Clinical efficacy of ceftriaxone versus ciprofloxacin in paediatric enteric fever

Objective: Determination of the clinical effectiveness of ciprofloxacin versus ceftriaxone in children with enteric fever on the basis of defervescence within 72 hours of commencement of treatment

Duration and Place of Study: This randomized controlled trial was carried out from 15th May to 15th November 2017 in pediatrics units of Benazir Bhutto Shaheed Teaching Hospital Abbottabad and Jinnah International Hospital Abbottabad

Methodology: 90 children with uncomplicated enteric fever were admitted and divided randomly into two groups, Group A was administered I/V Ceftriaxone 75mg/kg OD and Group B was given I/V Ciprofloxacin 10mg/kg BD for seven days. Response to drug was taken as defervescence within 72 hours while continued fever after 72 hours was taken as no response. The data was analyzed by using SPSS Version 21.00

Results: In our research study 53[58.9%] children were male and 37[41.1%] patients were female. The mean age was 8.43+/-3.17 years encompassing 4 to 14 years, mean weight of the patients in kg was 29.54+/-10.8 kg. Efficacy of ceftriaxone group was 93.3% while in ciprofloxacin group 62.2% patients became afebrile in 72 hours. The proportion of achieving defervescence within 72 hours was higher with ceftriaxone than with ciprofloxacin

Conclusion: Ceftriaxone is more efficacious in terms of achieving defervescence than ciprofloxacin in children having enteric fever

Visual outcome after pars plana vitrectomy in diabetic vitreous hemorrhage

Objectives: To determine visual outcome and frequency of complications after pars plana vitrectomy in diabetic vitreous hemorrhage

Methodology: This was interventional case series conducted at department of ophthalmology, Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar from January 2013 to June 2014. Known diabetic patients above 16 years of age, having vitreous hemorrhage were included. Standard three ports pars plana vitrectomy [PPV] with membrane peeling, endolaser and without endotamponade by single study surgeon was done in all patients. Best corrected visual acuity was noted pre operatively and on 1st day, 2nd week and 8th week post operatively. P- value <0.05 was considered statistically significant. Post-operative complications and visual improvement were noted at final visit

Results: Total of 50 patients having diabetic vitreous hemorrhage were included in the study. Mean age was 41.4 years. Male patients were 66%. Clear lens was present in 46% patients and cortical lens vacuoles in 36% patients. Fresh vitreous hemorrhage was present in 80%. Baseline and final post-operative best corrected visual acuity logarithm minimal angle of resolution was 1.01 +/- 0.17 and 0.74+/- 0.25 respectively. The difference in pre and post-operative best corrected visual acuity logarithm minimal angle of resolution was 0.045 which was statistically significant. There were no post-operative complications in 82% patients. Visual improvement was observed in 82%

Conclusion: Most patients with diabetic vitreous hemorrhage regain or retain useful vision after PPV. Many patients may suffer late complications like recurrent vitreous hemorrhage and retinal detachment after successful initial surgery requiring secondary intervention

Measles hectic in Pakistan; upsurge versus the lurking vaccination

Measles has claimed more lives than anticipated, as the outbreaks hit Pakistan severely in 2013 as compared to 2012. Claiming 350 lives through the year 2013, Measles became a headache for the health agencies, authorities and common people. The sudden appearance of the virus in different parts of the country both rural and urban at the same time can be linked to more than one cause. The notable being corruption in health system, poor health infrastructure, destabilized routine immunization, shortage in number of vaccinators, negligence among parents, and floods. As a consequence of these causative factors, the unclear picture of immunization coverage can be presumed as the ultimate etiology of outbreaks in such numbers. Therefore, there is an urgent needto draw out the actual data of immunisation coverage and focus on elimination of hurdles in the road to success in fully coverage with vaccines

Another dimension of pain

Pain is usually regarded as of two types, pain caused by tissue damage, also called nociceptive pain, and pain caused by nerve damage, also called neuropathic pain. A less known third category is psychogenic pain, which becomes an integral part, in due course of time, of the first two types. It is pain that is affected by psychological factors. Pain physicians tens to focus usually on the first, less commonly on the second and very rarely on the last type of pain. This ignorance may be the prime factor in failure of otherwise more rational pain management regimen. It needs to be adequately addressed, and expert help from qualified psychologist and /or a psychiatrist may be required in selected patients to incorporate body-mind techniques in the pain management. Key words: Pain; Nociceptive pain; Pain management; Imagery [Psychotherapy]; Relaxation Therapy

Correlation of hyponatremia with hepatic encephalopathy and severity of liver disease

