role of intraarticular platelet rich plasma [PRP] injection in patients with internal knee derangements

Platelet Rich Plasma [PRP] is an emerging biotechnology which uses patient's own blood components to create healing effect to their own injured tissues. This study was carried out to evaluate the clinical effects, adverse reactions and patient satisfaction after intraarticular injection of platelet rich plasma in a small group of patients with internal derangements of knee at Combined Military Hospital, Panoaqil, Pakistan. In this single center, open study, 10 patients with internal derangements of knee fulfilling the inclusion criteria received two doses of 3 ml of platelet rich plasma as intraarticular knee injection at two weeks interval. All patients were evaluated at 0, 4 and 12 weeks after treatment using IKDC, TEGNER, KOOS and VAS. Adverse events and patient's satisfaction was recorded. There was significant improvement in all scores. Intraarticular PRP injection is safe and effective method in the conservative treatment of internal knee derangements

Quality of life assessment in chronic skin disorders

To assess the impact of disease on quality of life of dermatological patients by using dermatology life quality index [DLQI]. One hundred consecutive adult patients with any dermatological disease lasting more than six months were interviewed and filled DLQI questionnaire. DLQI is a broad, self-administered, dermatology specific questionnaire that measures the impact of skin diseases on health-related quality of life in patients. It covers six domains [symptoms, feelings, routine daily activities, sports activities, work and school, personal relationships, and treatment] during the preceding one week. In our study, both original English and validated Urdu versions of the instrument were used for patients in either language of ease. There were 58 males and 42 females. Mean age was 42 +/- 17 years. A total of 26 dermatological diseases were found in our patients. Chronic eczema was the commonest diagnosis in 29% of patients, followed by melasma in 11%. The duration of illness varied from 6 months to 25 years whereas mean duration was 10.48 +/- 5.9 years. DLQI score varied from 0-20, mean score was 10.02 +/- 4.09. Score was significantly associated with disease duration [p value 0.0001, student t test]. The difference in DLQI scores between sexes was not significant [p value 0.32, student t test]. Skin diseases, irrespective of the diagnosis, impair quality of life which is directly proportional to the duration of disease

Guidelines on the use of acitretin in Pakistan

Actretin is a second generation retinoid which is commonly used in psoriasis and many other disorders of keratinization. The present review focuses on its uses, side effects and monitoring in the local perspective.

Comparison of low-dose meglumine antimoniate/ allopurinol combination therapy with full dose meglumine antimoniate alone in the treatment of cutaneous leishmaniasis - a randomized controlled trial

Objective: To compare the efficacy and safety of meglumine antimoniate 20 mg/kg/day with combination of meglumine antimoniate 10 mg/kg/day and allopurinol 20 mg/kg/day

Methods: A multi-center single blind randomized controlled trial was conducted. Soldiers over 18 years of age having parasitologically proven cutaneous leishmaniasis requiring systemic therapy, willing for admission to hospital for the study and regular follow up visits in outdoor, and consenting not to use any other treatment for cutaneous leishmaniasis while in study were included. On entry into the study patients were randomly assigned to either group A or group B using a random number table. Group A patients were given meglumine antimoniate 20 mg/kg/day/intramuscular till clinical resolution or for 28 days maximum. Group B patients were given intramuscular meglumine antimoniate 10mg/kg/day along with allopurinol 20 mg/kg/day/per oral till clinical resolution or for a maximum of 28 days. The ulcer and induration areas were recorded separately for each patient. Time to healing was recorded and compared among the two groups

Results: A total of 324 patients were included in the study. Group A had 151 [46.6%] patients while 173 [53.4%] were in group B. Three hundred and six patients completed the study and 18 dropped out due to various complications, 9 belonging to each group. Lesion size at baseline in group A was 29.7+16.4 mm, while in group B it was 28+15.8 mm [p=0.35]. Lesion size at the end of treatment period was 1.5+3.4 mm in group A and 0.9+2.6 mm in group B [p=0.07]. Lesion size at the end of follow-up period was 0.1+0.9 mm in group A and 0.03+0.4 mm in group B [p=0.40]. A total of 109 adverse effects were seen, 60 in group A and 49 in group B [p=0.05]

