Evaluation of insulin-like growth factor-1 and insulin-like growth factor binding protein-3 in diagnosis of growth hormone deficiency in short-stature children

Growth Hormone Deficiency [GHD] is conventionally diagnosed and confirmed by diminished peak Growth Hormone [GH] levels to provocative testing. Serum Insulin-like growth factor-1 [IGF-1] and insulin-like growth factor binding protein-3 [IGFBP-3] are under the influence of GH and reflect the spontaneous endogenous GH secretion. Owing to the absence of a circadian rhythm, it is possible to take individual measurements of IFG-1 and IGFBP-3 assays with Exercise and L-Dopa stimulation tests in the diagnosis of growth hormone deficiency in short stature children using ITT as gold standard. This validation study was conducted at Department of Chemical Pathology and Endocrinology, AFIP, Rawalpindi, from November 2005 to October 2006. Fifty-two short stature children were included in the study. Basal samples for GH levels and simultaneous IGF-1 and IGFBP-3 measurements were obtained and afterwards all children were subjected to sequential exercise and L-Dopa stimulation tests. Insulin Tolerance Test [ITT] was performed one week later with all the necessary precautionary measures. On the basis of ITT results, children were divided into two groups, i.e., 31 growth hormone deficient and 21 Normal Variant Short Stature [NVSS]. The diagnostic value of exercise stimulation test remained highest with sensitivity 90.3%, specificity 76.0%, Positive Predictive Value [PPV] 84.84%, Negative Predictive Value [NPV] 84.2% and accuracy 84.6%. The conventional L-Dopa stimulation had sensitivity 96.7%, specificity 38.0%, PPV 69.7%, NPV 88.8% and accuracy 73.0%. The serum IGF-1 and IGFBP-3 levels were positively correlated with post ITT peak GH levels [r=0.527, r=0.464 respectively, both p<0.001]. The diagnostic value of IGF-1 had sensitivity 83.87%, specificity 76.2%, PPV 83.87%, NPV 76.2% and accuracy 80.76%. The diagnostic value of IGFBP-3 had sensitivity 54.83%, specificity 90.47%, PPV 89.47%, NPV 57.57% and accuracy 69.23%. With combined use of IGF-1 and IGFBP-3 diagnostic value had sensitivity 69.35%, specificity 83.33% PPV 86%, NPV 64.81% and accuracy 75%. Growth Hormones provocative tests still remain the most useful investigations for the diagnosis of GHD. Measurements of IGF-1 and IGFBP-3 have shown comparable diagnostic performance with growth hormone stimulation tests and are valuable for patients' convenience and ease of performance and can be useful in the initial workup of short stature

Role of integrated PET/CT Fusion in lung carcinoma

Positron emission tomography has emerged as an important diagnostic tool in the management of lung cancers. PET is sensitive in the detection of lung cancer, but FDG [2-deoxy-2-18fluro-D-glucose] is not tumor specific and may accumulate in a variety of non-malignant conditions occasionally giving false negative result. The addition of CT to PET improves specificity foremost, but also sensitivity in tumor imaging. Thus, PET/CT fusion images are a more accurate test than either of its individual components and are probably also better than side-by-side viewing of images from both modalities. PET/CT fusion images are useful in differentiating between malignant and benign disease, fibrosis and recurrence, staging and in changing patient management to a more appropriate therapy. With analysis and discussion, it appears that PET/CT fusion images have the potential to dramatically improve our ability to manage the patients with lung cancer and is contributing to our understanding of cancer cell biology and in the development of new therapies

Supraclavicular artery flap "its weightage in reconstructing burn neck contracture"

