Safety of endoscopic retrograde cholangiopancreatography (ERCP) in cirrhosis compared to non-cirrhosis and effect of Child-Pugh score on post-ERCP complications: a systematic review and meta-analysis

Background/Aims@#The safety of endoscopic retrograde cholangiopancreatography (ERCP) in hepatic cirrhosis and the impact of Child-Pugh class on post-ERCP complications need to be better studied. We investigated the post-ERCP complication rates in patients with cirrhosis compared with those without cirrhosis. @*Methods@#We conducted a literature search of relevant databases to identify studies that reported post-ERCP complications in patients with hepatic cirrhosis. @*Results@#Twenty-four studies comprising 28,201 patients were included. The pooled incidence of post-ERCP complications in cirrhosis was 15.5% (95% confidence interval [CI], 11.8%–19.2%; I2=96.2%), with an individual pooled incidence of pancreatitis 5.1% (95% CI, 3.1%–7.2%; I2=91.5%), bleeding 3.6% (95% CI, 2.8%–4.5%; I2=67.5%), cholangitis 2.9% (95% CI, 1.9%–3.8%; I2=83.4%), and perforation 0.3% (95% CI, 0.1%–0.5%; I2=3.7%). Patients with cirrhosis had a greater risk of post-ERCP complications (risk ratio [RR], 1.41; 95% CI, 1.16–1.71; I2=56.3%). The risk of individual odds of adverse events between cirrhosis and non-cirrhosis was as follows: pancreatitis (RR, 1.25; 95% CI, 1.06–1.48; I2=24.8%), bleeding (RR, 1.94; 95% CI, 1.59–2.37; I2=0%), cholangitis (RR, 1.15; 95% CI, 0.77–1.70; I2=12%), and perforation (RR, 1.20; 95% CI, 0.59–2.43; I2=0%). @*Conclusions@#Cirrhosis is associated with an increased risk of post-ERCP pancreatitis, bleeding, and cholangitis.

Multienzyme and Antibacterial Potential of Bacteria Isolated from gut of Asian Honey Bee (Apis cerana Indica), Lahore Using Culture Dependent Method

Abstract The bacteria residing in the gut of honey bees (HB) has demonstrated a significant role in protecting bees against various pathogens, production of honey and wax. However, no information exists about the antibacterial potential of bacterial isolates from gut of Asian HB, Apis cerana Indica F. (Hymenoptera: Apidae), against human pathogens. This study aims to investigate the antibacterial and multienzyme potential of aerobic bacteria from A. cerana gut using culture dependent approach. A total of 12 HB gut bacteria were characterized morphologically and biochemically. These strains were further screened for their antimicrobial activity against pathogenic human microorganisms Escherichia coli, Pseudomonas aeruginosa, Klebsiella pneumonia, Bacillus licheniformis and Bacillus subtilis using cross streak (primary screening) and agar well diffusion methods (secondary screening). Preliminary characterization of cell-free supernatant (CFS) of two promising isolates was performed by measuring lactic acid concentrations, enzymatic digestion of antimicrobial compounds, stability over a range of temperature, pH and amplification of spaS (subtilin) and spoA (subtilosin) genes. In primary screening, among 12 HB isolates, eight strains showed statistically significant highest zones of inhibition (p≤0.05) against E. coli, K. pneumoniae and P. aeruginosa. 16S rRNA sequencing revealed that these isolates belong to Bacillus genus, identified as B. tequilensis, B. pumilus, B. xiamenensis, B. subtilis, B. amyloliquefaciens, B. safensis, B. licheniformis, B. altitudinis (Accession numbers: MT186230-MT186237). Secondary screening revealed that among eight isolates, B. subtilis and B. amyloliquefaciens showed statistically significantly strong inhibition (p≤0.05) against all tested pathogens. Antibiotic susceptibility testing revealed that both isolates were resistant to antibiotics and possesses proteolytic, lipolytic and cellulolytic activities. The nature of the compound causing inhibitory activity was found to be proteinaceous and showed stability over a wide range of temperature as well as pH. PCR study confirmed the presence of bacteriocins by successful amplification of important antimicrobial peptide biosynthesis genes spaS and spoA. These results suggest that the HB gut is a home to bacteria that possess antimicrobial activity and important enzymes with antimicrobial potential. To our knowledge, this is the first report demonstrating the antimicrobial potential of bacteria isolated from gut of HB (A. cerana) against human pathogens.