Conclusion: Low-dose meglumine antimoniate/allopurinol combination is equally effective and safe as compared to full dose meglumine antimoniate treatment

Awareness and frequency of hepatitis B vaccination in high-risk health care workers at a tertiary care hospital

To assess awareness of high risk health care workers about being at risk for contracting hepatitis B and importance of vaccination for them and to determine effectiveness of hepatitis B vaccination amongst them. A cross-sectional study was carried out at Combined Military Hospital, Kharian cantonment from August 2009 to July 2010. Two hundred high-risk health care workers were selected by convenience sampling. Anti-HBs titers were checked to see the effectiveness of vaccination. A questionnaire was administered to record frequency of vaccination, immunity status and their awareness of high risk and protective role of hepatitis B vaccination. Of the 200 participants, 125 [62.5%] were aware of being at high risk for acquiring HBV infection and protective role of vaccine against it. One hundred and six [53%] persons had received vaccination against hepatitis B. Among vaccinated, 87 [43.5%] had protective levels of Anti-HBs titers while 19 [9.5%] had undetectable titers. Nineteen [9.5%] remained unvaccinated despite being aware. A significant proportion of high-risk health care workers lack awareness, vaccination, or immunization against hepatitis B

Psoriasis in Pakistani population: associations, comorbidities, and hematological profile

To observe the clinical features, laboratory profile, associations and comorbidities of psoriasis in a segment of Pakistani population. This cross-sectional descriptive study was carried out at PAF base hospital, Sargodha from January 2010 to December 2010. One hundred consecutive patients with a diagnosis of psoriasis were included in the study. The diagnosis was confirmed by one of the consultant dermatologists. Pretested, especially designed questionnaire was filled by all the participating patients. Information regarding age, sex, duration of disease, clinical type and severity of disease, nail and joint involvement, koebnerization, associated diseases, and hematological profile including hemoglobin level, blood ESR, uric acid level and its association with joint involvement were recorded. Out of the 100 consecutive patients included in the study, 71 were males and 29 were females. Mean age of onset was 39.8 years. 88 patients had chronic plaque psoriasis, 8 had guttate and 4 had erythrodermic psoriasis. 46 patients had some sort of joint involvement and 29 patients had some sort of nail involvement. Only 14 patients gave history of koebnerization. Only 10 patients had associated skin disease while 15 patients had some associated medical disease. Mean hemoglobin levels were 13.25 gm/dl. Mean ESR was 22.6 mm/h. Rise in serum uric acid level was significantly associated with psoriatic arthritis. Pakistani patients with psoriasis are more likely to have a lower hemoglobin and a raised ESR. Rise in serum uric acid level is associated with joint involvement

Comparison of clinical and sonographical findings of Achilles tendon involvement in newly diagnosed and established cases of psoriasis

To compare the clinical and sonographical findings of Achilles tendon involvement in newly diagnosed [disease duration <6 months] and established psoriatic patients [disease duration >5years]. This cross-sectional, comparative study was carried out in Departments of Dermatology and Radiology, Military Hospital, Rawalpindi, over a period of six months. 70 patients of psoriasis were divided into two groups comprising 35 patients in each. Group I patients were newly diagnosed cases while group II included the established psoriatic patients. All patients with clinical and histological evidence of psoriasis were included. Patients with history of osteoarthritis, rheumatoid arthritis or foot trauma were excluded. Detailed history and complete clinical examination was carried out as per pro forma. The condition was considered symptomatic when there was tendon swelling, pain, tenderness or functional impairment. Ultrasound of Achilles tendon was done, keeping patient in prone position by using Pro Sound SSD 5500 Toshiba ultrasonographic machine with high frequency probe [7.5MHz] to assess findings of Achilles tendon in psoriatic patients. Fibrillar tendon structures, tendon thickness, peritenon, and bursae were evaluated. On clinical assessment 1 [2.8%] patient in group I and 5 [14.3%] patients in group II had Achilles tendon involvement. On ultrasonographic assessment, 3 [8.5%] patients in group I and 15 [42.8%] patients in group II showed involvement of Achilles tendon [p <0.05]. Achilles tendon involvement occurs in significant number of patients with long standing psoriasis as compared to newly diagnosed cases. It also revealed that enthesitis progresses with the duration of disease