To assess the frequency of low serum sodium levels and to correlate it with the severity of liver disease and hepatic encephalopathy [HE] in patients coming to the tertiary care hospital. Observational study. Shifa International Hospital, Islamabad, from January 2011 to January 2012. A total of 202 patients with hepatic encephalopathy and chronic liver disease had serum sodium measured. The HE was graded according to the West Haven classification [4 grades]. Relationship of hyponatremia was correlated with severity grade of encephalopathy using Spearman rank correlation test. Out of 202 patients, 62 [30.7%] patients had serum sodium less than 130 meq/l. Out of 202, HE was present in 69 [34.15%] patients and out of these, 38 had grade III-IV HE and 31 had grade I - II HE. Out of 69 patients with HE 57 had sodium less than 135 [p < 0.001]. Hyponatremia was a common feature in patients with cirrhosis and its severity increased with the severity of liver disease. The existence of serum sodium concentration < 135 mmol/L was associated with greater frequency of hepatic encephalopathy compared with patients with serum sodium concentration > 135 mmol/L

Hepatocellular carcinoma after sustained viral response of interferon and ribavirin therapy in cirrhosis secondary to chronic hepatitis C

To determine the frequency of development of hepatocellular carcinoma in patients with chronic liver diseases secondary to hepatitis C who had achieved sustained virological response with Interferon and Ribavirin therapy. Retrospective descriptive study. Shifa International Hospital, Islamabad, Pakistan, from January 2007 to January 2012. Hepatitis C related chronic liver disease patients who were treated with interferon and ribavirin, after they achieved sustained virological response, they were followed for a mean of 42 +/- 17 months. During this time, development of hepatocellular carcinoma was ascertained. All underwent surveillance with alpha-feto-protein and ultrasonography every 6 months. Out of the 58 patients who had achieved sustained virological response, 3 developed hepatocellular carcinoma after a mean follow-up of 38 +/- 14 months. It was multifocal in 2 cases and was single lesion in the 3rd. Two patients ultimately died, one with upper GI bleeding and the other with hepatic encephalopathy, while 3rd patient with single lesion is still surviving. Three out of 58 patients of hepatitis C related chronic liver disease developed hepatocellular carcinoma during follow-up in patients who had achieved sustained virological response. These patients need closer follow-up, for development of complications, even if they have achieved sustained viral response

Factors affecting patient satisfaction during endoscopic procedures

To assess the quality and patient satisfaction in Endoscopy Unit of Shifa International Hospital. Cross-sectional survey. Division of Gastroenterology, Shifa International Hospital, Islamabad, Pakistan, from July 2011 to January 2012. Quality and patient satisfaction after the endoscopic procedure was assessed using a modified GHAA-9 questionnaire. Data was analyzed using SPSS version 16. A total of 1028 patients were included with a mean age of 45 +/- 14.21 years. Out of all the procedures, 670 [65.17%] were gastroscopies, 181 [17.60%] were flexible sigmoidoscopies and 177 [17.21%] were colonoscopies. The maximum unsatisfactory responses were on the waiting time before the procedure [13.13%], followed by unsatisfactory explanation of the procedure and answers to questions [7.58%]. Overall, unsatisfied impression was 4.86%. The problem rate was 6.22%.The quality of procedures and level of satisfaction of patients undergoing a gastroscopy or colonoscopy was generally good. The factors that influence the satisfaction of these patients are related to communication between doctor and patient, doctor's manner and waiting time for the procedure. Feedback information in an endoscopy unit may be useful in improving standards, including the performance of endoscopists.

Treatment of decompensated cirrhosis secondary to hepatitis c with antiviral therapy

To treat decompensated hepatitis C patient with interferon, ribavirin and amantidine to ascertain the sustained viral response. Descriptive study. Shifa International Hospital, Islamabad, from January 2007 to January 2012. HCV PCR patients with decompensated hepatitis C, who had developed a complication like ascites, encephalopathy or variceal bleeding were included in the study. Those with uncontrolled ascites or other complications were excluded. Treatment with standard interferon 3 miU subcutaneously three times a week along with ribavirin 800 mg to 1200 mg and amantidine 100 mg b.i.d. was administered for 12 months. Patients were followed every month with CBC and ALT and HCV PCR was performed after 3 months to document early viral response. They had HCV PCR at the end of the treatment to document end of treatment response. All were further followed for another 6 months at monthly intervals and HCV PCR was performed at the end of this period to document sustained viral response. In all, 165 patients were treated. Treatment had to be discontinued in 42 [26%] patients. Out of these, 16 patients died. Thus, 123 completed treatment. Sustained viral response was documented in 58 out of the 123 [47%] patients. Hepatic encephalopathy, gastrointestinal bleeding, sepsis and development of ascites were the major complications during treatment. Forty seven percent of patients with decompensated hepatitis C cirrhosis were able to achieve sustained viral response after one year treatment with anti-viral therapy. However, complications developed during treatment and, therefore, frequent and close monitoring is necessary in these patients.

