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Nailing the Diagnosis

Nail – A window to bone and joint health

Take a long hard look at your nail as they may be saying something about health of your joints and bones. A recent study show that a mineral deficiency in toe nails is linked to risk of Osteoarthritis and finger nails give doctors a clue about the condition that elevate the risk of Osteoarthritis.

Osteoarthritis (OA), sometimes called Degenerative Changes, is the most common chronic condition of the joints. It may affect different parts of body including

  1. Knees
  2. Fingers
  3. Feet
  4. Hip
  5. Cervical Spine
  6. Lumbar Spine
  7. Riz arthritis of the thumb (Suffered by Manual Professionals)

In 2005, a research was presented in American College of Rheumatology (Atlanta) which shows that people with lower level of mineral “Selenium” are more prone to develop OA of knees. To prove the presence of Selenium in toe nails, clippings from 1000 people were measured as toe nails grow slowly and they reflect selenium level in the body. From past several months up to a year ago, no one realized and investigated if Selenium might be related to OA. Studies suggest that deficiency of selenium is common in many parts of Asia as they are not rich in this mineral. People in these areas tend to develop Kashin Beck Disease known as Arthritis Big Joint Disease. Another study shows that abnormal formation of Disulfide bonds in cells causes problems in nails and bones. Disulfide bonds are needed for joining Protein Molecules such as Nail Protein Keratin and Bones Protein Collagen. Research of Dr. Mark Towler from University of Limerick (Ireland) depicts that weak nails among Osteoporosis delved in to nails and bone properties. Result of his work is a device called “Selectis Bone Quality Test”. This test diagnoses Osteoporosis by analyzing the Disulfide Bonds in nail clippings. Device used in the test in as accurate as Dexa Scan which is currently being used to diagnose Osteoporosis and it is less expensive. On top of it, this test doesn’t require the presence of patient as only patient’s nail is needed. Suggest

Reducing Risks

To avoid the risk of Osteoarthritis, eat plenty of food which contains selenium.

  1. Nuts
  2. Meats
  3. Poultry
  4. Fish
  5. Whole grains

Do not increase the intake of any Vitamin or Mineral (including Selenium) without the consultation of physician. It might lead to Selenium Toxicity and increased harm to bones & joints.

 

References:

  1. Stanley Birge, “Should you Supplement Selenium?” 2006, Washington University, School of Medicine, St. Louis.
  2. , J.M., 2006. Selenium & OA Development, Thurston Arthritis Research Center, University of North Carolina, Chapel Hill.
  3. , M . 2006. Weak Nails among Osteoporosis Patient, Arthritis Foundation, University of Limerick, Ireland.
  4. Osteoarthritis Foundation, 2015. [Online] Available at < http://www.arthritis.org/about-arthritis/types/osteoarthritis/> [Accessed 15 December 2015]

 

By

Dr. Shafi Muhammad Chawdhry

(Rheumatologist)

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Shoulder Rehabilitation

Introduction:

Shoulder is one of the largest and most complex joints in the body. The shoulder joint is formed where the Humerus (upper arm bone) fits into the scapula (shoulder blade), like a ball and socket. Other important bones in the shoulder include:

  • The acromion, a bony projection off the scapula.
  • The clavicle (collarbone), meets the acromion in the acromioclavicular joint.
  • The coracoid process, a hook-like bony projection from the scapula.

The shoulder has several other important structures:

  • The rotator cuff is a collection of muscles and tendons that surround the shoulder, giving it support and allowing a wide range of motion.
  • The bursa is a small sac of fluid that cushions and protects the tendons of the rotator cuff.
  • A cuff of cartilage called the labrum forms a cup for the ball-like head of the humerus to fit into.
  • The humerus fits relatively loosely into the shoulder joint. This gives the shoulder a wide range of motion, but also makes it vulnerable to injury.

Shoulder Conditions:

  • Frozen shoulder: Inflammation develops in the shoulder that causes pain and stiffness. As a frozen shoulder progresses, movement in the shoulder can be severely limited.
  • Osteoarthritis: The common “wear-and-tear” arthritis that occurs with aging. The shoulder is less often affected by osteoarthritis than the knee.
  • Rheumatoid Arthritis: A form of arthritis in which the immune system attacks the joints, causing inflammation and pain. Rheumatoid Arthritis can affect any joint, including the shoulder.
  • Gout: A form of Arthritis in which crystals form in the joints, causing inflammation and pain. The shoulder is, however, an uncommon location for gout.
  • Rotator cuff tear: A tear in one of the muscles or tendons surrounding the top of the Humerus. A rotator cuff tear may be a sudden injury, or result from steady overuse.
  • Shoulder impingement: The acromion (edge of the scapula) presses on the rotator cuff as the arm is lifted. If inflammation or an injury in the rotator cuff is present, this impingement causes pain.
  • Shoulder dislocation: The Humerus or one of the other bones in the shoulder slips out of position. Raising the arm causes pain and a “popping” sensation if the shoulder is dislocated.
  • Shoulder tendonitis: Inflammation of one of the tendons in the shoulder’s rotator cuff.
  • Shoulder bursitis: Inflammation of the bursa; the small sac of fluid that rests over the rotator cuff tendons. Symptoms include pain with overhead activities or pressure on the upper, outer arm.
  • Labral tear: An accident or overuse can cause a tear in the labrum, the cuff of cartilage that overlies the head of the Humerus. Most labral tears heal without requiring surgery.

