Analysis of primary intrathoracic extrapulmonary hydatid cysts a rare clinical entity

To evaluate the anatomic location of cysts, operative characteristics of intrathoracic extrapulmonary hydatid cyst and to determine the outcome of aggressive surgical interventions.Case series. Thoracic Surgery Unit Lady Reading Hospital Peshawar from 1[st] July 2008 to 30[th] June 2011. All patients admitted to Thoracic unit from July 2008 to June 2011 with intra thoracic hydatid cysts were evaluated prospectively as to age, sex, symptoms, diagnostic procedures, anatomic location of cysts, surgical procedures, complications, and outcomes. Chest radiography, computed tomography, and thoracic and abdominal ultrasonography had been performed preoperatively in all of them. Bronchoscopy and spirometry was also performed in all patients for assessment and operability.Echocardiography had been used in 2 patients to determine the contiguity of the cyst to the pericardium. Cystectomy and wide resection were the chief operative procedures. Most of the patients were having cysts in the pulmonary parenchyma only 10 patients had intrathoracic cysts in extrapulmonary locations. This group of patients was included in the study. We excluded patients who had a parenchymal cyst that had perforated to the pleura, myocardial hydatid and patients who had Total of 149 patients were operated for hydatid cystectomy, out of these 139 patients had pulmonary hydatid and 10 patients had intrathoracic extrapulmonary hydatid cysts. These 10 patients constitute our study group; out of these 7 were men and 3 women whose mean age was 39.14 +/- 16.8 years range, [16-69 years]. Eight [80%] of these were symptomatic, most commonly with chest pain, two patients were asymptomatic. There were 2 [20%] mediastinal hydatid, 2 [20%] diaphragmatic, 2 [20%] pericardial, 2 [20%] oblique fissure, and 1 [10%] each in chest wall and pleural hydatid in our study. Albendazole [10 mg/kg] was prescribed to all patients for as long as 3 months postoperatively. No complication, recurrence, or death occurred during the follow up period of 13 +/- 15.4 months [range, 2-36 months].The extrapulmonary location of Hydatid cysts within the thorax is very rare. This rarity may cause difficulties in diagnosis. To avoid recurrence, it is necessary to resect the affected tissues completely and an anthelmintic medical regimen post operatively

Physico-chemical comparison of famotidine tablets prepared via dry granulation and direct compression techniques

Famotidine is generally employed for the treatment of gastric ulcer. The present study was conducted to fabricate famotidine tablets using various diluents. The binder was incorporated to the formulations in different proportions. Both the dry granulation and direct compression techniques were employed to develop the tablets. Physical evaluation of tablets i.e. tablets hardness, friability, weight variation, thickness and diameter was determined. In vitro dissolution studies of the prepared tablets were carried out for 60 min using the USP apparatus II and 900 ml 0.1 M HCl stirred at 37 +/- 0.5[degree sign] C with a speed of 50 rpm. Physical analysis of tablets prepared via direct compression showed satisfactory results regarding the weight variation, hardness and friability, since their respective values were within the BP limits. All the prepared famotidine tablets exhibited diffusion based mode of drug release. 100% release of drug occurred in less than 60 min. The drug release from all the formulated tablets has elaborated the involvement of diffusion [Higuchian drug release]. This comparative study exhibited that physical parameters of tablets are affected by the technique of tabletting

Surgical interventions in multidrug-resistant tuberculosis: retrospective analysis of 27 patients treated at a tertiary level care center

To assess the results of surgery for Muttidrug- Resistant Tuberculosis [MDR-TB]. Retrospective analysis was done in 27 cases of multidrug- resistant tuberculosis in whom some surgical interventions were carried out at department of Thoracic surgery, Lady Reading Hospital Peshawar between the years 2002 to 2007. There were 18 male and 9 female patients in the age group of 14-54 years. All were sputum positive at the time of surgery. Majority of patients were treated with pulmonary resections [pneumonectomy [n=07], bitobectomy [n=08] and lobectomy [n=10]], while primary thoracoplasty with apicotysis was done in two patients. Post operatively 2[nd] line anti tubercular chemotherapy was prescribed for 24 months. There was one early and one Late death. Postoperative complications were seen in three cases. One patient developed bronchopleural fistula with empyema. At a mean follow-up of one year bacteriological cure was achieved in 24 patients. Judiciously performed adjuvant surgery can yield excellent long term bacteriological cure with acceptable mortality in multidrug- resistant tuberculosis. Morbidity and drug compliance remain as problem areas

Tube thorocostomy: management and outcome in patients with penetrating chest trauma

