Audit of pediatric surgical emergency: need for self evaluation

Background: The clinical or surgical audit is a systematic process in which the standard of clinical care being provided to the patients is sought through review of clinical records against specific criteria. The clinical or surgical audit is a mandatory element of the professional competence in many countries

Objective: To evaluate the yearly performance and to establish the pattern and frequency of various Pediatric Surgical emergencies encountered

Methodology: This was an observational, descriptive study covering the year 2016 with retrospective data collection was carried out in the Department of Pediatric Surgery Emergency Mayo Hospital/King Edward Medical University, Lahore

Results: A total of 3880 patients including 2350[60.6%] males and 1530[39.4%] females were admitted during the study period. The highest number of admissions were Burn Patients with the percentage of 37.8%, followed by trauma cases 23.9%, and acute appendicitis 18.6%. There had been 86 deaths which gave rise to 2.2% Mortality

Conclusion: Burn injuries and trauma are common injuries in pediatric surgery ward. It is suggested that audit must be conducted routinely and should be officially declared as a compulsory action to provide vision and feedback to the working of surgeons

Practice and enforcement of national Hospital Waste Management 2005 rules in Pakistan

Background: Hospital waste management [HWM] rules in Pakistan were issued in 2005. Despite a decade of enactment, adherence to HWM 2005 rules has been inconsistent and systematic assessment of adherence using a World Health Organization [WHO]-recommended questionnaire has not been done in all teaching hospitals of Peshawar District.

Aims: This study assessed the adherence to HWM 2005 rules by tertiary care teaching hospitals of Peshawar District with respect to HWM personnel, policy and practices.

Methods: Pretested structured questionnaires based on WHO recommendations were used to survey all teaching hospitals of Peshawar District from January to March 2015. Data were also collected on HWM infrastructure and processes from 1 randomly selected medical, surgical, paediatric, and obstetrics/gynaecology unit in each hospital. Besides descriptive statistics, public and private hospitals were compared using Fisher's exact and Wilcoxon rank-sum tests.

Results: Most surveyed hospitals lacked formal HWM plans [70%], written procedures [80%], related job descriptions [80%] or records [90%]. Many hospitals neither had trained HWM supervisors [56%] nor did they organize formal HWM trainings for new staff [40%]. None of the hospitals followed waste segregation and colour coding. When compared to national HWM 2005 rules, multiple gaps in appropriate transportation, storage and disposal were found with no statistically significant difference between public and private hospitals.

Conclusions: Serious gaps in adherence to HWM 2005 rules exist in surveyed hospitals. With recent devolution of environmental function, the Government of Khyber Pakhtunkhwa should enact provincial HWM rules [and ensure their implementation] to facilitate effective HWM practice across provincial healthcare facilities

Pattern of dynamic intestinal obstruction in adults

Background: Pericardial effusion in clinical practice is commonly under diagnosed or missed especially minimal to moderate effusion. Aim and objectives: To study the clinical and etiological profile of pericardial effusion and to recognize radiological, electrocardiographic and echocardiographic features that are characteristic of pericardial effusion and to analyze pericardial fluid in various etiologies. Materials and methods: It was prospective study in patients presenting with pericardial effusion in department of Medicine and Cardiology. Total of 30 patients who presented with pericardial effusion based on clinical criteria and confirmed by echocardiography were included in the study. Results: The causes of pericardial effusion in this study were Tuberculosis (33.33%), Uremia (20%), Viral /Idiopathic (16.67%), Bacterial (10%), Malignancy (10%), Hypothyroidism (3.33%), and post MI with ischemic cardiomyopathy (3.33%), SLE (3.33%). 3 cases (10%) were HIV positive among viral causes,1 patient had tuberculous pericarditis. ECG findings of low voltage complexes were present in 90% of patients and electrical alternans was seen mainly in tamponade cases. Chest X-ray finding of cardiomegaly was present in 90% patients with pleural effusion in 13.3% patients. ADA levels elevated in all 10 patients of tuberculous effusion with 100% sensitivity and among them smear for AFB was positive in 3 patients. Increased levels of ADA>60U/L was associated with increased incidence of effusive constrictive pericarditis in TB effusion. Pericardial fluid IFN-ᵞ increased greater than 200 pg/L, tuberculous etiology showed 100% sensitivity and specificity. In all 10 patients of M Manjusha, B. Manoj Kumar, N. Venkat Rajaiah, P. Narayana. Study of characteristic of pericardial effusion and to analyze pericardial fluid in various etiologies. IAIM, 2017; 4(10): 221-229. Page 222 2Dimensional echocardiographic findings of right atrial, right ventricular collapse and left atrial collapse was seen predominantly in tamponade cases. Pericardiocentesis showed hemorrhagic effusion in malignancy and uremia, serous and serofibrinous in tuberculosis and purulent in pyogenic effusion. In 3 cases of pyogenic effusion, culture revealed Staphylococcus aureus in 2 patients and Klebsiella pneumonia in 1 patient. Among 3 cases of HIV, one patient had ADA >40 and smear for AFB positive suggesting tuberculous etiology and other 2 cases were directly due to HIV. In HIV with tubercular effusion the patient presented with cardiac tamponade. Conclusions: ADA>40U/L is diagnostic of tuberculous effusion which showed 100% sensitivity and specificity. Increase of ADA>60 U/L is associated with effusive constrictive pericarditis which has poor prognosis. IFN-ᵞ is increased >200pg/l in all patients of tuberculous etiology showing 100% sensitivity and specificity

