Manipulation under local anesthesia in idiopathic frozen shoulder--a new effective and simple technique

Manipulation under anesthesia has been used to speed up the recovery of frozen shoulder (FS), which is said to be a self-limiting disease. This is a randomized prospective clinical trial performed in a tertiary care hospital. Thirty-one patients with idiopathic unilateral frozen shoulder underwent suprascapular nerve block and intraarticular local anesthesia with Methyl prednisolone acetate followed by manipulation of the glenohumeral joint. Differences in range of motion and pain were assessed before manipulation and at 7 days 6 weeks and 12 weeks. Passive range of motion increased significantly for abduction, external rotation, and internal rotation. Significant decrease in visual analogue pain (VAS) scores between initial and follow-up assessments was observed. Our results revealed that manipulation under suprascapular nerve block and intra-articular local anesthesia is a very simple, safe, cost effective and minimally invasive procedure for shortening the course of an apparently self-limiting disease and can improve shoulder function and symptoms quickly.

Subperiosteal osteoid osteoma of the neck of talus

Juxta-articular, subperiosteal osteoid osteomas arising around the ankle are unusual. Tumors arising on the neck of the talus commonly produce symptoms mimicking monoarticular arthritis. Patients are usually treated for arthritis or ankle sprain, which often leads to a delay in definitive diagnosis. Here we present a case of osteoid osteoma of neck of talus which was presented as ankle pain. It puzzled us until MRI was done. Diagnostic dilemma and delay can be avoided by high index of suspicion. The patient was treated with open removal of the tumor. We also present brief review of literature about juxta-articular, subperiosteal osteoid osteoma which is uncommon from the typical osteoid osteoma occurring elsewhere in the body.

Bilateral slipped capital femoral epiphysis: a case report and review of literature

Slipped capital femoral epiphysis (SCFE) is a common adolescent problem in the western populations but it is extremely rare in the Asian regions. We report a case management of a teen age boy (16 years old at the time of operation) with bilateral SCFE. After fall injury, the boy sustained SCFE on the left side and was treated. Again after six months with trivial injury he got SCFE on the right side. In both cases the boy was managed by closed reduction and percutaneous cannulated cancelleous screws fixation under c-arm fluoroscopy control. The cannulated screws were removed after one year of insertion confirming of a good fusion in plain x-ray films. During the regular follow up of up to one year the patient had good hip functions and other daily activities. The patient lost to follow up for about three years and suddenly presented to us with restricted hip joints movements and other activities. The x-ray showed tilted pelvis, reduced, incongruent hip joint spaces with malunited femoral physis, widened neck and tilted femoral head along with visible physeal scan on both sides. The patient and patient party are still satisfied with these results and reluctant to go for further surgical intervention.

Knowledge, attitudes and practice of university students regarding waterpipe smoking in Pakistan

OBJECTIVES

To study the awareness, perceptions and practice of university students in Karachi, Pakistan, with regard to shisha (waterpipe) smoking.

DESIGN

Cross-sectional survey conducted among students at four different universities of Karachi, selected through random cluster sampling.

RESULTS

A total of 450 participants, 59.6% males (n=268) and 40.4% females (n=182), were included in the study. About half of the participants reported having ever smoked shisha (n=241, 53.6%). On examining factors associated with starting shisha smoking, curiosity was found to be the most common reason (n=148, 61.4%), followed by pleasure-seeking (n=113, 46.9%), peer pressure (n=55, 22.8%), boredom (n=43, 17.8%) and stress (n=26, 10.8%). Of 241 participants who had ever smoked waterpipes, the majority (n=149, 61.8%) were current smokers. A vast majority of participants (n=269, 60%) considered waterpipe smoking to be less unhealthy than cigarette smoking. Boredom in youth, use of waterpipe in leisure activities and peer pressure were identified as the most common reasons for the escalating popularity of waterpipe smoking in Pakistan.

CONCLUSIONS

Waterpipe smoking is very popular among Pakistani university students, and knowledge among university students about the dangers of waterpipe smoking is alarmingly low.

Bony hydatid disease of superior pubic ramus with extension into pelvis and proximal thigh

Hydatid disease is caused by the tapeworm of genus ;Echinococcus. Genus Echinococcus has different species including Echinococcus vogeli, Echinococcus granulosus and Echinococcus multilucularis. Echinococcus granulosus is the most common cause of hydatid disease in humans. This disease can take place either directly through ingestion of parasite eggs from contact with infected dogs or indirectly from the ingestion of contaminated water or food. Infestation of hydatid disease in humans most commonly occurs in the liver (55-70%), followed by the lungs (18-35%). Bone hydatidosis however is very rare,whenever it occurs; it is usually secondary to visceral involvement. We present herein a case of primary hydatid cyst involving superior pubic ramus in a 43 years male patient, which is not a common site for the occurrence of this disease. Diagnosis is usually delayed if high index of suspicion is not there. MRI is a good tool for reaching diagnoses.