Surgical outcome of pancreaticoduodenectomy in pancreatic and periampullary neoplasms

Objective: To report the results in the surgical treatment of pancreatic and periampullary neoplasms with emphasis on surgical technique, short-term postoperative outcome and the lessons learnt

Study Design: Case series

Place and Duration of Study: This study was carried out at Shaukat Khanum Memorial Cancer Hospital and Research Center, Lahore, from October 2014 to May 2016

Methodology: Patients undergoing surgical treatment of pancreatic and periampullary neoplasms were selected. Patients' characteristics including demographics, surgical technique, and 30-day morbidity and mortality were recorded. International Study Group of Pancreatic Fistula [ISGPF] classification was used to define postoperative pancreatic fistula and Clavien-Dindo classification to grade complications

Results: A total number of 65 patients underwent the trial of dissection; 50 had pancreaticoduodenectomy and 15 patients underwent palliative bypass and were excluded from analysis. Sixty-four percent were males and 36% were females. The most common tumor was periampullary [n=29, 58%] followed by pancreatic head [14, 28%] and duodenal tumors [n=07, 14%]. Mean age was 52.92 +/- 13.27 years; mean operating time was 470 +/- 358.28 minutes and median blood loss was 400 [287-500] ml. Pancreaticogastrostomy [PG] was the preferred reconstruction technique in 37 [74%] verses pancreaticojejunostomy [PJ] in 13 [26%] patients. Four [08%] patients needed portal vein reconstruction and two [04%] replaced right hepatic artery resection and reconstruction due to tumor involvement. There were seven Grade A, and one Grade B and C pancreatic fistulae each. Three patients [06%] needed endoscopic therapy for gastrointestinal hemorrhage from pancreatic stump. There was one death in postoperative period

Conclusion: Pancreaticoduodenectomy is a safe procedure with excellent postoperative outcome, if carried out in a specialized hepato-pancreato-biliary unit. A PG reconstruction can be a safer alternative to PJ

Assessment of availability of essential human resource for health for EmONC services in public sector of Pakistan

Objective: To assess availability and establish the current situation of essential human resource shortage for provision of emergency obstetric and new born care in public sector health facilities

Study Design: Observational / descriptive / cross sectional study

Place and Duration of Study: This study was conducted at the Department of Public Health, Contech School of Public Health, Lahore from January 2013 to December 2013

Materials and Methods: A robust surveys were conducted by stratified sampling technique by taking 100% samples. 20% sample of basic health units was taken to assess the availability of essential human resource for health to meet the progress of Millennium Development Goal 4 and 5

Results: Situation of availability of essential human resources at district and tehsil level for provision of maternal and newborn health services was found only 33% at district head quarter hospitals and 3% at tehsil headquarter hospitals. This is an escorting cause of not reducing maternal and child mortality as per target

Conclusion: Study results suggest accelerated provision of essential human resource for health to provide emergency obstetric and new born care to reducematernal and neonatal mortality in the country

Comparison of morbidity in rubber band ligation and milligan morgan hemorrhoidectomy

Background: Hemorrhoidectomy treatment has multiple options, depending on grade of disease

Objective: This study was conducted to compare the postoperative morbidity of rubber band ligation [RBL] and milligan morgan haemorrhoidectomy in terms of frequency of pain and bleeding in patients with third degree hemorrhoids

Material and Methods: This study was conducted in Department of Surgery, District Headquarter Hospital Faisalabad, affiliated with Punjab Medical College from 25[th] January, 2012 to 24[th] January, 2014. This study included 140 [70 in each group] patients of grade 3 hemorrhoids. Patients were randomly allocated into either the rubber band ligation [RBL] group or milligan morgan haemorrhoidectomy groups by using computer generated random number tables. Both groups were observed for the impact of these treatment modalities on post operative pain and bleeding

Results: In group A, 49 patients [70%] and in group B, 47 patients [67.2%] were male. Regarding postoperative pain, 2 patients [2.9%] of group A and 22 patients [31.4%] developed mild postoperative pain [p<0.001], 1 patient [1.4%] of group A and 31 patients [44.3%] of group B faced moderate postoperative pain [p<0.001], 1 patient [1.4%] of group A and 11 patients [15.7%] has severe postoperative pain [p=0.002]. In group A, 2 patients [2.9%] and in group B, 10 patients [14.3%] has mild postoperative bleeding, 1 patient [1.4%] in group A and 8 patients [11.4%] in group B developed severe postoperative bleeding