Burn patients; causes of death and factors affecting mortality a 4 years study at a tertiary care hospital

To determine major risk factors of mortality and causes of death in patients presented with burn injury. Prospective Descriptive Study. Setting and duration: Department of Burns and Plastic Surgery, Khyber Teaching Hospital, Peshawar, Pakistan from April 2008 and June 2012. A prospective descriptive study was performed among the patients who admitted to the Department of Burns and Plastic Surgery, Khyber Teaching Hospital, Peshawar, Pakistan between April 2008 and June 2012. All relative information was collected through a detailed proforma and patient's treatment files. Patients of any age, any degree of burns and burns exceeding 10% TBSA were included. Patients presenting after more than one week post burn or patients referred from other hospitals were excluded. Within this period, demographic data, treatment, and outcomes of treatment were reviewed and analyzed. Survivors and non-survivors among burn patients were compared to define the predictive factors of mortality. Between April 2008 and June 2012, 1850 patients were admitted with burn injuries. There were 1150 male patients [62%] and 700 female patients [38%]. Mean age was 36 years with range of 1-70 years. Inhalation injuries were present in 45 patients [2.40%]. Causes were flame burns [65.0%], electrical burns [15%], scalds [13%] and chemical burns [7.0%]. The total body surface area [TBSA] burn ranged from 10- 100%, with a mean of 38% TBSA burn. Mean length of hospital stay was 12 days [ranging from 24 hours to 170 days]. Mortality rate was 11.2%. Higher age, larger burn area, wound infection, longer hospital stay and the presence of multi-system organ failure significantly predicted increased mortality. Prevention is a key factor in reducing the morbidity and mortality associated with burn injury. A campaign to educate people that burns can be prevented will be important in our community. The prevention of multi-organ failure and septicemia are likely to be more effective than their treatment

Comparison of oral health related quality of life in hypodontia patients and patients with acquired missing teeth

Hypodontia is the developmental disorder, one or more teeth are congenitally missing in these patients. This affects their aesthetics, phonetics, function and has a psychosocial impact in their life. A questionnaire [OHRQoL] Oral Health Related Quality of Life measures the potential consequences of the condition to day to day lives of the patient

Aim of the study: To compare the OHRQoL in patients with hypodontia and patients with acquired missing teeth

Material and Method: Group A, 40 patients with hypodontia and Group B, 40 patients with acquired tooth loss were evaluated with OHRQoL questionnaire. This consists of 14 questions. Response were made on 5 point Likert scale. [0 = never, 1= hardly ever, 2= occasional, 3= fairly often, 4= very often] SPSS software version 11 was used to analyze the data. Two groups compared for OHRQoL scores by using t test. P values < 0.05 was considered to be significant

Results: The mean age of hypodontia patient group A was 22 years, and Group B with acquired loss of teeth was 25 years. The response of 1-3 missing teeth in both groups were not different for function and aesthetics. When 4-6 teeth were missing significant difference was found. In the analysis statistically significant psychological discomfort was found in hypodontia patients

Conclusion: Loss of missing teeth has impact on function and aesthetics equally if the teeth are congenitally missing or lost by trauma or disease. But there is more psychological discomfort in the hypodontia patients

Metacarpal and phalangeal lengthening of the hand; utility of distraction osteogenesis

