, whereas bone union outcome was excellent in 6 patients, good in 14, fair in one, and poor in 2. The mean time to union was 8 (range, 3-31) months. The mean external fixation index was 4.2 (range, 1.5-15.7) cm/month. Complications encountered were pin tract infection (n=5), re-fracture (n=2), soft tissue impingement by Ilizarov rings (n=2), recurrence of wound infection (n=1), mal-union (n=1), and mortality (n=1). CONCLUSION: Ilizarov ring fixation is a viable option for infected non-union of the tibia. Adequate assessment of bone union is crucial before removal of fixator to prevent re-fracture.

Transfusion practice in orthopedic patients: do we really need it?

OBJECTIVE: To determine the proportion of inappropriate transfusions in patients undergoing orthopaedic surgery at a tertiary care university hospital, and factors associated with inappropriate transfusions. METHODS: The prospective study was conducted at Aga Khan University Hospital, Karachi, from December 2008 to September 2009, and comprised patients admitted to the Orthopaedic Department and received transfusion of at least one packed cell. Patients were divided into four groups: A, those with haemoglobin < 7, B, haemoglobin 7.1-10 without ischemic heart disease, C, haemoglobin 7.1-10 with ischemic heart disease, and D, haemoglobin >10. Variables recorded were, pre-transfusion haemoglobin level, co-morbids, symptoms of hypovolemia, pre-transfusion volume replacement with fluids, transfusion reactions, and haemoglobin after 48 hours. Indications of transfusion were assessed in accordance with available data. RESULTS: Of the 126 patients, 65(52%) were males and 61(48%) were females. There were 18(14%) patients in group A, 88(70%) in group B, 12(10%) in group C, and 8(6%) in group D. Overall, Overall, 44(35%) were transfused appropriately according to the criteria, and 82(65%) were inappropriate. CONCLUSIONS: The number of inappropriate transfusion was quiet high and demands revision of institutional policy of packed cell transfusion in accordance with available guidelines.

Use of distally based random flap in the management of soft tissue defects in upper two thirds of leg.

OBJECTIVE: To assess the results of cases with complex wounds exposing tibia who were managed with distally based random flaps. METHODS: The retrospective study was conducted at Aga Khan University Hospital, Karachi, and Dow University Hospital, Karachi and comprised data between February 2000 and March 2013of patients who had been admitted with a recent or prior history of trauma with a soft tissue defect in upper two-thirds of tibia and who had undergone coverage procedure using distal based flap. RESULTS: The mean age of the total 21 patients in the study was 29±9 years, and 20(95%)were male. Road traffic accident was the most common mechanism of injury in 13(62%). Tibia was exposed in all the 21(100%) cases requiring soft tissue coverage. There was associated fracture of tibia in 18(86%) patients. Mean flap length was 12±1.7 cm and width was 5.3 ±0.86 cm. Maximum size for the flap dissected was 15x7cm. Donor site was covered with split thickness skin graft in 19(90.5%) patients. Flap survival rate was 100%. Only 2(9.5%) patients developed partial flap necrosis. Clinical outcome was graded as good in 19(90.5%) patients and fair in 2(9.5%). Superficial infection was observed in 2(9.5%) patients. CONCLUSIONS: Distal based flap appeared to be an effective solution for the coverage of soft tissue defects in upper two-thirds of leg.

Chondromyxoid fibroma; experience of 36 cases of an intriguing entity.

OBJECTIVE: To evaluate the clinico-pathological features and treatment options of chondromyxoid fibroma patients. METHODS: The retrospective study was conducted at the Aga Khan University Hospital (AKUH), Karachi, and comprised data of all cases of chondromyxoid fibroma of bone diagnosed between 1996 and 2013.The diagnosis had been made mostly histopathologically, but also included patients in whom preoperative incisional biopsies had been used. Histopathological and radiological findings along with various treatment options and follow-up was recorded on a proforma. RESULTS: Of the total 36 patients,14(39%) were females and 22(61%) were males, with an overall mean age ± of standard deviation 20.9 years ± 9.8 (range: 6-51 years). Diagnosis was made histopathologically in 27(75%) patients and biopsy was used in 9(25%) cases. The most common site of involvement was tibia in 16(44.4%). The main presenting symptom was pain in 30(83.3%) and/or swelling in 6(16.6%). Radiological examination revealed no foci of soft tissue involvement. Bizarre large atypical cells were seen in 14(39%) cases and osteoid formation in 2(5.5%), leading to extreme difficulty in diagnosis. Treatment options included wide resection and marginal excisionin 22(61%) cases, intra-lesional curettage in 14(39%). The mean ± standard deviation follow-up was 48.8 ± 40.2 months (range: 8-152 months). Follow-up details were available only for 19(53%) patients. Among them, recurrence occurred in 7(36.8%) patients. No functional loss developed after surgical treatment, but 3(16%) patients developed wound-site infection. CONCLUSIONS: Chondromyxoid fibroma is clinically and histopathologically rare and difficult to diagnose because of the absence of typical diagnostic features in every case.

