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Ticagrelor is a part of dual antiplatelet therapy (DAPT) which has proven benefits in patients with acute coronary syndrome especially in those undergoing percutaneous coronary intervention (PCI). However, like most other drugs, it can lead to undesired and adverse effects such as dyspnoea, easy bruising and gastrointestinal bleeding. We present a case of 70-year-old woman who developed diarrhoea following initiation of DAPT comprising of aspirin and ticagrelor following PCI. After excluding more common causes, it was attributed to ticagrelor administration and completely resolved after it was replaced with another oral antiplatelet agent. On follow-up, the patient reported complete resolution of symptoms.

To reducing the risk of venous thromboembolic (VTE) events and subsequent mortality in covid-19 patients is still a matter of research. This systematic review and meta-analysis serve the purpose of comparing the mortality associated with the intensity of anticoagulation in patients admitted with covid-19.A total of 7120 patients were recruited in 11 studies comparing using prophylactic anticoagulants against therapeutic anticoagulants.Our study showed that using prophylactic anticoagulants was associated with a 42% reduction in mortality compared to therapeutic anticoagulants (OR 0.58 (95% CI:0.676-0.499),Our meta-analysis favors using prophylactic anticoagulation in covid-19 patients reduces all-cause mortality in comparison to therapeutic anticoagulation however the impact on mortality when compared with no anticoagulation was not significant.PROSPERO Number: CRD42021257320.

Objectives: To compare the mean improvement in pain on Visual Analogue Scale by Suprascapular Nerve block and Intra-articular steroid injection in patients with hemiplegic shoulder pain. Study Design: Randomized Controlled Trial Place and Duration of Study: Pain Clinic, Armed Forces Institute of Rehabilitation Medicine Rawalpindi from 25th October 2017 to 24th April 2018 Patients & Methods: 60 patients with CVA and shoulder pain on hemiplegic side for at least 2 weeks were included in study after non-probability consecutive sampling after meeting inclusion criteria. Subjects were randomized by lottery into two groups; Group A receiving Suprascapular Nerve block with 5ml of 1% Lignocaine with Group B receiving Intra-articular 40mg Triamcinolone Acetonide plus 1 ml of 1% Lignocaine injections. Mean change in pain scores on VAS was calculated between score at baseline and at 4 weeks post-intervention Results: The mean age of patients in group A was 59.17 ± 9.81 years and in group B was 39.96 ± 11.11 years. Out of 60 patients, 34 (56.67%) were males and 26 (43.33%) were females with male to female ratio of 1.3:1. Mean duration of stroke was 7.50 ± 2.66 months. Mean pain change on VAS in Group A (Suprascapular Nerve block) was 3.83 ± 1.12 cm while in Group B (Intra-articular steroid injection) it was 2.17 ± 0.99 cm (p-value = 0.0001). Conclusion: This study concluded that Suprascapular Nerve block offered better improvement in hemiplegic shoulder pain on Visual Analogue Scale at 4 weeks as compared to intraarticular steroid injection.

We have reported here two cases of coronavirus disease-2019 (COVID-19) patients aged 29 and 68 years who were diagnosed with pneumomediastinum (PM). PM is a rare complication that is being reported in association with COVID-19. Patients with COVID-19 can present with a variety of etiologies that make them vulnerable to PM. Respiratory complications due to COVID-19 are widely known, and it presents as mild to severe and critical illness. Spontaneous PM is a known complication of COVID-19. Despite seeming to be a lesser-known condition, PM can have a significant impact on disease progression and prognosis. We have presented here two contrasting cases of PM. The first patient was young and with moderate COVID-19 pneumonia and PM, while the second one was an old man with severe COVID-19 pneumonia manifestations. Both patients were diagnosed with PM, but their outcomes were completely different.

Diabetes mellitus is a well-recognized contributor to increased COVID-19 severity. Endothelial dysfunction has been implicated in the pathogenesis of COVID-19, while thrombocytopenia has been identified as a potential risk factor for severe COVID-19. In this study, we evaluated the combined effect of thrombocytopenia and other markers of endothelial dysfunction on disease outcomes in patients with type 2 diabetes and active COVID-19 infection. Our aim was to risk stratify patients with COVID-19 and type 2 diabetes mellitus, which can help identify patients with high-risk features who will benefit the most from hospital admission and a high level of care. This cross-sectional study was performed after reviewing secondary data of 932 patients with COVID-19 and type 2 diabetes mellitus in the outpatient and inpatient settings across Qatar between March 1, 2020 and May 7, 2020. Univariate and multivariate analyses, with adjustment for low platelet counts, were performed for the following variables: age, hemoglobin, white blood cells (WBC), lymphocytes, monocytes, eosinophils, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, ferritin, D-dimer, and interleukin 6. Increasing age was associated with an increased risk for death and/or intensive care unit admission in diabetic patients with COVID-19 who have low platelet counts. These findings support the evidence found in the literature and give special attention to COVID-19 patients with low platelet counts and diabetes mellites. These results can guide physicians in making clinical decisions regarding hospital admission and escalation of care during follow-up in this population of patients.