Penetrating chest trauma is common in this part of the world due to present situation in tribal areas. The first line of management after resuscitation in these patients is tube thoracostomy combined with analgesia and incentive spirometry. After tube thoracostomy following surgery or trauma there are two schools of thought one favours application of continuous low pressure suction to the chest tubes beyond the water seal while other are against it. We studied the application of continuous low pressure suction in patients with penetrating chest trauma. This Randomized clinical controlled trial was conducted in the department of thoracic surgery Post Graduate Medical Institute Lady Reading Hospital Peshawar from July 2007 to March 2008. The objectives of study were to evaluate the effectiveness of continuous low pressure suction in patients with penetrating chest trauma for evacuation of blood, expansion of lung and prevention of clotted Haemothorax. One hundred patients who underwent tube thoracostomy after penetrating chest trauma from fire arm injury or stab wounds were included in the study. Patients with multiple trauma, blunt chest trauma and those intubated for any pulmonary or pleural disease were excluded from the study. After resuscitation, detailed examination and necessary investigations patients were randomized to two groups. Group I included patients who had continuous low pressure suction applied to their chest drains. Group II included those patients whose chest drains were placed on water seal only. Lung expansion development of pneumothorax or clotted Haemothorax, time to removal of chest drain and hospital stay was noted in each group. There were fifty patients in each group. The two groups were not significantly different from each other regarding age, sex, pre-intubation haemoglobin and pre intubation nutritional status. Full lung expansion was achieved in forty six [92%] patients in group I and thirty seven [74%] in group II. Partial lung expansion or pneumothorax was present in three [6%] in group I and 10 [20%] in group II. One patient in group I and three [6%] patients in group II had no response. The mean time to removal of chest drains were 8.2 +/- 3.14 days in group I and 12.6 +/- 4.20 days in group II. The length of hospital stay was 7.2 +/- 2.07 days and 12.4 +/- 3.63 days in group I and II respectively. Clotted Haemothorax requiring surgery developed in three [6%] patients in group I and 8 [16%] patients in group II. Placing chest tubes on continuous low pressure suction after penetrating chest trauma helps evacuation of blood, expansion of lung and prevents the development of clotted Haemothorax. It also reduces the time to removal of chest drains, the hospital stay and the chances of surgery for clotted Haemothorax or Empyema

Thymectomy for myasthenia gravis: Peshawar experience of 27 cases in five years

To determine the safety and efficacy of Thymectomy for myasthenia gravis. This observational descriptive study was conducted at Departments of Cardiothoracic Surgery and Neurology Lady Reading Hospital Peshawar from January 2002 to December 2006. Computerized clinical data of 27 diagnosed cases of myasthenia gravis that underwent thymectomy were retrospectively analyzed. Patients who were unfit for surgery were excluded from the study. CT scan was done in all patients apart from routine investigations. Preoperative medication included anticholinesterase drug. They all underwent Thymectomy via median sternotomy. A total of 27 patients [09 males and 18 females] with a mean age of 30.5 years [range 15-50 years] were analyzed. The preoperative duration of the disease ranged from 0.5 to 120 months [mean=25.72 +/- 30.68 months]. According to the Myasthenia Gravis Foundation of America [MGFA] clinical classification, 20 [74.07%] patients were in stage two while 7 [25.925%] patients were in stage three. The histology of thymus glands consisted of hyperplasia in 12 [44.4%] patients, normal in 10 [37.1%], atrophic thymus in 3 [11.1%] and thymoma in 2 [7.4%] patients. Hospital mortality was 7.4% [n=2/27] while morbidity was 3.7% [n=1/27]. The mean follow up period was 31.5 months [3-63 months]. Complete remission was achieved in 55.55% [n=15/27] patients, and marked improvement in 25.92% [n=7/27], for a total benefit rate of 80%. Five [18.51%] patients remained unchanged and had no clinical improvement. Thymectomy is a safe and effective treatment for patients with myasthenia gravis

Determinants of success of decortication

Background: To find out different factors which lead to failed decortication and to evaluate their management and outcome

Study Design: Retrospective observational descriptive study

Place of Study: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital Peshawar from January 2003 to Sep 2006

Materials and Methods: Clinical record of 300 patients who underwent decortication tor chronic empyema during the last 3.9 years was retrospectively analyzed and their results evaluated. Detailed scrutiny of the computerized clinical record was carried out to analyze the aetiology of failure of the operation. The variables studied were persistent broncho- pleural fistula, poor postoperative efforts by the patients, wound infection, old chest drain site infection, technical failure and nutritional state of the patient