Herpes zoster: seasonal variations and morphological patterns in Pakistan

To determine the relevance of seasonal variations and pattern of herpes zoster among the labor community in Lahore. This observational, cross sectional study was conducted at Nawaz Sharif Social Security Teaching Hospital from June, 2009 to May, 2010. Entitled patients that included the industrial labour and their dependents who were clinically diagnosed to be suffering from Herpes zoster during the above mentioned period were included in the study. All the findings were recorded on a pre-designed pro forma. Fifty two enrolled patients constituted 0.46 per cent of overall OPD patients, with male to female ratio of 2:1 and the mean age at presentation was 47 years. Average duration of symptoms at presentation in Herpes zoster ophthalmicus [HZO] was 4.5 days while in remaining cases it was 5.6 days. The surge of the cases was noted with onset of summer and most common dermatomes involved were thoracic followed by ophthalmic division of trigeminal nerve. There is a relationship between Herpes zoster and seasonal variations which seems to be different from temperate climate of western countries

Risk profile in young patients with acute myocardial infarction

The objective of this study was to determine the frequency of risk factors in young patients with acute myocardial infarction and thus with ischemic heart disease [IHD], aged 20 to 40 years, in our population. A descriptive study. This study was carried out at Combined Military Hospital, Kharian Cantonment Pakistan from January 2007 to December 2008. All patients who fulfilled the inclusion criteria who presented to emergency reception of the hospital with a diagnosis of Acute MI were included. The patients were admitted to coronary care unit [CCU] and were managed for Acute myocardial infarction [MI]. Their detailed history was then taken including symptoms at presentation and their risk factors were assessed with the help of history and laboratory investigations. A total of 137 patients were included during the study period. Mean age was 36 years [SD=3.67]. Majority of patients were males. Smoking was the major risk factor [64.2%] followed by family history of IHD [30.7%]. Most frequent risk factor for Acute myocardial infarction [MI] at young age is smoking followed by family history

Frequency of various cutaneous disorders in chronic hepatits C virus infection

Silent chronic hepatitis C [HCV] infection is endemic in our society. Several different cutaneous manifestations have been studied with it. Understanding these may help in early diagnosis of HCV disease. To determine the types and frequency of various cutaneous disorders in chronic hepatitis C virus infection. This cross sectional study was conducted at the medical department of Combined Military Hospital, Kharian cantonment, Pakistan. Patients of chronic hepatitis C confirmed by serological markers, ELISA, and positive PCR were enrolled from outpatient department. Detailed history taking and relevant systemic examination was carried out. All enrolled patients were specifically examined by a dermatologist to diagnose or rule out the presence of skin disease. Biochemical profile including complete blood count, platelet count, cryoglobulins, and antibodies against nucleus, neutrophil cytoplasm, cardiolipin, and smooth muscle were done. All this information was entered into a specially designed pro forma. All data was analyzed using SPSS Program 10.0. Descriptive statistics were calculated for the study variables. One hundred patients were enrolled during the study period. 47% patients with chronic HCV infection were found to have at least one dermatological disease. Cryoglobulinemia was the commonest finding followed by lichen planus and chronic urticaria. Manifestation with lesser frequency included vitiligo, xerostomia, and purpura. Dermatological diseases are fairly common in patients with chronic HCV infection and can help to identify the silent cases

Comparison of methotrexate and azathioprine in the treatment of psoriasis: a randomized controlled trial