Importance Obesity is associated with increased prevalence of gastroesophageal reflux disease (GERD); with recent reports suggesting improvement in GERD symptoms and weight loss following bariatric surgical intervention. However, the exact impact of the type of bariatric surgery on the evolution of GERD symptoms have remained unexamined. Objective To characterize the exact evolution of GERD symptoms, post bariatric surgery.Data sources We systematically searched electronic databases (PubMed, EMBASE, Web of Science, and the Cochrane Library from inception to December 2018) for eligible studies that satisfy pre-specified inclusion criteria. Study selection We included clinical trials of all designs (prospective and retrospective) that reported on GERD outcomes following Laparoscopic Sleeve Gastrectomy (LSG) or laparoscopic Roux-en-Y gastric bypass (LRYGB).Data extraction and synthesis Two independent reviewers extracted relevant data based on the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guideline. Data were pooled using a random-effects model.Main outcomes Symptomatic improvement in GERD symptoms following bariatric surgery Results A total of 39 studies were analyzed and a robust-error meta-regression model was used to conduct a Dose-Response Meta-Analysis (DRMA) synthesizing data on 39 studies that reported GERD outcomes after bariatric surgery. Out of 43,994 patients who underwent either LSG (N = 9,547 patients) or LRYGB (N = 34,447 patients), 32.4% experienced improvement in symptoms (95% CI 20.62 to 45.45); The DRMA demonstrated a window period of two years for sustained improvement after which symptoms began to recur in those that were asymptomatic. Conclusion and relevance Bariatric surgery may improve GERD symptoms in obese patients who underwent LSG, however, the most favorable effect is likely to be found after Roux-en-Y gastric bypass surgery. The effects were not sustained and returned to baseline within 4 years.

Tooth loss is a process in which one or more teeth come loose and fall out. Tooth loss is normal for deciduous teeth (baby teeth), when they are replaced by a person's adult teeth. Otherwise, losing teeth is undesirable and is the result of injury or disease, such as dental avulsion, tooth decay, and gum disease. The cross-sectional study was conducted among outdoor patients in a tertiary care hospital. A total of 87 patients were enrolled in this study. The basic demographic data i.e. name, age, gender, disease duration, brief history, reasons for tooth loss were noted on a predefined proforma. All the data was entered and analyzed with SPSS Ver. 22.0. There were 38 male and 49 female patients. The mean age of the patients was 36.45±3.78 years. The mean duration of disease was 1.23±0.43 years. The main reasons of tooth loss (extraction) were dental caries, periodontal disease and trauma. The tendency was greater in patients with younger age i.e. between the ages of 20 and 30 years. Keywords: Tooth Loss, Outdoor Patients

mRNA vaccines including Pfizer BioNTech and Moderna have categorically been considered safe when it comes to preventing COVID-19. However, there is still a small associated risk of thromboembolic phenomenon including venous sinus thrombosis with it and our case report highlights one.We describe a patient who developed severe progressive headache, tinnitus and visual disturbance symptoms post-Pfizer-SARS-CoV-2 vaccination. His medical history included essential tremors, hypertension, type 2 diabetes mellitus, chronic kidney disease stage 3, anxiety, depression and long-term catheterisation. Systemic examination revealed hypotonia, generalised reduced power and central diplopia along with peripheral visual field defect in the left eye. He was extensively investigated, the COVID-19 PCR test was negative and all routine blood tests were in the normal range except a marginally raised D-dimer of 779 ng/mL. CT head was unremarkable. He was also tested for myasthenia gravis; however, acetylcholine receptors antibodies were negative and nerve conduction studies were normal. Subsequent MRI of the brain with venography confirmed venous sinus thrombosis. A 24-hour Holter monitoring test did not reveal any cardiac rate or rhythm abnormality. He was treated with apixaban as per a neurologist’s advice. His clinical condition started to improve and was later discharged from the hospital with an outpatient neurologist clinic follow-up.

