Sahibzada Nasir Mansoor

Longitudinal cleavage of the penis in chronic spinal cord injury: two case reports

Context: Penile cleavage is a rare complication of spinal cord injury (SCI) in patients with a chronic indwelling catheter. We report two cases of chronic SCI who developed penile urethral cleavage after prolonged use of an indwelling catheter for bladder management. Findings: A 25-year-old wheelchair mobile male with T7 American Spinal Injury Association (ASIA) Impairment Scale (AIS) grade A paraplegia developed a 4 × 1.5 cm ventral urethral cleavage after using an indwelling catheter for four months with inadequate care. He had an associated urinary tract infection and undiagnosed diabetes mellitus. A suprapubic catheter was inserted and surgical repair recommended after resolution of UTI and adequate control of his diabetes mellitus. After initial treatment he was lost to follow-up. The second patient was a 15-year-old male with AIS grade B tetraplegia who presented with a 2.5 cm cleavage on the ventral aspect of penis for the preceding three months. He had been using an indwelling catheter for bladder management for the previous 18 months. He had modified Ashworth scale grade III spasticity in lower limbs resistant to conservative management. There was no history of trauma, infection or diabetes mellitus. The patient was advised penile urethral repair surgery but was lost to follow-up. Conclusion: Penile cleavage is a rare complication of neurogenic bladder in SCI patients. Patients and care givers should be trained in proper bladder management techniques during the hospital stay, counseled regarding the need for regular follow up, and be taught identification and prevention of common complications.

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.

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.

Ochronotic Arthropathy: Two Case Reports from a Developing Country.

Alkaptonuria is a rare inborn error of metabolism, which is classified as an orphan disease. It is due to the lack of an enzyme homogentisate 1,2-dioxygenase, which results in an accumulation of homogentisic acid in different areas of the body, including sclera, skin, cardiac valves, articular cartilage of the large joints and intervertebral disks. We present two cases of alkaptonuria resulting in ochronotic arthropathy with advanced secondary generalized osteoarthritis, intervertebral disk calcifications, skin and scleral pigmentation. In these case reports, both patients had symptoms for >10 years before being diagnosed. Conservative management in the form of high-dose ascorbic acid, exercises, and gait aids was offered to both of them, which resulted in some symptomatic improvement in the first case, while the second case was lost to follow-up. Alkaptonuria is a rare disease, and although it does not clearly impact mortality, early diagnosis may improve the quality of life.

Patellar Tendon Rupture: Case Report of a Rare Complication of Total Knee Replacement

Total Knee Replacement (TKR) is the procedure of choice for patients with advanced knee osteoarthritis when non surgical treatment options fail. Complications of TKR include infection, deep vein thrombosis and joint loosening. A rare but debilitating complication is patellar tendon rupture, which may be due to inherent weakness of the tendon and/or damage to the tendon during surgery or trauma. We report a case of patellar tendon rupture after TKR in a 75 years old female. On post operative day 22, she had rupture of patellar tendon while trying to get up from a low lying commode Site of rupture was confirmed by MRI and musculoskeletal ultrasound. Patellar tendon repair surgery was done using semitendinosis graft followed by knee immobilization for six weeks. Rehabilitation was continued for twelve weeks. Patient was able to walk with cane and was independent in activities of daily living. Care should be taken before, during and after surgery. Low lying commode chairs and commode can lead to rupture of an already compromised tendon. Clinical examination and radiographs can confirm the diagnosis. Surgical repair is the only option for treatment. Prognosis is usually not good.