Diabetic foot ulcer; sequelae

Objective: The number of diabetic patients is increasing at a rapid rate1. Management of diabetic foot has been a challenge for medical professionals. This study was carried out to find the sequelae of diabetic foot ulcer management. Study design: Observational analytical study. Setting: Military Hospital, Combined Military Hospitals Rawalpindi and MIMC teaching Hospital, Mirpur [AJK]. Period: Sep 2009 to August 2013

Materials and methods: Total 310 patients were included in this study as outdoor and indoor cases. Out of these 184 were males and 126 were females. Age affected ranged from 20 years to 90 years. Average age was 50 years. Wagner's grading for diabetic foot ulcer was used as guideline for management

Results: Hyperglycemia was controlled in consultation with physicians in all these patients. Out of these 310patients 199 [64%] patients got their feet wounds healed on conservative management without amputation while 111[35.8%] patients had to undergo some amputation at some level

Conclusion: Diabetes mellitus, fore runner of so many diseases requires multidisciplinary approach. Well controlled diabetes mellitus, good feet hygiene, rational antibiotics in light of culture/sensitivity report and timely conservative or active surgical intervention produce good results in diabetic foot management

Frequency of thymoma in thymectomy specimens in myasthenic patients

This study was carried out to determine the frequency of thymoma in different age groups and sexes in thymectomy specimens in Myasthenia Gravis patients. Observational study. The study was carried out in General Surgery Department at PIMS over a period of three years from 2009-2012. PIMS is a tertiary care centre where large population of Islamabad and Surrounding territory, including AJK, Gilgit Baltistan, Hazara division, Peshwar and nearby districts of Punjab gets treatment. A total of 30 patients selected at random, were included in this study. Patients were of different age groups, above 12 and under 52 years of either sex. Patients with poor medical control of disease with no contra indication for surgery. Patients with operable mediastinal mass [thymoma] were included. Generalized myasthenia gravis was diagnosed in patients. Pre-operative plasmaphoresis was carried out in all patients. Transsternal approach was used in all cases although now video assisted thoracoscopic thymectomy is becoming popular. Intraoperative findings were noted with emphasis on gross appearance and an information by histopathological report [frozen section]. In our study 17 % thymectomy specimens turned out to be Thymoma. Male to female ratio was 3:2. Age range was 12 years to 52 years. All patients undergoing thymectomy for Myasthenia Gravis don't have thymoma. Moreover all Thymomas are not associated with Myasthenia Gravis. Ages between 3[rd] to 5[th] decade are affected by thymoma and gender difference is very little

Polio vaccination; knowledge, attitude, and practice in district Abbottabad, Khyber Pakhtunkhwa, Pakistan

To assess knowledge, attitude and practice [KAP] about poliomyelitis [polio] vaccination in District Abbottabad, province Khyber Pakhtunkhwa [KPK], Pakistan, to identify reasons of failure of polio vaccination/ eradication campaign and to make recommendations in the light of the study. District Abbottabad, province KPK, Pakistan including both urban and rural areas. Three months from 1st June to 31st August 2012. This cross-sectional descriptive explorative study was conducted in District Abbottabad, of province KPK, Pakistan. A structured questionnaire was submitted to people in the urban and rural population using convenient sampling. Out of 200, only 142 questionnaires were filled by interviewing parents and guardians of the children followed by focused group discussions with the community heads and the parents of the children. Majority [61.78%] of respondents were of low income category with the mean age of 31 years. Amongst those [75%] were earning Rs.7,000-12,000 per month. Literacy rate was low with 45.77%. Out of which 40.67% fathers and 59.33% mothers were illiterate. Therefore a few respondents were aware about the mode of transmission of polio. Majority [80%] said that polio could be prevented by polio drops and about 86% said that this vaccine had no side effects. About 45% respondents refused to cooperate with polio teams, and 28% respondents believed, that Abbottabad Operation had bad effect on anti-polio campaign. Regarding the use of boiled drinking water, 95.8% respondents knew that it was good for health. While only 4.20% were using boiled water for drinking. Advice of the health professionals [69.71%] and other family members [7.74%] was respected in making health care decisions, therefore it was an opportunity for the government to involve these persons as well as media men in conveying message to the community to achieve ultimate goal of polio free Pakistan. Unawareness among the population of District Abbottabad, especially the knowledge about the disease, mode of transmission and its prevention are the most deficient areas. Secondly misconceptions about the nature of polio drops, and religious misinterpretations in masses, created by general public and religious leaders, are the major obstacles in the real success of vaccination campaign

Should we routinely expose recurrent laryngeal nerve[s] during thyroid surgery?