Is smartphone a necessity or luxury among orthopedic specialty?

OBJECTIVE: To assess the utilisation pattern of smart phones by residents and consultants with respect to their clinical work and academics. METHODS: The cross-sectional study was carried out in orthopaedic departments of various hospitals in Karachi in July 2014. Orthopaedic residents and consultants were asked to fill a questionnaire containing various questions, including utilisation of their smart phones for professional applications, books, internet and emails; and sharing of clinical data. RESULTS: A total of 98residents and consultants were approached and 83(84.7%) of them filled up the questionnaire. Of them, 70(84.3%) owned a smart phone and represented the study sample. Of them, 60(85.7%) were using applications on their mobile phone; and 27(38.6%) were using them for sharing clinical data with colleagues. The use of smart phone applications was more among residents than consultants (p=0.010) and the same applied to data sharing (p=0.028). AO Surgery reference was the most utilised application in 43(61.4%). Besides, 46(65.7%) respondents were using smart phones to read text books; 60(85.7%) were using internet on their smart phones for browsing web pages and to check emails; and 62(88.6%) wanted to have more applications available related to orthopaedic practice. Only 1(1.4%) respondent was willing to pay for these applications. CONCLUSIONS: Majority of orthopaedic caregivers owned a smart phone, but their clinical use was limited which may be enhanced to improve patient care.

Phytochemical and in vitro antioxidant evaluation of different fractions of Amaranthus graecizans subsp. silvestris (Vill.) Brenan

Objective: To evaluate the phytochemical and in vitro antioxidant ability of methanolic extract and different fractions of Amaranthus graecizans subsp. silvestris (A. graecizans subsp. silvestris). Methods: Methanolic extract of A. graecizans subsp. silvestris was obtained by cold maceration and then methanolic extract was subjected to fractionation and different fractions i.e. n-hexane, chloroform, ethyl acetate, n-butanol and aqueous fractions were obtained. Methanolic extract and all other fractions were subjected to phytochemical investigation by performing different phytochemical group tests like alkaloid, tannins, carbohydrates, lipids, proteins, etc. In vitro antioxidant activity of A. graecizans subsp. silvestris was evaluated by using 1, 1-diphenyl-2-picrylhydrazyl radical (DPPH), ferric thiocyanate assay, total antioxidant activity by phosphomolybdenum, ferric reducing antioxidant power, total phenolic content and lipid peroxidation methods. Results: Maximum antioxidant activity was shown by n-hexane fraction of the extract by carrying out DPPH (86.44±0.23), ethyl acetate fraction by total antioxidant (0.95±0.06) and ferric reducing antioxidant power (299.45±1.48) methods, while by employing total phenolic contents and inhibition of lipid per oxidation assays, methanolic extract (92.88±4.16) and n-hexane fraction (69.47±0.68) exhibited maximal activity. Ethyl acetate fraction showed the least IC

Phytochemical and in vitro antioxidant evaluation of different fractions of Amaranthus graecizans subsp. silvestris (Vill.) Brenan

