Simultaneous versus two stage surgical treatment of developmental dislocation of the hip with excessive femoral anteversion in children under the age of three years

Background: Delayed diagnosis and improper treated cases of developmental dysplasia of the hip (DDH) in presence of excessive anteversion of femoral head may lead to undesirable consequences including more extensive interventions with severe complications and functional disability. This study aimed to compare the clinical, radiological and complication outcomes of simultaneously versus two stage surgical procedures (open reduction and proximal femoral derotation osteotomy) in the treatment of DDH with excessive femoral anteversion among sample of Iraqi children aged less than three years old. Methods: A total of 26 DDH cases were treated in two groups (GI, GII) at Al-Wasity Hospital (Baghdad, Iraq) from January 2014 to March 2015. GI (15 hips) in 13 patients subjected to simultaneous open reduction (with/without salter osteotomy ) and proximal femoral derotation osteotomy. GII (18 hips) in 13 patients operated in two stages procedure; open reduction (with/without salter osteotomy) followed by proximal femoral derotation osteotomy 6 weeks later. Results: At the time of operation, the average age was 21.79±3.51months (range: 18-30). The mean follow-up period was 10.36±1.45 months (range: 8 -12). Statistically, the post-operative clinical, radiological and complication findings were not significantly different between the two groups. However, in post-operative clinical assessment (McKay's criteria), the satisfy results (excellent and good) were 93%  in GI and  88%  in GII respectively. Moreover, in radiological assessment (Severins grading), the satisfy results (excellent and good) were 94% in GI and 83% in GII respectively. Two cases of re-dislocation and avascular necrosis(AVN) were reported in GII. Conclusion: When the clinical and radiological findings of one and two stage open reduction and proximal femoral derotation osteotomy procedures are similar, the one-stage is more likely to overcome the two-stage in term of minimizing the cost, length of stay and the risk of AVN of femoral head

Simultaneous versus two stage surgical treatment of developmental dislocation of the hip with excessive femoral anteversion in children under the age of three years

Background: Delayed diagnosis and improper treated cases of developmental dysplasia of the hip (DDH) in the presence of excessive anteversion of femoral head may lead to undesirable consequences, including more extensive interventions with severe complications and functional disability. This study aimed to compare the clinical, radiological, and complication outcomes of simultaneously versus two-stage surgical procedures (open reduction and proximal femoral derotation osteotomy) in the treatment of DDH with excessive femoral anteversion among a sample of Iraqi children aged less than three years old.  Methods: A total of 26 DDH cases were treated in two groups (GI, GII) at Al-Wasity Teaching Hospital (Baghdad, Iraq) from January 2014 to March 2015. GI (15 hips) in 13 patients subjected to simultaneous open reduction (with/without salter osteotomy) and proximal femoral derotation osteotomy. GII (18 hips) in 13 patients operated in two stages procedure; open reduction (with/without salter osteotomy) followed by proximal femoral derotation osteotomy six weeks later.  Results: At the time of operation, the average age was 21.79±3.51months (range: 18-30). The mean follow-up period was 10.36 ±1.45 months (range, 8 -12). Statistically, the postoperative clinical, radiological, and complication findings were not significantly different between the two groups. However, in post-operative clinical assessment (McKay's criteria), the satisfying results (excellent and good) were 93% in GI and 88% in GII, respectively. Moreover, in radiological assessment (Severins classification), the satisfying results (excellent and good) were 94% in GI and 83% in GII, respectively. Two cases of re-dislocation and avascular necrosis (AVN) were reported in GII. Conclusion: When the clinical and radiological findings of one and two-stage open reduction and proximal femoral derotation osteotomy procedures are similar, the one-stage is more likely to overcome the two-stage in terms of minimizing the cost, length of stay and the risk of AVN of the femoral head

Carbon Monoxide: A Rare Cause of Myocardial Ischemia

In an acute care setting, chemical asphyxiants (CA) are a vice which cause debilitating injury. Carbon monoxide (CO) is one well known CA which causes hypoxic injury to cardiovascular and neurological tissue. CO poisoning is one of the leading causes of death in USA. As many as 6% of patients who get admitted with CO poisoning in the USA have acute myocardial infarction. A strong positive correlation of CO Hb concentration has been established with increased incidence of MIs. We present a case of a 75-year-old male with complaints of chest discomfort, dyspnea, diaphoresis that was attributed to CO poisoning. Over the course of his stay he had two sets of positive serial troponins and was diagnosed with a non-ST elevation MI. Most of the recent literature focuses on ST elevation and T wave inversions in patients with CO poisoning. Contrary to this, our patient did not exhibit any EKG changes at any point during his hospital course. CO poisoning can cause fatal complications including an MI

Kounis Syndrome: A simple MRI with contrast turned into a life threatening condition