Treatment of psoriasis requires a safe and effective drug which can be used on long term basis. Azathioprine is one such agent which was used in the past but has not been tested recently. A randomized controlled trial was conducted at dermatology department, Combined Military Hospital, Kharian, to compare the efficacy and safety of azathioprine with that of methotrexate in patients with severe psoriasis requiring systemic therapy. Patients included in the study were randomized into two groups. Group A received tablet methotrexate 10 mg weekly for 8 weeks. Group B patients received tablet azathioprine in a dose of 1.5-3 mg/kg/day. In all the adult patients who were weighing more than 50 kg azathioprine was started at a dose of 50 mg tablet thrice daily for 8 weeks. PASI score was assessed at the start and end of treatment. Scores were compared in the two groups before and after and statistically analyzed using paired and independent sample t test. 50 patients entered the study. Results were stratified into excellent, good, and poor response, based on improvement in PASI scores. Excellent response was seen in 73% patients in group A and 27% patients in group B [p<0.5]. Good response was seen in 45% patients in group A and 55% patients in group B [p>0.5]. Poor response was seen in one patient in each group [p>0.5, paired sample t test]. Azathioprine is less effective in systemic treatment of psoriasis. Nevertheless it can be a useful alternative in selected patients

Value of patch testing with indigenous battery of allergens in shoe dermatitis

To explore the potential allergens used in our domestic shoe industry and to determine the efficiency of indigenously prepared battery of allergens in shoe dermatitis. A comprehensive list of 49 chemicals used in local processing and manufacturing of footwear was acquired from local sources. Potential irritants were excluded and a finished battery of 20 allergens relevant to our industrial environment was prepared by using standard techniques. Fifty patients and same number of control subjects were enrolled in the study for patch testing using Finn chambers and polyethylene IQ chambers. Results were read using standard protocol at 1 hour, 48 hours, 4[th] day, and 7[th] day. A pre tested, structured questionnaire was filled for each patient. Data were analyzed using SPSS version 12.0 for statistical analysis. Chi square test was applied for comparative analysis between patients and controls. Out of 50 patients 33 [66%] were found to be allergic to 14 different chemicals present in indigenous test battery as opposed to 4 [8%] in control group [p<.0001, chi square test]. Fifteen [30%] patients were reactive to additives used in processing and manufacturing of rubber. Eight [16%] patients were sensitive to agents used in tanning the leather. Four [8%] patients exhibited sensitivity to both leather and rubber and 6 [12%] patients were allergic to the chemicals present in resins, glues, plastics, dyes and metals. No reaction was observed at the site of application of blank chamber and vehicle. The indigenous battery is reliable, cost effective and flexible to adapt to changes in exposure and to introduction of new allergens in market. It would be prudent to recommend exploring the other industries like perfume, garments, and rubber, etc. on similar lines

Frequencies and patterns of arrythmias in anterior and inferior myocardial infarction

The objective of this study was to identify the frequency and clinical patterns of arrhythmias in anterior and inferior myocardial infarction [MI]. A descriptive study. This study was conducted at critical care unit of Combined Military Hospital Kharian cantonment from January 2006 to December 2006. Hundred patients were included in the study that fulfilled the required criteria. They underwent detailed history taking and systemic examination. Patients were monitored through cardiac monitors and serial ECG recordings were taken especially if any rhythm disturbances were observed or if the patient suffered any symptom, till the time of discharge from the hospital. The relevant information was entered into a specially designed pro forma. All the data collected through the pro forma was analyzed through SPSS version 11 in terms of frequency, percentages and proportions. Premature ventricular contractions [PVCs] were the most common rhythm disturbance followed by ventricular tachycardia [VT]. Both were more common in anterior myocardial infarction [MI] than inferior MI. Bradyarrhythmias were more common with inferior MI. PVCs usually manifested with chest pain, VT was accompanied by palpitations and dyspnoea. Atrioventricular [AV] blocks clinically presented as syncope. PVCs are the most common rhythm disturbance after anterior and inferior MI. VT and ventricular fibrillation [VF] are frequent in anterior while bradyarrhythmias are common with inferior MI