To present our experience of distraction osteogenesis in Metacarpal and Phalangeal lengthening of the hand and analyze the factors which influence the period of healing. Experimental study. Period: December 2008 to April 2011. Department of Plastic and Reconstructive Surgery, Khyber Teaching Hospital, Peshawar. The patients were admitted through out-patient department and detailed history, clinical examination and necessary investigations were carried out. Informed consent was taken. Distraction has been performed in six metacarpal bones and four phalangeal bones in nine patients. The age ranged from 3 to 59 years. All the digits had traumatic amputations. The injury was in the right hand [dominant] in 6 patients and in the left hand in 3 patients. An isolated injury to the thumb was seen in 4 patients, while in the remaining patients other fingers had been injured. All patients were operated by the same surgeon using similar lengthening technique. Patients were followed regularly and assessed for bone lengthening by clinical and radiological methods. The achieved elongation of the metacarpal bones varied from 26 mm to 30 mm [average 27.66 mm], and of the digital phalanges from 10 mm to 17 mm [average 13.5 mm]. Average healing time was 2.05 months [range from 1.8-2.5]. Average healing index was 0.75 month/cm [range from 0.65-0.88]. Complications observed were pin tract infection [3 cases], necrosis of free grafted skin [2 cases], delayed spontaneous bone union [2 cases] and volar angulation [1 case]. Webplasty was performed in all cases. Strength of pinch improved by an average of 37% and that of grasp by 48% compared to the preoperative values. All patients were able to pick up a paper and a cup of water. Distraction osteogenesis is a successful and reliable method for the lengthening of short metacarpals and phalanges. However, severe complications such as stiffness, angulation, subluxation of the MCP joint and delayed union or non-union are associated with this procedure. To avoid these complications, we suggest protection of the periosteum, refraining from distraction rates of more than 2x0.25 mm/day and, if possible, avoid lengthening a bone by more than 40% or not more than 20 mm of the preoperative bone length

Frequency of fistula formation after two stage repair of cleft palate

To estimate the frequency of fistula formation after two stage repair of cleft palate. A total of 50 patients having completed cleft palate repair with or without lip repair were recruited from December 2007 to February 2009. Patients were diagnosed on history and oral examination. Informed consent was taken from parents. Width of the cleft measured preoperatively. Two stage repairs were done by a single surgeon with a time lapse of six months. Five patients developed clinically significant oronasal fistula. All these fistulas occurred at the junction of hard palate and soft palate within 3 weeks time. The overall rate of true fistula development was 12% over a mean follow up period of 6 months. The incidence of true fistulas that were symptomatic and subsequently required surgical repair was 10%. Fistula rates were higher for more wide clefts but were not affected by gender or age

Our experience of pectoralis major myocutaneous pedicled flap

The pectoralis major myocutaneous pedicle flap [PMMPF] has been considered to be the "workhorse" of pedicled flaps in head and neck reconstruction. Despite the use of free flaps, this flap is still considered the mainstay of head and neck reconstruction. The flap is usually associated with a high incidence of complications compared with the free fasciocutaneous flaps yet its size, viability, and versatility make it a valuable tool for extending the limits of resectability and reconstruction. It is type V muscle flap with the dominant vascular supply from the pectoral branch of thoracoacromial artery. To share our experience of pectoralis major myocutaneous pedicle flap in selected cases of head and neck reconstruction. The indications, type of reconstruction and complications of the flap utilization were evaluated. Between March 2005 and August 2010, a 37 head and neck reconstructive procedures using the PMMPF were carried out. The indications for the flap use were defects due to resection of stage II-IV cancer in the head and neck region. The site, stage of the disease and the postoperative complications were all documented. Pectoralis major myocutaneous pedicled flap reconstructions were used to reconstruct defects in the following sites: oral cavity [25 patients]; oropharynx/ hypopharynx, [7 patients]; and neck or face [5 patients]. Of the 37 PMMPF reconstructions, 30 flaps were carried out as primary reconstructive procedures, whereas 7 flaps were "salvage" procedures. Twentyfive patients [67.59%] had complications. A higher complication rates were associated with the utilization of the flap as a salvage procedure, number of co- morbidities, and in oral cavity reconstructions. The pectoralis major myocutaneous pedicled flap is still an acceptable method of head and neck reconstruction. It is fast, reliable, provides safe repair and is indicated especially where bulk is needed