OBJECTIVE@#To evaluate the phytochemical and in vitro antioxidant ability of methanolic extract and different fractions of Amaranthus graecizans subsp. silvestris (A. graecizans subsp. silvestris).@*METHODS@#Methanolic extract of A. graecizans subsp. silvestris was obtained by cold maceration and then methanolic extract was subjected to fractionation and different fractions i.e. n-hexane, chloroform, ethyl acetate, n-butanol and aqueous fractions were obtained. Methanolic extract and all other fractions were subjected to phytochemical investigation by performing different phytochemical group tests like alkaloid, tannins, carbohydrates, lipids, proteins, etc. In vitro antioxidant activity of A. graecizans subsp. silvestris was evaluated by using 1, 1-diphenyl-2-picrylhydrazyl radical (DPPH), ferric thiocyanate assay, total antioxidant activity by phosphomolybdenum, ferric reducing antioxidant power, total phenolic content and lipid peroxidation methods.@*RESULTS@#Maximum antioxidant activity was shown by n-hexane fraction of the extract by carrying out DPPH (86.44±0.23), ethyl acetate fraction by total antioxidant (0.95±0.06) and ferric reducing antioxidant power (299.45±1.48) methods, while by employing total phenolic contents and inhibition of lipid per oxidation assays, methanolic extract (92.88±4.16) and n-hexane fraction (69.47±0.68) exhibited maximal activity. Ethyl acetate fraction showed the least IC50 values by DPPH assay, hence a more pronounced potential for antioxidant activity.@*CONCLUSIONS@#The results indicate that A. graecizans subsp. silvestris has antioxidant potential and can be utilized as a natural source of antioxidant.

Patients' receptiveness for Medical students during consultation in Out patient department of a teaching hospital in Karachi Pakistan.

OBJECTIVE: Patients' attitude towards medical students' presence during treatment depends on the cultural values of the society. This study was conducted to find out the patients' receptiveness in our society to be involved in teaching process for medical students during consultation in out patient department of a teaching hospital in Karachi Pakistan. METHODOLOGY: This cross sectional study was conducted in the surgical Out Patient Department (OPD) at Dow University Hospital from May 2012 to June 2012. Four hundred and eleven patients consented for participation through non probability purposive sampling, in which 279 patients were from morning clinics in the presence of students for clinical teaching, while 132 patients participated through evening clinics of surgery, when students were not present for comparison in specific dimensions of care for patients' satisfaction. RESULTS: Majority of patients 293 (71%) agreed with the teaching of students during consultation and they feel they are contributing in future doctor's teaching, only 24% patients disagreed. Fifty two percent of patients who disagreed reported interference in privacy, 34% reported interference in consultation and 43% felt it resulted in prolong waiting time due to teaching. CONCLUSION: Majority of the patients agree to be part of teaching for medical students and this study can be used to assess the educational interventions designed to improve the patient based teaching.

Academic misconduct among students in medical colleges of Karachi, Pakistan.

OBJECTIVE: To determine the trends of academic misconduct in undergraduate students of different private and government section medical institutes. METHODOLOGY: This cross sectional study was conducted at three medical colleges of Karachi, Pakistan. The students were evaluated by giving a self reported questionnaire containing various questions assessing their educational dishonesty and cheating behaviors. RESULTS: A total of 274 students from different years completed the questionnaire. Mean age was 21.48 ± 1.89 years. Most of the students were in 4(th) year (n=86; 31.3%). There were 182 (66.5%) females and 92 (33.5%) males. Majority of the students (n=155; 55.1%) accepted that they have cheated at least once. There was no significant difference regarding acceptance of cheating among different years of study (p=0.23) however females were found to accept cheating more as compared to males (p=0.036). First year students were found more to ask teachers for answers during OSCE (p=0.01). A large number of students accepted that they mark proxy for their friends (85.7%) and also ask their friends to mark proxy for them (85.03%). Nearly half (44.02%) of the students rotating in wards also admitted to write fake histories. CONCLUSION: A large number of medical students admitted cheating and involvement in other academic misconduct. We need to improve our educational system, formally add professional session and strict disciplinary action should be taken against those who are found guilty.

Effect of early release of tourniquet in total knee arthroplasty.

OBJECTIVE: To evaluate whether tourniquet release intraoperatively is better than postoperative release in reducing overall blood loss, duration of surgery, duration of tourniquet, length of hospital stay, wound related complications and transfusion requirement. STUDY DESIGN: Comparative study. PLACE AND DURATION OF STUDY: Department of Surgery, The Aga Khan University Hospital, Karachi, from January 2004 to June 2007. METHODOLOGY: One hundred and thirty patient files were reviewed retrospectively. Patients were divided into two groups. Group-A consisted of 65 patients with early deflation of tourniquet and group-B comprised of 65 patients with the release of tourniquet after applying compressive dressing. Total blood loss (determined by Gross method) and other study variables were noted as per objective and computed. RESULTS: There were 22 males and 108 females with comparable BMI. All had undergone posterior stabilized cemented total knee replacement. Calculated blood loss was 1.208 L and 1.108 L in group-A and B respectively (p = 0.27). Significant increase in duration of surgery was noted in group-A patients. Four patients in group-B showed complication related to wound with 3 being minor and 1 requiring additional operation room visit. Mean length of hospital stay was 9 days. Transfusion frequency was higher in group-B despite comparable postoperative haemoglobin values. CONCLUSION: Intraoperative tourniquet release does not reduce overall blood loss with no effect in conserving blood after total knee replacement, however, this group had relatively shorter hospital stay.