Kounis syndrome [KS] is a hypersensitivity coronary disorder induced by various allergens. It is a rare condition which has been reported in every age group (2-90 years), every race and geographic location, its incidence has been reported to range from 7.9 to 19.4 per 100,000. The presentation of the detrimental effects of KS on coronary arteries ranges from vasospastic angina to allergic myocardial infarction. Drugs are the major iatrogenic cause of KS, but virtually everything in the environment around us can cause KS. In recent years contrast mediums used in the radiologic investigation have come forth as a leading cause of anaphylaxis. Gadolinium is a rare earth metal that is used in contrast mediums for magnetic resonance imaging is generally considered to be safe. This is a case of 52-year-old female who developed KS after receiving Gadobenate dimeglumine – a Gadolinium based contrast medium (GBCM)- for MRI brain as a work up for metastatic renal cell carcinoma. Her EKG was remarkable for ST elevations in the inferior leads. Cardiac catheterization was preformed which did not reveal any significant obstructive coronary artery disease. Patient was treated with anti-histamines, corticosteroids and norepinephrine after which she recovered and discharged home stable. GBCM induced KS is very rare and to our knowledge this is the third case of Kounis Syndrome reported in association with Gadobenate Dimeglumine

Incidence Of Panic Attacks In Patients Presenting To The Emergency Department Of A Tertiary Care Hospital In Karachi,Pakistan

Background: The DSM-IV outlines a panic attack as a distinct period of intense fear or discomfort which is accompanied by a minimum of 4 out of 13 listed somatic or cognitive symptoms. This is often associated with a sense of impending doom and the urge to escape which may leave ones psychological and physical functioning impaired. These are all signs of several Anxiety disorders. The aim of the study is to investigate the incidence of Panic attacks amongst patients presenting to an Emergency Department in a tertiary care hospital of Karachi, Pakistan. Methods: This cross-sectional study was conducted at the Emergency Department, Ziauddin University Hospital Clifton. Patients included in the study were those who had no previous co-morbid or psychiatric disorders except for Panic attacks, and who displayed a minimum of four signs for a Panic attack according to the DSM -4 criteria of Panic attacks. Patients included in the study were between the ages of 15-50 years. The total sample size fitting the aforementioned requirements came to 1506 patients. Results: The prevalence of Panic attacks amongst patients in the Emergency Department was an astonishing 9.49%. Division according to sex demonstrated a female predominance at 62.9% while males made up 37.1% of the total. The age group which was most effected was 30-34 years of age. Variation with relevance to time of day displayed that 44.8% of cases presented in the night time followed by evening and morning. Conclusion: It is evident that Panic attacks are a common finding amongst patients in an Emergency Department, be it due to new onset Panic Disorder, social phobias or other causes .Keeping the prevalence of mental disorders in mind, specifically Anxiety Disorders of which Panic attacks are a subset, further research into the causes, immediate and comparatively effective treatment needs to be done as well as emphasis on accurate diagnosis at the primary care level. Key Words: Panic attack, Anxiety, Emergency Department, prevalence, Pakistan, DSM-I

Automated Versus Manual Blood Pressure Measurement: A Randomized Crossover Trial in the Emergency Department of a Tertiary Care Hospital in Karachi, Pakistan: Are Third World Countries Ready for the Change?

BACKGROUND: Hypertension has proven to be a strong liability with 13.5% of all mortality worldwide being attributed to elevated blood pressures in 2001. An accurate blood pressure measurement lies at the crux of an appropriate diagnosis. Despite the mercury sphygmomanometer being the gold standard, the ongoing deliberation as to whether mercury sphygmomanometers should be replaced with the automated oscillometric devices stems from the risk mercury poses to the environment.AIM: This study was performed to check the validity of automated oscillometric blood pressure measurements as compared to the manual blood pressure measurements in Karachi, Pakistan.MATERIAL AND METHODS: Blood pressure was recorded in 200 individuals aged 15 and above using both, an automated oscillometric blood pressure device (Dinamap Procare 100) and a manual mercury sphygmomanometer concomitantly. Two nurses were assigned to each patient and the device, arm for taking the reading and nurses were randomly determined. SPSS version 20 was used for analysis. Mean and standard deviation of the systolic and diastolic measurements from each modality were compared to each other and P values of 0.05 or less were considered to be significant. Validation criteria of British Hypertension Society (BHS) and the US Association for the Advancement of Medical Instrumentation (AAMI) were used. RESULTS: Two hundred patients were included. The mean of the difference of systolic was 8.54 ± 9.38 while the mean of the difference of diastolic was 4.21 ± 7.88. Patients were further divided into three groups of different systolic blood pressure <= 120, > 120 to = 150 and > 150, their means were 6.27 ± 8.39 (p-value 0.175), 8.91 ± 8.96 (p-value 0.004) and 10.98 ± 10.49 (p-value 0.001) respectively. In our study 89 patients were previously diagnosed with hypertension; their difference of mean systolic was 9.43 ± 9.89 (p-value 0.000) and difference of mean diastolic was 4.26 ± 7.35 (p-value 0.000).CONCLUSIONS: Systolic readings from a previously validated device are not reliable when used in the ER and they show a higher degree of incongruency and inaccuracy when they are used outside validation settings. Also, readings from the right arm tend to be more precise

The Influence of Body Mass Index on Survival and Length of Stay in Patients with Septic Shock