Shoulder Tests:

  • (MRI Scan): This scanner uses a high-powered magnet and a computer to create high-resolution images of the shoulder and surrounding structures.
  • (CT Scan): A CT scanner takes multiple X-rays, and a computer creates detailed images of the shoulder.
  • Shoulder X-ray: A plain X-ray film of the shoulder may show dislocation, Osteoarthritis or a fracture of the Humerus. X-ray films cannot diagnose muscle or tendon injuries.

Shoulder Treatments:

  • Shoulder surgery: Surgery is generally performed to help make the shoulder joint more stable. Shoulder surgery may be Arthroscopic (several small incisions) or open (large incision). In an Arthroscopic surgery, the surgeon makes small incisions in the shoulder and performs surgery through an endoscope (a flexible tube with a camera and tools on its end). Arthroscopic surgery requires less recovery time than open surgery.
  • Physical therapy: An exercise program can strengthen shoulder muscles and improve flexibility in the shoulder. Physical therapy is an effective, nonsurgical treatment for many shoulder conditions.

Strength:

Strengthening the muscles that support your shoulder will help keep your shoulder joint stable. Keeping these muscles strong can relieve shoulder pain and prevent further injury.

Flexibility:

Stretching the muscles that you strengthen is important for restoring range of motion and preventing injury. Gently stretching after strengthening exercises can help reduce muscle soreness and keep your muscles long and flexible.

Target Muscles:

The muscle groups targeted in this conditioning program include:

  • Deltoids (front, back and over the shoulder)
  • Trapezius muscles (upper back)
  • Rhomboid muscles (upper back)
  • Teres muscles (supporting the shoulder joint)
  • Supraspinatus (supporting the shoulder joint)
  • Infraspinatus (supporting the shoulder
  • Subscapular (front of shoulder)
  • Biceps (front of upper arm)
  • Triceps (back of upper arm)

Pain relievers:

  • RICE Therapy: RICE stands for Rest, Ice, Compression (not usually necessary), and Elevation. RICE can improve pain and swelling of many shoulder injuries.
  • Corticosteroid (cortisone) injection: A doctor injects cortisone into the shoulder, reducing the inflammation and pain caused by Bursitis or Arthritis. The effects of a cortisone injection can last several weeks.

Shoulder Replacement Indications: Severe Osteo or Rheumatoid Arthritis where the predominant feature is pain.

Post-Shoulder Replacement Treatment Protocol

In Patient
Day 0
  • Master sling with body belt or Cold Compression sling fitted in theatre
  • Finger, wrist and elbow movements
  • Occupational Therapy
Day 1Level 1 Exercises
  • Body belt removed
  • Axillary hygiene taught
  • Pendular exercises
  • Scapular setting
  • Passive flexion in the scapula plane as comfortable
  • External rotation to neutral
  • Discharge usually at day 1
Out Patient
Day 5 – 3 weeksLevel 2 exercises
  • No resisted internal rotation or forced passive external rotation (reattached subscapular is muscle is vulnerable)
  • Begin passive abduction (maintain shoulder in IR)
  • Passive external rotation to neutral only
  • Active assisted flexion in supine and progress to sitting position as soon as the patient is able.
  • Progress to active when possible
  • Begin isometric strengthening of all muscle groups (except IR)
  • Remove sling as able
  • Functional reaching activities below 90 degrees
3 weeks +Level 2 exercises
  • Encourage active movement into all ranges with some gentle self-stretching at the end of range.
  • Add isometric IR
  • Progress functional activities
6 Weeks +Progress to level 3 exercises
  • Progress strengthening through range
  • Regularly stretch the joint to the end of its available range
  • Soft tissue manipulation if required

 

Improvement continues for 18 months to 2 years and the patients should continue exercising until their maximum potential has been reached.