Outcome of Supracondylar Fractures of the Humerus in Children Treated by Closed Reduction and Percutaneous Pinning

Supracondylar fractures of humerus in children are common injuries. Displaced fractures areinherently unstable. Conservative treatment results in malunion. Open reduction and internalfixation (ORIF) is more invasive and recovery is prolonged. From September 2004 to September 2005, 102displacedsupracondylarfractures of humerus, agedbetween one andhalf yearto 13 years, weretreated using close reduction and percutaneous Kirschner (K) wire fixation under c-arm fluoroscopy. Seventy nine patients were treated by cross K-wires and in twenty three cases lateral two K-wireswereput.Above elbow plaster ofparis back slab was appliedinall cases for atleastfour weeks.Backslab,K-wireswere removedafterfourweeks andelbowrangeofmotionexercisewas started.Resultswere analyzed using Flynn’s criteria. All patients were followed up to 14th week postoperatively. Incross K-wire group(N=79) 70.8% had excellent, 22.7% good, 3.8% fair and 2.5% had poor results at eight weeks follow up which was improved to 91.1% excellent, 6.3 good, 1.2% fair and 1.26% poor results at 14 weeks follow up. In lateral K-wire group (N=23) 70% had excellent, 21.7% good, 4.3% fair and 4.3% had poor result at eighth week which was improved to 91.3% excellent, 4.3% good, 4.3% fair and no poor result at 14th week follow up. Eight patients got superficial pin tract infection and seven patients sustained ulnar nerve injury post operatively.We recommend this procedure fordisplacedsupracondylarfractures inchildrenas itis safeandcost effectiveprocedurewithacceptablecomplication rates.Key words: closed reduction, humerus, percutaneous pinning, supracondylar fracture

Prospective comparison of prediction rules of mortality risk for CAP in a developing country

SETTING

Aga Khan University Hospital, Karachi, Pakistan.

OBJECTIVE

To prospectively compare 30-day mortality with CURB65 and CRB65 scores and the three mortality risk groups (low, intermediate and high) based on these scores in hospitalised patients with community-acquired pneumonia (CAP).

DESIGN

Longitudinal observational cohort study of adult in-patients fulfilling the definition of CAP between October 2006 and May 2007.

RESULTS

A total of 137 patients was included. The 30-day mortality was 13.1%. Areas under the receiver operating characteristic curve for CURB65 and CRB65 scores were respectively 0.863 and 0.835. Odds of death among patients in the high mortality risk group of CURB65 score was 15.4 and those of CRB65 was 11.1 compared with the low and intermediate mortality risk groups combined as reference. CURB65 and CRB65 scores classified 46% and 24.8% patients, respectively, into the low mortality risk group. Length of hospital stay increased with the CURB65 score-based mortality risk groups but not with those based on the CRB65 score.

CONCLUSION

CURB65 and CRB65 scores showed no significant difference in predicting 30-day mortality. Both scores, and the CURB65 score in particular, categorised reasonable proportions of patients into the low mortality risk group who could be discharged from the emergency room and managed as out-patients.

Outcome of supracondylar fractures of the humerus in children treated by closed reduction and percutaneous pinning

Supracondylar fractures of humerus in children are common injuries. Displaced fractures are inherently unstable. Conservative treatment results in malunion. Open reduction and internal fixation (ORIF) is more invasive and recovery is prolonged. From September 2004 to September 2005, 102 displaced supracondylar fractures of humerus, aged between one and half year to 13 years, were treated using close reduction and percutaneous Kirschner (K) wire fixation under c-arm fluoroscopy. Seventy nine patients were treated by cross K-wires and in twenty three cases lateral two K-wires were put. Above elbow plaster of paris back slab was applied in all cases for at least four weeks. Back slab, K-wires were removed after four weeks and elbow range of motion exercise was started. Results were analyzed using Flynn's criteria. All patients were followed up to 14th week postoperatively. In cross K-wire group(N=79) 70.8% had excellent, 22.7% good, 3.8% fair and 2.5% had poor results at eight weeks follow up which was improved to 91.1% excellent, 6.3 good, 1.2% fair and 1.26% poor results at 14 weeks follow up. In lateral K-wire group (N=23) 70% had excellent, 21.7% good, 4.3% fair and 4.3% had poor result at eighth week which was improved to 91.3% excellent, 4.3% good, 4.3% fair and no poor result at 14th week follow up. Eight patients got superficial pin tract infection and seven patients sustained ulnar nerve injury post operatively. We recommend this procedure for displaced supracondylar fractures in children as it is safe and cost effective procedure with acceptable complication rates.