Flexion contractures of neck are a common sequel of deep burns. Severity varies from discrete linear bands to severe labiomentosternal contractures leading to functional and cosmetic impairment. Use of local flaps can produce best restoration of form and function. This study was meant to analyze clinical utility, advantages and any complications specific to islanded supraclavicular artery flap. This was a descriptive study carried out at department of plastic and reconstructive surgery Mayo hospital Lahore between January 2005 and November 2006. Ten patients presenting with neck contractures with out evidence of trauma in supraclavicular fossae, shoulder and deltoid region were included in the study. History and physical examination details including extent of contracture and cosmetic impairment were endorsed. Essential preoperative workup was done accordingly including assessment by anesthetist. Ten patients with varying severity of neck contractures were included in the study. Age range was 15-35 years. Average hospital stay was 10 days. Five patients had severe labiomentosternal contractures. Eight patients reported neck wound appearing excellent at 6 months postoperatively. In contrast donor area appearance was reported satisfactory by 7 and poor by 3 patients at 6 months. Functional consequences were most with 6 patients having full range of motion [ROM] and 4 patients having limited but satisfactory ROM. There is no reported recurrence so far. Supraclavicular artery based islanded fasciocutaneous flap is a reliable reconstructive tool ideally suited to cover defects in the region of neck to restore form and function

prospective study of postanaesthesia recovery room complications. incidence and treatment

To audit the incidence and nature of post-anesthesia recovery room complications, their treatment and review the role of recovery room in modern anesthetic practice. 3151 patients who received general or regional anaesthesia were admitted to the recovery room during six months period [August 01, 1995 to January 31, 1996]. Information noted on forms by recovery nurse by encircling the pre coded complication. Out of 3151 patients, 2716 patient's data forms could be collected. Therefore results reflect 86% of the patients passing through the recovery. The overall incidence of complications in our population was 36.26%.Complications referable to CNS were 52.29%, the commonest of which was pain[51.26%], agitation [0.18%] and excessive drowsiness [1.01%].The second commonest system was GIT[25.07%] nausea [14.31%] and vomiting [12.18%].The third system was CVS [21.52%],bradycardia [5.48%], tachycardia [7.61%],hypertension [4.26%],hypotension [2.53%],myocardial ischaemia [0.81%] myocardia infarction [0.10%] and new arrhythmias [1.41%].The fourth system was Respiratory system [5.58%], hypoventilation [l.42%], bronchospasm [0.81%], laryngospasm [0.1%] and desaturation [Sp02 < 90%] in [0.1%].0.6% patients had to be reintubated. Two patients had oliguria. Miscellaneous complications were [9.94%]. More than one complication was observed in some patients. The incidence of mortality in our study during this period was 0.10%. Every third patient is susceptible to get some form of complications in the immediate post-anesthesia recovery period. It reflects the importance and need of a specialized designated area called recovery room with qualified staff

Factors influencing the choice of anesthesia as a career in a developing country

Career choice in medicine is influenced by several factors. Our aim was to look at reasons for choice of anesthesia as a career in a cohort of doctors applying for the residency training in a university hospital in a developing country. A semi-structured interview form is used in our department and includes a question related to career choice. Each applicant is interviewed by two faculty members independently. All interview forms between 1992 to 2004 were reviewed and the reason for choosing anesthesia was coded in different categories. The sample consisted of 167 applicants and 334 forms. There were 29 females and 138 males. The mean age of the applicants was 28 years. Sixty two percent chose anesthesia because of general interest and nature of the specialty, 24% of these mentioned had no specific reasons, 17% thought the specialty was intellectually challenging, 8% liked the technical aspect, 5% were interested in physiology and pharmacology, 2% liked the operating room environment, and 6% liked the immediate results. The second major group [36%] cited the reason as better economic opportunities. Sixteen percent were influenced by friends or relatives in their choice. Twenty six percent chose anesthesia primarily because of their interest in critical care, pain management or emergency management. Our data indicates that selection of career in anesthesia in our county is strongly related to the nature of specialty and future employment opportunities. A significant number were influenced by family and friends. This pattern is different from that reported from Australia and United States

