Chemotherapeutic Response and Survival for Patients With an Anal Squamous Cell Carcinoma and Low Hemoglobin Levels

PURPOSE: Anemia is associated with poor treatment results for a variety of cancers. The effect of low hemoglobin levels on long-term outcomes after the treatment of patients with an anal squamous cell carcinoma (SCC) remains unclear. For that reason, this study aimed to investigate the effect of anemia on treatment outcomes following chemoradiation for an anal SCC. METHODS: This was a retrospective study of all patients who underwent curative treatment for an anal SCC between 2009 and 2015 at 2 trusts in the United Kingdom. Data were collated from prospectively collected cancer databases and were cross-checked with operating-room records and records in the hospitals’ patient management systems. RESULTS: We identified 103 patients with a median age of 63 years (range, 36–84 years). The median overall survival was 39 months (range, 9–90 months), and the disease-free survival was 36 months (range, 2–90 months). During the follow-up period, 16.5% patients died and 13.6% patients developed recurrence. Twenty-two people were anemic prior to treatment, with a female preponderance (20 of 22). No differences in disease-free survival (P = 0.74) and overall survival (P = 0.12) were noted between patients with anemia and those with normal hemoglobin levels. On regression the analysis, the combination of anemia, the presence of a defunctioning colostomy, lymph-node involvement and higher tumor stage correlated with poor overall survival. CONCLUSION: In this study, anemia did not influence disease-free survival or overall survival. We suggest that the interaction between anemia and survival is more complex than previously demonstrated and potentially reliant on other coexisting factors.

Percutaneous dilatational tracheostomy: a prospective analysis about the safety of procedure among ICU patients

Objective: To evaluate the percutaneous dilatational tracheostomy procedure safety among the critically ill Medical ICU patients

Methodology: The study was descriptive and conducted in Medical ICU, Department of Pulmonary and Critical Care Medicine, Services Institute of Medical Sciences, Lahore, from February 2015 to May 2016. Fifty three Medical ICU patients underwent tracheostomy procedure through percutaneous dilatational technique using both Grigg's and Ciaglia's methods. Procedure was performed at bed side using local anesthesia, sedation and systemic analgesia, under bronchoscopic guidance. Patients were monitored for intraprocedural and postprocedural complications like: hemorrhage, stomal infection, injury to adjacent structures, arrhythmias, transient hypoxemia, transient hypotension, paratracheal insertion, pneumothorax, sub-cutaneous emphysema, loss of airway, accidental decannulation, tracheal ring fracture and new lung infiltrate or atelectasis

Results: A total of 53 procedures were performed. Intraprocedural complications included: Transient hypoxemia 4/53 [7.5%] and hypotension 3/53 [5.6%], hemorrhage 3/53 [5.6%] and one case of paratracheal placement. No procedure related mortality was noted. 10 patients died during the ICU stay due to the primary underlying disease and one patient died after a successful decannulation. 36 patients had uneventful decannulation. Six patients were directly discharged from ICU

Conclusion: Percutaneous dilatational tracheostomy is a safe procedure with low complications rate and suitable for critically ill ICU patients

Carcinomatous meningitis: a rare complication of pancreatic adenocarcinoma

Carcinomatous Meningitis [CM] is a relatively uncommon metastatic complication of systemic solid tumors. The condition is mostly diagnosed by presence of malignant cells in the cerebrospinal fluid. The prognosis of the condition is generally poor. CM very rarely complicates pancreatic cancers and very few cases have been reported in the literature. We present a case of a 58-year old female patient operated for pancreatic head carcinoma. She made an immediate uneventful recovery after her pancreatico-duodenectomy. She presented 3 weeks post-surgery with acute confusional state and was diagnosed as a case of CM

