Seduced by tobacco, killed by cancer.

The practice of placing a small amount of chewing tobacoo or snuff in the oral cavity and leaving it in place for extended periods of time appears to be finding its way in to young and middle aged adults as a socially accepectable and popular habit. Cancer development at the site of placement and other oral mucosal lensions caused by these products has been described from several population groups. As the composition and the pattern of use of the product vary, evaluation of each type of smokeless vtobacco (ST) has to be undertaken with caution. This review thus, highlights the use of ST and its significance as the causative for oral cancer.

Microbiology of bile in symptomatic uncomplicated gallstone disease

To determine the microbiology of the bile culture and antimicrobial susceptibility in patients with symptomatic gallstone disease in our setup. A descriptive study. Surgical Department Combined Military Hospital [CMH] Kharian from Oct, 2010 to Jun, 2011. A total of 106 patients underwent cholecystectomy due to symptomatic gallstones and their bile was cultured for aerobic and anaerobic bacteria and culture sensitivity was performed. Data was analysed by using statistical package for social sciences [SPSS] version 13. Bile culture was negative in 81 patients [76.4%] and was positive in only 25 patients [23.6%]. Escheria Coli was the most common cultured organism in 10 [40%] patients, Klebsiella in 5 [20%] patients, Pseudomonas in 5 [20%] patients, Proteus in 2 [8%] patients, Staphlococcus aureus in 2 [8%] patients and mixed organisms were cultured in 1 patient [4%]. Cefoperazone with sulbactum and Amikacin were the most effective prophylactic antibiotics. Bile in majority of patients with symtomatic uncomplicated gallstone disease is sterile. E. coli is the most commonly cultured organism and cefoperazone with sulbactum and amikacin are the most appropriate antibiotics in our setup

Endoscopic disectomy: learning curve and outcome evaluation

Background: Minimally invasive techniques for Lumbar disc surgery are becoming common. It is therefore essential that we assess their learning curve and evaluate their results before their across the board application to lumbar disc herniation surgery

Objective: This prospective study was conducted to evaluate steepness of learning curve and outcome of Endoscopic disectomy

Study Design: This is a prospective study carried out at PNS Shifa, which is a tertiary care hospital, from Jan 2011 to Jan 2013

Patient Interventions: Forty three patients underwent Endoscopic disectomy for a single level herniated disc using an interlaminar approach; all procedures were performed under general anesthesia. All patients were followed prospectively. Endoscopic system used in this study consisted of tubular dilators and an endoscope with xenon light source and HD image system from Karl Storz co. Germany

Outcome measures: Outcomes were assessed by analyzing the video of the procedure to pinpoint the areas where maximum time was spent and thus devising ways to cut down the operating time. Patient outcome was measured by using Oswestry disability index and Macnab criteria

Results: 43 patients [29 males, 14 females] underwent Endoscopic disectomy for prolapsed lumbar intervertebral disc. Mean operating time was 70 minutes. The mean operation time for the first and last 10 cases was 140 and 58 minutes, respectively. The procedures affecting a prolonged operation time were evaluated. The time required for surgery reduced considerably after 12 cases. Follow up ranged from 3 to 15 months with a mean follow up of 10.8 months. Thirty five patients had an excellent outcome while five had a good outcome. Three patients had a poor outcome and underwent open disectomy. Five patients early in the study had to be converted to open disectomy due to technical difficulties. These cases were excluded from the study

Conclusions: Endoscopic disectomy is clinically effective and reliable. The learning curve, however, is steep. It requires at least 10-15 cases before surgeon can achieve command of the procedure