Results: Of the 300 deoortications performed over the period of 3.9 years, 260 patients had a successful outcome in terms of lung expansion and improved pulmonary functions. In thirty patients [19 males, 11 females with age range of 12 to 70 years] decortications failed to achieve the desired results. These patients had to undergo space obliteration procedures for persistent infected space. Twenty three patients had history of tuberculosis and seven patients had nontuberculous empyema. All patients had chronic empyema with duration of more then 12 weeks before the first operation. All patients were nutritionally compromised. Thoracoplasty [compete or partial] was performed in 25 patients to obliterate the persistent infected space. Five patients with recurrent broncho-pleural fistula had an additional procedure of intercostal muscle reinforcement over the fistulae, in addition to thoracoplasty. All patients had successful obliteration of the persistent space with no mortality and minor wound infection in only three patients

Conclusion: Early referral, old drain site infection control, meticulous closure of broncho pleural fistula and space obliteration procedure in combination primarily instead of secondarily, lead to a successful outcome

Cholesterol gallstones; Various fractions of blood cholesterol, a possible link to coronary artery disease

Fifty patients suffering form cholesterol gallstones and twenty five healthy control subjects were studied for blood lipids and lipoprotein pattern. The qualitative analysis of stones was performed to include only the cholesterol stone type patients in the study. The aim of study was to put emphasis on various types of lipoprotein cholesterol, like the HDL-C and LDL-C which was not done in previous studies. The serum total cholesterol, triglycerides and LDL-C were significantly raised in these patients while the HDL-C was significantly reduced when compared with age and sex matched controls. The study suggests that not only the simple lipids but the important lipoproteins, like the HDL-C and LDL-C are involved in pathogenesis of cholesterol gallstones. Our results of low HDL-C and high LDL-C in these patients further suggest that such patients are at risk to develop CAD at any time in their future life, such patients after diagnosis of gallstones must be investigated for CAD and kept under observation

Effect of menopause on serum HDL-cholesterol level

There is a marked difference in the risk of coronary heart disease between men and women of reproductive age but this gap closes with advancing age. It seems likely that some factors of reproductive physiology are responsible for this. The present study was designed to evaluate the difference in HDL Cholesterol level in premenopausal and postmenopausal women in relation with change of estradiol level. Fifty premenopausal and 50 postmenopausal women were included in the study. Estradiol was estimated by radioimmuoassay while HDL-C was estimated by Kit method. There was a significant [p<0.01] decrease in the HDL-C level of the postmenopausal women [46.72'1.009] as compared with premenopausal women [63.68'1.78]. HDL-C is an independent risk factor for coronary heart disease. This study favours the view that decrease in estradiol level and associated decrease in HDL-C seen in postmenopausal women may be responsible for the increased risk of coronary heart disease after menopause

Comparison of troponin T and enzyme levels in acute myocardial infarction and skeletal muscle injury

The objective of this study was to compare the levels of troponin T and enzymes levels in myocardial infarction and skeletal muscle injury. This study was carried out at Basic Medical Sciences Institute, JPMC Karachi, Pakistan. Ninety subjects were selected. Thirty controls, thirty patients suffering from myocardial infarction and thirty suffering from skeletal muscle injury were selected from National Institute of Cardiovascular Diseases. Creatine kinase, aspartate amino-transferase, lactate dehydrogenase and Troponin T were determined by kit methods. Troponin T level rises significantly [p<0.01] in patients suffering from myocardial infarction. Creatine kinase [CK], CKMB, aspartate aminotransferase and lactate dehydrogenase levels rises significantly [p<0.01] in both groups compared with controls. Troponin T is an early indicator of myocardial infarction and is superior to CKMB in diagnosis of myocardial injury. There is no increase in troponin T levels in skeletal muscle injury

Effects of an oestrogen only and oestrogen progestin regimen of hormone replacement therapy on lipid profile in postmenopausal women

Hormone replacement therapy [HRT], is known to be accompanied by changes in blood lipid profile. The use of a progestin in addition to oestrogen is believed to negate or attenuate the effects of oestrogen on lipids and lipoproteins. In this study, we compared the lipid profiles of two groups of postmenopausal women who had been using the two different types of regimens of HRT. Each group consisted of twenty women. The first group of women consisted of women who had undergone surgical menopause and were using an oestrogen only HRT [Premarin]. The second group consisted of women who had undergone natural menopause and were on a combined, sequential regimen of oestrogen and progestin [Progyluton]. For each group, total cholesterol, triglycerides, VLDL-C, LDLC, HDL-C, ratio were estimated. Certain difference were observed in these parameters of the two groups but statistical analysis showed no significant. Thus our study indicated that the presence of a progestin in HRT may have some effects on lipid profile, but it does not alter it significantly