Role of radiotherapy in early Breast Cancer: an overview

Radiotherapy has an established role in reducing the local relapses in breast cancer patients. The objective of this review was to investigate whether radiotherapy or its omission after breast surgery has measurable consequences on local tumor recurrence and patient survival. The late excess of cardiac deaths has also been published in various reports but important advances in the delivery of radiotherapy have overcome this problem to the extent that, excess cardiac deaths do not appear to be occurring in more recent trials. In this article some recent data, suggesting that radiotherapy following mastectomy and/or breast conserving surgery has a beneficial effect on survival is reviewed. Omission of radiotherapy is associated with a large increase in risk of ipsilateral breast tumor recurrence and with a small increase in the risk of patient's mortality

Role of radiotherapy in early breast cancer: an overview

Radiotherapy has an established role in reducing the local relapses in breast cancer patients. The objective of this review was to investigate whether radiotherapy or its omission after breast surgery has measurable consequences on local tumor recurrence and patient survival. The late excess of cardiac deaths has also been published in various reports but important advances in the delivery of radiotherapy have overcome this problem to the extent that, excess cardiac deaths do not appear to be occurring in more recent trials. In this article some recent data, suggesting that radiotherapy following mastectomy and/or breast conserving surgery has a beneficial effect on survival is reviewed. Omission of radiotherapy is associated with a large increase in risk of ipsilateral breast tumor recurrence and with a small increase in the risk of patient's mortality

Chest wall defects and their reconstruction

Chest wall reconstruction remains one of the most challenging areas of Plastic and Reconstructive Surgery. The purpose of this study is to report our 4 year experience with chest wall reconstruction. A review of 62 patients who had chest wall reconstruction from 2001 to 2004, is included in the paper. Indications include, defects secondary to congenital deformity correction, post neoplastic reconstructions, post burn defects and sternotomy wounds. Procedures performed included direct closure after debridement, vacuum assisted closure with and without skin grafting, pectoralis major flap, rectus abdominis flap, omental flap and free flaps including latissmus dorsi flap. The average hospital stay was 13 days. The uneventful recovery was seen in 50 patients. Minor complications were seen in 12 patients whereas major complications were not seen in any patient. Chest wall reconstruction can be performed with satisfactory outcome provided that reconstruction ladder is followed

audit of postoperative minor complications of anesthesia

To look at minor complications attributable to anesthesia in adult surgical patients at our Institution and to identify various contributing factors. Descriptive cross sectional audit. Aga Khan University Hospital, Karachi, Pakistan. Seven hundred and thirty surgical patients undergoing elective surgery were recruited. This was a non-interventional study and data was collected prospectively based on predefined criteria. The incidence of nausea, vomiting, sore throat, headache, drowsiness, phlebitis, dizziness, myalgia, transient nerve palsy, conjunctivitis, ringing of ears, low backache, lip injury, dental injury or any other minor complications were looked at. Nausea, sore throat and vomiting were the highest reported complications. The incidence of nausea, drowsiness and dizziness was less in patients more than sixty years of age. Incidence of nausea and vomiting was higher in ASA 1 patients and in surgery lasting less than ninety minutes. Headache and dizziness were reported high in certain surgical specialties. The overall rate of minor complications following anesthesia was 12.6%. No complications were reported by 30% of the study population. The data has given us a benchmark for patient information and will be used for risk reduction in our Department of Anaesthesiology

