Outcome of chronic kidney disease patients on the basis of referral to nephrologist: a one-year follow-up study

Objective: To determine the outcome of chronic kidney disease [CKD] patients presenting for dialysis on the basis of referral to nephrologist. Study Design: Observational study. Place and Duration of Study: Nephrology Department of King Edward Medical University/Mayo Hospital, Lahore, from January 2014 to January 2016

Methodology: All patients who were presented in nephrology outpatients department and with the indication of dialysis were included in study. Patients who refused dialysis, and with acute kidney failure were excluded from the study. Proforma was designed for demographics, vital signs, volume status, and laboratory data [hemoglobin, urea, creatinine, albumin, bicarbonate etc.] of all the patients. On the basis of referral, patients were divided into two groups, i.e. early referral and late referral. Early referrals were those patients who were referred to a nephrologist more than three months before dialysis initiation. Late referrals were those patients who were referred to a nephrologist less than three months before dialysis initiation. Patients were followed up at one, three, six, and 12 months for outcome, i.e. still on dialysis or died

Results: One hundred and seventy-six patients were enrolled in the study, and 141 were followed up to one year. Seventy two [51.1%] patients were male, 69 [48.9%] were female and most [n=69, 48.9%] were in the middle age group. Major causes of end-stage renal disease [ESRD] were hypertension 70 [49.6%] and diabetes mellitus 66 [46.8%]. Seventy-six [53.9%] patients were in fluid overload and acidotic [n=123, 87.2%]. Twenty-seven [19.1%] patients were referred early and 114 [80.9%] were referred late. Overall mortality was 78 [55.3%] at one year. Factors affecting mortality were financial status and metabolic acidosis, but not referral. Temporary access for hemodialysis has 1.38 times more risk for mortality than the patients with permanent access

Conclusion: There is no difference on the outcome of dialysis patients on the basis referral to nephrologist. Factors affecting overall mortality in both groups were financial status, metabolic acidosis, and temporary access for dialysis. Most of the patients were referred late to the nephrologists

Efficacy of gauze-based negative pressure wound therapy after split-thickness skin graft in the care of large wounds

Background: Negative-pressure wound therapy [NPWT] or vacuum dressings involve the application of a controlled negative pressure on the wound. Traditionally, STSGs were fixed with Bolster technique, where sutures are used to fix pressure dressings over the top of recently placed grafts. Taking it a step further in our study we applied an effective and user friendly filler material [surgical roll gauze] on very large defects. The objective of this study was to assess the clinical efficacy of gauze-based negative pressure wound therapy as an adjunctive therapy to STSG, over complex and very large wounds

Material and Methods: This descriptive study was conducted at Army Burn Center, Combined Military Hospital Kharian and PNS Shifa Hospital Karachi from January 2016 to June 2017. Gauze based VAC system used. Negative pressure was applied at -80 mm Hg. Evaluation was carried out to assess the performance of gauze-based NPWT

Results: Total of 63 patients, 42 males and 21 females, with mean age of 32 years SD+15 were included in the study. The wound size included in the study ranged from 12x10 cm to 88x66 cm. Mean duration of NPWT dressings was 15 days and 313 dressings were employed in total with satisfactory healing achieved in 3 to 4 VAC dressings in most of the cases. Mean duration of hospital stay was 23.92 days at which point graft uptake percentage was in the range of 90% [n=7] to 100% [n=20]. Only 3.2% [n=2] cases required partial re-grafting for complete coverage of residual wounds

Conclusion: Gauze-based Negative-pressure wound therapy over split thickness skin graft is a cost-effective addition to the care and management of large and complex wounds

Skin sparing mastectomy and immediate breast reconstruction

To evaluate skin sparing mastectomy[SSM] and immediate breast reconstruction[IBR] in terms of the survival, chances of recurrence, aesthetic restoration and prevention of psychosocial problems. An interventional study. The Department of Plastic and Reconstructive Surgery, CMH, Rawalpindi from November 1998 to November 2003. Twenty-eight patients of breast cancer, included in the study, were discussed in a Multidisciplinary Breast Clinic. Detailed metastatic work-up was performed. In all patients SSM with en-bloc level II axillary clearance and IBR was done. The patients' age ranged between 25-46 years. Two patients [7%] were nullipara. Tumor size was T1 in 10 [36%] and T2 in 18 patients [64%]. In all the patients a circum-areolar incision was used. A contralateral uni-pedicled TRAM flap was used in 24 [86%] and latissimus dorsi flap in 4 patients [14%]. All the flaps survived completely. There was marginal necrosis of native skin flaps in 03 [10.5%], infection in 03 [10.5%], axillary seroma in 03 [10.5%] and abdominal seroma in 01 patient [3.5%]. As late complication 5 patients [19%] developed fat necrosis. Adjuvant chemotherapy was given in 6 [21%] and adjuvant radiotherapy in 4 patients [14%]. No recurrence encountered in maximum follow-up. We found an excellent aesthetic restoration in 23 [82%], good in 1 [3.5%] and fair in 4 patients [14%]. SSM for patients with early breast cancer is an oncologically safe procedure. IBR can greatly reduce the psychological trauma associated with breast loss including diminished feelings of feminity, decreased libido, social behavior, sense of mutilation and depression