Surgical correction of grown up tetralogy of fallot

Objective: To get an audit of outcome of our patients operated for total correction for grown up Tetralogy of Fallot

Study Design: Observational / analytic study

Place and Duration of Study: This study was conducted at the Department of Cardiac Surgery, NICVD, Karachi from January 2015 to August 2016

Materials and Methods: We reviewed our surgical record and collected the data of patients with age 18 years and beyond, who underwent for total correction in Tetralogy of Fallot. We had included the patients whose prospective record of their surgical as well as socioeconomic outcome

Results: Total 35 patients were identified, out of 35 patients 19 were selected as final cohort of patients for our study they included 11[48%] females and 8 [42%] males with age range of 18 to 28 years. Procedures for TOF repair included trans-annular patch [n=7], trans-ventricular [n=5], trans-atrial [n=2]. While the remaining patients [n=3] had combined approaches [tran-atrial with trans-pulmoary or trans-ventricular with trans-pulmonary]. The 30-day mortality rate was 16% [right ventricular failure n=1; tamponade n=1; low cardiac output with pulmonary edema as a result of residual ventricular septal defect n=1]. 3 patients were re-explored due to mediastinal bleeding with one of them had developed cardiac tamponade. Follow-up of minimum 3 month to maximum of 15 months was feasible in 16 out of 19 survivors, improvement in functional class [NYHA] was observed in 11 patients

Conclusion: Complete repair of TOF in patients 18 years or older is possible but carries increased operative risk. Survivors have improvement in their functional class as well as social status however it is difficult to commit on economical productivity of patients

Medicinal plants and management of diabetes mellitus: a review

Diabetes is a metabolic disorder characterized by chronic hyperglycemia and associated with dysfunction and failure of various body organs. Alarming increase in prevalence rate has made this disorder a major health problem globally. The available treatment modalities are not sufficient to combat diabetes and associated complications. A number of medicinal plants have a significant antidiabetic potential against diabetes mellitus. We have listed the use of important medicinal herbs for the treatment and management of diabetes in this review

Total cavopulmonary connection for functionally single ventricle without cardiopulmonary bypass support

A heart with two atriums but one ventricle, an anatomy with a unique physiology, is responsible for many creative surgical and interventional approaches in history. Different surgical techniques have been used to address this strange physiology of parallel circulation. All these attempts met with failure till the concept of Fontan circulation was described. Currently, controversy exists between multistage vs. single stage total cavopulmonary connections. Total cavopulmonary connection is the only definitive procedure performed to provide palliation for patients with complex congenital heart defects which cannot support a biventricular circulation. We report a case with tricuspid atresia with transposition of great arteries and pulmonary stenosis with persistant left-sided superior vena cava and functionally single ventricle. Patient successfully underwent single stage extra-cardiac total cavopulmonary connection. In this case, bilateral Glenn with extra-cardiac inferior vena cava to main pulmonary artery shunt was performed off-pump

Comparison on the use of semi-automated and automated core biopsy needle in ultrasound guided breast biopsy

Objective: The aim of this study was to compare the use of semi-automated (Medax Velox 2; Poggio Rusco, Italy) and automated (Bard Magnum Biopsy Instrument; Covington, GA, USA) core biopsy needles, for ultrasound guided breast biopsy. Materials and Methods: A 14G semi-automatic spring loaded core biopsy needle with a 22-mm-throw (Medax Velox 2; Poggio Rusco, Italy) and 14-gauge automated needle device with a 22-mm-throw biopsy gun (Bard-Magnum Biopsy Instrument, Covington, GA, USA) were used for breast biopsies under ultrasound guidance on alternate months during the study period between July 2009 and May 2011. One hundred and sixty lesions were biopsied and specimens were sent for histological evaluation. Results: The automated needle obtained a higher number of histology reports at 84% (67/80) as compared with the semiautomated needle at 60% (48/80) (Fisher exact test, p value=0.023). Inadequate samples with the automated needle were much less at 9% (7/60) than with the semiautomated needle at 23% (18/60) (Fisher exact test, p value=0.028). The semi-automated needle showed slightly less fragmented samples. However, the number of fragmented samples with definitive diagnosis was slightly higher with the automated compared with the semiautomated needle, at 16% (13/80) and 13% (10/80) respectively. Compared with histology of 29 lesions that were excised, the semi-automated needle had higher sensitivity (100%) but lower specificity (75%) and accuracy (90%) compared with the automated needle (88% sensitivity, 100% specificity, 95% accuracy). Conclusion: Definitive diagnosis from the study samples slightly favours the use of automated core biopsy needle as compared to semi-automated core biopsy needle.