Ivor Lowis esophagectomy: experience at Jinnah hospital, Lahore

Although different approaches have been used for surgical resection of esophageal cancer, the Ivor Lewis approach is the standard technique at most centers for resection of the diseased middle and lower third esophagus. This procedure has historically been associated with significant morbidity and mortality. However, modern literature suggests that Ivor Lewis esophagectomy can be performed with an acceptable complication rate and mortality. Patients and methods: We conducted a case series of thirteen consecutive patients who underwent an Ivor Lewis esophagectomy at Jinnah Hospital Lahore from January, 2001 to December, 2002. The objective was to examine the morbidity, mortality and short-term outcome of this surgical procedure. The mean age of the patients was 45.9 years +/- 18.3 years [median: 44.5 years; range: 22 to 78 years]. 7 patients were men and 6 patients were women. 6 patients [46.2%] were operated for benign corrosive esophageal strictures whereas seven patients [63.8%] had esophageal cancer. The median age of the patients with benign strictures was 28 years [range: 20 - 35 years]. The median age of the cancer patients was 58 years [range: 54-70 years]. Of these patients, one had Stage I cancer [9.29%], two had Stage II a [28.57%], two had Stage II b [28.57%], and two had Stage III disease [28.57%]. Five patients [71.42%] had adenocarcinoma and two [28.57%] had squamous cell carcinoma. Seven patients [53.8%] had one or more co-morbid conditions, including diabetes, hypertension, cardiovascular disease and chronic obstructive pulmonary disease. Four patients [30.77%] had history of smoking. The mean operative time was 270 minutes +/- 31 minutes. The mean operative blood loss was 1500 ml +/- 102 ml. The median ICU stay was one day [range: I to 7 days]. The median hospital stay was 19 days [range: 15 to 38 days]. Eight patients [61.54%] developed post-operative complications. Most of these complications were medical [60%] rather than surgical [40%]. Respiratory complications were the commonest [30.77%]. Of the surgical complications, the most common was the development of an anastomotic leak [23.08%]. All of these were managed conservatively and none proved fatal. There were two mortalities on post operative days 7 and 8, due to ARDS and multi-organ failure respectively. The operative mortality was 15.39%.Ivor Lewis esophagectomy represents a major physiological and surgical insult. However, careful patient selection, perioperative monitoring and early aggressive treatment of complications can significantly reduce morbidity and mortality

Is breast cancer in younger women a more aggressive variant? a comparative study

Breast cancer is the commonest malignancy in women in the world. About 5% of all breast cancer patients are 35 years old or younger. Current literature suggests that breast cancer in these younger women may be different in etiology, clinical features and outcome from the disease seen in older women. We included all breast cancer patients who underwent surgical treatment at Surgical Unit IV, Jinnah hospital, Lahore from December, 1998 to December, 2003. All patients who left against medical advice or were lost to follow up before completing treatment at our hospital wee excluded. The patients were divided into two groups by age. Those who were 35 years old or younger were placed in group 1 [88 patients] and those older than 35 years were placed in group 11[54 patients], which served as the control group. We compared the clinical presentation, the risk factor profile, and the grade and the stage of the tumor at presentation in younger women and their older controls. The mean age in group I was 29.38 years +/- 3.68 years. While the mean age in group II was 44.41 years +/- 7.64 years. The commonest mode of presentation in both groups was a painless lump. [93.2% in group I and 66.67% in group II; p value < 0.001]. The distribution of classical risk factors was similar in the two groups. These included family history [12.5% in group I and 11.1% in group II], nulliparity [7.95% in group I and 7.4% in group II], and oral contraceptives use[14.77% in group I and 12.96% in group II]. Younger patients presented with a greater number of poorly differentiated [Grade III] tumors compared to the older patients. [73.76% vs.24.07%; p value <0.001]. They also presented more frequently with hormone insensitive tumors [79.55% in group I vs. 24.52% in group II; p value < 0.001]. Mammography was positive more often in older women compared to the younger ones [97.44% vs.41.38%; p value < 0.001]. Ultrasound was done in 67.05% of the younger women and 27.78% in the older women. It was suggestive of malignancy in 89.83% of the younger women and 86.67% of the older ones. Modified radical mastectomy was done in 75% of the younger patients [Group I] and 61.11% of the older patients [Group II]. Radical mastectomy was done in 19.32% of group I patients and 27.78% of group II patients. Older women underwent breast conservation treatment more often than the younger women [11.11% vs. 5.68%; p value < 0.05] Adjuvant chemotherapy was given more often to younger women [73.86% in group I vs. 9.26% in group II; p value < 0.0001]. On the other hand, older patients received hormonal therapy more often that the younger ones [74.07% vs. 20.45%; p value < 0.001]. Younger patients also received adjuvant radiotherapy more frequently than their older counterparts [84.32% vs. 49.26; p value <0.05]. We conclude that women with breast cancer who are 35 years old or younger have more aggressive tumors than the older patients i.e. they present at a higher stage with poorly differentiated tumors that are frequently hormone insensitive

