Frequency of urological carcinomas presenting as gross Haematuria in Punjab Pakistan and recommendation for its early diagnosis

Objective: To determine the frequency of various causes of gross Haematuria presenting in our hospital and recommend a working protocol to young doctors. Study Design: Prospective descriptive study. Place and Duration of Study: Urology Department, District Headquarter and Teaching Hospital, Sargodha Medical College, from Mar 2012 to Mar 2014

Material and Method: All fresh patients reporting to the hospital with complaints of 'blood in urine' were included in the study, while patients presenting with Microscopic haematuria were excluded. The patients, after being managed by the urology registrar, were given a questionnaire to fill, assisted by a resident, a reference number allotted for follow-up. A request for urine routine examination and urine microscopy/cytology was made to confirm haematuria and exclude malignant cells. Followed by ultrasound, X-Ray KUB, cystoscopy and IVU/CTU scan, as required. The results obtained were recorded and analyzed

Results: A total of 391 patients presented with complaints of 'blood in urine'. Trauma: was the most frequent cause seen in 21.7% [n=85], followed by Urinary tract infections [21.0%, n=82], Urolithasis [20.2%, n=79] and Urological tumors seen 19.4% [n=76] cases. About two thirds of the patients [56.6%, n=43] with urological tumors were not investigated, at primary health care level, to ascertain the cause and presented with advanced disease

Conclusion: General practitioners should be encouraged to request ultrasound scan for patients presenting with gross haematuria, as urothelial tumours, if detected early, can be managed effectively with better long term outcome

Miniature radiography

Objective: This study was designed to find out the utility of MMR in hospital-based setup. Study Design: An observational, analytical study

Place and duration: The study was conducted at Radiology Department POF Hospital Wah Cantt for a period of two years. The study was started on 01[st] August 2009 and ended on 31[st] July 2011

Results: Out of 1401 patients attended 988 were advised MMR for pre employment med checkup and 413 reported for annual checkup [Table I]. 91% [1291] were male and 110 were female [Table II]. Majority [64%] of the subjects belonged to age group 20 to 30 years. [Table III].16 patient had pulmonary tuberculosis. [Table IV]

Conclusions: MMR is suggestive rather than diagnostic .It merely separates persons for whom further investigations are required. According to international standard our facility is much underutilized

Malignant tumors; frequency at Sargodha, a single centre, retrospective study

As in most developing countries, incidence of cancer is also increasing in Pakistan. It is important that information on the frequency and epidemiology of malignant tumors be updated, as it is the basis of future health planning for the population at risk. This retrospective study was carried out to find the prevalence of various cancers in the population of Sargodha district [central Punjab, Pakistan] and to compare the regional and international studies, so as to plan and develop the oncology setup of Sargodha Medical College on a rationalized basis of disease prevalence. Data from July 2010 to June 2013 was retrieved from the department of statistics of the hospital and variables of interest were collected and analyzed using SPSS 10.0. It was observed that the most frequent cancer in our patients was breast cancer [n=172] while carcinoma of lungs was the most frequent carcinoma in male population [n=24]. However our observations were a bit different from the international studies published on the subject, the probable reason being the availability of treatment facility and easier access in the nearby districts of Faisalabad and Lahore where many patients still go directly. More over the illiterate and poorer faction of the society does not come to the hospitals for management of the disease but rather go to the quakes and faith healers to relieve them of their sufferings. It is concluded that the department of clinical oncology should arrange cancer awareness programs for the general population to avoid delays in getting consultation, as at present they report to the hospital when the disease is quite advance and surgery is often not possible. Our study also revealed a somewhat different pattern of malignancies in our community raising a need for further studies to evaluate the reasons for this changed pattern in relation to various etiological factors

Clinical audit of hemodialysis patients at dialysis centre a tertiary care hospital

Background: The incidence of end stage renal disease [ESRD] is between 100-150 new cases per million per year, with a disease burden of 27000 new cases each year in Pakistan. The treatment of first choice for these patients is renal transplantation, which is available to only 5% of patients, rest have no other option except to resort to dialysis to sustain their life

Objective: The objective of the study was to critically review and analyze the data of patients on the basis of etiology, dialysis type and outcome during the last three years so as to improve the patient care