Comparison of lateral anal sphincterotomy [closed method] versus anal dilatation

To compare lateral anal sphincterotomy [closed method] with anal dilatation in the management of primary chronic anal fissure. A prospective, comparative, interventional study. Department of Surgery Combined Military Hospital Kohat from Jan 2001 to Mar 2002. During the period, all patients with primary type of chronic anal fissure, who were above 12 years of age and were fit for surgery, were selected for study. They were divided into two groups for both surgical procedures in a randomized manner. After their respective surgical procedures patients were followed up for four weeks on weekly basis. The changes in signs and symptoms were thoroughly reassessed and noted in a separate proforma maintained for each patient for the purpose of comparison. The total number of patients was 49 with an average age of 40 years. Male to female ratio was 7:1. In 44 [89.79%] patients the fissure was located posteriorly while in 5 [10.20%] patients it was located anteriorly. Closed lateral anal sphincterotomy [LAS] was done in 28 [57.14%] patients, of which 25 [51.02%] were males and 3 [6.12%] females. While anal dilatation [AD] was done in 21 [42.85%] patients, 18 [36.73%] males and 3 [6.12%] females. In all the patients in whom LAS was done, there was disappearance of all the symptoms and complete healing of ulcer. Those operated by AD, there was disappearance of all the symptoms and complete healing of ulcer in only 8 [38%] patients. Incontinence was present in 9 [18.36%] patients. Three [14.2%] patients had persistence of ulcer while one [4.76%] was having recurrence of ulcer. Lateral anal sphincterotomy, especially close method gives excellent results as compared to anal dilatation in terms of ulcer healing, disappearance of symptoms and lower rate of ulcer recurrence or incontinence

Acute anal fissure; effect of topical glyceryl trinitrate [GTN] on its management

To evaluate the role of topical glyceryl trinitrate [0.2% GTN] on the clinical features of acute anal fissure. A prospective, open label therapeutic trial was carried out at Combined Military Hospital, Kharian Cantonment during one calendar year. All adult males and females presenting with acute anal fissure were included. Patients with chronic anal fissure, associated pathology [hemorrhoids, fistula in ano], age < 15 years, previous surgery of anal canal were excluded. The diagnosis was based upon history and physical examination. A detailed history was taken regarding their symptoms like painful defecation, bleeding per rectum, constipation and itching. Then the patients were examined to look for anal fissure, associated mucus discharge and sphincter tone and recorded in the proforma. 0.2% topical GTN ointment was prescribed twice daily for local application in the anal canal with the help of cotton pledget on a stick [soaked completely in ointment]. The duration of treatment was four weeks and their symptomatology and healing of anal fissure was assessed weekly. A total of 40 patients were treated in this study. Age varied between 22 - 51 years. 36 patients [90%] were male while only 4 patients [10%] were females. Painful defecation [100%], bleeding PR [87.5%] constipation [50%], and itching [40%] were the main complaints. Posterior fissure was seen in 85%, anterior fissure in 12.5%, while both anterior and posterior fissures were seen in 2.5% of patients. Out of 40 patients 21 had complete healing of anal fissure while 03 patients recovered partially. Thus the healing rate was 60%. Topical glyceryl trinitrate is an effective treatment modality for acute anal fissure

Radial nerve injuries; presenting as wrist drop-analysis of 100 patients

To highlight etiological factors leading to radial nerve injury resulting in wrist drop, with particular reference to iatrogenic causes. Retrospection and Descriptive. One hundred patients of all ages and both sexes with wrist drop. Data of clinical assessment after detailed history and examination as well as electro diagnostic studies was recorded on pre-designed assessment proforma. The outcome was charted down for frequency of etiology of the wrist drop. Rehabilitation Medicine Department of Combined Military Hospital [CMH] Multan and Armed Forces Institute of Rehabilitation Medicine [AFIRM]. The major cause of injury was splinter/gun shot injury 31%, mis-placed injection at mid-arm 21%fracture of humerus was 21%, compression neuropathy 16%, and stab wound 11% caused wrist drop. Electro-physiological studies revealed that 85% patients had injury to radial nerve at mid-arm, 9% had injury to posterior interosseous nerve while 4% had injury to superficial branch of radial nerve and only 2% had normal study. Electrodiagnostic studies also revealed that majority of the patients suffered from axonotmesis [44%] and neurapraxia [38%], whereas [16%] were neurotmesis. The most common cause of radial nerve injury is trauma. It is also found that the frequency of radial nerve palsy due to iatrogenic causes is quite high. In addition to the clinical examination, the nerve conduction studies and electromyography proved to be the better investigation technique in the assessment of the location, severity and extent of the peripheral nerve injury and subsequently guides in starting the proper treatment option due to early referral of patient to the concerned fields