Return to functional activities

  • Driving           After 4 weeks
  • Swimming

Breaststroke:   6 weeks

Freestyle:        12 weeks

  • Golf                 3 Months
  • Lifting            Light lifting can begin at 3 weeks.
    Avoid lifting heavy items for 6 months.
  • Return           Sedentary job: 6 weeks
    to work          Manual job: Guided by Surgeon

 

References

  1. O’Sullivan. S. and Schmitz. T.,2011. Physical Rehabilitation. 5th Edition. F.A. Davis Company.
  2. ShoulderDoc, 2015, Shoulder Replacement. [Online] Available at < https://www.shoulderdoc.co.uk/article/16> [Accessed Dec 21, 2015]
  3. Healthwise, 2014, Shoulder Replacement Surgery. [Online] Available < http://www.webmd.com/arthritis/shoulder-replacement-surgery> [Accessed Dec 21, 2015]
  4. Porter. S., .2008, Tidy’s Physiotherapy. 14th Edition. Elsevier Health Sciences.

 

By

Dr. Riafat Mehmood

(Physiotherapist)

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Brain Aneurysm

Brain Aneurysm (Cerebral or Intracranial aneurysm) is the weak area of an artery in the brain which causes a localized blood filled balloon, like bulge, in the wall of blood vessel. Aneurysm is caused from wear and tear of the arteries, injury, infection and inherited tendency. It can occur to all age groups but incidence increases gradually after the age of 25. Most affected age group is 50 to 60 and women have more tendency of prevalence.
Large unruptured aneurysms lead to symptoms based on the pressure on the brain tissue, nerves and surrounding structures. Symptoms include weakness or paralysis on one side of the face, pain above and behind the eye, numbness, enlarged pupil or changes in vision. Unruptured Aneurysms require different assessment and treatment. When cerebral aneurysms rupture, bleeding is usually caused in to the brain and surrounding space known as “subarachnoid space”. Approximately 2% – 3% of people with brain aneurysm suffer from bleeding. It is an emergency situation and stiff neck, blurred vision, nausea and vomiting and loss of sensations are usual symptoms.


Diagnosis
Ruptured aneurysms are diagnosed by finding signs of subarachnoid hemorrhage via CT scan (Computerized Tomography). Cerebral Angiogram, a test, is performed by neuro-interventional expert to determine the exact size, location and shape of an aneurysm. Cerebral angiography is a medical procedure when dye is injected in to the arterial system through a catheter. MRA (Magnetic Resonance Angiography) and CTA (Computed Tomographic Angiography) are non-invasive alternative procedures to the traditional methods. Contrast dye injected in to the vein which travels to the brain arteries and images are created using CT scan. These images show how blood flows in to the brain arteries.



Treatment
There are two type treatment options available for brain aneurysm.
1. Aneurysm Clipping
2. Aneurysm Coiling



Aneurysm Coiling
Objective of Aneurysm Coiling is to isolate an aneurysm from the normal circulation without blocking off nearby arteries or contracting main vessel.
Microcatheter is inserted through initial catheter and the coil is attached with the microcatheter. Once the microcatheter reaches the aneurysm and gets inserted in to it, coil is separated from catheter with the use of electric current. This coil will cap the opening of the aneurysm and it is placed permanently in aneurysm. More than one coil may be needed depending upon the size of aneurysm. Coils used in this procedure are spring shaped and made of soft platinum metal. These coils are very thin and small, ranging from less than the width of human hair to twice to the width of a single hair. Fluoroscopy supports the whole procedure of Endovascular Coiling. It is a special type of X-ray movie. Physicians use Fluoroscopy in order to locate the aneurysm and guide catheter for all movements.
Patient can return to home spending one night in Intensive Care Unit after surgery and may be expected to resume normal life activities within 2 days. Exact details regarding procedure and discharge for a particular case could be obtained from the physician.


By

Umair Rashid Chaudhry
(Neuroradilogist)

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PCR for Clostridium Difficile

PCR test for Clostridium Difficile detection is now available at KIH. It gives rapid and accurate diagnosis of all toxigenic strains of Clostridium difficile causing diarrhea and Colitis.
Test Name : PCR for Clostridium Difficile
Reporting time: 6 hours

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Kulsum International Hospital Successfully Achieves ISO 9001:2015

KIH Management takes pleasure to announce that Kulsum International Hospital had a successful transition to ISO 9001:2015 (Risk Based Thinking) from ISO 9001:2008. This achievement demonstrates our undeviating commitment to provide the highest quality services to our customers.

We are committed to provide high standards to attain customer satisfaction by ensuring services and practices which consistently meet customer’s requirements including quality, safety, cost and delivery.

We faithfully comply with all the requirements of ISO 9001:2015 and aim to consistently improve our quality management system.

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Spine Clinic by Dr. Mohammed Akmal

Dr. Mohammed Akmal, a globally renowned Spinal Surgeon is visiting Kulsum International Hospital on December 12-13, 2017. He is working as a Consultant Orthopedics and Spinal Surgery with some of the prestigious institutions of United Kingdom. He will conduct Spine Clinic at Kulsum International Hospital and will perform related surgeries especially in chronic and trauma patients.