Conclusion: RBL is a reliable and safe procedure with minimum complications and morbidity after the procedure

Compliance of anti-smoking regulations by cigarette industry in Pakistan

Background: The hazards of cigarette smoking and its increasing consumption are well known despite the ongoing tussle between the tobacco industry and global governments. To curb the menace of smoking, anti-smoking laws have been enforced from time to time by various governments. In 2003, Ministry of Health [MoH] Government of Pakistan has imposed certain regulations on cigarette manufacturing industry. The aim of this study was to highlight the compliance of the industry with these regulations. Methods: A cross-sectional study of major cigarette selling shops was conducted in Abbottabad. It was aimed at determining the availability of total cigarette brands and their compliance with the regulations and also to find out attributes of cigarette customers. Results: A total of 39 varieties of 18 cigarette brands are available in Abbottabad city, out of which 71.8% are imported varieties. A total of 38.4% varieties have displayed health warnings [28.2% pictorial health warning, 10.2% have written health warning. Majority of cigarette customers ar between 20–40 years of age, while 5.6% customers include youngsters between 10–20 years of age. Female customers, accounting for 8% of total cigarette customers, buy only those brands which have not displayed the health warning. Conclusions: Observed compliance with governmental regulation for displaying health warning is 39% which is far less than desired. Sale of cigarette to children is also practiced. Ministry of Health [MoH] should assure the display of these warnings on all the brands so that smokers must be fully aware about the risk involved in smoking Keywords: Cigarette smoking; anti-smoking regulations; protection of non-smoker health

Lindane toxicity in a 7 year old boy

Lindane [gamma-benzene hexachloride] is widely used as a scabicide by general practitioners and dermatologists in Pakistan. We present a case of a 7 year old boy who had suffered from scabies 1 week ago, for which he was prescribed lindane along with other medications by a general practitioner. After 3 application of lindane the child began to experience Grand mal seizures, ataxia, weakness, incoordination and severe burning paresthesias. Lindane is known to cause neurotoxicity and for this it has been recommended as a 2nd line treatment for scabies by FDA

Pattern of joints involvement in Kashin-Beck disease: a local osteochondropathy in China

Kashin-Beck Disease [KBD] is an endemic osteochondropathy. The disease starts in childhood and attacks the growth of joint cartilage, the joints become deformed and painful, and the worst forms result in dwarfism. The most frequent joints involved are the finger, wrist, ankles, knees and elbows. In this study the pattern of joints involved in KBD was studied. A total of 368 patients aged above 13 from 6 villages in endemic areas of the Shaanxi province, located in the northwest of China, were selected through multistage stratified sampling. The patients were diagnosed based on the clinical criteria for diagnosis of KBD. The patients were administered with a battery of questionnaires along with clinical examination for joint involvement. The patients presented both as oligoarticular as well as polyarticular pattern. Smaller joints were more frequently involved with a proximal-distal pattern. The number of joints involved increased with the severity of the disease. Proximal smaller joints are more frequently involved in the disease. The involvement of bigger joints takes place in later stages of disease, i.e., in the second and third degree. The pattern of joint involvement shows some correlation with Rheumatoid Arthritis which needs further investigation and comparative studies