Burn wound infection; significance of rule of nine in microbial surveillance

Burn injuries are common and major health problem throughout the world. The burn wound represents as a favorable area for opportunistic colonization of microorganisms with exogenous and endogenous origin. In burns patients infections arise from multiple sources. Burn wounds become initially colonized and infected with Gram positive bacteria, mainly Staphylococci, that are superseded during the second week by Gram Negative bacteria. it is a microbial surveillance retrospective study; that aimed to evaluate the significance of Rule of nine in diagnosis of aerobic bacterial burn wound infection and carried out in between June 2007 to September 2011 in the Department of Pharmaceutics, University of Karachi.Descriptive retrospective study. A total of 118 patient irrespective of age, sex, date and time of burn, date and time of hospital admission, interval between time of burn and hospital admission, degree and percentage [%] of burn and duration of hospital stay [when specimen collected] were registered for this study. All patients were divided into two groups [A and B]. Out of 58 patients of group A isolation rate per patient was 1.1 while in group B it becomes 3.0. According to TBSA the isolation rate in group B rises with rise in TBSA. Most prevalent organism in these patients was found S. aureus[23%] P.aeruginosa[21%]. Burn patients are incubator for variety of aerobic bacteria and rate of isolation of these organisms increase with rise in TBSA. The wounds of these patient must required continuous microbial surveillance that may reduce the rate of mortality

Risk factors of congestive heart failure in patients admitted for coronary artery bypass grafting

Background: Congestive heart failure, has high morbidity and mortality outcomes

Objective: To evaluate the association between the risk factors and congestive heart failure in patients admitted for CABG surgery

Subjects and Methods: This comparative cross sectional study includes 102 consecutive patients aged >50 years, admitted for CABG surgery and were classified as with and without congestive heart failure. They were selected from cardiac surgery department of Punjab Institute of Cardiology, Lahore over a period of 6 months from 1[st] January 2014 to 31[st] June 2014. Pre-operative risk factors were recorded while, the data was analyzed by using SPSS Version 20. P-value < 0.05 was taken as significant

Results: Out of 102 patients, 48 were males and 54 were females. Females were older than males. Risk factors i.e. AF, raised creatinine [>1.4 mg/dl], impaired LV function, renal disease, valvular heart disease [VHD], COPD, smoking and hypertension were found to be comparatively higher in heart failure group than non- HF group. [P<0.05]

Conclusion: CHF in patients admitted for CABG surgery leading to increased morbidity. Male gender, age, hypertension, smoking, renal disease, VHD, raised creatinine [mg/dl], impaired LV function, chronic obstructive pulmonary disease [COPD] and artial fibrillation were independently associated with CHF

Role of prophylactic antibiotics in low risk elective laparoscopic cholecystectomy: is there a need?

Elective cholecystectomy for symptomatic gall stone disease carries low risk of postoperative infective complications. Yet the routine use of prophylactic antibiotic is in vogue in many centres. The aim of this study was to find out the efficacy of antibiotic prophylaxis in preventing postoperative infective complications in low risk elective laparoscopic cholecystectomy patients. Randomised controlled trial was carried out in our hospital from 1[st] Nov 2009 to 15[th] Oct 2011. A total of 350 patients were included in the study and were divided into Group A [n=177], and Group B [n=173]. Group A was given single dose of injection Cefuroxime 1.5 gm as prophylactic antibiotic at the time of induction of anaesthesia, and Group B was not given any antibiotic. In both groups, age, sex, duration of surgery, American Society of Anesthesiologists classification, duration of surgery and length of hospital stay were recorded. Patients were followed-up weekly for 4 weeks and rates of superficial surgical site infections as well as intra-abdominal infections were recorded. There were no significant differences in both groups in terms of age, sex, duration of surgery, length of hospital stay. Eight [4.5%] cases of superficial surgical site infection were noted in Group A and 7 [4.0%] in Group B which was insignificant statistically [p>0.05]. In low risk patients antibiotic prophylaxis does not seem to affect the incidence of postoperative infective complications in elective laparoscopic cholecystectomy. The use of prophylactic antibiotics should be reserved for high risk patients undergoing laparoscopic cholecystectomy

Importance of clinical assessment in diagnosis of acute appendicitis and its role in decreasing negative appendicectomy rate

Appendicitis is a common diagnosis, but is by no means a simple one to establish. It is impractical to have a definitive preoperative diagnosis, which leads to an appreciable rate of negative appendicectomy as reported in world literature varying from 20-40% with its morbidity around 10%. This retrospective study investigated the value of clinical assessment and medical imaging [ultrasonography] for patients with suspected appendicitis. Negative appendicectomy rate and appendiceal perforation with or without medical imaging were used as end points for this investigation. This study reviewed all patients admitted in Sheikh Khalifa Bin Zaid Hospital with suspected acute appendicitis. The patient cohort was identified from the unit registry and review of medical records. The medical records were analysed, and the outcomes of patients were followed up. Between June 2010 to June 2012, 375 patients' medical records were audited. These included 56.3% males and 43.7% females. The negative appendicitis rate was 7.2% and appendiceal perforation rate was 5.3%. Ultrasound was done in 103 [27.4%] patients in whom diagnosis of appendicitis was doubtful. Medical imaging had a 50% prediction rate for acute appendicitis, 40% false-negative rate, and 10% false-positive rate. Overall, the prediction rate for appendicitis by clinical assessment supplemented by laboratory tests and medical imaging at clinician's discretion was 92.8%.Despite studies advocating routine use of medical imaging for patients with suspected acute appendicitis, this study showed that the clinical evaluation is still paramount to the management of patients with suspected acute appendicitis before considering medical imaging.