This research study was conducted on socio-economic conditions of families living in squatter’s settlement of Karachi. The urban population is booming with unprecedented growth due to heavy influx or migration of rural population to the cities especially in Karachi. The rural families are migrating to the city in a way to have better employment; improved lifestyles in urban societies. Migrators usually accommodated in squatters’ settlements of Karachi because of high residing cost in urban areas. The squatters’ settlements are located at outskirt of the city on government owned lands. However the provincial government has set up Sindh Katchi Abadi Authority (SKAA) department for upgrading or regularizing Katchi Abadis which are working under specific rules and regulations. In this study the role of SKAA also highlighted to analyze the working preferences of organization for the rehabilitation or betterment of squatter settlements. The research topic is chosen in order to investigate about the socio-economic issues of families living in squatters settlements. The data is collected from 200 respondents of squatters from squatters’ settlements which are situated in six different districts of Karachi. Data is collected by the self-prepared questionnaire which was prepared in a way to investigate socio-economic issues and problems of squatters’ families living in the settlements. This research found that whole sample of squatters is of migrators. These settlements are considered illegal and have no provision of basic necessities including drinking safe water; inadequate sanitation system; and low standard of housings.

Physical disabilities such as a spinal cord injury (SCI) may change the sexual functioning of a person. The aim of this study was to estimate the frequency of sexual dysfunction (SD) in a cohort of Pakistani men with SCI and explore the influence of level and completeness of SCI, financial and educational status, and rural versus urban living on SD. Fifty-nine men with SCI (mean age: 32 ± 9 years) participated in the study. They were asked about sexual desire, sexual intercourse before and after SCI, type of penile erection they could achieve, methods they used to attain erection, attainment of orgasm and ejaculation, and the level of satisfaction with their sexual life. The majority (83.1%) possessed sexual desire but only 22% performed sexual intercourse following injury. Most men (81.4%) were able to achieve erection. The commonest type of erection was reflexogenic (n = 42) and masturbation was the preferred method (n = 35). Only 35.6% were successful in reaching orgasm and 13.6% had effective ejaculation. No one could have children following injury. The largest proportion (n = 20) reported somewhat satisfaction with their post-injury sexual life. Statistical analysis showed that men with incomplete lesions were significantly better in terms of sexual intercourse (p = 0.008) and achieving ejaculation (p = 0.001). Men of younger age were significantly better (p = 0.026) in terms of sexual desire. Educational grade, financial status, urban versus rural living, and the level of SCI did not significantly influence sexual desire, sexual intercourse, reaching orgasm, achieving erection or ejaculation, and satisfaction in sexual life. In conclusion, following SCI, most men in our sample possessed sexual desire and attained penile erection, however, less engaged in sexual intercourse, reaching orgasm, successful ejaculation, or becoming fathers. Individuals with an incomplete injury and younger age seemed more sexually active than those with a complete injury and older age. However, the majority were satisfied with their sexual life.

Objective: To assess and compare the relative efficacy of silk ligation and diathermy coagulation techniques in controlling bleeding during tonsillectomy in the first 24 hours. Methods: This prospective study was conducted at the Department of ENT, DHQ teaching hospital, Sargodha and this department related consultants’ private clinics from August, 2017 to December 31, 2017. The study included 180 cases. All patients included were having history of recurrent, acute tonsillitis, with more than 6–7 episodes in one year, five episodes per year for two years, or three episodes per year for three years. All the surgeries were performed by dissection method. Haemostasis during the procedure was secured by either ligation with silk 1 or using diathermy. The results were analyzed using SPSS 16.0 for windows. Results: A total of 180 cases were included in the study. The ages of the patients ranged from 5 to 40 years with the mean age of 15.56 years and a std. deviation of +/- 8.24. The male to female ratio was 1.25:1. The number of hemorrhages occurring was greater in the ‘diathermy coagulation’ group as compared to the ‘silk ligation’ group. However, the observed difference was statistically insignificant (p>.05). Conclusion: Primary haemorrhage occurring during tonsillectomy is a serious threat and control of bleeding during the procedure should therefore be meticulous. Both suture ligation and coagulation diathermy for control of bleeders during the procedure by dissection method are equally effective. Keywords: Tonsillectomy, Diathermy, Suture Ligation, Haemostasis, Primary haemorrhage.

Pakistan is one of the three countries in South East Asia that has an active postgraduate physical medicine and rehabilitation (PM&R) training program. College of Physicians and Surgeons Pakistan (CPSP) offers a four-year structured training program in PM&R. It consists of clinical teaching, lectures, rotations in other specialties, and writing a research dissertation. The aim of this survey was to provide an objective analysis of the current PM&R training program, including the facilities available for training, the participation of residents in academic activities, and their participation in different PM&R procedures. Hospital ethics committee approval was obtained. The questionnaire had sections on informed consent; basic demographics; the different components of residency training; and self-assessement of competence in different procedural skills. It was approved by the dean of PM&R at CPSP. There are six accredited training centers in Pakistan. Twelve residents are undergoing residency training at four different centers (Dec 2015). Key persons were nominated at each center to facilitate data collection. All residents (100% response rate) completed the survey. Almost all had read the CPSP training manual. Most had submitted the research dissertation. Training facilities varied across different centers, with the military center being the best equipped. The self-assessed competence of residents in different PM&R procedures varied among different centers, but overall it conformed to the competency levels specified in the training manual. Overall PM&R residency training in Pakistan is satisfactory, but there is a need to strengthen the weak areas and standardize the training across all centers in the country.

