Presentation and management outcome of tibial infected non-union with Ilizarov technique

Objective: To document the presentation of tibial infected non-union and analyze the management outcome with Ilizarov technique in terms of bone results, functional outcome, bone transport time, external fixation time, external fixation index and any complications

Methods: This case series was conducted at the Departments of Orthopedic Surgery, National Institute of Rehabilitation Medicine [NIRM], Islamabad and Civil hospital, Quetta over a period of 3-years

Results: There were 56 patients with 53[94.64%] males and 3[5.35%] females. The age range was 16-50 years with a mean of 32.58+/-9.98 years. According to ASAMI criteria, bone results were excellent in 37[66%], good in 10[17.85%], fair in 6[10.71%] and poor in 3[5.35%]. The functional results were excellent in 37[66%], good in 9[16%], fair in 7[12.5%] and poor in 3[5.35%]. The bone union rate was 98.21%

Conclusion: Ilizarov method beautifully addresses the formidable issue of infected non union of tibia with good outcome in terms of bone healing and infection eradication. The treatment period is relatively lengthy and hence patience on part of patient as well as the surgical team is imperative for achieving favourable outcomes

Presentation and management of neglected developmental dysplasia of hip [DDH]: 8-years'experience with single stage triple procedure

Objective: To document the clinical presentation of neglected DDH and evaluate the outcome of triple procedure

Methods: It was a descriptive case series study, conducted at the Department of Orthopedic Surgery, National Institute of Rehabilitation Medicine [NIRM], Islamabad over a period of 8-years. It included children aged >1 and <9 years who underwent the triple procedure of open reduction, femoral shortening and Salter's osteotomy. Clinical evaluation was performed using McKay's criteria. Tonnis classification and Severin's scoring system were employed for the radiological evaluation

Results: There were 193 children with 213 DDH affected hips. The mean age was 3.31+/-1.6 years. The preoperative severity of the femoral head dislocation per Tonnis classification was Grade-I in 7.98%[n=17], Grade-II in 48.35%[n=103] and Grade-III in 43.66% [n=93] hips. The postoperative MacKay criteria was 'Good' to 'Excellent' in 193[90.61%] hips. The postoperative Severin's class was I in 113[53%] hips, II in 48[22.53%] hips, III in 43[20.18%] and IV in 9[4.22%] hips. The preoperative acetabular index ranged from 39 degree to 51 degree with a mean of 43.91+/-3.69 degree. The mean postoperative AI was 18.42+/-2.99 degree. The postoperative centre edge angle ranged from 21 degree to 26 degree with a mean 23.18 +/-1.35 degree

Conclusions: The single stage triple procedure offers the surgical remedy of choice with favourable results for managing neglected and late diagnosed DDH among children aged 1-8 years

Diagnostic accuracy of leukocytosis in prediction of acute appendicitis

An analytical study was conducted to find out the diagnostic accuracy of leukocytosis in predicting acute appendicitis in patients undergoing emergency appendicectomy. The degree of inflammation of the resected specimens was grossly assessed and graded into acute inflammation, acute inflammation with complications [such as gangrene, perforation, abscess] and un-inflamed appendix. The operative findings were correlated with leukocyte counts using 2 x 2 table. Out of 233 appendicectomies, with exclusion of the negative appendicectomies [17.59%, n = 41], there were 67.38% patients [n = 157] with elevated leukocyte count. The overall sensitivity, specificity, positive predictive value and negative predictive value of elevated leukocyte counts for inflamed appendix were 91.81%, 43.55%, 81.77% and 65.85% respectively

Informed consent for surgery: do our current practices conform to the accepted standards?