Effectiveness of beta lactam antimicrobial drugs against gram negative bacteria

To study the micro flora in wounds of the burn patients from three tertiary care medical hospitals in Karachi. In burn patient infections arise from multiple sources and infect burn wounds by a variety of micro-organisms. Gram negative bacterial infection results from translocation from colon, further more burn patients are infected by Hospital acquired bacteria by various invasive and non invasive procedures. July 2002 to December 2002. This study was conducted at the Department of Microbiology, Basic Medical Sciences Institute, Jinnah Postgraduate Medical Centre, Karachi. Observational study. A retrospective study of fifty five patients with burn wound infection was carried out at burn units of Civil Hospital Karachi, National Institute of Child health Karachi and Abbasi Shaheed Hospital, Karachi. Patients who received burn injuries with clinical signs and symptoms of infection were included in this study. In the present study 46[29%] isolates of P. aeruginosa were recovered, in which most strains were MDR and their sensitivity against Imipenem was 38 [78%]. The over all prevalence of the Oxidase negative Gram negative coli form bacteria was more than 70%, in which the most prevalent organism belongs to Proteus Spp;[27%] follows the Enterobacter Spp;.[15.5%]. Bacteria belongs with family Enterobacteriacae were more prevalent i.e. >70% while P. aeruginosa was individually more prevalent than any member of family Enterobacteriacae and was most resistant to multiple antibiotics than any other bacteria. Imipenem was the most effective drug against all gram negative bacteria follows the 4[th]. generation Cephalosporin Cefepime

Presentation of complications of chronic liver disease at a tertiary care hospital

To see presentations of various complications of chronic liver disease at a tertiary care hospital. Retrospective study. This Study was conducted at Medical Unit 1, Nishtar Hospital, Multan for a period of 6 months from 01-01-2010 to 30-06-2010. Patients admitted at Medical Unit 1, Nishtar Hospital, Multan were included in the study. The medical record of these patients was checked. The data obtained were entered in SPSS-11 and analyzed. A total number of 50 patients were studied, 30 [60%] were male and 20 [40%] were female. Age of the patients ranged from 36-58 years. Mean age of the patients was 45.39 +/- 4.77 years. All the patients presented with fatigue, generalized weakness, oedema feet, anorexia and nausea. Twenty [40%] patients presented with jaundice. Abdominal distension was present in 42 [84%] patients. Twenty two [44%] patients were having altered consciousness. Twenty three [46%] patients presented with haemetemesis and 28 [56%] with melena. Low grade fever was present in 26 [52%] patients. Epistaxis was present in 2 [4%] patients. Previous history of jaundice was present in 40 [80%] patients and history of alcohol intake was present in 12 [24%] cases. On examination, all the patients were found emaciated with protuberant abdomen. Twenty [40%] were clinically jaundiced. Oedema feet was detected in 48 [96%] patients. Palmar erythema was present in 26 [52%]. Hepatic flaps were present in 24 [48%] patients. Shifting dullness and fluid thrill was present in 46 [92%] patients and engorged paraumblical veins were present in 36 [72%] patients. Splenomegaly was seen in 36 [72%] patients. Laboratory investigations revealed raised serum bilirubin in 26 [52%] patients and level of bilirubin was 3-6 mg/100 ml in most of the cases. ALT levels were raised in 33 [66%] patients above the twice of the upper limit of the normal value. Serum alkaline phosphatase was raised only in 1[2%] of patients. Platelet count was below 70000 in 32 [64%] patients. Anti HCV and HBsAg were detected in 38 [76%] and 12 [24%] patients respectively. Prothrombin time was prolonged 25 seconds [than control] in 36 [72%] patients. Serum albumin was less than 3 g/100 ml in all cases. Abdominal ultrasonography revealed coarse echotexture with nodular liver in 46 [92%] patients. Ascites was detected in 48 [96%] patients. Two patients [4%] had hepatic mass. Upper GI endoscopy revealed esophageal varices in 33 [66%] patients, fundal varices in 12 [24%] patients, gastric ulceration in 17 [34%] patients and duodenal ulceration in 11 [22%] patients. Patients of chronic liver disease present in tertiary care hospital at a very late stage of the disease and most common presentations are ascites, hepatic encephalopathy, upper GI bleeding and low grade fever. Awareness may be created to motivate the patients to report to tertiary care hospital at an early stage, so that development of these complications can be managed at the very initial stage