Acute liver failure: an update

Acute liver failure is a serious medical emergency resulting from various insults that liver sustains. In our setting, viral etiology is the commonest cause. The syndrome results in significant liver damage leading to hepatic encephalopathy, coagulopathy and several other serious clinical consequences. Sepsis, cardio vascular failure and renal failure can result in multi system organ failure and fatal consequences. Management requires identification of etiologic agent as soon as possible. Nursing care in intensive care unit [ICU] setting is recommended. Attention towards correction of electrolyte imbalance, coagulopathy, encephalopathy and systemic complication along with judicious use of antibiotics help in obtaining a favorable outcome. Transplant remains the ultimate management

Visual results following intravitreal bevacizumab in neovascular age-related macular degeneration

To determine the visual and anatomic outcome of intravitreal Bevacizumab injection in the treatment of neovascular age-related macular degeneration [AMD]. Quasi-experimental study. Layton Rahmatulla Benevolent Trust Eye Hospital [LRBT], Lahore, from January to July 2010. Patients who received, one or more intravitreal Bevacizumab injections [1.25 mg per 0.05 ml] for exudative AMD were included in the study. Outcome measures included standardized visual acuity, optical coherence tomography [OCT], macular thickness, intraocular pressure, and blood pressure at 24 or more weeks follow-up. Descriptive statistics were obtained. Fifty eyes with exudative AMD were observed for six months. The mean VA improved from 0.21 +/- 0.11 before injections to 0.43 +/- 0.11 after injections at six months. Overall, mean OCT macular thickness decreased by 99 micron at last follow-up. At last follow-up, all eyes received an average of 3.28 +/- 0.85 injections. There was no incidence of severe vision loss or adverse effects like endophthalmitis or retinal detachment. Intravitreal Bevacizumab has the potential for improvement of vision in exudative AMD for at least 6 months

Causes of visual impairment in children with low vision

To determine the main causes of visual impairment in children with low vision. To assess the need of spectacles and low vision devices [LVDs] in children and to evaluate visual outcome after using their LVDs for far and near distance. Observational study. Khyber Institute of Ophthalmic Medical Sciences, Peshawar, Pakistan, from June 2006 to December 2007. The clinical record of 270 children with low vision age 4-16 years attending the Low Vision Clinic were included. All those children, aged 4-16 years, who had corrected visual acuity [VA] less than 6/18 in the better eye after medical or surgical treatment, were included in the study. WHO low vision criteria were used to classify into visually impaired, severe visually impaired and blind. Results were described as percentage frequencies. One hundred and eighty nine [70%] were males and 81 [30%] were females. The male to female ratio was 2.3:1. The main causes of visual impairment included nystagmus [15%], Stargardt's disease [14%], maculopathies [13%], myopic macular degeneration [11%] and oculocutaneous albinism [7%]. The percentages of visually impaired, severe visually impaired and blind were 33.8%, 27.2% and 39.0% respectively. Spectacles were prescribed to 146 patients and telescopes were prescribed to 75 patients. Spectacles and telescope both were prescribed to 179 patients while Ocutech telescope was prescribed to 4 patients. Retinal diseases nystagmus and macular conditions were mainly responsible for low vision in children. Visually impaired children especially with hereditary /congenital ocular anomalies benefit from refraction and low vision services which facilitate vision enhancement and inclusive education

Treatment of oroantral fistula - a study

The aim of this study was to evaluate and analyze the occurrence, characteristics and treatment outcome of oroantral fistula in 29 patients from Sept 2004 to Nov 2009. These patients were examined both clinically and radio-logically for oroantral fistula. Data regarding the age, gender, cause and site of fistula and treatment outcome was evaluated and reviewed. The age range was 18-60 years with high frequency occurring in 31-40 years. Male outnumbered female. The common cause of OAF was extraction of teeth [n=25, 86.5%] followed by cysts [n=2, 6.7%]. The most common involved tooth in the causation of OAF was upper first molar [n=13, 52%]. Surgical technique used to close the fistula was buccal advancement flap. Recurrence of fistula occurred in 2 patients [6.7%] and were re-operated using the palatal flap. The merits and demerits of the procedure are discussed

Impacted mandibular third molars: pattern of presentation and postoperative complications

