Farooq Azam Rathore

Spinal Cord Injury Management and Rehabilitation: Highlights and Shortcomings From the 2005 Earthquake in Pakistan

Recent natural disasters have highlighted the lack of planning for rehabilitation and disability management in emergencies. A review of our experience with spinal cord injury (SCI) after the Pakistan earthquake of 2005, plus a review of other literature about SCI after natural disasters, shows that large numbers of people will incur SCIs in such disasters. The epidemiology of SCI after earthquakes has not been well studied and may vary with location, severity of the disaster, available resources, the expertise of the health care providers, and cultural issues. A lack of preparedness means that evacuation protocols, clinician training, dedicated acute management and rehabilitation facilities, specialist equipment, and supplies are not in place. The dearth of rehabilitation medicine specialists in developing regions further complicates the issue, as does the lack of national spinal cord registries. In our 3 makeshift SCI units, however, which are staffed by specialists and residents in rehabilitation medicine, there were no deaths, few complications, and a successful discharge for most patients. Technical concerns include air evacuation, early spinal fixation, aggressive management to optimize bowel and bladder care, and provision of appropriate skin care. Discharge planning requires substantial external support because SCI victims must often return to devastated communities and face changed vocational and social possibilities. Successful rehabilitation of victims of the Pakistan earthquake has important implications. The experience suggests that dedicated SCI centers are essential after a natural disaster. Furthermore, government and aid agency disaster planners are advised to consult with rehabilitation specialists experienced in SCI medicine in planning for the inevitable large number of people who will have disabilities after a natural disaster.

Disability and health-related rehabilitation in international disaster relief

Background Natural disasters result in significant numbers of disabling impairments. Paradoxically, however, the traditional health system response to natural disasters largely neglects health-related rehabilitation as a strategic intervention. Objectives To examine the role of health-related rehabilitation in natural disaster relief along three lines of inquiry: (1) epidemiology of injury and disability, (2) impact on health and rehabilitation systems, and (3) the assessment and measurement of disability. Design Qualitative literature review and secondary data analysis. Results Absolute numbers of injuries as well as injury to death ratios in natural disasters have increased significantly over the last 40 years. Major impairments requiring health-related rehabilitation include amputations, traumatic brain injuries, spinal cord injuries (SCI), and long bone fractures. Studies show that persons with pre-existing disabilities are more likely to die in a natural disaster. Lack of health-related rehabilitation in natural disaster relief may result in additional burdening of the health system capacity, exacerbating baseline weak rehabilitation and health system infrastructure. Little scientific evidence on the effectiveness of health-related rehabilitation interventions following natural disaster exists, however. Although systematic assessment and measurement of disability after a natural disaster is currently lacking, new approaches have been suggested. Conclusion Health-related rehabilitation potentially results in decreased morbidity due to disabling injuries sustained during a natural disaster and is, therefore, an essential component of the medical response by the host and international communities. Significant systematic challenges to effective delivery of rehabilitation interventions during disaster include a lack of trained responders as well as a lack of medical recordkeeping, data collection, and established outcome measures. Additional development of health-related rehabilitation following natural disaster is urgently required.

Exploring the attitudes of medical faculty members and students in Pakistan towards plagiarism: a cross sectional survey