When drotaverine [No-Spa] injected in to the perivascular tissues of internal mammary artery [IMA] relives the peri-operative vascular spasm and increases the blood flow in IMA when used as a pedicle graft in CABG

To compare two groups of patients submitted to different modes of delivery of Drotaverine and its effect on internal mammary artery spasm during Coronary artery by pass grafting at The National Institute of Cardiovascular Diseases, Karachi. Experimental study. This study was carried out at the National Institute of Cardiovascular Diseases Karachi from 1[st] Jan 2013 to 31[st] December 2013. Data was analyzed from one hundred patients who underwent CABG at our institute. They were divided into two groups: Group 1 consisted of 50 patients in which Drotaverine [No-Spa] was sprayed topically over the IMA: Group 2 also consisted of 50 patients in which Drotaverine [No-Spa] was injected with blunt needle in the peri vascular tissue of IMA. After Drotaverine application, the mean blood flow were significantly low in Group I was 117.2 +/- 4.87ml/min as compared to Group II which was 136.2 +/- 7.11 ml/min [p<0.01]. Result of our study suggests; Drotaverine injected perivascularly better relieves spasm of internal mammary artery and increases the blood flow

Impact assessment of educational intervention among private dental practitioners about infection control practices in district Peshawar

Cross infections occur frequently in dental health care personnel therefore, to protect themselves and their patients; they have to strictly follow infection control practices. To assess the impact of educational interventions on knowledge and practices of private dental practitioners. Interventional study, done from March 2012 to June 2013 in private practitioners of Peshawar using convenient sampling technique. After acquiring base line data on the practices, pertaining to prevention of cross infection in dental practitioners, educational knowledge intervention was applied to them on same day and repeated after two months. Post intervention data was collected using same questionnaire. The data was analyzed using Statistical Package for Social Sciences [SPSS] version 16.0. A total of 90 dental practitioners were included, of whom 49 [54.4%] were qualified and 41 [45.6%] unqualified. Their overall mean age was 33.77 +/- 8.97 years. The mean age of qualified practitioners was 36.24 +/- 10.40 years. Their pre and post intervention practices showed significant improvement in various practices like; screening of patients prior to procedure [p <0.043], hepatitis B vaccination [p < 0.000], type of gloves used [p < 0.031], hand washing [P < 0.004] separate instrument processing area [p < 0.004], floor cleansing with disinfectant [p < 0.000] and proper ventilation [p <0.021]. The mean age of unqualified practitioners was 30.80 +/- 5.73 years. Their pre and post intervention change in knowledge and practices showed poor compliance to most interventions. Qualified dental practitioners had a positive attitude towards educational infection as compared to unqualified practitioners. Yearly health education certification should be implemented for all health care professional [qualified and unqualified] to keep them abreast with the infection control practices

Frequency of smear positive precancerous cervical lesions in patients attending outpatient department of a tertiary care hospital

To find out the frequency of precancerous cervical lesions by doing Pap smear. It was a descriptive study conducted by Pakistan Medical and Research Council in outpatient department of Obstetrics and Gynaecology at Hayatabad Medical Complex Peshawar from 1st July 2007to 3oth June 2008. Four hundred and fifty patients all married, sexually active, between 20 and 60 years of age were included in the study. Those who were menstruating or with a suspicious looking cervix, a history of Cervical Intraepithelial Neoplasia [CIN], Carcinoma of the Cervix, Ovary or Endometrium or pregnancy were excluded from the study. A detailed history and examination was done and a Proforma was filled. Pap smear was done in the outpatient department and was sent to cytologist for reporting. Data was analyzed by SPSS version 13. The Pap smear result showed inflammatory smear in 112 [24.88%] cases, 248 [55.11%] cases had a normal smear, 85 [18.88%] reported to be inadequate. Low grade squamous intraepithelial lesion was reported in 5 [1.11%] cases and none of these cases on colposcopic guided punch biopsy had CIN. The most frequent abnormality found in Pap smear study was infective bacillary background. The frequency of premalignant lesion was found to be very low in this largest study conducted in KPK. More studies are needed to confirm this finding in this ethnic population