Stridor in afebrile children

To enlist the causes of stridor in afebrile children under twelve years of age. Design: Descriptive study. Carried out in ENT Dept CMH Rwp from Sep 2001 to Feb 2003. Fifty children presenting for the first time with symptoms of stridor were selected according to the inclusion criteria by non-probability purposive sampling. Every patient was evaluated by detailed history, thorough physical examination and investigations including radiographic studies, laryngoscopy and bronchoscopy. Data was recorded on the performa attached as Annex 'A'. Of the 50 patients, there were 29 males and 21 females. The mean age at presentation was 3.8 years. About forty-eight diagnostic observations were made during the initial endoscopic procedure on these 50 children. Acquired lesions [76%] outnumbered the congenital lesions [24%]. Of the congenital type, laryngomalacia [42%] was the commonest cause followed by vocal cord paralysis [17%], laryngocele [17%], laryngeal web [8%], tracheomalacia [8%] and tracheal stenosis [8%]. The most important acquired lesion was foreign body in the Aerodigestive tract [55.26%], followed by respiratory papilomatosis [21.05%], traumatic [13.16%] and subglottic stenosis [10.13%] Because of chronic and presistent upper airway obstruction, tracheostomy was electively performed in 02 cases in this series. There was no complication associated with complete endoscopic examination Foreign body in the tracheobronchial tree is the most frequent cause of stridor in afebrile children followed by congenital conditions and recurrent respiratory papillomatosis

Frostbite in gangrene; role of classification

The objective of this study is to determine if classification of cases of frost bite in 1st, 2nd, 3rd and 4th degree have any predictive value on the future complications e.g. skin necrosis and gangrene. A non-interventional and descriptive study. The study was carried out at the Surgical Department, of Combined Military Hospital Gilgit from January 2002 to February 2005. All the patients who reported to the hospital with frost bite were admitted and enrolled in the study. The local examination of wound was done and all the physical signs were recorded, The frost bite was labeled according to the severity from 1st to 4th degree in accordance to the specified criteria. All the patients were placed on a standard treatment protocol comprising of injection of Benzyl Penicillin 10 lac U x 6 hourly, injection of Heparin 5000 IU s/c x 6 hourly and tablets Ibuprofen 400mg x 8 hourly for 5-7 days. The condition of wound was assessed daily till 8 weeks after admission. The end point of medical treatment was a clear demarcation of dry gangrenous and viable tissue, or the formation of moist gangrene or infection in frost bitten area which was spreading proximally. Once this condition was reached the patients were planned for amputation surgery. Total numbers of patients included were 96. Among them 33 had 1st degree, 37 had 2nd degree, 16 had 3rd degree and 10 had 4th degree frost bite. All the 33 patients of 1st degree frost bite recovered well and were discharged from the hospital without any surgical intervention. 16 patients among the total 37 who sustained 2nd degree frost bite developed superficial ulcers over the skin. These patients required regular wound dressings and recovered well by 6 weeks of treatment without any limb loss. 7 out of total 16 patients of 3rd degree and all the 10 patients of 4th degree frost bite developed gangrenes. They were observed till 8 weeks and after that they underwent amputations. In accordance to the results it is concluded that most of the patients who had r degree of frostbite and all the patients who sustained 4th degree frost bite developed gangrene by 8 weeks of hospitalization despite of the treatment. None of the patient of 1st and 2nd degree frostbite developed gangrene. Hence the initial assessment of a patient was very useful in predicting the chances of development of gangrene