To compare the frequency of recurrent laryngeal nerve[s] [RLNs] palsy after various thyroid procedures with and without identification of recurrent laryngeal nerve during the operation. Randomized controlled trial. Department of Surgery, Military Hospital, Rawalpindi, from August 2008 to April 2010. Patients undergoing indirect laryngoscopy with normal vocal cords and those with carcinoma and re-do surgery having normal vocal cord were included in the study. Patients with hoarseness of voice, abnormal vocal cord movements and with solitary nodule in the isthmus were excluded. These patients were randomly divided into 2 groups of 50 each using random number tables. RLN was identified by exposing the inferior thyroid artery and traced along its entire course in group-A. Whereas, in group-B, nerves were not identified during the operations. Immediate postoperative direct laryngoscopy was performed by a surgeon with the help of an anaesthesiologist for the assessment of vocal cords. Patients with persistent hoarseness of voice were followed-up with indirect laryngoscopy at 3 and 6 months. Temporary unilateral recurrent laryngeal nerve palsies occurred in 2 [4%] patients in group-A where the voice and cord movements returned to normal in 6 months. In group-B, it occurred in 8 [16%] patients, 2 bilateral [4%] injuries requiring tracheostomy and 6 unilateral injuries [12%]. Among the 2 bilateral recurrent laryngeal nerve injuries, the tracheostomy was removed in one case after 6 months with persistent hoarseness of voice but no respiratory difficulty during routine activities. Tracheostomy was permanent in the other case. Among the 6 cases of unilateral nerve injuries, the voice improved considerably in 4 cases within 6 months but in 2 cases hoarseness persisted even after 6 months. Frequency of recurrent laryngeal nerve palsies was significantly lower in group-A as compared to group-B [p = 0.046]. For safe thyroid surgery, recurrent laryngeal nerve[s] should be routinely exposed in its entire course

Appendicectomy; assessment of caecal invagination of appendicular stump

To evaluate the usefulness of invagination/burial of appendicular stump after removal of appendix. A prospective, non randomized comparative study. CMH Kharian and PAF Hospital Mianwali. 2005-2007. Three hundred patients were included in this study. Appendicectomy was performed through Lanz incision .After removal of the appendix stump was buried/ invaginated in 150 patients while it was not buried in other 150 patients. 198 patients were males and 102 patients were females. The youngest patient was 14 years old and the eldest was 55 years old. Perforated and gangrenous appendices were not included in this study. There was hardly any difference in outcome of patients in both groups except that 10 patients in first group had longer hospital stay due to symptoms like more pain, fever and infection. Burial or otherwise of appendicular stump does not make much difference. It was concluded that there was no added benefit of invagination of appendicular stump rather it takes more operative time and at times it has negative implications too

Morbidity of mesh repair in inguinal hernias

Hernia is protrusion of any viscous or part of viscous from its proper cavity. Inguinal hernias are the commonest variety amongst all ages and both genders. The most widely practiced operation for inguinal hernia is Lichtenstein tension free mesh repair. Mesh repair, although is best known technique, it still has got morbidity in form of postoperative pain at operation site, urinary retention, scrotal hematoma, wound infection, testicular atrophy and recurrence. In experienced hands, however, this morbidity is significantly reduced. Bring to light the morbidity in our setup and then compare it with other studies available from eastern setup. We studied a total of 200 male patients having inguinal hernias, in CMH Kharian, from Mar 2005 to Mar 2007. Unilateral Lichtenstien tension free mesh repair was performed under general aneasthesia as indoor case. All patients were followed up in OPD, upto one year, to see any complication. 69 patients had mild pain, 113 patients had moderate pain and 18 patients had severe post op pain. Wound infection occurred in 03 patients. Scrotal hematoma formed in 05 patients. Urinary retention occurred in 07 patients, Testicular atrophy occurred in 01 patient. Chronic scar pain was reported by 02 patients. We came to the conclusion that mesh repair is the safest procedure having minimal morbidity

Hinman syndrome; non-neurogenic neurogenic bladder

Inadequate bladder emptying is a common urinary dysfunction in children. Proper evaluation of the child to rule out neurogenic cause is highly desirable before labeling him/her a non-neurogenic neurogenic bladder. This case report describes a male child of 3 years age who presented with clinical features of neurogenic bladder but found to have no neurogenic cause hence diagnosed as Hinman syndrome. After diagnosis he was placed on alpha-adrenergic blocker. along with psychological support and showed satisfactory response