Cranial CT in the evaluation of coup and countercoup head injuries

Objective: To describe the role of Cranial Computed Tomography [CT] in the evaluation of Coup and Countercoup head injuries with its outcome

Study Design: A comparative cross-sectional study

Settings: Radiology Department of PMC/Allied Hospital Faisalabad. Duration: 09 months, October 2012 to June 2013

Sample Size: 150 patients

Materials and Methods: The patients with coup and countercoup head injuries were studied and divided into two groups: Coup injuries [n=117], countercoup injuries [n =33] .The groups were comparable with respect to age, Glasgow Coma Scale [GCS] and outcome. Site of primary impact was determined by CT scan pattern

Results: The mortality rates in each group were compared with respect to age, GCS and CT pattern. Significance was calculated using Chi-Square test. There was a statistically significant difference in mortality between patients with coup injuries [p

Conclusion: Presence of a countercoup component on CT scan may show a worse outcome in head injuries and may warrant closer monitoring and more aggressive management of these patients

Assessment of knowledge, attitude and practices pattern of hand washing in some major public sector hospitals of Pakistan [a multi-center study]

To assess knowledge, attitude and practices of hand washing in major Public sector Hospitals of Pakistan and see the differences in practices in different levels of health care workers. Cross sectional hospital based survey conducted in all provinces of Pakistan in major tertiary care hospitals. A Cross sectional hospital based survey was conducted on knowledge, attitude and practices of hand washing in doctors, nurses and paramedical staff. From each hospital 10 OPD's and 10 wards i.e. 2 medical, 2 Surgical, Gynae, Peads, Dermatology, Eye, ENT, and Causality/ICU were selected and from each unit. Four doctors, four nurses and two paramedical staff were interviewed. A total of 3243 respondents were interviewed. Of these 87.3% had knowledge of hand washing. Hand washing facilities were available at 75% places and 69% respondents practiced hand hygiene, but only 58.8% washed their hands for more than 20 seconds. Majority used antibacterial soap bought by them. Rush of the patients, shortage of time, non availability of soap and water and lack of encouragement by seniors were the major causes for low hand hygiene practice. Almost 25% sites in major public sector tertiary hospitals did not have hand washing facilities but where available most health care providers were using them. Majority despite having knowledge, need motivation and continuous education of hand hygiene. Facilities of hand hygiene should be made available

Low-cost assays for monitoring HIV infected individuals in resource-limited settings.

Use of a combination of CD4 counts and HIV viral load testing in the management of antiretroviral therapy (ART) provides higher prognostic estimation of the risk of disease progression than does the use of either test alone. The standard methods to monitor HIV infection are flow cytometry based for CD4+ T cell count and molecular assays to quantify plasma viral load of HIV. Commercial assays have been routinely used in developed countries to monitor ART. However, these assays require expensive equipment and reagents, well trained operators, and established laboratory infrastructure. These requirements restrict their use in resource-limited settings where people are most afflicted with the HIV-1 epidemic. With the advent of low-cost and/or low-tech alternatives, the possibility of implementing CD4 count and viral load testing in the management of ART in resource-limited settings is increasing. However, an appropriate validation should have been done before putting them to use for patient testing.

HIV-1 Drug Resistance Among Newly HIV-1 Infected Individuals Attending Tertiary Referral Center in Chennai, India.