The purpose of this prospective study was to evaluate the occurrence, characteristics and postoperative complications of impacted mandibular third molars in 260 patients from Oct 2008 to July 2010. Clinical and radiographic examinations were carried out. Data regarding the age, gender, angulations type, depth and width of impactions and postoperative complications were evaluated and analyzed. The age ranged from 17 to 59 years with high frequency occurring in 3rd decade. The common cause for extraction was pericoronitis. Mesioangular impaction was most common [n=124, 48%] followed by vertical [n=90, 34%]. Majority of the patients presented with Class IIA [n=84, 32.3%] followed by IA [n=61, 23.5%]. Postoperative complications included persistent pain and swelling [16.5%] followed by dry socket [4.2%] and trismus [4.2%]. There was a greater risk of developing complications in horizontal and distoangular types, and in Class IIIC and IIIA impactions

Odontogenic keratocysts: a clinical and radiographic study

This descriptive study was carried out, at Khyber College of Dentistry, Peshawar from Sept 2005 to Jan 2007, on 40 patients having histopathologically confirmed odontogenic keratocysts.. Maximum patients [62.5%] presented in the 2nd and 3rd decades. 21 were male while 19 were female. Seventy five percent cases occurred in the mandible, with the posterior region involved in maximum number of cases in both the jaws. Facial asymmetry, pain and cheesy aspirate were 75%, 50% and 82.5% respectively. Radiographic findings were well defined borders, multilocularity, impacted tooth and root resorption, in 45%, 55%, 50% and 7.5% of cases respectively. The objective of the study was to list the common modes of presentations of odontogenic keratocysts and educate the general dental practitioners about the aggressive nature of this lesion. As a prophylactic measure, routine dental check up will help a lot in the prevention and timely diagnosis of odontogenic keratocysts

Occurrence and characteristics of maxillofacial injuries - a study

This descriptive study was undertaken to evaluate and analyze the pattern of maxillofacial fractures in 340 patients reported to the Department of Oral and Maxillofacial Surgery, Khyber College of Dentistry, Peshawar from Oct 2005 to May 2007. These patients were examined both clinically and radiologically for maxillofacial fractures. Data regarding the age, gender, cause of fracture and site of fracture were evaluated and reviewed. The age range was 2-28 years [mean 25 +/- 16.4years] with high frequency occurring in 21-30 years age group. The male to female ratio was 3:1. The leading cause of maxillofacial fracture was road traffic accident [RTA [n=154; 45.2%]], followed by accidental fall [n=101; 29.7%] and firearm injury [FAI [n=49; 14.4%]]. It was noted that road traffic accident and fall caused most of the parasymphyseal [n=90] and condylar fractures [n=65] in mandible, while firearm injury and assault caused more body [n=18] and angle [n=20] fractures. Maxillary bone fractures [55.5%] were common followed by zygomatic bone [38.8%]. This study can guide us to formulate strategies and policies to prevent maxillofacial fractures

comparative analysis of rigid and non rigid fixation in mandibular fractures: a prospective study

The aim of this prospective study was to compare the postoperative outcome in 80 mandibular fractures patients, treated by open reduction and internal fixation [ORIF] and intermaxillary fixation [IMF] at Oral and Maxillofacial Surgery Unit, Khyber College of Dentistry, Peshawar from 10th February 2006 to 9th February 2007. The most common age group involved was 21-30 years and the common cause of fractures was road traffic accidents [38.75%], followed by fall [31.25%]. Most common site of fractures was parasymphysis [41.24%] followed by angle [25%]. Patients were divided in two treatment groups, having 40 patients in each group. Rigid internal fixation was assigned as group A and intermaxillary fixation as group B. Data regarding the study was evaluated and reviewed. Two patient groups were not significantly different in relation to postoperative normal occlusion [p=0.45], malocclusion [p=0.45], mAl union [p=0.45], delayed union [p=0.07], non union, infection [p=0.28] and sensory disturbances [p=0.07]. The result was significant in relation to mouth opening [p=0.0001]. This study will help us regarding the measures to be taken in prevention of postoperative complications

Anti vascular endothelial growth factor [bevacizumab] in central retinal vein occlusion: an interventional case series