Patients and Methods: In this descriptive study, all the patients, who underwent dialysis during three years [2009-2011] was retrieved from the statistics department. Variables of interest were identified. Data was collected, entered and analyzed in SPSS version 15. The results were then compared with national and international studies on the subject

Results: In this study, a total of 457 patients under went dialysis at the centre and 14687 dialysis sessions were performed during the period under study. Male to female ratio was 1.6:1 and mean age was 44.15 years. Hypertension [70%] was the major cause of ESRD. Fifty three percent patients had an arterio-venous fistula and 23.63% were suffering from hepatitis [C] before the first dialysis. Average survival was 7.7 months and 46.17% deaths were recorded

Conclusion: The management of ESRD being very expensive, government alone with a less than 0.5 to 0.8 percent of the GDP allocation for health cannot extend this facility to all the sufferers. The society should follow healthy life style practices so as the preventable causes of ESRD such as hypertension and DM can be controlled. Social groups should be formed in which these patients should actively participate, encourage and guide each other to improve their quality of life

Radiology request form; a neglected medical document

An incompletely filled Radiology Request Form [RRF] is a common problem faced by both radiologists and radiographers. The study was carried out to objectively evaluate the adequacy of completion of radiology request forms in a tertiary care centre. Indoor and outdoor patient departments of POF Hospital Wah Cantonment. Descriptive, retrospective study. Radiology Department POF Hospital, Wah Cantonment. 01 Jul 2009 to 01 September 2009. A total of 1500 request forms received by the radiology department from 01Jul 2009 to 01Sep 2009 were reviewed. These included requests for a variety of examinations from different departments within POF Hospital, Wah Cantonment. A database of the collected forms was created, noting which of the various fields were adequately completed. Only 270 out of the 1500 forms were completed in full and 1230 were not completely filled. The only parameter fulfilled in all the forms was the presence of referring doctor's signature. The commonest blank fields were as follows: patient location: 62%, clinical notes: 67.26%, doctor's name: 47.33% and date of referral: 14.2%. The inadequate transmission of clinical information observed in this study is typical example of the various problems that radiologists have to face

'Vitamin A' a potential teratogen

To determine the teratogenicity of Vitamin A excess on intrauterine development of thymus in albino rats. Experimental studyThis study was conducted at the Department of Anatomy/ Histopathology, Shaikh Zayed Postgraduate Medical Institute, Lahore from September 2008 to September 2009. Study was conducted with 18 pregnant female albino rats, of Sprague-dawley variety. These female rats were randomly separated into equal groups, A, B and C [n=6]. Vitamin A was used in the form of Isotretinoin [13-cis retinoic acid]. The dose of isotretinoin used in this study was constant i.e, 2.5mg/kg body weight of rats for every experimental group. Taking the trimester of pregnancy as variable of the study dose was given on 9 [mid trimester] and 17 [late trimester] days of pregnancy to the mother rats. The sample size was obtained by collecting 18 foetuses from each group. Thymuses were collected from the rat foetuses of each group after dissection. The foetuses of experimental group whose mother rats received the dose of Vitamin A in mid trimester showed thymic ectopia in a significant number of foetuses [P<0.01], while dose of Vitamin A given in late trimester caused thymic hypoplasia [P<0.01] in fetuses of albino rats. It is obvious with these findings that single dose of Vitamin A can cause deleterious effects on developing thymus in albino rats. Caution must be taken while administration of Vitamin A to a pregnant woman

Idmbotomy; an under utilized incision for renal and upper ureteral access

Urolithasis is a common urological ailment since antiquity. Treatment of urolithasis has witnessed a revolutionary change with the advent of minimally invasive endoscopic techniques. However in developing countries very few cases of the renal stone disease are being treated using minimally invasive techniques and vast majority are still being managed with open surgery. The objective of the study was to compare the two incisions used for renal and proximal ureter access, and find out which was better in our set up. We carried out a study at our center, comprising of 50 cases of solitary renal stones, to compare the traditional oblique lumbar [OL] incision with dorsal lumbotomy [DL]. Patients included in the study were with a BMI of less than 30, all ages, having single large stone of renal / proximal ureter, extra renal pelvis, no previous surgery on the ipsi-lateral side. The study revealed that the lumbotomy incision is better than the traditional lumbar oblique incision in terms of surgery time, post operative pain, early return to work and cosmetically accepted scar. After analyzing the data we came to the conclusion that the lumbotomy incision was superior to the oblique lumbar incision in selected cases and we recommend that it should be used specially in centers where facilities for endoscopic/minimally invasive management are not available