Context: In the era of free HAART, accessibility and availability of ARV has been dramatically increased in India. However, rates of treatment literacy and adherence appear to be sub-optimal. Therefore, it is essential to monitor the extent of primary drug resistance in such settings. Materials and Methods: Between July and October 2006, 18 anti-retroviral-naοve individuals were identified as recent infected by the BED-Capture enzyme immunoassay in a VCTC clinic in Chennai. Specimens from these individuals were subjected to genotypic drug resistance testing. Phylogenetic trees were generated using MEGA for Windows version 4.0 using neighbor-joining method. The significant differences in polymorphic mutation frequencies between the study specimens and established subtype C-specific polymorphisms were examined using the Chi-square test. Results: Amino acid substitution (K103N and V106MV) at drug resistance positions occurred in two (11%) isolates, conferring high-level resistance to the non-nucleoside reverse-transcriptase inhibitors nevirapine (NVP), efavirenz (EFV), delavirdine (DLV) and notably extensive genetic variations were observed. K122E (94.4%) and K49R/KR (11.1%) polymorphisms identified in this study have not been previously described in established subtype-C specific polymorphisms. The rate of polymorphisms showed marked difference at the locations V60, D121, V35, and D123 (P < 0.0001). All the sequences showed maximum homology with Indian HIV-1 subtype C reference strain C.IN.95IN21068. Conclusions: The finding of resistance to NNRTIs is of public health importance. There is an urgent need to establish surveillance for primary drug resistance in large scale. Further studies are required to determine the phenotype impact of newer polymorphic mutations in relation to drug resistance and viral fitness.

Estimation of heavy metals in the seeds of blue and white Capitulum's of Silybum marianum grown in various districts of Pakistan

About 70-80% of the world population relies on herbal products, especially in the developing countries. Herbal products are available in various dosage forms for different types of ailment. Contamination of medicinal plants with heavy metal is of great concern. Heavy metals are known to affect the normal physiological function when the level of heavy metals exceeds in plants or animals. It can cause various acute and chronic effects in living organisms. Silybum marianum commonly known as milk thistle is used for varieties of liver diseases. Concentration of Fe 375 mg/kg is found high in the blue capitulum's seeds and concentration of Cr 49.80 mg/kg is present high in the white capitulum's seeds from district Sawabi. Less concentration of Zn 32.00 mg/kg is determined in the blue capitulum's seeds from Karak, while high concentration 30.00 mg/kg of Mn is noted in blue capitulum's seeds from Charsadda. Copper concentration 27.15 mg/kg is recorded in blue capitulum's seeds from Charsadda. High concentration of Cd 1.00 mg/kg is present in white capitulum's seeds from Khyber agency, while concentration of Pb is not detected in white capitulum's seeds collected from Karak district

Family planning methods and gender distribution of children in a defined rural community of Peshawar

To determine frequency of different family planning methods in rural community of Peshawar and to determine gender composition of children in women practicing family planning. Data was collected from family planning program started with health education and motivation in the model community of Pakistan Medical Research Council at the village Budhni, Peshawar. The family planning method along with age of women, numbers of male and female children were recorded. Injection was a method of choice used by majority [59%] of the women. Most of the women 157 [28.3%] started family planning practice were in the age group of 26-30 years. Number of women having up to 04 children was greater [54.4%] than women [45.6%] having more than 04 children. Most [54%] of them had two male children at the time of starting of family planning. Out of 40 women with one child, 70% had one male child and 30% had a female child. Women having more male children were more likely to adopt family planning practices