Cigarette smoking among adolescent females in Pakistan

SETTING

Tobacco use among adolescent females is gaining importance as they take up smoking in increasing numbers. Recent studies show that sex differences in tobacco use are disappearing and that tobacco companies are agressively targeting females in developing countries.

OBJECTIVE

To determine the factors influencing the use of cigarettes among female high-school students in Karachi, Pakistan, and hence to identify areas for future intervention.

METHOD

A two-stage cluster sample of 644 females was drawn from government and private schools in a locality in Karachi. A self-administered questionnaire was used for data collection.

RESULTS

The mean age was 15.29 years. The prevalence of ever-smokers was found to be 16.3%. Univariate analysis indicated that private school attendance, underage sale of tobacco at shops, tobacco use by family members and exposure to cigarette advertisements predicted smoking among girls. Knowledge assessment of the subjects showed that most girls had good knowledge about the hazards of smoking.

CONCLUSION

Our study has identified several risk factors for smoking among young girls. Appropriate interventions are needed in the form of public education programmes, effective anti-tobacco laws and stricter enforcement of existing laws to restrict the number of young female smokers.

Surgical treatment of isthmic spondylolisthesis with radicular pain in adults

A common consensus has not yet been reached on surgical management of isthmic Spondylolisthesis especially regarding the optimal surgical procedure. This prospective study was carried to see the outcome of Posterolateral fusion with instrumentation without decompression. Eight consecutive patients, aged between 43 to 55 years, underwent primary surgery for isolated L4, L5 lumbar isthmic Spondylolisthesis of less than grade II that presented with radicular pain and exhibited instability on dynamic radiograph. The surgical procedure consisted of instrumentation with pedicle screws and rods (Moss Miami System) and posterolateral fusion in situ by placement of autogeneous bone graft, harvested from posterior iliac crest. Postoperatively Clinical and Radiological status were assessed and were graded according to Stauffer and Coventry method. The patients were followed up for one to three years. Radiological evidence of fusion was clearly evident by six months in all cases. Symptomatically all were relieved of radicular pain completely. One patient had recurrent backache due to causes unrelated to the illness of surgical procedure requiring occasional analgesic. No serious complication was encountered. This lead to conclusion that in adults of our population with low grade isthmic spondylolisthesis and radicular pain Instrumentation with Posterolateral fusion without decompression was sufficient to relieve symptoms.

Smoking habits and beliefs of future physicians of Pakistan

OBJECTIVE

To assess the habits, knowledge and attitudes towards smoking among Pakistani medical students.

METHODS

A cross-sectional study was conducted from March 2004 to July 2005 at three medical colleges using a World Health Organization (WHO) questionnaire. A total of 1,029 medical students participated in the study.

RESULTS

The prevalence of smoking was found to be 11.2%. Smoking was more prevalent among males, hostel residents and first year medical students. Almost half of the smokers had tried to quit smoking. A family member or a friend was considered to be the most likely person to help quit smoking. The majority believed that passive smoking was harmful to health and were generally supportive of legislative measures to reduce tobacco use, such as the restriction of smoking in public places and the prohibition of sale of tobacco to children. Lesser but significant numbers thought that there should be a complete ban on smoking advertisements and that the price of tobacco products should be increased.

CONCLUSION

The study shows a high prevalence of tobacco use in future physicians in spite of adequate knowledge about and a satisfactory attitude towards smoking.

Massive unilateral chylous pleural effusion: a rare initial presentation of Behcet's disease

Pulmonary manifestations of Behcet's disease are not very common and usually include pulmonary artery aneurysms, central venous thrombosis, pneumonia and pleurisy. Chylothorax secondary to superior vena caval obstruction is a rare complication and has been reported in only a few cases. We report a case of a 24-year-old man presenting with massive chylothorax as the initial presentation of Behcet's disease that was successfully treated conservatively.