Laparoscopic cholecystectomy; outcome in patients with co-morbidity

To determine the frequency of bleeding, surgical site infection and common bile duct injury after laparoscopic Cholecystectomy in patients with co-morbidity. Descriptive Study. [Case series]. Department of Allied and D.H.Q hospital Faisalabad. July 2006 to December 2007. It comprised of 30 consecutive patients of cholelithiasis with co-morbidity presenting in surgical department. Patients having uncontrolled hypertension, chronic obstructive airway disease and malignancy were excluded. Detailed history and physical examination was carried out as per protocol. It was followed up by relevant investigations. All the cases underwent laparoscopic cholecstectomy. The age of the patients ranged from 23-68 y, with mean age of 40-56 y. Among these 14 cases were having D.M [46.66%], 06 patients were cirrhotic [20%], 06 patients had acute cholecystitis [20%], 02 patients were having H.T.N [6.6%] and 02 patients were > 70 years [6.6%]. All the patients were females. Out of diabetic patients undergoing laparoscopic cholecystectomy, SSI was noted in 02 [6.66%] patients. While mild postoperative bleeding was noted in 01 [16.6%] of cirrhotic patients after laparoscopic cholecystectomy.No untoward event was noted in patients with H.T.N ac, Cholecystitis and advanced age. In high risk patients undergoing laparoscopic cholecystectomy, very few complications were noted. Postoperatively, Morbidity following above procedure was quite low as compared to conventional one. Laparoscopic cholecystectomy should be the preferred option in high risk patients for better outcome

Endoscopic removal of bullet from orbital apex

Penetrating injuries of face are not uncommon. Bullets or pallets may be lodged anywhere in the cavities of skull as a result of firearm injury. Lodgment of a bullet within the orbit through nose is uncommon. An eighteen 18 years old married woman sustained a bullet injury, which entered through lateral wall of the nose and lodged at left orbital apex area. The bullet was removed endoscopically via left nostril without any damage to the eye or disturbance in vision

Parasite density and the spectrum of clinical illness in falciparum malaria

To determine the impact of percentage parasitemia and clinical features on morbidity and mortality in patients with P. falciparum malaria. Case series. Department of Medicine, Medical Unit II, Jinnah Postgraduate Medical Centre, Karachi, Pakistan from May to November 2005. Seventy-six adult patients of smear positive P. falciparum malaria were selected for the study. Parasite density was estimated on thin blood film and expressed as percentage of red blood cells parasitized. Patients were divided into three groups on the basis of parasite density. The data was analyzed on SPSS version 12. Results were expressed as percentages, mean and standard deviations. P-value <0.05 was taken as significant. Data of 76 study patients who fulfilled the inclusion criteria was analyzed on the basis of parasite density. Thirty-one [40.79%] patients had parasite density < 5%, 22 [28.95%] had parasite densities between 5% and 10% and 23[30.26%] patients had parasite density >10%. Comparative analysis of the groups showed that pallor, impaired consciousness, jaundice or malarial hepatitis, thrombocytopenia, acute renal failure, DIC, and mortality were all strongly associated with the density of Plasmodium falciparum malaria [p=0.001]. Parasite density was not related to age, gender and hepatosplenomegaly. High parasite density was associated with severe clinical illness, complications and mortality. Parasite counts of > 5% may be considered as hyperparasitaemia in this population of the world

Foley's catheter in management of subglottic and tracheal injuries

In patients of Sub glottis and tracheal stenosis adequate lumen is achieved by endoscopic diathermization or open surgical techniques. However it is difficult to maintain patency of the created lumen due to formation of granulation and fibrous tissues. Many prosthetic devices like Laryngeal stents, Montgomery T tubes are available which are inserted and fixed after attaining an adequate lumen during a surgical procedure. Purpose of this study was to design a cheap and easily available prosthetic device for such patients. It is a descriptive case series study of ten cases. A specially tailored stent of silicone lined Foley's catheter, which is freely available and economically priced was used for Subglottic and Tracheal stenosis. Good air way was achieved after one year with no decanulation difficulty in 9 cases [90%] with an unsatisfactory result [10%]. After removing the folly's catheter Tracheostomy tube was corked for one month to observe the patency of newly formed airway in the Subglottic and upper tracheal region. When no difficulty in air way was observed it was finally taken out and the Tracheostomy was allowed to close by itself. Silicone lined specially tailored stent of Foley's catheter is a good cheap alternate addition in prosthetic devices for restoration lumen in Subglottic and Tracheal stenosis

assessment study of maternal mortality ratio databank in five districts of North Western Frontier Province Pakistan