Patterns of psoriatic arthritis

To describe the clinical patterns of arthritis in psoriasis. Cross-sectional, observational study. Combined Military Hospital, Kharian Cantonment, Pakistan, from January to December 2007. One hundred consecutive patients with psoriasis reporting to dermatology outpatient department were included. Pregnant ladies [due to X-ray hazard] and rheumatoid factor positive patients were excluded. The demographic profile of patients was recorded. Psoriatic arthritis was diagnosed on the basis of Moll and Wright criteria. Standardized examination of axial and peripheral joints was made. The severity of psoriasis was assessed by PASI score. The presence of a clinical type of psoriatic arthritis, enthesitis, dactylitis, and nail changes were noted. X-ray films of involved joints were taken. A statistical analysis using chi-square test and student's t-test were done where applicable. The mean age of patients was 39.8+15.8 years. Seventy one percent were males and 29% were females. Forty six percent of the patients gave a history of joint involvement and fulfilled the Moll and Wright criteria. The mean PASI score in non-arthritic patients was 26.8 +/- 34.8 and in psoriatic arthritis patients it was 28.4 +/- 41.2, p=0.08. Thirteen patients [28.2%] had predominantly axial disease, while the rest had predominantly peripheral disease. Single joint involvement [monoarthritis] was the commonest clinical presentation. Nail involvement was seen in 29% of the patients without arthritis while in patients having arthritis, nail involvement was 74% [p=0.001]. Joint involvement is common in psoriatic patients. However, the criteria of diagnosis lack consensus

Outbreak of cutaneous leishmaniasis in Somniani, Balochistan - implementation of preventive measures for deployed personnel of armed forces

To evaluate the number of cutaneous leishmaniasis [CL] cases reporting from Somniani between years 2001 to 2005 and to explore the preventive measures being used against sandfly bite. This observational study was conducted at the dermatology department of Combined Military Hospital, Malir Cantonment, Karachi from January 2001 to December 2005. Between year 2001 and 2005, suspected cases of CL reporting from Somniani, Balochistan were identified, evaluated, diagnosed and included in this study. Diagnosis was based on clinical examination, slit skin smear for detection of Leishman-Donovan [LD] bodies and skin biopsy for histopathology. Patients were then asked to fill a structured, anonymous, self-administered and close ended questionnaire which included questions about the use of various preventive measures against cutaneous leishmaniasis. A total of 108 patients were diagnosed as CL from Somniani during the study period. The peak was seen in year 2004 [n=58] which coincided with increased troop activity in the area. Nodulo-ulcerative lesions were the commonest mode of presentation. Skin biopsy for histopathology was the most effective method of diagnosis. Overall only 28% personnel were using preventive measures against sand fly bite. Only 15% personnel had disease awareness. Lack of application of preventive measures and knowledge of disease were the reasons for increase in CL cases

Value of transverse section scalp biopsy in alopecia areata - a clinicopathological correlation

To correlate the histopathological features of alopecia areata with clinical stage by means of transverse sectioned scalp biopsy specimens, in terms of extent and duration of disease. Cross-sectional. Department of Dermatology, Combined Military Hospital, Kharian Cantonment, Pakistan, from January 2002 to December 2004. Fifty consecutive patients with alopecia areata were included in the study Four millimeter punch biopsy was taken and representative horizontal sections from lower and upper dermis were examined. Patients were divided according to disease extent i.e. Group I [<25% of scalp surface area], Group II [25 - 75% of scalp surface area] and Group III [>75% of scalp surface area including alopecia totalis and universalis]. Patients were also analyzed according to the disease duration, i.e. 0-6 months, > 6-12 months, > 1-5 years and > 5 years. Follicular unit counts and density/ mm[2], terminal to vellus hair ratio, anagen to telogen ratio, cellular infiltrate and fibrosis were measured to assess the diagnosis and prognosis of disease. Chi-square test was used to assess statistical significance. Diagnosis of alopecia areata could be made in 82% of biopsies. Follicular unit counts and density per mm[2] decreased with the disease duration [p=0.01]. Catagen and telogen hair follicle counts increased with disease duration [p=0.0001]. Cellular infiltrate decreased and fibrosis increased with the duration of disease [p=0.0001]. Anagen telogen ratio and terminal to vellus hair ratio inverted in long-standing disease. Transverse section scalp biopsy can help in the diagnosis of alopecia areata and the disease stage can be predicted by analyzing the histopathological findings quantitatively