Back Pain - Are Health Care Undergraduates At Risk?

BACKGROUND: To study the prevalence of low back pain in medical and nursing undergraduate students in our institutes and its association with physical activity, smoking, depression, use of computer and other variables. METHODS: It was a comparative cross sectional study carried out at two institutes of Dow University of Health Sciences, Karachi, Pakistan during October to December 2011. Two hundred and fifteen undergraduate students representing different semesters were asked to fill out the structured questionnaire. Back pain was assessed in terms of lifetime, one year and point prevalence. Bivariate analysis was done to study the relationship between back pain and different variables; including gender, study program, smoking, computer use, depression and level of physical activity. Both the groups were compared for duration/intensity of pain, seeking medical advice and duration of computer use. RESULTS: There were 183 undergraduate students who completed the questionnaire for back pain. Mean age was 22.84 (SD ± 5.85) years. Gender distribution was nearly equal (females = 51.4%). Life time prevalence was 57.9% (72% in medical students; 41% in nursing students). Medical students were 0.47 times more at risk of having back pain (95% CI 0.15-1.48; P=0.198). Smoking (OD=0.39; 95% CI 0.04-3.6; P=0.001) and use of laptop (OD=4.9; 95% CI 1.2-19.2; P=0.031) were found to be associated with increased prevalence of back pain. Nursing students sought medical opinion more as compared to medical students but it was not significant. However duration of computer use was more in medical students which was significant (P=0.03). CONCLUSION: High lifetime prevalence of back pain was observed in undergraduate students. Medical students appeared to be more at risk. Preventive measures are required to improve the quality of life in future health care professionals.

The medial plantar artery flap: a series of cases over 14 years.

Coverage of the weightbearing heel poses a unique technical challenge to the reconstructive surgeon. In the present study, we share our clinical experience with the use of the medial plantar artery-based flap for coverage of tissue defects around the heel. Eighteen medial plantar artery flaps performed from January 1996 to December 2009 were included. All the procedures were performed by 2 surgeons at Aga Khan University and Hospital (Karachi, Pakistan) and Bahawal Victoria Hospital (Bahawalpur, Pakistan). Of the 18 patients, 16 were male and 2 were female. The indications were traumatic loss of the heel pad in 13, pressure sores in 2, and unstable plantar scars in 3. All the flaps were raised as sensate fasciocutaneous pedicled flaps based on the medial plantar artery. All the flaps healed uneventfully without major complications. The donor site was covered with a split-thickness skin graft, and we had partial graft loss in 1 case. The sensate flaps had slightly inferior protective sensation compared with the normal side. From our results, we suggest that the medial plantar artery flap is a good addition to the existing armamentarium. It provides tissue to the plantar skin with a similar texture and an intact protective sensation. The technique is easier to master compared with free microvascular flaps and has less risk of any functional donor site morbidity.

The posterior tibial island flap for coverage in complex injuries of the lower extremity.

The lower third of the leg poses a surgical challenge in patients with complex injuries requiring reconstruction of soft tissue defects. The posterior tibial island fasciocutaneous flap is recognized as a suitable option for coverage of these defects, and provides a versatile solution for a complex problem. A retrospective audit was conducted at our institution from 1996 to 2008 including all patients who underwent this procedure. Patient's demographics, clinical features, outcome, and complications were noted. The study population was 24 patients (23 males, one female) with age ranging from 11 to 60 years. Mechanism of injury was road traffic accident in 20 patients and firearm injury in 4. The defect was located in the lower half of the leg in all cases. Tibial fracture was present in 15 patients, treated by external fixation in 13 and internal fixation in two patients. Fasciocutaneous flap from the medial aspect of leg was raised based on a perforator of the posterior tibial artery and rotated distally. Average length of the flaps was 12.3 cm. Patients were followed for an average of 11 months (minimum 3 months). Clinical outcome was graded as good in 19 patients, fair in four patients, and poor in one patient. Posterior tibial island flap appears to be a safe and reliable option for coverage of complex wounds in lower third of the leg.