Low cost quality control human serum: method of perparation, validation of values and its comparison with the commercial control serm

To prepare low-cost quality controls [QC] human serum and scientifically evaluate its advantages/disadvantages when compared with commercially available sera. The home made QC serum was prepared as per WHO recommended protocol from four healthy volunteers. It was screened for HIV, HCV and HBV, pooled together and stabilized with ethylene glycol. The initial 40 values were used for calculation of means, SDs and CVs for seventeen routinely measured analytes and results were compared with those of commercially available lyophilized human sera. The average concentrations of seventeen commonly analyzed constituents were found to be near the middle of the physiological range of healthy subjects and the home made serum could be a good substitute for the commercial serum of normal range. The narrower CVs of the analytes imply a lesser vial to vial variation in the home made sera. Additional advantages include easy preparation, no need for reconstitution and lower cost. Home made serum is a good substitute for the commercial serum of the normal range especially in developing countries like Pakistan

Midazolam and thiopentone co-induction: looking for improvement in quality of anaesthesia

To evaluate improvement in quality of anaesthesia induction using thiopentone and midazolam for co-induction of anaesthesia. An additional end point was taken as loss of response to a tetanic stimulation [50 Hz] delivered for 5 seconds after the loss of verbal contact and eyelash reflex. Ninety ASA I and II patients, within the age range of 20-60 years were studied. Patients were randomly divided into three equal groups; A, B and group C Onset of induction and loss of response to a tetanic stimulation was achieved earlier in group B as compared to the other study groups [p<0.05]. Co-induction with midazolam 0.02 mg.kg-1 followed by thiopentone 3 mg.kg-1 was superior to other two groups. Induction of anaesthesia in this group was found to be smoother and faster, provided better hemodynamic stability, better airway maintenance and with lesser incidence of untoward effects

Sonographic prevalence of acquired cystic renal disease in patients receiving haemodialysis

To determine the sonographic prevalence of Acquired Cystic Renal Disease [ACRD] in patients on maintenance haemodialysis and its relationship to the duration on dialysis. All patients with end stage renal disease [ESRD] who were receiving maintenance haemodialysis in Urology Department of Mayo Hospital Lahore between November 1997 to February 1998 were screened by ultrasound for the prevalence of ACRD. Forty patients with ESRD on maintenance haemodialysis were evaluated. The mean age of patients was 39.9 years. The male to female ratio was 2.3:1. Four patients [10%] had documented ACRD. The proportion of patients with ACRD increased with increasing duration of dialysis; ACRD was found in 60% of patients who had dialysis for more than 3 years, 20% in those who had been dialyzed for 1-3 years, and no patient developed ACRD who was on dialysis for less than one year. All patients remained asymptomatic except one, who had intermittent macroscopic haematuria. There was no evidence of neoplasm in any of these patients on clinical grounds or on ultrasound. We found a low prevalence of ACRD in the population studied compared to previously published series. This can be explained by the fact that most of our patients were on dialysis for less than one year. A further study is suggested with greater numbers in a center where patient stay on dialysis for longer period and patient turnover is low

Anatomical variations of internal jugular vein as seen by Site Rite II ultrasound machine-an initial experience in pakistani population

OBJECTIVE: To determine the anatomical variations of the internal jugular vein [IJV] in Pakistani adult population with the help of Site Rite II ultrasound machine. MATERIAL AND METHOD: The right IJV relation to the carotid artery was visualized at four different landmarks [angle of the mandible, thyroid cartilage, cricoid cartilage, and the supraclavicular area]. Size of IJV in comparison to carotid artery was also seen. In 49 cases the IJV was found in aberrant relation to carotid artery at the angle of the mandible [p value < 0.05], 22 at the thyroid cartilage, 20 at the cricoid cartilage, and 46 at the supraclavicular area [p value < 0.05]. In 93% of cases the IJV was found to be larger than the carotid artery. Care should be taken while cannulating IJV at the angle of the mandible and supra clavicular area by external landmark guided technique. Ultrasound guided technique should be used in every anticipated difficult case