Chilblains among soldiers - a negative impact of this preventable disease on military preparedness in peace

The objective of this study was to determine the frequency of chilblains among soldiers in general and recruits and cadets in particular during peace time at a climatically cold weather station. A descriptive study. The study was carried out in dermatology department of Combined Military Hospital, Abbottabad during the winter months of Dec 2004 to Mar 2005. Serving soldiers of all ranks who were clinically diagnosed to be suffering from chilblains were included in the study. They were interviewed in detail and examined thoroughly. All the findings were recorded in a pre designed proforma. A separate proforma was filled for each patient. During the period mentioned above, 493 soldiers were registered in dermatology outpatient department of Combined Military Hospital, Abbottabad for various skin diseases. A total of 41 [8.3%] soldiers were diagnosed and treated as chilblains cases. Out of 364 regular soldiers [Officers, Junior Commissioned Officers and Other Ranks] 10 [2.7%] were having chilblains. On the other hand, out of 129 newly inducted soldiers [Recruits and cadets] 31 [24.0%] were diagnosed as having chilblains. Twenty eight [90.3%] of these newly recruited soldiers belonged to climatically warmer areas and this was their first winter at this cold weather station. Twenty nine [70.7%] of the 41 soldiers were treated in outdoor, whereas 12 [29.3%] were hospitalized. The number of wasted days ranged from 20 to 106 with a mean of 34.66 days. Chilblains are more frequent among newly recruited soldiers, who are not acclimatized properly and are more exposed to cold because of their training activities

Scrofuloderma neck with chest wall abscess

Cutaneous tuberculosis [TB] is among the uncommon varieties of tuberculosis but it is also on the rise, commensurate with the general resurgence of the disease. A case of scrofuloderma of neck with tuberculous abscess of anterior chest wall is, hereby, reported. The patient presented with a non-healing ulcer of neck with swelling of anterior chest wall, which responded to antituberculous treatment. This complication of scrofuloderma neck is very rare and should be kept in mind in the differential diagnosis of such lesions

Basal cell carcinoma involoving the skin of breast a rare site

Basal cell carcinoma [BCC] is the most common and least lethal form of all cancers. The estimated lifetime risk of BCC in the white population is 33-39% in men and 23-28% in women. It occurs most frequently in people over 50 years of age and almost twice as often in men as in women. Up to 85% of BCCs are found in the head and neck region, but the lesions occasionally occur in unusual and routinely photoprotected locations. These include breast, vulva, scrotum, earlobe and middle ear. With such an atypical presentation of BCC, a keen and skeptical eye for diagnosis is required. No population-based epidemiologic studies to assess the incidence of BCC have been done in Pakistan. However, some scattered data can be found in local medical literature, which shows the highest frequency in 51-60 years age group with a male preponderance. We report a case of non healing ulcerated lesion over breast that was being treated for 5 years unsuccessfully. On skin biopsy, it came out to be BCC. As far as we have searched, it is the first report of such a case in Pakistani literature

Simultaneous onset of herpes zoster in a father and son

The Varicella Zoster virus persists in sensory nerve ganglion cells after chicken pox and gets reactivated to cause herpes zoster after variable periods of time as a result of waning of specific cellular immunity. Susceptible contacts of herpes zoster can develop chicken pox and very rarely herpes zoster. We report an interesting case of a father and his son who developed herpes zoster simultaneously without any obvious common predisposition and discuss the possible underlying mechanism