Acute renal colic; comparison of nelbuphine hydrochloride with diclofenac sodium during emergency management

To compare the efficacy of Nelbuphine hydrochloride [opioid] and Diclofenac Sodium [NSAID] in management of Acute renal pain. Prospective non-randomized quasi experimental study. This study was conducted in Emergency department [ED] of Combined Military Hospital, Lahore. From 1st April 2008 to 31 July 2009. A Total of 100 patients presenting in emergency department with a clinical diagnosis of renal and Ureteric colic were studied. They were randomly divided in to equal and comparable groups, Group A and B. Severity of pain was assessed using a Visual Analogue scale [VAS]. Group A was treated with Intravenous Nelbuphine 10mg and group B was given intramuscular Diclofenac Sodium 75mg. Assessment of Pain relief, both onset and complete response was assessed in both groups. In addition to the pain relief, side effects like Nausea, vomiting, respiratory depression, drowsiness and injection site pain were also assessed. Nelbuphine was found significantly superior [p=0.05] to Diclofenac, both for time of onset of pain relief and complete pain relief. Moreover less patients required rescue analgesia in Group A [p=0.05]. Only one patient treated with Group A had respiratory depression which was statistically insignificant [p=0.05]. There was a 3.5% increase in Nausea and vomiting in Nelbuphine treated patients. Nelbuphine is a safe and rapid acting Opioid with few side effects. It should be preferred over Diclofenac sodium in treatment of Acute Renal pain

Ureteral stenting; after ureteroscopic lithotripsy for ureteric calculi

To assess the need for routine ureteral stenting after ureteroscopic lithotripsy. Prospective interventional study. Study was carried out between November 2006 to march 2009 at C.M.H Peshawar and C.M.H Lahore. A total of 100 patients were equally randomized into stented and non stented group. All these patients under went ureteroscopy and lithotripsy. The inclusion criteria was stone 6 to 10 mm. Those patients with large stones previous surgery or ESWL were excluded 8.9 Fr rigid ureteroscope was used with pneumatic lithotripter and 4.7 to 6 Fr double pigtail catheter was placed in stented group for 02 weeks. No ureteral dilator was used and stones were fragmented and no extraction device was used. A complete urine analysis x-ray KUB and USG were performed before and after operation in each patient. Pain score and lower urinary tract symptoms were recorded at the time of admission and three days after the operation. Regarding post operative pain no statistically significant difference was noted between the two groups [p <0.5]. The stone free rate was 100% with hydronephrosis resolved equally in both groups. 20 patients [40%] in stented group complained of at least two irritative bladder symptoms and only 05 patients [10%] in the non stented group experienced bladder discomfort. There was no significant difference in patients reported Haematuria in either group. Two patients in each group developed urinary tract infection. All those patients who were without a stent after uncomplicated ureteroscopic lithotripsy have similar renal function recovery and satisfactory pain reduction and with less irritative symptoms as compared to those with stent. We suggest that it is not necessary to place a ureteral stent in every case after ureteroscopic lithotripsy for stones smaller than 01 cm

In-hospital outcome of acute myocardial infarction in correlation with 'thrombolysis in myocardial infarction' risk score