A qualitative investigation was undertaken to determine and analyse the pattern of existing practices regarding informed consent for surgery at PIMS, Islamabad. Adult postoperative patients who had undergone surgical interventions were randomly selected face-to-face with the help of a team of junior doctors. A questionnaire was employed for data collection and the responses of the patients to the questions regarding various attributes of the consent process were analysed. Overall inadequacy existed in the prevailing practices. There is a need to revisit the consent related practices and make the process more informed and adequate. Instead of taking it as a casual formality, our doctors should regard it as an equally important exercise equivalent to other components of care such as the surgery itself

Postgraduate medical education: residents rating the quality of their training

To determine the residents' rating of the quality of their residency training by measuring their level of satisfaction with the various educational attributes of their training. Cross-sectional survey. Department of Medical Education [DME], Pakistan Institute of Medical Sciences [PIMS], Islamabad, from September to November 2008. Residents who had been pursuing residency training for over a period of one year were included. A comprehensive questionnaire consisting of 14 questions was employed which covered fundamental attributes of the quality of postgraduate training. A five point response scale was used to rate responses to questions. Results for each of the measures of all the included residents were added up, and then an average was calculated and scaled to a score out of 100 to form the Index Score. In this way the residents' level of agreement or disagreement with the questioned statement was measured from 'Strongly disagree' [0%] to 'Strongly agree' [100%]. Out of a total of 150 residents contacted, 109 answered the questionnaire. The response rate was thus 73%. Residents variably rated the various educational attributes of their residency training. Relatively favourably rated areas included regular conduct of case/ topic discussions [75.96%], consultant's supervision during interventional procedures [70.27%] and regularly holding journal clubs [69.54%]. The less favourably rated areas included constructive feedback by supervisor [54.49%], consultant as role model [54.49%] and faculty as the source of learning [50.82%]. Overall, the Index Score was 60.55%. Significant room exists for improvement in the quality of residency training as indicated by the less than desirable ratings of the various educational attributes of the residency programme. Faculty members who constitute the cornerstone of educational process are pivotal to effect the desired improvements

Fatal toxic epidermal necrolysis induced by sodium valproate

A 26 years old manual labourer from Azad Jammu Kashmir presented with four days history of an extensive exfoliation of skin involving the entire body. Histology of the lesion showed epidermal necrolysis. The patient was a recently diagnosed case of epilepsy and had been started on therapy with sodium valproate three weeks ago. Following admission in our center, intensive care and wound care were instituted according to standard protocols. Despite all therapeutic measures the patient kept on deteriorating and developed multi-organ failure with pneumonia. He died on 7[th] day of hospitalization

Surgical presentation and outcome of parotid gland tumours

To assess the clinical presentation and outcome of surgical management of various parotid gland disorders requiring parotidectomy. Case series. Department of General Surgery, Pakistan Institute of Medical Sciences [PIMS], Islamabad, from January 2003 to December 2010. Patients presenting in surgical OPD with parotid gland disorders requiring parotidectomy were included. Data were obtained through the Hospital Management Information System [HMIS] and patient charts. The sociodemographic profile of the patient, presenting features among patients, benign versus malignant nature of the disease, FNAC reports, type of surgical procedure instituted, complications encountered and histology reports of the surgical specimens were all recorded on a proforma. The data were subjected to statistical analysis with SPSS version 15. Out of 126 patients, 62 [49%] were males and 64 [51%] females with mean age of 41 +/- 12.6 years. All had presented with a lump usually painless. One hundred and fourteen [90.47%] patients had benign pathology while 9.52% [n = 12] had malignanciy. Superficial parotidectomy was carried out in 79.36% [n = 100] patients, total parotidectomy in 19% [n = 24] and extended total parotidectomy was performed in 2 cases [with mucoepidermoid carcinoma]. The most common post-operative complication was greater auricular nerve paresis [n = 19; 15%] followed by facial nerve transient paresis [n = 10; 8%]. There was no in-hospital mortality. Parotid gland lumps commonly affect relatively young individuals of either gender. Most of the patients have benign pathology. Superficial parotidectomy is the most commonly offered surgical procedure. Parotid surgeries are safely performed in general surgery units with low morbidity and no mortality