Objective To provide an update on disability and outline potential barriers and facilitators for implementation of the World Health Organization Global Disability Action Plan (GDAP) in Pakistan. Methods A 6-day workshop at the Armed Forces Institute of Rehabilitation Medicine, Islamabad facilitated by rehabilitation staff from Royal Melbourne Hospital, Australia. Local healthcare professionals (n = 33) from medical rehabilitation facilities identified challenges in service provision, education and attitudes/approaches to people with disabilities, using consensus agreement for objectives listed in the GDAP. Results Respondents agreed on the following challenges in implementing the GDAP: shortage of skilled work-force, fragmented healthcare system, poor coordination between acute and subacute healthcare sectors, limited health services infrastructure and funding, lack of disability data, poor legislation, lack of guidelines and accreditation standards, limited awareness/knowledge of disability, socio-cultural perceptions and geo-topographical issues. The main facilitators included: need for governing/leadership bodies, engagement of healthcare professionals and institutions using a multi-sectoral approach, new partnerships and strategic collaboration, provision of financial and technical assistance, future policy direction, research and development. Conclusion The barriers to implementing the GDAP identified here highlight the emerging priorities and challenges in the development of rehabilitation medicine and GDAP implementation in a developing country. The GDAP summary actions were useful planning tools to improve access and strengthen rehabilitation services.

Objective: To describe the pattern of Urodynamic evaluation at ArmedForces Institute of Rehab Medicine, Rawalpindi. Study Design: Descriptive study. Materials and Methods: This studywas conducted on 466 patients reporting for urodynamic evaluation at Urodynamic/Incontinence Clinic at A F Instituteof Rehab Medicine from Feb 2003 to Dec 2006. We considered the age, gender, etiology, reason for referral, andpresenting complaints whereas results were formulated according to Classification of voiding disorders by Internationalsociety of Incontinence. Data was analyzed using statistical package forSocial Science version 10. Results: In all (466)patients, 58% were males and 42% were females. Mean age was 46.8 years. Increased frequency (61%) andincontinence (52%) were the most common presenting complaints, 158(34%) had spinal cord injuries, 58 were casesof myelodysplasias and 128 reported with stress incontinence. Urodynamic studies showed that 152(33%) hadhyperactive bladders, 110(24%) had a contractile/hypo-contractile bladders, 104(22%) had stress incontinence and56(12%) cases had normal results. Conclusion: Urodynamics helps in diagnosis of potentially life threatening urinaryproblems. The availability of this equipment and trained staff must be encouraged at tertiary care hospital. Moreresearch is required in this regard in Pakistan, which shall help in formulating better management protocols in future

To determine the pattern of peripheral nerve injuries in Pakistani soldiers in the War against terror.Case series.Department of Electrodiagnosis at Armed Forces Institute of Rehabilitation Medicine (AFIRM), Rawalpindi, Pakistan, from June 2008 to June 2011.All new cases of war wounded soldiers with peripheral nerve injuries were consecutively enrolled. Physical examination and electrodiagnostic study was carried out by experienced physiatrists. Data was entered in pretested especially designed questionnaire which was analysed using SPSS version 17.0. Seddon's classification system was used to assess the severity of injury.There were 418 cases of peripheral nerve injuries with 504 different nerve segments. Mean age was 29.41 ±8 years. Blast was the main cause of nerve injury in 244 (48.5%) cases followed by gunshot in 215 (42.7%) and 45 (8.9%) cases had nerve injuries secondary to fall, burial under debris and motor vehicle accidents. Eighty six (17%) cases had multiple nerve injuries. Most commonly injured nerve was ulnar (20.6%) followed by sciatic (16.7%), median (16.5%), radial (16.3%), peroneal (8.7%), brachial plexus (8.5%), axillary (4.8%), tibial (2%), femoral (1.8%), long thoracic (0.4%) and others (3.8%). Axonotmesis was seen in 459 (91.1%) cases, 44 (8.7%) cases revealed neurotmesis and 1 (0.2%) case had neuropraxia.Peripheral nerve injuries are a major component of war related injuries mainly involving the upper limbs. Electrodiagnostic studies help in assessing severity and determining prognosis. Precise documentation of severity of nerve injuries is important to estimate the burden on our resources and to extend rehabilitation services.