Child laborers; abuse is universal at Rawalpindi

In Pakistan there are about 3.3 Million unprotected child laborers. They are constantly exposed to all kinds of dangers and abuse intimidating the future of the country. These child laborers are without the basic necessities of life including food, shelter, schooling and healthcare services, which has devastating effects on our socio-economic fabric. It is quite imperative to comprehend and unveil the perilous picture of the working conditions of child laborers and the abuse inflicted upon them at such an impressionable age. Cross sectional study. Rawalpindi city including workshops, shops and streets of Rawalpindi. January 2008-Dec 2008. Objective: To assess the presence of any Verbal, Physical and Sexual abuse among the child laborers at Rawalpindi city. Out of the total sample of 700 study subjects 315 [45%] of the Child laborers reported being abused whereas 385 [55%] reported no abuse. Out of the fraction which reported to be abused the break up is as follows. 214 [67.9%] reported verbal abuse, 75 [23.8%] reported Physical abuse and 25 [7.9%] reported sexual abuse. This study concluded that the child laborers are open to the elements of the adversities that come along with their work environment. The government should be urged to take necessary steps to trim down the abuse against child laborers and its frightening effects on their families, society and nation at large by constituting strict laws and ensuring their speedy implementation

Through service learning to provide social justice

In Pakistan there are 3.3 Million child laborers without healthcare services and educational opportunities, which affect our social fabric. We report how structured 'Service Experience' helped broaden medical students understanding of social justice. To produce health professionals who are ready to work for a cause without voracity. A Cross sectional survey through a focal group discussion. Do opportunities for structured Service Learning help modify student's perception of their role as doctors in society? Foundation University Medical College, Islamabad. Fifteen months, from January 2008-April 2009. Fifteen students interviewed 700 child laborers using a piloted interview form during a fifteen months period. Focus group discussions were held with these students to discuss their experiences. Qualitative analysis of the discussion is reported. Students empathized that children worked on a contractual basis averaging $1 per 10 hours with no meals. Parents encouraged them to earn money and they felt more satisfied pleasing them. Children didn't attend school because of the school quality and fear of abuse. "Our exposure to child labor had been limited; this has taken us to the core of the issue. We now feel responsible as a physician and a leader to ensure 'security of children in every respect' as part of their health." "We will avoid employing children at our homes and will council parents, trying to be role models for others." "As future leaders we will propose measures including establishment of free quality educational systems with paid vocational tracks." Service learning will inculcate empathy for the oppressed groups of the community and also develop a social and civic responsibility in medical students

Management of gastric carcinoma; comparative analysis of various treatment modalities

To find the best treatment modality for carcinoma stomach. Case series study. Combined Military Hospital Rawalpindi. From January 1996 to December 1999. 42 cases of gastric carcinoma are included in this study. The mode of treatment predominantly remained surgical with the aim to cure the patient of this disease. The disease occurred mostly above the age of 50 years. Common clinical features were unexplained weight-loss, malnourishment and anaemia, respiratory tract infections. No specific etiological factor was detected except that, out of 42 patients 35 were smokers or had quit smoking during the past six years. Nearly all were having at least 8-10 cups of hot tea per day. Adenocarcinoma was the most frequently encountered histological type. 03 patients could not be operated upon because of extremely poor prognosis due to multi-organ failure. 12 patients were selected for surgery curative resection was carried out, whereas the remaining 27 were subjected to palliative resections. Five patients died during or within one month of surgical intervention. Out of the remaining 34, only 21 patients reported for follow up. In most of the patients in whom curative resection was performed, the quality of life was reasonably good. At the end of one year, another eight patients had died of tumour dissemination and cachexia, three patients developed tumour recurrence at the anastomotic site, and one patient developed stricture at anastomotic site. Patients with recurrence were sent for radiotherapy. It is concluded that for carcinoma of stomach the only possible treatment is surgery either alone or in combination with radiation and chemotherapy, the most common, preventable etiological factor is smoking, probably in combination with hot beverages in excess. The most common presentation remains weight loss with dyspepsia or weakness and anorexia, commonly effected age group is middle and old age, preoperative nutritional build-up achieves good postoperative results, palliative surgical procedures made the quality of life of the patient better. The prognosis remains extremely poor, in terms of morbidity and mortality