Effective risk stratification is integral to management of acute coronary syndromes [ACS]. The Thrombolysis in Myocardial Infarction [TIMI] risk score for ST-segment elevation myocardial infarction [STEMI] is a simple integer score based on 8 high-risk parameters that can be used at the bedside for risk stratification of patients at presentation with STEMI. To evaluate the prognostic significance of TIMI risk score in a local population group of acute STEMI. The study included 160 cases of STEMI eligible for thrombolysis. TIMI risk score was calculated for each case at the time of presentation and were then followed during their hospital stay for the occurrence of electrical and mechanical complications as well as mortality. The patients were divided into three risk groups, namely 'lowrisk', 'moderate-risk' and 'high-risk' based on their TIMI scores [0-4 low-risk, 5-8 moderate-risk, 9-14 high risk]. The frequencies of complications and deaths were compared among the three risk groups. Post MI arrhythmias were noted in 2.2%, 16% and 50%; cardiogenic shock in 6.7%, 16% and 60%; pulmonary edema in 6.7%, 20% and 80%; mechanical complications of MI in 0%, 8% and 30%; death in 4.4%, 8%, and 60% of patients belonging to low-risk, moderate-risk and high-risk groups respectively. Frequency of complications and death correlated well with TIMI risk score [p=0.001]. TIMI risk score correlates well with the frequency of electrical or mechanical complications and death after STEMI

Asymptomatic bacteriuria in pregnancy: assessment of frequency and risk factors

To determine the frequency and risk factors of asymptomatic bacteriuria during pregnancy. Hospital based cross sectional study. This study was undertaken at outpatient department of Obstetrics and Gynecology at Jinnah Medical College Hospital Karachi from May 1, 2008 till September 30, 2008. Two hundred pregnant women who met the inclusion criteria were included in the study after informed consent and evaluated for bacteriuria. Data collected was analyzed utilizing statistical programme for social sciences [SPSS] version 10. Out of Two hundred antenatal mothers screened, 12 had significant bacteriuria giving frequency of 6%. Out of them 3 [7.8%] patients were below 20 years, 7[5.78%] were between 20 and 30 years and 2 [4.87%] women were aged above 30 years [p=0.842]. Regarding parity 3[4%] primigravida and 9[7.2%] multigravida had asymptomatic bacteriuria [p=0.275]. It was observed that prevalence was highest, 9% in lower socioeconomic class as compared to 2.24% in lower middle and upper middle class. The difference was found to be statistically significant [p=0.041].Regarding education status 10.97% of women were uneducated and only 2.54% were educated [p=0.016]. The study revealed high incidence in [58.33%] in women with previous history of urinary tract infection [p=0.000]. The frequency of asymptomatic bacteriuria among pregnant women was 6%. It was associated with lower socioeconomic status, illiteracy and past history of urinary tract infection

Correlation of severity of ST segment elevation in acute inferior wall myocardial infarction with the proximity of right coronary artery disease

A number of researchers have used different electrocardiographical criteria to predict the culprit vessel in acute inferior wall myocardial infarction [MI] cases. Therefore, the determination of infarct related artery in AMI is extremely important with regard to prediction of potential complications, furthermore, predicting the probable site of occlusion within RCA is worthwhile because proximal occlusions are likely to cause greater myocardial damage and an early invasive strategy may be planned in such cases. Our study aimed at evaluating the ECG criteria to predict the proximity of lesion in the right coronary artery [RCA] in acute inferior wall MI cases. The Objectives were to predict the presence of a proximal lesion in right coronary artery by severity of ST segment elevation in inferior ECG leads. This cross-sectional study carried out at the department of cardiology and cardiac catheterization at Jinnah Hospital, Lahore from April 2008 to September 2008. A total of 60 patients who suffered from inferior wall MI were included in the study who underwent coronary angiography in the first week. The ECGs of these patients were then compared with the angiographic findings to correlate the proximity of culprit lesion in RCA with the degree of ST segment elevation in inferior limb leads. Out of 60 patients, 29 [48.4%] had the culprit lesion in proximal, 23 [38.5%] in mid and 8 [13.4%] in distal RCA. Patients with proximal RCA disease showed a mean ST segment elevation of 12.55 +/- 1.38 mm, with mid RCA disease 8.39 +/- 0.89 mm and with distal RCA disease 6.0 +/- 0.54 mm. This study demonstrated that the severity of ST segment elevation was correlated with proximity of RCA lesion

Depression in primary care: Clinical epidemiology and clinical decision analysis an analytical review

A clinical decision analysis [CDA] is a mathematical tool designed to facilitate complex clinical decisions in which many variables should be considered simultaneously. CDA is a feasible tool for multifaceted problem of management of depression in primary health care. It provides a systematic frame work for organizing all data relevant to the decision on recognition and management of depression. Clinical epidemiological perspective is used for assessing the validity of screening instrument. A decision matrix based on reported probabilities is also constructed. Chance nodes and decisions pertinent to co-morbidities, illness severity and treatment options for depression are also presented