Objective. The objective of this survey was to explore the attitudes towards plagiarism of faculty members and medical students in Pakistan. Methods. The Attitudes Toward Plagiarism questionnaire (ATP) was modified and distributed among 550 medical students and 130 faculty members in 7 medical colleges of Lahore and Rawalpindi. Data was entered in the SPSS v.20 and descriptive statistics were analyzed. The questionnaire was validated by principal axis factoring analysis. Results. Response rate was 93% and 73%, respectively. Principal axis factoring analysis confirmed one factor structure of ATP in the present sample. It had an acceptable Cronbach’s alpha value of 0.73. There were 421 medical students (218 (52%) female, 46% 3rd year MBBS students, mean age of 20.93 ± 1.4 years) and 95 faculty members (54.7% female, mean age 34.5 ± 8.9 years). One fifth of the students (19.7%) trained in medical writing (19.7%), research ethics (25.2%) or were currently involved in medical writing (17.6%). Most of the faculty members were demonstrators (66) or assistant professors (20) with work experience between 1 and 10 years. Most of them had trained in medical writing (68), research ethics (64) and were currently involved in medical writing (64). Medical students and faculty members had a mean score of 43.21 (7.1) and 48.4 (5.9) respectively on ATP. Most of the respondents did not consider that they worked in a plagiarism free environment and reported that self-plagiarism should not be punishable in the same way as plagiarism. Opinion regarding leniency in punishment of younger researchers who were just learning medical writing was divided. Conclusions. The general attitudes of Pakistani medical faculty members and medical students as assessed by ATP were positive. We propose training in medical writing and research ethics as part of the under and post graduate medical curriculum.

A comment on management of spinal injuries in the october 2005 Pakistan earthquake.

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Case Report of a Pressure Ulcer Occurring Over the Nasal Bridge Due to a Non-Invasive Ventilation Facial Mask

Non-invasive ventilation (NIV) is used in patients with respiratory failure, sleep apnoea, and dyspnoea related to pulmonary oedema. NIV is provided through a facial mask. Many complications of NIV facial masks have been reported, including the breakdown of facial skin. We report a case of an elderly male admitted with multiple co-morbidities. The facial mask was applied continuously for NIV, without any relief or formal monitoring of the underlying skin. It resulted in a Grade II pressure ulcer. We discuss the possible mechanism and offer advice for prevention of such device-related pressure ulcers.

Knowledge Regarding Basic Facts of Stroke Among Final Year MBBS Students and House Officers: A Cross-Sectional Survey of 708 Respondents from Pakistan.

Introduction: Stroke is the leading cause of neurological disability in the world. In Pakistan, house officers (HOs) are usually the first contact for a stroke patient in the emergency department. Sometimes they need to make quick decisions regarding diagnosis and management without specialist supervision. Thousands of current final year MBBS (Bachelor of Medicine, Bachelor of Surgery) students will be performing the duties of HOs soon. This study documents the knowledge and confidence levels of final year students and HOs in Pakistan regarding basic facts related to initial diagnosis and management of stroke. Materials and Methods: A questionnaire was developed using two standard textbooks of medicine and current stroke guidelines of the American Heart Association. The pre-tested self-administered questionnaire was distributed among 800 final year MBBS students and HOs in 14 medical colleges and hospitals in four different cities. The response rate was 88.5%. Data analysis was done using SPSS V.21. The CMH Lahore Medical College Ethics Review Committee approved this project. Results: Respondents included medical students (n=496) and HOs (N= 212); most were female (n = 452, 63.9%). Of these, 31.4% had managed or assisted in the management of a patient with a stroke and had a higher confidence level in its diagnosis (p< 0.001) and management (p <0.001). Having a family member with stroke was associated with higher confidence in the diagnosis of stroke (p < 0.05) but not with confidence in its management (p = 0.41). Most correctly defined stroke (60.6%), identified the CT scan as the initial diagnostic modality (88.1%), knew the dosage of aspirin (64.9%), knew the time limit for thrombolysis (67.4%), and were familiar with the risk of deep vein thrombosis in immobilized stroke patients (85.4%). Less than half (44.5%) chose tissue plasminogen activator (t-PA) as the preferred initial intervention for acute ischemic stroke. Conclusion: This multicenter survey shows that the knowledge and confidence of medical students and HOs in Pakistan regarding initial diagnosis and management of stroke are inadequate in most domains. There is a need to improve the medical training for stroke in emergency departments for optimal outcomes. Public education campaigns about stroke should be conducted to increase the general awareness of the population about the prevention, signs, symptoms, and emergency steps to be taken when encountering a case of stroke.