Prevalence of diabetes mellitus in rural adults of district Peshawar

In Pakistan, approximately 8 million people have diabetes mellitus, making it the fourth leading country in the list of world diabetic patients. To measure the prevalence of diabetes mellitus and its associated risk factors in a rural community of Peshawar. A cross-sectional study conducted in PMRC model research community village of Budhni. All adults over the age of 40 years residing in the specific village were selected for the study. During door to door visit, consent was taken from all the subjects and they were informed that a fasting blood sugar level would be checked a day or two later. All those who consented were interviewed according to pre-designed proforma and their height, weight and blood pressure were recorded using standard methods. Fasting blood samples were drawn the next day and sent to PMRC research laboratory where they were checked using Microlab 200 Merck. Data was analyzed using Epi Info version 6.0. According to American Diabetic Association criteria, fasting blood sugar level of >126 mg/dl was diagnosed. Estimated population of adults > 40 years in the village is 1249 individuals. Nine hundred nine [72.7%] consented to participate in the study. A total of 345 subjects were screened for diabetes using fasting blood sugar as the proxy indicator. Eighty one [23.4%] had blood sugar over 126 mg/dl and were therefore, diagnosed to be diabetic. Of these 81 cases 46[56.8%] were known diabetics while, 35[43.2%] were newly diagnosed. Majority [39] were between 51-60 years, followed by 29 between 40-50 years and remaining 13 subjects were above 60 years of age. Among the 46 known diabetics, 42[91.3%] were non insulin dependent and only 4[8.7%] were insulin dependent. The duration of diabetes was between 1-5 years in 26[57%] cases who were known diabetic's. Those individuals who were not sure about their exact duration of diabetes were 9[19%]. Cases with a family history of diabetes, were at twice more risk to develop diabetes as compared to those who had no family history [OR=1.86 [1.05

Clinical manifestations and risk factors of otitis media with effusion in children presenting in tertiary care hospital

This study was conducted to find out the pattern of presentation and the risk factors associated with otitis media with effusion, in three major tertiary care hospitals of Karachi. Prospective descriptive study. This study was conducted at three major tertiary care hospital of Karachi including Civil Hospital Karachi, Lyari General Hospital and Abbasi Shaheed Hospital, Karachi, over a period of two years from November 1998 to October 2000. Two hundreds and fifty patients diagnosed as otitis media with effusion have been included in this study. Otoscopic examination, tympanic membrane mobility with Siegel's pneumatic speculum, examination of the nose and throat, pure tone audiogram and tympanometry were done in all the cases. There were 140 male and 110 female patients with mean age incidence was 7.3 [ +/- 1.2] years. Hearing impairment was the commonest symptom present in 98% of the cases. Retracted tympanic membrane was noted in 151 cases [60.4%]. Enlarged adenoids were present in 115 cases [46.0%]. Average hearing loss on pure tone audiogram was found to be 23.4 dB. Myringotomy was required in 84 cases [33.6%]. The peak age incidence of otitis media with effusion in this study was impairment with retracted tympanic membrane was the commonest clinical presentation. Enlarged adenoids was the most common and important risk factor

Depressed skull fracture; Interrelationship between CT evaluation of and its clinical findings

The purpose of study was to interrelate CT findings of depressed skull fracture with clinical findings. This was exploratory study. The study was conducted at Mayo Hospital Lahore and Lahore General Hospital. From March 9,2004 to October 2004. Fifty patients irrespective of their age and sex were included. Only the newly admitted patients in the above mentioned hospitals were included in the study. Previously diagnosed depressed skull fracture or the patients having associated facial abdominal and thoracic injuries were excluded. Patients having depressed skull fracture were clinically evaluated and thereafter subjected to 4[th] generation spiral CT scan at the radiology department of the above mentioned hospitals. Both bone and brain window were taken for various intracranial structures. Analysis of the data for association between the variables of clinical and CT findings revealed that patients with conscious level, with DSF and having mild head injury were less associated with scalp injury [p=0.1156] which is statistically insignificant. DSF with moderate and severe head injury had more probability of scalp injuries. Scalp laceration seen with DSF had association with scalp injury [p<0.001]. It is a key for clinician and neurosurgeon to use GCS score in congestion with the CT findings for early management of DSF

Morbidity and mortality in children in rural community of district Peshawar

In Pakistan more than 20 million people are under five years age. The aim of this study was to determine the mortality rate, morbidity and its various causes in children of less than 5 years age in a rural community of District Peshawar. This descriptive study was conducted in the village Budhni of District Peshawar, from 1[st] January 2005 to 31[st] July 2006. Sampling technique was purposive. The data was analyzed in PMRC Research centre PGMI, Peshawar by using SPSS version 14. Descriptive statistics was given for qualitative variables and presented in the form of frequency and percentage. Two hundred and eighty-three children under 5 years age, presented to Budhni Health Centre during the study period. Male to female ratio was 1.9:1. Nine deaths occurred in children under 5 years during the study period. Most of the deaths 7[78%] were in the neonatal period. Among the diseases, acute respiratory infection was the leading disease comprising 27% of the total. Causes of death were neonatal jaundice [22%], diarrhea [11%], fits [11%], and unknown [45%]. Majority of deaths occurred in the neonatal period, which enhances the importance of antenatal care in the first month after birth. Infant/Child mortality in this region can be reduced by improvement in the health care system at peripheral level