Our experience with macrodactyly: a rare congenital anomaly

To present our experience with [Macrodactyly] a rare congenital anomaly and its associated anomalies. Macrodactyly is an increase in the size of one or several fingers or toes. The overgrowth is limited to or predominantly affects the digits. It is characterized by an increase in all mesenchymal elements particularly fibro-adipose tissue. It does not appear to be an inherited condition and is thought to be caused by abnormal nerve supply, abnormal blood supply or abnormal humeral mechanisms. Pathologically, they are benign, soft tissue growths. Macrodactyly is commonly an isolated condition but other congenital anomalies are associated with it. It can be static or a progressive disorder. Soft tissue debulking, phalangectomies, ray resection, ostetomies and arthrodesis of interphalangeal joints are different modes of treatment. Descriptive case series. This study was conducted in Plastic Surgery Unit of Hayatabad Medical Complex Peshawar and Orthopaedic unit of Khyber Teaching Hospital, Peshawar from April 2007 to December 2009. A total of 32 patients were registered during the study period. Patients were admitted through out patient department, written informed consent was obtained from all individuals. Detailed history was taken, every patients was assessed clinically and radiologically. All patients were followed for recurrence. 2 patients were lost in follow up and the study was completed on 30 patients. Mean age of the patients was 13.7 years. Out of 30 patients, 19 were male and 11 were female. Hands were involved in 20 patients and feet in 10 patients. There was no bilateral hands or feet involvement. Eighteen patients had progressive and 12 patients have static macrodactyly. Seventeen patients had isolated macrodactyly while in 13 patients macrodactyly was associated with other congenital anomalies most commonly syndactyly. Most commonly involved digit was index finger in hand and big toe in foot. Macrodactyly is a rare congenital anomaly but cosmetic and functional disability of the patient is significant. Although it is mostly isolated but a significant number of cases were associated with other congenital anomalies which necessitate further research in this field

Anterolateral thigh flap: versatility and anatomic variations

To determine the pattern of the cutaneous perforator of the lateral circumflex femoral artery in anterolateral thigh perforator flap. Antero lateral thigh flap has become one of the most commonly used flap for the reconstruction of various soft tissue defects. The anterolateral thigh flap is known for variations of its vascular pedicle. Its major limitation has been uncertainty in predicting perforator anatomy, with the occasional absence of suitable perforators and high variability in their size and course. Reconstruction of 13 composite defects in 13 consecutive patients by free microvascular anterolateral thigh flap at the Department of Plastic and Reconstructive Surgery, Hayatabad Medical complex, Peshawar. Thirteen patients were operated and free microvascular anterolateral thigh flap was used. In 12 patients the main vascular supply was through the descending branch of the lateral circumflex artery [LCFA]. One patient has a vascular supply through the transverse branch of the lateral circumflex femoral artery. Transmuscular perforators [mostly 3,] were found in all the patients, commonly arising from descending branch of lateral circumflex femoral artery

Glomus tumor-a diagnostic dilemma

To see the diagnostic utility of Xrays, MRI and C.T. scan in the diagnosis of glomus tumor. Descriptive study done from 1998 to 2005 at the department of plastic and reconstructive surgery Hayatabad Medical Complex, Peshawar. All cases diagnosed clinically as glomus tumor of the frigers were included in the study. The major presenting features were pain in12 patients and bluish discoloration of nail in 4 patients. On examination local tenderness was present in 9 patients and ice cube test was positive in 7 patients. Confirmation was done by histology in all cases. All patients were subjected to radiological examination while specialized tests like MRI was performed in 10 patients and CT scan in 2 patients. Twelve patients were included in the study. Positive findings on MRI and X-rays were observed in only, three patients and in one patient on CT scan. X-Ray findings were negative in 9 out of 12 patients [75%] while MRI finding were negative in 7 out of 10 patients [70%] and CT scan was done in 2 and was negative in 1patient [50%]. Keeping the high cost of MRI and poor results in small size tumors it is recommended to depend on clinical findings and histology to establish the diagnosis rather than CT and MRI

Functional outcomes of single follicular hair graft technique

To assess the percentage survival of follicular hair graft technique and the factors influencing it. A non-interventional descriptive study. Plastic Surgery Unit, Hayatabad Medical Complex from November 2003 to April 2004. A total of 30 patients were included in the study with pattern of baldness ranging from type II to type VII. Age ranged from 24 years to 50. Hair bearing skin strips were harvested from occipital area and sliced under magnification into grafts of various sizes. Either punch or slit knife was used for making holes in recipient area and grafting follicles. Patients were followed at 2 weeks, 3 months and 6 months. Graft survival was measured at 6 months postoperative interval. In 7 patients graft survival was above 90%; in 12 patients above 80% but less than 90%; in 7 patients between 70 and 80%; in 2 patients above 60% but less than 70%; in 2 patients less than 20% which was considered as failure. Survival was greater with punch method than use of slit knife. Chances of failure increased with the large size session, larger grafts and unknown factors that need further investigations