Maternal mortality ratio is an indicator to measure the summary of information about mother and child health. It is estimated that about 500 maternal deaths occur per 100,000 live births each year in Pakistan. It is a well known fact that all health statistics coming out of the developing countries are calculated "guesstimates" some are perhaps more close to the real figures than the others. There is a dire need to help generate information that can be used by health professionals, health care planners and managers to save women's lives by improving the quality of care provided to turn away maternal mortality. The maternal mortality ratio for Pakistan as well as for NWFP is projected as 533 /100,000 live births for the year 1990-91 produced by National Institute of Population Studies, Pakistan. This was a retrospective cross-sectional quantitative study for the period [2001-2002] conducted in five districts of [NWFP] North Western Frontier Province, Pakistan. National HMIS data opened the maternal mortality ratio for; Haripur as 0.168 and 0.173, Mansehra 00 and 00, Battagram 00 and 00, Swat 0.051 and 0.524 and Swabi 00 and 0.968 per/1000 live births, respectively. The small part exercise outcome [the study] endorsed more shadowy side of the actual maternal mortality ratio for the same period in the same districts. In our country there is a urgent need to institute an efficient mode of operation to get accurate maternal mortality database. Verbal Autopsy method is cost effective and feasible approach for implementation in a country like Pakistan

Role of toluidine blue in early detection of oral cancer

Oral cancer is one of the ten most common cancers in the world with marked geographic incidences in occurrence. The range of frequency of this dreadful cancer varies form negligible in Japan to 45% in Sir Lanka, Nepal, India and Pakistan when compared with the over all incidence of all bodily cancers. In Pakistan oral cancer constitute 10% of all malignant tumors standing second to bronchogenic carcinoma in males and breast carcinoma in females. The more early it is diagnosed the better is the prognosis. This prospective study was planned to use Toluidine Blue as a diagnostic material for early diagnosis of oral cancer. Patients with oral lesions having no clinical evidence of oral cancer, but presenting as non-healing oral ulcers more than 6 months or raised margins were selected. They belonged to both sexes and all age groups. Toluidine Blue [ORA SCAN] was used to stain the lesion and biopsy was taken from stained area, 30 patients which in some cases was more than one place. These patients were randomly selected. Histopathology revealed squamous cell carcinoma in twelve patients and dysplasea in five patients. Tuluidine Blue can be used as early diagnostic aid in cancer of oral mucosa

Doctors perception about staying in or leaving rural health facilities in district Abbottabad

An imbalance exists between offered medical services and needed health care for the people in rural areas of Pakistan. Many studies have found non-availability, of health care providers as major contributors to the poor health indicators of the rural areas. Methods and An endeavor to attend the issue has been made through a cross-sectional survey of the Medical Officers working in the different health facilities of District Abbottabad. The study found that the doctors are neither trained to work in rural setups nor they are given proper facilities and service structure to work there. They perceive to face disadvantages affecting their social, professional and family life, if they join in rural areas. Recommendations: This study recommends strengthening of Community Oriented Medical Education for motivating doctors towards participation in rural health services. Doctors working in rural health facilities might be given financial and professional incentives and a conducive environment to retain them

Control of burkholderia [pseudomonas] bacteraemia in the intensive care and paediatric units

Investigation and control of nosocomial bacteraemia caused by Burkholderia [Pseudomonas] cepacia in the Intensive Care and Paediatric Units of a general care hospital. Design: A cross-sectional analytical study. Place and Duration of Study: Departments of Pathology, Intensive Care and Paediatrics, Kahota Research Laboratory Hospital, Islamabad from January 1998 to June 2002. Subjects and Blood cultures from patients admitted to Intensive Care Unit and Paediatric Ward were inoculated into brain heart infusion broth and incubated for upto 10 days. Any Gram-negative rods isolated were characterized by API-20E. Environmental samples were inoculated on blood and MacConkey's agars and isolates, if any, were identified as above. Intensive intervention in the form of hand washing, strict adherence to aseptic practices and standard sterilization techniques were adopted and then cultures were again carried out with similar methodology. Cultures yielded 58 strains of Burkholderia cepacia, 52 from blood cultures and 6 from hospital environment, including 1 from the washbasin of the ICU. Thirty- four of these were isolated before intervention measures were adopted, mainly during 1998. Findings suggested a strong probability of nosocomial transmission, with washbasin as the common source. After a lapse of about a year, B. cepacia infection re-emerged in a sporadic form but remaining confined to paediatric unit. Only 18 isolates were yielded over the next two and-a-half years. The intervention measures for Burkholderia bacteraemia within the hospital, proved effective in stopping the nosocomial transmission leading to disappearance of B. cepacia from blood cultures. We emphasize the crucial role of hand hygienic practices in the hospital setting, especially in critical care units