Non-operative management is superior to surgical stabilization in spine injury patients with complete neurological deficits: Some additional perspectives

Dear Sir, We read “Non-operative management is superior to surgical stabilization in spine injury patients with complete neurological deficits: A perspective study from a developing world country, Pakistan” by Shamim et al.[9] with interest. Their work is from one of the largest and well-established and respected private health care hospitals in Pakistan. Their observations and recommendations about non-surgical management of traumatic spinal cord injuries (SCIs) in the context of a developing country are very valid. We would, however, like to add few salient comments. In developing countries (including Pakistan), healthcare is more focused on curative medicine rather than preventive medicine. Unfortunately, SCI in the majority of cases in Pakistan results in neurological deficits that cannot be reversed by any surgical or pharmacological means at present. Prevention of SCI is, therefore, an important strategy that can reduce the number of traumatic SCI (secondary to motor vehicle accidents, falls, sports events, etc.) or prevent secondary injury after SCI occurs. The pre-hospital trauma care in Pakistan has improved in the last one decade.[1,10] Still there are deficient areas when it comes to initial management of SCI at the trauma site and evacuation to a medical facility.[8] We noted that one of the reasons of having a greater prevalence of paraplegia (instead of the global trend of tetraplegia) at presentation to the emergency departments is the poor evacuation and management techniques in the pre-hospital phase, such that persons with tetraplegia do not survive.[7] In Pakistan, most of the patients with SCI are from lower socioeconomic groups with low educational and literacy levels.[8] Many cannot understand the true nature of a permanent disability like SCI and often opt for surgical management in the hope that surgery will repair the injured cord. In our experience and interaction with SCI patients and their families over the last 6 years, we have found that most of these patients were not counseled about the difference between surgical stabilization of the bony spinal column versus their perceived idea of the injured spinal cord being surgically repaired. Moreover, many patients are operated weeks after their initial injury when the bony callous formation is already in progress and there is little hope left for neurological recovery. The reported benefits of spinal surgery are in cases operated within 72 hours.[3,5] This is not the case in Pakistan and most of the developing countries where patients may present weeks after sustaining the injury.[6] In these circumstances, spinal instrumentation should only be offered if it can be of any benefit to the patient. In most cases, the cost of the surgical implant has to be borne by the patient/patients family. This leaves very little finances for the postoperative spinal injury rehabilitation which is the only intervention known to improve the long-term functional outcomes and improve Quality of Life in these patients. We have had several patients consulting at our institute for SCI rehabilitation who never underwent rehabilitation due to the lack of funds. Similar findings have been recently been reported from Nigeria where non-surgical management is more cost-effective than surgical interventions.[4] We propose the following as a food for thought for the healthcare policy makers and healthcare professionals involved in the care of SCI in Pakistan: A national trauma/SCI registry should be established to accurately determine the demographics and actual burden of this long-term disability in the country. “An ounce of prevention is worth more than a pound of cure” is the approach needed to reduce the incidence of traumatic SCI in Pakistan. Road safety laws should be enforced and the work conditions should be improved. The pre-hospital evacuation protocols should be revised to specifically address the immobilization and transport of a suspected case of SCI, so that further neurological damage during transport can be prevented.[2] Patient education and counseling is of paramount importance and should not be neglected or omitted in any case. Explaining the nature of the permanent disability should be completed before undertaking expensive spinal surgery without the prospects of improving neurological functions in a neurological complete injury. The facilities of spinal cord injury rehabilitation in the country are very inadequate.[7] The concept of a true interdisciplinary rehabilitation team is largely missing and SCI rehabilitation is being performed at some places without the active involvement and supervision of a physiatrist who specializes in SCI medicine. There is a need to educate the public as well as the healthcare professionals about the need and importance of an interdisciplinary SCI rehabilitation team to provide a comprehensive continuum of care to the patient. In the absence of large, good-quality studies proving that spinal surgery is better than the conservative management, especially if being performed weeks after injury, all patients with traumatic complete SCI should initially be considered for non-operative management.