Necrotizing enterocolitis in premature babies; Laparotomy versus peritoneal drainage

Premature infants with necrotizing enterocolitis [NEC] or intestinal perforation [IP] are treated either surgically with laprotomy or peritoneal drain placement. [1] To develop a hypothesis about the relative effect of these 2 therapies on risk adjusted outcomes through 18 months in premature infants. [2] To obtain data that would be useful in designing and conducting a successful trial of this hypothesis. A prospective, observational study. In pediatric surgical departments of Military Hospital Rawalpindi and Combined Military Hospital Rawalpindi. From Nov 2005 to April 2007. To assist in risk adjustment, the attending pediatric surgeon recorded the preoperative diagnosis and intraoperative diagnosis and identified infants who were considered to be too ill for laprotomy. Severe NEC or IP in 156 of 2987 premature infants; 80 were treated with initial drainage and 76 were treated with initial laprotomy. By 16 months, 76 [50%] had died; outcome remained worse in subgroup with NEC. Laprotomy was not performed in 76% [28 of 36] of drain treated survivors. Drainage was commonly used, and outcome was poor. Our findings, particularly the risk adjusted odds ratio favoring laparotomy, indicate the need for a large, multicenter clinical trial to assess the effect of initial surgery therapy on out come at > 16 months

Atyical tongue - tie to congenital tongue- palate fusion

A neonate was brought in an emergency with feeding problem. The major complaint was neonate's inability to take nipple or teat in the mouth cavity for feeding. Signs of respiratory distress were also present. Intraoral examination revealed a tongue curtain across the oral cavity formed by the stretched anterior two-third of the tongue having its tip fused with palate. Moreover, lateral sides of the tongue were also seen approximating with pharyngeal pillars on both sides. This tongue curtain was obstructing nipple or teat passage into the neonate's oral cavity as well as blocking the natural oral communication with the alimentary canal. This developmental anomaly was of grievous nature and needed immediate surgical correction. In this particular case the thick fibrous band causing tongue-palate fusion was snipped with sterile scissors under general anesthesia. It involved minimal bleeding and was simple and risk-free procedure. Recovery was uneventful. Normal feeding activity was established immediately after band snipping and tongue-release

Unresolving submandibular swelling following enucleation of dermoid cyst in mouth floor

A young patient, who had enucleation of dermoid cyst in the floor of mouth more than seven years ago, developed postoperative complications like persistent bulging out of submandibular region on right side, increase in size of swelling and discomfort during meal and intermittent swelling and pain in throat. He was completely eased after removal of Surgical gauze tightly packed and left erroneously in the submandibular space during surgical procedure in the past. A 32 years old male with beard presented with persistent swelling at the angle of mandible on right side with throat pain, dysphagia, saltish taste and foul smell in mouth. In the past, he was operated through an extra-oral approach by a transverse incision in the submental region for dermoid cyst. Patient developed a huge neck swelling just after surgery which was considered a postoperative hematoma. On 13th postoperative day, stitches were removed and on squeezing the swollen area, pus was drained out through infected wound. Patient was discharged and advised follow-up. Patient repeatedly consulted the operating surgeon as well as other doctors for unresolved persistent postoperative swelling but could not get permanent relief except that the change of medicines sometimes helped to reduce the pain. On extra-oral examination, enlarged right submandibular salivary gland was palpable, while right side of floor of the mouth was found elevated and edematous on intra-oral examination. Bimanual palpation of the floor of the mouth or affected side did not feel as soft as the other side. External approach by upward pushing of the floor of the mouth on affected side, yielded a whitish creamy material of slightly thick consistency discharge through sinus located in the retromolar region. Dental probe was inserted through the sinus opening to evaluate the depth and nature of the sinus tract. It was felt that the probe stucked up in a mass which caused hindrance in its free movement inside the sinus. When probe was pulled back a soft smooth whitish mass, caught by the probe tip, came out smoothly through the sinus. This whitish mass was 'surgical gauze' which was then completely removed and the patient got great relief. Enlargement of submandibular gland and other symptoms also subsided within two weeks