Foreign body aspiration in adults

Foreign body aspiration is not an uncommon problem, particularly in children, the elderly, and those with predisposing factors like neurological impairment. In adults, regional differences exist in the type of foreign body aspirated. We report four cases of foreign body aspiration in South Asian adults, three of which were related to the widespread habit of chewing stimulant seeds such as betel nuts (two) and tamarind seed (one). It is important for clinicians to maintain a high index of suspicion for the diagnosis of foreign body inhalation in the appropriate clinical setting. Bronchoscopy is necessary not only for the diagnosis but also for the removal of foreign body from the bronchial tree. Once the foreign body is removed, the improvement in symptoms is usually dramatic, making it rewarding for any physician to manage.

Medical interns knowledge of TB in Pakistan

Of 460 interns from five Pakistani teaching hospitals surveyed, only 22% correctly identified the estimated number of new TB cases in Pakistan. The majority (96%) knew that droplet infection was the usual mode of transmission. Only 38% considered sputum smears for acid-fast bacilli as the best test for diagnosis of pulmonary TB and 43.5% for follow-up during TB treatment. The recommended four-drug anti-TB regimen was prescribed by 56.5% in the initiation phase and the recommended two-drug combination in the continuation phase by 52%. Most interns (82%) were unable to identify a single component of directly observed treatment short course (DOTS) strategy. Our study reflects poor awareness of and low compliance to the World Health Organization/National Tuberculosis Programme guidelines among interns. For effective control of TB, immediate action to improve undergraduate and continuing medical education is essential, with special emphasis on national guidelines.

Smoking prevalence, knowledge and attitudes among medical students in Karachi, Pakistan

A survey of smoking prevalence and attitudes was made among medical students randomly selected from classes at the Aga Khan University, Karachi, Pakistan. Of 271 respondents, 14.4% were current smokers (22.0% male and 3.8% females) and 3.3% ex-smokers. A majority of students recognized the dangers associated with active as well as passive smoking although only 55% of current smokers planned to quit in the near future. Most smokers (96%) believed that they as well as other health professionals needed training on smoking cessation and 95% of all students believed that doctors should play a role model in smoking cessation by not smoking themselves. Specific training and counselling should be a part of the required curriculum at medical schools.

Trends in hospital-based management of acute asthma from a teaching hospital in South Asia

The aim of this study is to evaluate the hospital-based management of acute asthma in south Asia and to compare practices over a 10-year period. Adult patients (n = 102) admitted at a teaching hospital with acute asthma were studied. Documentation of precipitating factors, family history and physical signs were inadequate in more than half of patients. Pulse oximetry was documented in 95 (93%) patients, but peak flow monitoring was performed only in 50 (49%) patients. Ten-year trend showed deterioration in history and physical examination skills, under use of peak flow readings, and poor pre-discharge instructions. Some aspects of improved care included frequent use of pulse oximeter, preference of inhaled over systemic bronchodilators and increased use of systemic steroids. Significant deficiencies were identified in hospital-based management of acute asthma. Most aspects of asthma care continued to fall short of asthma guidelines.

Invasive aspergillosis with polyarthritis. Fallbericht. Invasive Aspergillose mit Polyarthritis

We report a case of septic arthritis of multiple joints in an 18-year-old male caused by Aspergillus fumigatus. His initial presentation was of low-grade fever followed by involvement of both knee and ankle joints. Later, there was also involvement of metacarpophalangeal joints. Diagnosis was based on biopsy and culture of the skin and joint lesions. The symptoms resolved readily under administration of itraconazole. We recommend that clinicians should be alerted of potential fungal etiology in cases of fever and chronic arthritis, which is unresponsive to conventional medical therapy.

Asthma management by general practitioners in Pakistan

SETTING

Teaching university hospital in Karachi, Pakistan.

OBJECTIVES

Asthma management guidelines have been developed to assist practising physicians in treating asthma patients. The objective of this study was to evaluate if the prescribing habits of practitioners in Karachi were consistent with the published asthma guidelines.

DESIGN

A questionnaire survey was conducted among practitioners attending a pulmonary continuing medical education (CME) programme. Three case scenarios of asthma were given, and the doctors were asked to write a prescription for each case. Doctors were asked about their views on inhaler therapy and dietary restrictions in asthma.

RESULTS

Of 120 doctors, 100 (83%) responded. Thirty different regimens of short acting beta2-agonist and 16 regimens of steroid therapy were prescribed by the practitioners. Only 35% of the doctors prescribed corticosteroids for persistent asthma symptoms. The great majority of doctors were not aware of treatment options for persistent symptoms despite the use of preventive therapy (8% prescribed long-acting beta2-agonists, 6% high-dose inhaled corticosteroids and 13% theophyllines). Misconceptions about inhaler therapy and diet were found in 20 and 50 doctors, respectively.