Hospital incidence of urolithiasis in Quetta division

Objective The purpose of this retrospective study was to analyze the cases with urinary calculi, operated at the department of Urology, Sandeman Hospital, Quetta. Methods All patients with urinary calculus disease admitted to the Sandeman Hospital from January 1989 to December 1991 were included. Data was retrieved from the record sheets which included patient demography, site of stones, nature of operation and climatic condition. Results Of the 1008 cases, 82% were males and 18% females. There were 418 renal, 73 ureteric and 505 bladder calculi. The maximum number of renal stones were found in the 20 to 29 years age group whereas bladder stones were most prevalent in children below 9 years of age. The frequency of admissions was highest [33%] in the quarter June to August. Conclusion The hospital prevalence of urinary tract stones was 21 per 100,000 population in Quetta division which is comparative to other regions falling in the stone belt of the world

Ultrasonographic changes in experimental ureteric ligation

This experimental work was done to see the hydronephrotic changes in kidney of completely ligated ureter. Five young healthy mongrel dogs weighing 20-25 kg. were induced in this study. They were kept on standard diet and free access to water. Ultrasound of experimental and control kidney was done for the measurement of hydronephrosis and changes in control kidney. On day 1 there was fullness of pelvis and calyces in experimental kidney on day 3 minimal to mild degree of hydronephrotic changes observed on day 5th mild to moderate degree of hydronephrosis was found. At the end of one week hydronephrosis was marked to severe and contralateral kidney was hypertrophied. At the end of the experimental work dogs were sacrificed and bilateral nephrectomy was done to observe the gross and microscopic changes in both kidney

Experience of spontaneous small bowel perforations at the Mayo Hospital

Hospital record of 84 consecutive cases of spontaneous small bowel perforation managed by one surgical unit of mayo hospital over a period of two years was examined. Fifty eight male and 26 female cases were dealt with. Age ranged from 15-70 years. Perforations were caused by enteric fever in 50% cases tuberculosis 31%, adhesive bowel disease and non-specific in 9%. Eighty one percent cases had only one, 12% cases had two and 7% cases more than 2 perforations. Primary repair of perforation was done in 60% cases, resection and anastomosis in another 23% and in 13% cases the perforation was exteriorized. In 2% cases simple tube drainage of the coelomic cavity was done. Twenty One cases had postoperative complications out of these 5 patients expired

Experience of ureteric obstruction following ESWL and its management

One hundred consecutive patients with radiopaque renal stones size ranging between 5 to 35 mm were included. Prior to ESWL treatment double J ureteral stent was inserted in all patients [n=23] who had stone size over 20 mm to prevent risk of ureteric obstruction. Renal ultrasound and x ray KUB were required in every patient at each follow up to assess pulverization, steinstrasse and hydronephrosis. Overall ureteric obstruction due to steinstrasse was noted in 16 patients [16.0%]. The incidence of steinstrasse was 15/77[19.4%] when stone size was 5 to 20mm while it was 1/23 [4.3%] when stone size was above 20mm with double J ureteral stent in place. Adequate pulverization for clearance was 0% at the end of 4 months in the patients with stone size over 20mm. In 3 unstented patients ureteric obstruction was complicated with fever, nausea, vomiting and moderate to severe colic and hydronephrosis and uncomplicated in remaining 13 patients [1 stented and 12 unstented]. Double J ureteral stent was costly and associated with complications like frequency [34.8%], urgency [30.4%], lumber pain [39.1%], bladder pain [34.8%] fever [34.8%], burning micturition [8.7%], difficulty in walking [8.7%]. For complicated ureteric obstruction following ESWL in 5-20 mm size stones PCN and repeat ESWL is recommended in preference to double J stent wich is associated with a high morbidity. ESWL should not be offered to patients with stone size more than 20 mm.