Prolactin level in non-lactating and lactating women

Objective: to study the prolactin level in non-lactating and lactating women, its relation to infants suckling and also to compare it in various groups like menstruating, non-menstruating, an ovulatory and ovulatory

Method: the study was conducted on 35 women, 25 lactating and 10 non-lactating [control], aging from 16 to 35 years, resident of different areas of Karachi and Hub [Balochistan]. None of them were taking hormonal contraceptive. Prolactin estimation was done in blood and milk of the lactating, and in serum of non-lactating, whereas the urinary estradiol in both groups was carried out for determination of ovulation

Results: suckling episodes and breast feeding on demand were found to be the determinant of prolactin level. Out of all lactating only five were found to be ovulatory and within normal range of prolactin. While almost all of non-lactating were found to be ovulatory and showed significant decrease in level of prolactin

Conclusion: during lactation prolactin level remains high due to which fertility return before six months is unlikely provided breast feeding is frequent and without supplementation

Biochemical parameters for detection of haemmolysis in pregnancy induced hypertensive

A study on biochemical parameters for detection of haemolysis in pregnancy induced hypertensive [PIH] women was carried out in gynaecology units of Civil Hospital and Jinnah Postgraduate Medical Centre, Karachi. One hundred and fourteen cases were studied. Among them thirty were normal non pregnant women, thirty normal pregnant women, twenty seven pre-eclamptic and twenty seven eclamptic women. Serum bilirubin, lactate dehydrogenase, aspartate aminotransferase levels were determined for detection of haemolysis in PIH women and then compared with controls. Highly significant rise was observed in serum levels of bilirubin, lactate dehydrogenase and aspartate aminotransferase in PIH women as compared to non pregnant and pregnant women. Early detection of haemolysis by these parameters can prevent the patients from going into HELLP syndrome ie syndrome of haemolysis, elevated liver enzymes and low platelet count

Magnitude of lipoprotein [a] in diabetes mellitus

One hundred and three patients, 76 with diabetes mellitus alone [48- Non-Insulin dependent diabetes and 28 Insulin dependent diabetes] and 27 diabetics having coronary heart disease [CHD] and 27 normal control subjects were included in this study. All the 27 diabetics with CHD were Non-Insulin dependent. The patients and the controls were investigated for serum Lp [a], triglycerides, cholesterol, VLDL-C, LDL-C, HDL-C, apo A1 and apo B. The objective was to assess and compare the level of lipoproteins, especially the lipoprotein [a], in diabetic and non-diabetic subjects and to compare the level of the aforementioned parameters in diabetics with and without CHD. The Lp [a] and other lipid parameters were significantly raised [P < 0.001] except HDL-C and apo A1 that were significantly decreased [P < 0.001] both in diabetic patients with and without CHD, as compared to the control group. The diabetics with CHD showed significantly elevated [P < 0.001] Lp [a] and lipid profile, and significantly low [P < 0.001] HDL-C and apo A1 levels as compared to the patients having diabetes alone. No significant difference was observed in the levels of the above parameters when NIDDM patients were compared with IDDM group. In both NIDDM and IDDM patients significantly low [P < 0.001] HDL-C level and significantly high [P < 0.001] Lp [a] level along with the aforementioned lipid parameters was observed as compared to control group. Elevated levels of Lp [a] and lipid profile in diabetic subjects suggest their involvement in atherogenesis and subsequent development of CHD

Gamma Glutamyl transferase [GGT] activity in pregnancy induced hypertensive women

To find out the activity of gamma glutamyl transferase [GGT] in pregnant as well as pregnancy induced hypertensive women. Design: Case control study of one hundred and fourteen cases over a period of one year. Setting: Study was carried out in biochemistry department Basic Medical Sciences Institute [BMSI] J.P.M.C., Karachi. Samples were collected from Gynae Units of Civil and Jinnah Hospital, Karachi. Subjects: The study included thirty non pregnant, thirty normal pregnant, twenty seven preeclamptic and twenty seven eclamptic women. Main outcome measures: GGT activity in non pregnant, pregnant and pregnancy induced hypertensive women. GGT activity decreases highly significantly in normal pregnant women as comapred to non pregnant women. [control group]. GGT activity in preeclamptic and eclamptic women increases highly significantly as comapred to control group and increases significantly and markedly significantly in preeclamptic and eclamptic women respectively as compared to control group. GGT is better and earlier indicator of detection of patients going into pregnancy induced hypertension and HELLP syndrome