Effect of topical glyceryl trinitrate on the management of acute anal fissure

To find out the effect of topical glyceryl trinitrate on the symptoms and signs of acute anal fissure. Seventy-five patients were treated with 0.2% topical glyceryl trinitrate twice daily as local application in the anal canal with the help of cotton pledget, which was soaked in the ointment for four weeks and their symptomatology, and healing of anal fissure was assessed weekly. The study was carried out at a surgical unit of Combined Military Hospital Rawalpindi for six months from June 2004 to December 2004. Out of 75 patients, 42 had complete healing of anal fissure while six had partial healing. Thus the healing rate was 64% observed in our study. 0.2% Glyceryl trinitrate ointment is an effective way of treating acute anal fissure

Aetiology of nasal polyp-a study of 200 cases at combined military hospital Rawalpindi

To know the aetiology of nasal polyp in our setup so that the underlying cause can be addressed at the same time for a better treatment outcome. DESIGN. This is a descriptive study. PLACE AND DURATION OF STUDY. The study had been carried out at the ear, nose and throat department, Combined Military Hospital Rawalpindi, a tertiary care centre, over a 03 years period from January 2000 to January 2003. PATIENTS AND METHODS: The study was carried out on 200 patients. Patients of all age groups and both sexes who presented for the first time in our setup and found to have nasal polyp / polypi on examination, were included in this study. Patients who had history of nasal polypectomy with no nasal polyp at the time of presentation were excluded from the study. On the basis of detailed history, thorough clinical examination and investigations patients were placed in different groups like intrinsic rhinitis [vasomotor rhinitis], nasal allergy, sinonasal infection, sinonasal growths, drug allergy [aspirin hypersensitivity] and cystic fibrosis. In this study majority of the patients were found to be in second to fifth decade, male to female ratio was 2:1, 59% were diagnosed to have vasomotor rhinitis, 18.5% had nasal allergy, 12% had asthma, 14% had fungal rhinosinusitis, 4% had acetylsalicylic acid hypersensitivity, 6% had sinonasal growth, 2% had bacterial rhinosinusitis and 0.5% had cystic fibrosis. 84% of our patients turned out to be having bilateral nasal polypi, 16% had unilateral nasal polyp, out of which 6.5% antrochoanal polyp. The exact cause of nasal polyp is still an enigma, majority has simple aetiology but nasal polyp with sinister pathology-do present. So the management of nasal polyp should only at the symptomatic relief of nasal obstruction but the underlying cause and pathologies should also be addressed

Otological manifestations of bomb blast injury

The study was conducted to assess the spectrum and pattern of otological injuries in bomb blast. Observational/non-interfering descriptive study of the trauma to the auditory system in a bomb blast in a bus was explored. This study was conducted from 28 to 30 Oct. 2001 in a tertiary care hospital, following a bomb blast in a bus on 28'h October 2001. An explosive charge detonated under a seat in a local urban transport bus on 28th October 2001, killing 3 passengers on the spot. All the survivors who required medical treatment were transferred to a major medical facility located about 100 metres from the scene of the incident. All those, admitted or reporting to ENT Department, were examined for any ear nose or throat injury. In the otological evaluation the audiological and vestibular symptoms were recorded and tuning fork tests, pure tone audiometery and Hallpike manoeuvre were also performed. The otological manifestation of blast trauma were hearing loss, tinnitus, ear discharge and pain. Vertigo was not a symptom of blast trauma. Perforation of tympanic membrane was a common sign in blast trauma. Sensorineural hearing loss was also one feature of bomb blast injury. Typical noise induced deafness was found in 36% of total ears tested on PTA. The 256 Hz tuning fork was more sensitive in detecting conductive deafness as compared to 512 Hz tuning fork in Rinne test. The results of the study call for the necessity of early ENT observation of all the patients who are subjected to explosive trauma because the ear is particularly susceptible to damage