Profile of the Consultant: 

Dr. Mohammed Akmal

MBBS, MD, FRCS (Ortho), CCST (UK),

Fellowship Spinal Surgery (UK)

 

Consultant Trauma, Orthopedics and Spinal Surgery,

Hospital of St John and St Elizabeth & Imperial College Healthcare NHS Trust,

London, United Kingdom.

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Visit of KIH Management to Cleveland Clinic Abu Dhabi

Dr. Iqbal Saifullah Khan (Director, Saif Healthcare Limited) and Dr. Muhmmad Saleem Khan (CEO, Saif Healthcare Limited) visited Cleveland Clinic Abu Dhabi. Aim of the visit was to learn the healthcare practices adopted by Cleveland Clinic and implementing them at Kulsum International Hospital.

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Seminar on Cardiac Electrophysiology

Kulsum International Hospital in collaboration with Getz Pharmaceutical organized a seminar on Cardiac Electrophysiology for the General Practitioners and medical fraternity of Rawalpindi and Islamabad. Dr. Jamal J. Ahmed (Consultant Cardiac Electrophysiologist, Upstate Medical University, New York, USA) was the key speaker. Various case presentations along with diagnosis, treatment and modalities were discussed in detail with participants by Dr. Jamal.  This seminar was chaired by Lt. Gen. S.M Imran Majeed (Vice Chancellor, National University of Medical Sciences), Professor Dr. Sohail Aziz (Consultant Cardiologist and Head of Cardiology, Armed Forces Institute of Cardiology) and Maj. Gen. (R) Dr. Waqar Ahmed (Consultant Interventional Cardiologist – Kulsum International Hospital, Ex- Commandant – Armed Forces Institute of Cardiology). Speaker and Chair persons were accompanied by Dr. Muhammad Saleem Khan (Chief Executive Officer, Kulsum International Hospital).

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ISO 9001:2008 Certification

Management of Saif Healthcare Limited is pleased to announce that Kulsum International Hospital is now ISO 9001:2008 certified for its quality management system. We take pride in achieving this milestone and it demonstrates our commitment to provide the highest quality services to our customers.

Our management is committed towards maintaining highest standards of customer satisfaction by ensuring best practices and consistently meeting customer’s requirements including quality, safety, cost and service delivery.

We devotedly comply with all  requirements of ISO 9001:2008 and will consistently improve our quality management system for service excellence.

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New Consultants at KIH

Maj. Gen. Prof. Dr. Maqbool Ahmed (Retd)

Renowned General and Laparoscopic Surgeon Dr. Maqbool Ahmed joins Kulsum International Hospital. He has served in Pakistan Army on senior ranks including Professor of Surgery – Army Medical College, Director General (General Surgery), Pakistan Army and Head of General Surgery – Military Hospital and Combined Military Hospital (Rawalpindi). He was also deputed on UN Pakistan Medical Mission to Somalia. He has extensive experience in General and Laparoscopic Surgery specifically Redo Surgery and complicated cases. He is of the view that general surgery is on the “cutting edge” because it continues to reinvent itself to the benefit of the patient. According to him, due to accessibility of high-tech instrumentation and advanced technology, procedures are now replaced with minimally invasive laparoscopic techniques that often reduce pain, accelerate recuperation and reduce cost without sacrificing good outcomes. We choose the procedures we feel most comfortable with to provide services for our patients, he adds. Dr. Maqbool Ahmed is a valuable addition to KIH.

Brig. (R) Dr. Nadir Ali

One of the well-known Hematologists of the region Dr. Nadir Ali joins Kulsum International Hospital. He completed his MBBS in 1983 from Liaquat National Hospital & Medical College – Karachi, MCPS (Hematology) in 1999 and Ph. D (Hematology) in 2009. He served Pakistan Army for more than 3 decades as a consultant Hematologist in different hospitals. His last two postings were at Armed Forces Institute of Pathology, Rawalpindi and Combined Military Hospital, Peshawar. Dr. Nadir’s contribution towards academia is commendable. He has 46 national and international research papers on his credit with presentation in 18 national and international conferences. He is also a chapter writer of 3 text books. More than 71 trainees in Ph. D, M. Phil and FCPS are the beneficiaries of Dr. Nadir’s teaching. Keeping in account his contribution towards hematology, he is selected as a life time member of Pakistan Society of Hematology.

Dr. Beena Mamoon

Dr. Beena Mamoon has joined Kulsum International Hospital as Consultant Psychiatrist. She is She started her specialization from Khyber Medical Teaching Hospital, Peshawar, Pakistan. For advance training, she went to UK and has worked in various disciplines of psychiatry i.e. adult, old age, child and adolescent as well as drugs & alcohol addictions. She is Diplomat of Clinical Psychiatry from Ireland and did her clinical fellowship from UK.  She is committed to develop Psychiatry Services at KIH.

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