Garlic [allium sativum] a review of controlled studies

Garlic has been claimed to be effective, without serious untoward effects, against a variety of diseases. Most studies on garlic have been primarily in the fields of cardiovascular and cancer research. In cardiovascular studies, the cardioprotective effects of garlic are related to its antiatherogenic [by lowering plasma cholesterol and triacylglycerol concentrations] and anti-thrombogenic activities [by inhibiting platelet aggregation]. In addition, the vasodilatory effect and antioxidant properties of some compounds present in the garlic extract contributes to cardioprotection. Anti-cancer effects of garlic and its constitutes have been widely investigated in vitro and in vivo. Epidemiological studies also suggest the significant role of garlic as a potent antitumour and anticarcinogenic substance

Thrombocytopenia in preeclampsia: an earlier detector of Hellp syndrome

Platelet count was determined in eighty four pregnant women by direct visual method. Among them thirty normal pregnant women were taken as control. Twenty-seven were preeclamptic and twenty seven eclamptic women. There was significant [P < 0.01] reduction in platelet count of preeclamptic and highly significant [P < 0.001] in eclamptic women as compared to controls. It is concluded that there is need to do platelet count in all pregnancy induced hypertensive women, which can be an earlier detector for HELLP syndrome

Hematologic effect of vitamin A supplementation in anemic Pakistani children

To assess the prevalence of vitamin A deficiency in anemic Pakistani children and investigate the hematologic response to vitamin A supplementation, 4-8 year old primary school children from the slum areas of Karachi were surveyed for anemia. Of 101 anemic children selected, 16% had low level of vitamin A [<20 micro g/dl] and an additional 2% had deficient level [<10 micro g/dl]. Serum Retinol level showed positive associated with serum iron, ferritin, hemoglobin, hematocrit and Mean cell hemoglobin concentration. A non-randomized control trial was then carried out. Oral vitamin A capsules were given to 42 children and 53 children served as controls. After 6 weeks, there were significant differences between the two groups for Retinol, Retinol-Binding-Protein and Hematocrit. However, no significant difference could be found for Hemoglobin, RBC count, Mean Corpuscular Volume, Mean Corpuscular Hemoglobin, Mean Corpuscular Hemoglobin Concentration, Serum iron, ferritin or transferrin. A single vitamin A supplement improved the hematocrit in 6 weeks. Long-term studies are needed to find if the WHO recommended periodic massive doses of vitamin A besides improving the morbidity and mortality will also improve the overall picture of anemia in children

Risk of coronary heart disease and hydrogenated vegetable oils the role of trans-fatty acids: some basic concepts

In Pakistan, hydrogenated oils [commonly called ghee] are the predominant source of dietary fats. Several metabolic and epidemiological studies have contributed to concern about the adverse effects of the transisomers of fatty acids which are formed when liquid, vegetable oils are partially hydrogenated to form ghee, margarine, etc in Pakistan, palm oil is the main precursor for hydrogenation, to get semisolid form or ghee. Polyunsaturated fatty acid contents of palm oil are lower than those of other popular edible oils derived from soyabean, sunflower and corn. Physicians encourage vegetable oils rich in polyunsaturated fatty acids and discourage the use of animal fats because of their high contents of saturated fats and cholesterol. By many people the use of ghee and margarine derived from cholesterol free vegetable oils, is regarded as a healthy eating behaviour, as opposed to butter fat. These partially hydrogenated vegetable oils with high contents of the trans fatty acids, in fact, are even greater health hazards than the cholesterol containing dairy fat

study on serum triglyceride and lipoproteins cholesterol in coronary heart disease patients

Sera obtained from 42 patients of myocardial infarction, 28 of unstable angina and 25 healthy control subjects were assayed for total triglycerides, cholesterol, LDL cholesterol [LDL-C], HDL Cholesterol [HDL-C] and VLDL Cholesterol [VLDL-C]. The level of Cholesterol was also determined among the sub-fractions of HDL. The levels of total triglycerides, Cholesterol, LDL-C and VLDL-C were significantly raised in both groups of patients. Total high density liporotein Cholesterol was low in patients, which was highly significant in HDL[2]-C and not in HDL[3]-C. These results suggest that serum lipids are directly correlated with the severity of coronary heart disease [CHD]. Total Cholesterol when measured in major lipoprotein classes and further partitioned into subfractions, increase their sensitivity, specificity and hence their predictive value as sensitive markers for the assessment of CHD risk