Retrosternal goitre, presentation and treatment outcome

To assess the clinical presentation, surgical out come and complications of retrosternal goitre [RSG]. A descriptive retrospective study. Departments of Ear Nose Throat and Head and Neck Surgery, Fatima Hospital Baqai Medical University and Civil Hospital Dow University of Health Sciences Karachi, between January 2002 to March 2008. Twenty seven patients of both gender and different ages of retrosternal goitre who under went for thyroidectomy between January 2002 to March 2008 were studied regarding their clinical presentation, and surgical outcome. Only two [7.4%] of our patients were presented with acute air way obstruction. Six [22.2%] patients were complained of dsypnoea only in supine posture, dysphagia and hoarseness were noticed in 3[11.1%] and 1 [3.7%] patients respectively while fifteen [51.5%] were asymptomatic apart from the obvious neck swelling. Total thyroidectomy was performed in twenty two [81.4%] cases and lobectomy with isthemectomy was done in five [18.1%] patients. CT scan was done in seven [25.9%] cases. Majority of our cases i.e. twenty five [92.6%] were benign while malignancy was noted in only two [7.4%] cases. Complications noted was haematoma formation in one [3.7%], recurrent laryngeal nerve injury in four [14.8%], hypoparathyroidism [transient] was recorded in three [11.1%] patients, and wound infection was observed in two [7.4%] patients. There was no mortality pre and post-operatively and no case of permanent hypoparathyroidism was noted where as only one patient had permanent unilateral recurrent laryngeal nerve injury. Retrosternal goitre is often asymptomatic and thyroidectomy is the treatment of choice with very low mortality and morbidity

Osteolytic lesions in plasma cell myeloma

The purpose of this study was to evaluate the frequency of osteolytic lesions and their pathogenesis in plasma cell myeloma [PCN]. The study was conducted in Ghurki Trust Teaching Hospital [GTTH], Combined Military Hospital, Jinnah Hospital and a Private Clinic at Lahore from January 2002 to November 2007. A total of 26 indoor male and female patients from Orthopaedic, ICU and Medical wards were included in the study. Among these patients, 18 cases reported to GTTH, 2 each from CMH Lahore and JHL respectively and 4 cases reported to a Private Clinic. Clinical parameters were further differentiated into Male n=15; 57.6%, Female; n = 11; 42.3% and mean age was 63 year. Lymphadenopathy was seen in 5 patients [n=5, 19.2%], hepatomegaly in 8 patients [n=8, 30.7%], splenomegaly in 7 [n=7, 26.9%] and bone pain in 20 patients [n=20; 76.9%]. Osteolytic bone lesions as revealed by conventional X-ray skeleton was seen in majority of patients [n=17; 65.3%]. After fulfilling the criteria for the diagnosis of Plasma cell myeloma, frequency/ prevalence of osteolytic lesions were assessed and compared with clinical and laboratory parameters. Multiple osteolytic lesions revealed, by conventional radiography, were most commonly seen in the skull, verterbrae, ribs, pelvis and proximal long bones. However, use of MRI indicates that skeletal abnormalities exist in nearly all patients with myeloma. These osteolytic lesions evolve from imbalance between osteoblasts and asteoclasts interplay with primary derangement originating in bone marrow microenvironment. The basic stimulus is interaction of malignant plasma cells with bone marrow stromal cells and the production of different cytokines and growth factors. These inflammatory factors produce proliferation and differentiation of osteoclasts, inhibition of osteoblasts and formation of osteolytic lesions. The resultant demineralisation is manifested as raised serum calcium level