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Background: Approximately 1% to 2% of hospitalized patients get discharged or leave from the hospital against medical advice and up to 26% in some centers. They have higher readmission rate and risk of complications than patients who receive complete care. In this study we aimed to determine the rate of leave against medical advice (LAMA) and reasons for the same across different in-patient departments of a tertiary care hospital. Methods: Retrospective cohort study on patients admitted in all departments at our institute over a 1-year period. All patients who were admitted to an in-patient ward at the hospital and who left against medical advice by submitting a duly filled LAMA form were included. Univariate and multivariate logistic regression models with forward selection methods were employed. Revisit to hospital within 30 days; to clinic or emergency department was outcome variable for regression. Results: From June 2015 to May 2016 there were 429 LAMA patients, accounting for 0.7% of total admissions. Females were 223 (52%) compared to males 206 (48%). Finances were quoted as the most common reason for LAMA by 174 (41%) patients followed by domestic problems 78 (18%). Internal medicine was the service with the highest number of LAMA patients ie, 153 (36%) followed by Pediatric medicine with 73 (17%). Of the 429 patients, 147 (34%) patients revisited the hospital within 30 days. Sixty-one percent of these ‘bounced-back’ LAMA patients had worsening or persistence of same problem, or new problem/s had developed. In unadjusted bivariate logistic model, patients who were advised for follow-up during discharge against medical advice were four times more likely to revisit the hospital. Patients who were married had an increased odd of revisiting the hospital. Conclusion: Financial reasons are the most common stated reasons to LAMA. Patients who LAMA are at a high risk of clinical worsening and ‘bouncing back.’ This is the first study from our region on in-patient LAMA rates, to our knowledge. The results can be used for planning measures to reduce LAMA rates and its consequences.

Ultrasonography (US) is a safe and noninvasive imaging modality that is gaining popularity in different medical and surgical fields. Its introduction in musculoskeletal and sports medicine has taken this advanced subspecialty to a higher level. It has the advantage over other imaging techniques with regards to ease of use, availability, comfort and cost. Not to mention, in terms of safety profile, patients are not exposed to radiations, like in x-rays, and it can be performed on patients with metal or pacemaker implants, which are contraindicated in MRI. Standard diagnostic sonography doesn't have any known harmful effects on humans. In this article we will discuss the role of ultrasound in sports medicine, highlighting the diagnostic and interventional indications, uses and limitations.

IntroductionSynovial chondromatosis is a benign mono-articular arthropathy affecting synovial joints. It mostly affects knee joint, followed by hip, elbow and wrist and is rarely reported for shoulder joint. The exact pathogenesis is not known. Usual symptoms are pain, difficulty in movement due to mechanical obstruction. The classic treatment is arthrotomy, removal of chondromatoid loose bodies and synovectomy. With recent advances arthroscopic removal of the chondromatoid loose bodies is a good option with relatively better post op rehabilitation and faster recovery.Case presentation20 years old gentleman presented to clinic with history of pain in right shoulder for 2 years and decreased range of motion. There was no history of trauma or fever. Work up done and diagnosed with synovial chondromatosis. Arthroscopic removal of chondromatoid loose bodies and synovectomy was done. More than 120 loose bodies were removed. On two (2) years follow-up patient is pain free and having full range of motion at right shoulder joint.DiscussionSynovial chondromatosis is rare in shoulder joint. The Primary synovial chondromatosis of unknown etiology, and secondary synovial chondromatosis due to degenerative joint disease. Classic treatment is arthrotomy and synovectomy. With recent advances, arthroscopic removal of loose bodies and synovectomy is also a good option for its treatment. In literature only few cases have been reported treated with arthroscopic removal of loose bodies and synovectomy.ConclusionArthroscopic treatment of synovial chondromatosis is a good option if expertise is available. It causes less surgical trauma, better visualization during surgery, early recovery.

Introduction Motorcycles are an inexpensive and popular mode of transportation in Karachi, Pakistan, despite the increasing number of motor vehicle injuries. Although motorcycle-related injuries have been studied previously, to our knowledge, there are no published reports on the orthopedic injuries associated with motorcycles crashes. Methods We conducted a cross-sectional study of medical records of patients with motorcycle-related injuries in 2015, at the Aga Khan University in Karachi, Pakistan. We reviewed the patient demographic and medical data, helmet use, the Glasgow coma score, the spectrum of injuries, length of stay, specific injury diagnosis, and final disposition of patients. Data were analyzed using IBM SPSS Statistics for Windows, Version 20.0 (IBM Corp., Armonk, NY). Results We identified 450 motorcycle crash injuries. Ninety percent of these victims were males, and 81% were driving at the time of the crash. More than 50% of crashes involved patients age under 29 years, and most crashes (35%) involved patients in the third decade of life. We observed that 6.8% of accidents involved patients younger than 10 years of age. For all the motorcycle-related injuries, 45% occurred during the weekend (Saturday and Sunday). Helmets were worn by only 7% of patients. The most common types of collisions were motorcycle versus car followed by lone motorcycle fall. Of the injuries sustained, the cumulative frequency of orthopedic injuries was the highest (63%), of which 34% were lower limb injuries and 29% were upper limb injuries. The second highest frequency of injuries were head injuries (46%). We also found that 85% motorcycle injury victims sustained fractures. Conclusion The frequency of motorcycle-related injuries was high among young adults, and closed fractures of the lower limbs were the most common orthopedic injuries related to motorcycle crashes. Use of helmets among motorcyclists needs to be reinforced to prevent head injuries. We suggest motorcyclists to use protective clothes and motorcycle sidebars to prevent fractures of the lower limb. Further research is needed to determine the type of fractures, type of head injuries, surgical interventions required, and morbidity and mortality in motorcycle-related injuries and whether designing separate lanes for motorcycles will reduce the burden of these injuries on the healthcare system.