Bladder management practices in spinal cord injury patients: A single center experience from a developing country

Context/Objective: Inadequate bladder management in spinal cord injury (SCI) patients results in significant morbidity and even mortality. Clean intermittent catheterization (CIC) is the recommended option for SCI patients. The objective of the study was to document the bladder management practices of SCI patients in a developing country. Design: Questionnaire based cross sectional survey Setting: Armed Forces Institute of Rehabilitation Medicine, Rawalpindi, Pakistan Participants: All patients with SCI (irrespective of duration, level and etiology) Interventions: Data documentation included demographics, level, severity and time since injury, bladder management techniques used, details of CIC, results of Urodynamic studies (if available), complications resulting from bladder management technique and patient awareness of the yearly follow up. SPSS V 20 was used for analysis. Outcome Measures: Not applicable Results: Thirty four consenting patients were enrolled. All were males. Mean age was 31.24 ± 10.9. Most (17) of the patients were thoracic level paraplegics, while 12 patients had sustained a cervical SCI. Majority (23) had complete injury (ASIA A). Fifteen patients used CIC for bladder management followed by in dwelling Foley catheters in thirteen patients. Those using CIC performed the procedure every four hours and used disposable catheters. The same ‘disposable’ catheter was used for 5-7 days by half of these patients. Only Six patients independently performed CIC. Three patients on CIC reported urinary tract infection. Conclusions: In the largest spinal rehabilitation unit of a developing country; Pakistan CIC was the preferred method of bladder management followed by indwelling catheter. Re-use of disposable catheters is a common practice due to cost issues. The rate of UTI was significantly lower in patients on CIC.

Restless Genital Syndrome: Case Report of a Rare Disorder from Pakistan

Restless genital syndrome (RGS) is a newly recognized syndrome characterized by difficult to describe genital sensations, including itching, tingling, contractions, and even pain. It can be a source of distress for the patient and may lead to social withdrawal and delayed diagnosis. Many pharmacologic and non-pharmacologic treatment options have been documented in the literature. Dopamine agonists have been shown to be the most effective in symptomatic relief. We present a case of an Asian female with symptoms suggestive of RGS for 11 years before she was diagnosed who responded well to ropinirole. We discuss the pathophysiology and reasons for the delayed diagnosis.

Combating Scientific Misconduct: The Role of Focused Workshops in Changing Attitudes Towards Plagiarism

Introduction Scientific misconduct is a global issue. There is low awareness among health professionals regarding plagiarism, particularly in developing countries, including Pakistan. There is no formal training in the ethical conduct of research or writing for under- and post-graduate students in the majority of medical schools in Pakistan. Internet access to published literature has made plagiarism easy. The aim of this study was to document the effectiveness of focused workshops on reducing scientific misconduct as measured using a modified version of the attitude towards plagiarism questionnaire (ATPQ) assessment tool. Materials and methods A cross-sectional study was conducted with participants of workshops on scientific misconduct. Demographic data were recorded. A modified ATPQ was used as a pre- and post-test for workshop participants. Data were entered in SPSS v20 (IBM< Armonk, NY, US). Frequencies and descriptive statistics were analyzed. An independent sample t-test was run to analyze differences in mean scores on pre-workshop ATPQ and differences in mean scores on post-test scores. Results There were 38 males and 42 females (mean age: 26.2 years) who participated in the workshops and completed the pre- and post-assessments. Most (59; 73.75%) were final-year medical students. One-third (33.8%) of the respondents had neither attended workshops related to ethics in medical research nor published manuscripts in medical journals (32.5%). More than half (55%) admitted witnessing unethical practices in research. There was a significant improvement in attitudes toward plagiarism after attending the workshop (mean difference = 7.18 (6.2), t = 10.32, P < .001). Conclusions Focused workshops on how to detect and avoid scientific misconduct can help increase knowledge and improve attitudes towards plagiarism, as assessed by the modified ATPQ. Students, residents, and faculty members must be trained to conduct ethical medical research and avoid all forms of scientific misconduct.