CONCLUSION

General practitioners in Pakistan did not follow asthma management guidelines. There was serious lack of knowledge about asthma medications coupled with misconceptions about inhaler therapy and dietary factors.

Clinical characteristics of 110 miliary tuberculosis patients from a low HIV prevalence country

SETTING

A university teaching hospital in Karachi, Pakistan.

OBJECTIVE

To define the clinical characteristics and outcome of miliary tuberculosis (TB) patients from a low human immunodeficiency virus (HIV) prevalence country.

DESIGN

Review of adult miliary TB patients admitted between 1994 and 2001. Clinical characteristics of those dying from miliary TB were compared with those of the survivors.

RESULTS

Most of the 110 cases reviewed were middle aged or elderly, with a female preponderance. An underlying medical condition was present in 47%. Presenting symptoms were of several weeks' duration, and mostly constitutional (fever and weight loss). Common laboratory findings included anaemia (62%), lymphopaenia (71%), hyponatraemia (74%), elevated serum alkaline phosphatase (57%) and hypoalbuminaemia (92%). Typical miliary pattern was observed in 77% of radiographs. Sputum smear and culture were positive in respectively 36% and 52% of those tested. Biopsy was performed in selected patients. Mean hospital stay was 8.8 days, and mortality was 30%. Those who died were significantly older than survivors and had a more fulminant course. Presence of altered mental status, lung crackles, leucocytosis, thrombocytopaenia and the need for ventilation were associated with increased mortality.

CONCLUSION

Miliary TB carries a high mortality. It should be considered in patients who present with prolonged systemic symptoms. A positive TB culture or biopsy is needed to establish a diagnosis.

An uncommon case of neck fistula

Congenital fistulae of the neck are branchial in origin and of these 2nd arch fistula is by far the most common, 3rd and 4th arch fistulae being very rare. Here, a case of fistula present since birth and extending from the neck, near the midline to the alveololingual sulcus, considered very rare, is presented. The patient was a 32-year-old male having sticky discharge through an opening in the upper part of the neck. Examination revealed an opening of approximately 1 mm diameter about 1 cm to the left of the midline just above the hyoid bone. A sinogram revealed a fistulous linear tract communicating with the oral cavity. Surgery was undertaken and the fistulous tract was excised.

Cancer patterns in Quetta (1998-1999)

INTRODUCTION

Quetta, the capital of Baluchistan, is located at latitude 30.25; longitude 67.00. It has a population of 759,245; 425,474 males (56%) and 333,771 females (44%); Census 1998. The majority of residents are Persian or Baluchi speaking Baluchs.

METHODOLOGY

The cancer cases from Quetta reported to the Karachi Cancer Registry were reviewed. The data included cases from the Aga Khan University Hospital (AKUH), Pathology Department (Quetta collection point) and health care facilities in Karachi. The residents of Baluchistan were ascertained and cancer cases residents of Quetta identified with the help of recorded addresses and retraceable telephone numbers.

RESULTS

During a 2-year period, 1st January 1998 to 31st December 1999 the Karachi Cancer Registry received 1077 cancer notifications from Quetta. Approximately half the cases were registered from the AKUH Quetta collection point. Others were the referral patterns in Karachi. The age-standardized incidence rate (ASR) of cancer, all sites (1998-99) was 137.0 for males and 92.8/100,000 for females. The commonest cancer in the males and females was cancer of the esophagus (ICD-10 categories C15; males- ASR 25.5, 17.2%; females-ASR 23.4,23.1%). One ofthe highest in the world, for both genders. Incidence of cancer breast in the females (ICD-10 categories C50; ASR 11.8, 13.3%) was low.

CONCLUSION

The cancer data from Quetta is quite distinct from the cancer pattern of Karachi. It represents only a part of the cancer burden of Quetta; nonetheless it gives a glimpse into the cancer profile of Baluchistan. The high incidence of esophageal cancer indicates an extension of the geographical limits of the esophageal cancer belt.

The current naming of plant viruses: a critical appraisal

The revised International Code of Virus Classification and Nomenclature [7] followed by the Seventh Report of the International Committee on Taxonomy of Viruses (ICTV) [9] have generated a lot of criticism [2,4-6]. The main causes of criticism are (i) use of monomials instead of non-latinized binomials, as has been practice for some time in the past, e.g., tobacco mosaic tobamovirus, tobacco ringspot nepovirus etc. (ii) in toto italicization of official virus names. Following the expression of different views among virologists on this issue, it is being debated and an opportunity has been provided for reconsideration of the revised ICTV code [1,8,10]. This note attempts to analyse the existing criticisms being raised and justifies the continuation of the present ICTV code.