Background: Obesity is one of the most widespread epidemics of our time. In fact, currently 65.7% of US adults age 20 and older are overweight, while 30.6% are obese. It has been well-established that obesity has numerous adverse effects on long-term health, however the specific effect on patients treated for sepsis and septic shock is unclear. Body Mass Index (BMI) is a measure of total body fat content and surrogate marker for obesity. In our study, we aimed to identify if BMI was an independent risk factor for poor survival or increased length of stay (LOS) in patients with sepsis. Methods: We retrospectively selected patients with diagnostic codes of sepsis and septic shock who were admitted to the ICU over three years. These patients were further separated into groups of alive and deceased. Based on their perceived association with mortality in sepsis, numerous variables were investigated, such as BMI, LOS, age, cirrhosis, chronic kidney disease (CKD), lactate, age, multiple organ dysfunction syndrome (MODS), and APACHE II scores. Specifically, BMI was classified into sub-groups, including underweight (BMI30). The alive and deceased groups were initially compared for any significant differences with univariate analysis. Thereafter, the significant variables were analyzed using multivariate analysis to assess whether any were able to independently predict mortality in sepsis. Results: Our study selected 293 patients with sepsis, including 185 alive and 108 deceased. Interestingly, our univariate analysis revealed that underweight and obese patients exhibited slightly less mortality in sepsis compared to normal and overweight patients. However, these results did not reach statistical significance, with a p-value of 0.30; this was confirmed in multivariate analysis, which resulted in a p-value of 0.08. Additionally, underweight, overweight, and obese patients had a slightly decreased median LOS in the ICU and hospital compared to patients with normal BMI. Nevertheless, these results were not significant either, with ICU LOS p-value of 0.22 and hospital LOS p-value of 0.45. Univariate analysis identified certain variables that reached statistical significance, including cirrhosis (p2 (p=0.03), median lactate (p=0.05), age (p\u3e.01), and APACHE II scores (p\u3e0.01). Multivariate analysis of these variables established that only the presence of cirrhosis (p=0.03), age (p Conclusion: The data suggests that normal BMI in patients with sepsis may result in increased mortality and LOS both in the ICU and hospital, though this was not statistically significant. Other variables that were significant independent predictors for mortality in sepsis were cirrhosis, mean age, and mean APACHE II score. As the obesity epidemic continues to rise, further inquiry into the association of BMI and mortality in sepsis is needed

Prasugrel Inappropriate Use in Patients Post-percutaneous coronary intervention (PCI). A Single Center Study

Prasugrel is a thienopyridine that was approved by the US Food and Drug Administration (FDA) in combination with aspirin for the reduction of thrombotic events as well as stent thrombosis in patients with ACS who undergo PCI. This retrospective study aims to assess the frequency of inappropriate use of prasugrel and to emphasize that prasugrel still needs more attention as inappropriate use may result in significant morbidity

Varenicline versus placebo for waterpipe smoking cessation : a double-blind randomized controlled trial

Background and Aims: Waterpipe tobacco smoking is a growing public health concern. There is limited research using pharmacotherapy and no research using varenicline (established treatment for smoking cessation) in waterpipe smokers. We tested the efficacy of varenicline in achieving abstinence from all tobacco use among waterpipe smokers. Design: Two-arm, parallel group, placebo-controlled, double-blind, multi-centre (n = 4), individually randomized trial with follow-up to 25 weeks. Settings: District general hospitals and catchment communities within four districts of Punjab, Pakistan. Participants: Adult daily waterpipe smokers (n = 510; 253 in varenicline and 257 in placebo arms), who were interested in quitting, were recruited and analysed between March and November 2016. Of these, 220 (87%) in the varenicline and 239 (93%) in the placebo arms completed all follow-ups. Participants were on average aged 49 [standard deviation (SD) = 15.2] years, daily smokers and smoked for the last 27 (SD = 15.9) years. More than half (261, 51.2%) also smoked cigarettes. Intervention and comparator: All trial participants received two structured sessions of behavioural support (of 30 and 10 minutes) one at the time of registration and the other 1 week later. Participants were randomized to varenicline (active arm) and placebo (control arm) stratified on district, sex and concomitant cigarette smoking. Varenicline and placebo were dispensed as identical unlabelled tablets for 12 weeks: 0.5 mg for 1 week (once on days 1–3, twice on days 4–7) and 1 mg for the subsequent 11 weeks (twice daily). Measurements: The trial participants were followed-up for a period of 25 weeks post-randomization. The primary outcome was 7-day repeated point prevalence abstinence from all forms of tobacco, self-reported at each of weeks 5, 12 and 25, verified by carbon-monoxide cut-off < 10 parts per million. Findings: No evidence of statistically significant difference in repeated point prevalence abstinence between the varenicline (12 of 253; 4.7%) and placebo (11 of 257; 4.3%) arms (relative risk = 1.11, 95% confidence interval = 0.50–2.47, P = 0.80) was observed (Bayes factor = 0.048). Adverse events reported in 27 participants were 34 (15 in varenicline and 19 in placebo); none was serious. Conclusions: Varenicline was not more effective than placebo in aiding cessation of tobacco use in long-term daily waterpipe smokers