Vascular endothelial growth factor plays major role in ocular angiogenesis and retinal edema production and is a step forward in the management of ocular neovascularization and retinal edematous pathologies. To determine the efficacy and safety of intra-vitreal Avastin [Bevacizumab] in cases having central retinal vein occlusion. A prospective interventional study. This study was done at Said Anwar Medical Centre, Dabgari Gardens, Peshawar from June, 2007 to September, 2009. All patients with central retinal occlusion occurring in the past 3 months and seen between the study period were included in the study. Diagnosis of central retinal vein occlusion was made clinically by slit lamp biomicroscopy with 78D examination Patients who had received any treatment for and eyes which already had developed Anterior Segment Neovascularization, Neovascularization elsewhere or Neovascularization on disc at presentation were excluded. Dose of 0.05 ml [1.25mg] of Avastin [Bevacizumab] was used as intra vitreal injection every month for 3 months in cases that presented within a month of occlusion and less injections were given in dose presenting later. Follow-up was done at 30th, 60[th], 90[th] and 120[th] day after the onset of disease. Visual outcome was defined as Snellen's or LogMar Best Corrected Visual Acuity at final follow up, of 120[th] day, compared to the visual acuity at presentation. Data were analyzed by SPSS version 17. Total of 17 eyes of 17 patients were included in this study. Eleven [64.7%] patients were males while 6 [35.3%] were females. Total of 40 intra-vitreal injections of Avastin were given to patients with a mean of 2.35 injections per eye. Good visual outcome was achieved in 10 [58.8%]] eyes, while 7[41.2%] had stable visual outcome. Mean initial Best Corrected Visual Acuity [LogMar] in all 17 eyes was 1.79 [SD +/- 0.87] which significantly improved to a mean of 1.18 [SD+0.77] at final follow up. Mean improvement in Best Corrected Visual Acuity [LogMar] after paired sample test in all patients at final follow up on day 120 was 0.61[SD+0.84]. Retinal hemorrhages and macular edema decreased clinically on examination on consecutive follow up visits. No eye developed neovascularization elsewhere, neovascularization on the disc, neovascularization, retinal tears, retinal.detachment, lens trauma, endophthalmitis or anterior chamber activity. Bevacizumab [Avastin] is an effective and safe treatment option for central retinal vein occlusion affected eyes and resulted in improvement in visual acuity. It reduced macular edema and prevented ocular neovascularization at least for short term

Complications of conventional sclera buckling occurring during and after treatment of rhegmatogenous retinal detachment

To identify and determine the frequency of the intra-operative and early postoperative compkicaitons of Cinventional Scieral Buckling [CSB] ans the primary surgical intervention in patients with Phegmatogenous Retinal Detachment [RRD]. A quasi-interventional study. Khyber Institute of Ophthalmic Medicl Sciences [KIOMS], Postgraduate Medical Institute [PGMI], Hayatabad Medical Complex [HMC], Peshawar, from April 2005 to June 2006. Fifty consecutive patients who underwent CSB and fulfilled the inclusion criteria, were included in the study. Operative details and any intra-operative complications were noted. The patients underwent another detailed clinical examination and pain assessment on the first postoperative day. All the patients were followed-up minimum for 3 months. Postoperative complications were identified and recorded. The data was analyzed on SPSS 120 for measures of central tendency and dispersion. There were 36 males and 14 female subjects. Mean age was 37.18 +/- 20.145 years. Encirclement [56%] was the most frequently used CSB technique, sixteen [32%] patients had at least one intra-operative complication. Intra-operative complications were iatrogenic sclera break [2%], accidental Sub Retinal Fluid [SRF] drainage [8%], choroidal haemorrhage [2%], subretinal haemorrhage [14%], retinal incarceration [2%], vitreous haemorrhage [6%], raised [4%] or very low [2%], intra-operative IOP and hyphema [2%]. Postoperative complications included systemic complications [24%], choroidal detachment [8%], vitreous haemorrahge [16%], raised IOP [22%], angle closure [2%] and explants exposure [6%]. Mean refractive change in spherical equivalent was -1.478 +/- 0.698 D. final re-attachment rate was [82%] and final BCVA of > 6/60 was achieved in 62% of the subjects in the treated eyes. CSB is a safe and effective option for treating uncomplicated RRD, but it is associated with certain complications. Sub-retinal bleed was the most common intra-operative complication. Raised IOP was most the common early postoperative complication followed by choroidal detachment

Outcome of rigid internal fixation of mandibular fractures: a prospective study

This prospective study was undertaken to analyze the postoperative outcome in 80 mandibular fracture patients treated by open reduction and internal fixation at Oral and Maxillofacial Surgery Unit, Khyber College of Dentistry, Peshawar from Jan 2006 to June 2007. Data regarding the pattern of fracture and postoperative outcome was evaluated and reviewed. The most common cause of fracture was road traffic accident and common site was parasymphysis. Sixty two patients [n=62; 77%] had successful uneventful postoperative outcome. Infection was the common complication [n=7; 8.7%] followed by malocclusion [n=5; 6.2%]