burnt child: an epidemiological profile and outcome

To determine the epidemiologic pattern and outcome of childhood burns by finding the presenting features of the burn victims, causes / circumstances of burn injury, involvement of body area, need for hospitalization, duration of hospital stay and mortality. Case series. The Burns Care Centre [BCC], Pakistan Institute of Medical Sciences [PIMS], Islamabad, from January 2008 to June 2010. All children of either gender with burn injuries who were managed at the centre after primarily presenting to the study centre were included. Children over 15 years were excluded. Lund and Browder chart was used to calculate the total body surface area [TBSA] burnt. Children with extensive and critical burns, high voltage electric burns and those needing any surgical interventions were admitted for indoor management. Data were recorded on a proforma. A total of 1725 children were included in the study. Out of those, 66.84% [n=1153] were males and 33.15% [n=572] were females. The mean age was 5.04 +/- 2.78 years. Majority [67.47%] of children were aged 3-6 years. Scalds were the commonest burns [70.31%]. Household environment was the commonest site of acquisition of burns [91.47%]. Winter was the most frequent season of sustaining burn injury [63%]. The commonest anatomic regions affected were hands / upper limbs [65.68%]. Overall the affected mean TBSA was 9.37 +/- 9.61%, while for the hospitalized children it was 27.07 +/- 10.84%. Two hundred and ninety seven children [17.21%] were admitted. The mean hospital stay was 15.59 +/- 5.61 days. The mortality rate was 9.09% for the hospitalized children and 1.56% for the entire study sample. Male gender, age of 3-6 years and winter season were found to have an increased frequency of childhood burns. Scalds were the commonest type of injuries, and hands/ upper limbs were the most frequently affected body parts. There is a need to revisit the health care system and institute focused burn prevention strategies consistent with our local circumstances

Alvarado scoring system in prediction of acute appendicitis

To evaluate the diagnostic accuracy of Alvarado score for the prediction of acute appendicitis. Analytical study. This study was carried out in the Department of Surgery, Pakistan Institute of Medical Sciences [PIMS], Islamabad, during the period from January 15, 2009 to July 15, 2010. The study included all adult patients of either gender who presented with clinical findings suggestive of acute appendicitis, who were assigned Alvarado score of < 4 pre-operatively and subsequently underwent emergency appendicectomy with histological examination of the resected specimens. Based on the Alvarado score, the patients were stratified into two groups. i.e. Group I [with a score of > 7] and Group II [with a score of 5-7]. Alvarado score was compared with the histopathology. The data was subjected to statistical analysis to measure the objective. The overall sensitivity, specificity, positive predictive value and negative predictive value of Alvarado score for acute appendicitis were 66%, 81%, 96%, 29% respectively. The sensitivity was higher though not significant, for males with a score over 7 than females with similar scores [97% vs. 92%]. However, for scores less than 7, sensitivity among males was significantly higher than females with similar scores [79% vs. 61%; p < 0.05]. The presence of a high Alvarado score in adult males is highly predictive of acute appendicitis, however, in women of child bearing age other causes of similar clinical presentation lead to a low diagnostic accuracy of the score

Vacuum-assisted closure therapy as a pretreatment for split thickness skin grafts

To evaluate the effect of vacuum-assisted closure [VAC] therapy on wound management by measuring the graft take, wound healing time, need for any re-grafting and duration of hospitalization. Single blinded randomized controlled trial. This study was carried out in the Department of Plastic and Reconstructive Surgery, Pakistan Institute of Medical Sciences [PIMS], Islamabad, from October 2007 to December 2009. A total of 100 adult patients of either gender with acute traumatic wounds were included. Patients who needed flap coverage as the primary intervention, and those with Diabetes, malignancy, bleeding diathesis were excluded. Half of the patients were randomly assigned to the intervention group and the rest to the control group with lottery method. All wounds were initially subjected to thorough excision. Wound bed preparation for STSG [split thickness skin graft] was achieved using 10 days pre-treatment with VAC dressings in the intervention group while employing normal saline gauzes in the control group. All patients were subsequently treated with STSG. The primary outcome measure was graft take while the secondary outcome measures included wound healing time, need for any re-grafting and duration of hospital stay. Results were compared in both groups using chi-square test. Marked differences were found in favour of the VAC therapy group with respect to the various wound management outcome measures studied. i.e. graft take [greater than 95% graft take in 90% of VAC therapy group vs. 18% of controls], wound healing time [2 weeks postgrafting in 90% of VAC therapy group vs. 18% of controls], need for regrafting [none among VAC therapy group vs. 8% of controls] and duration of hospital stay [less than 3 weeks in 90% of VAC therapy group vs. 18% of controls]. VAC therapy should be employed in the pre-treatment of wounds planned to be reconstructed with STSG, since it has marked advantages in the wound bed preparation compared with the traditional normal saline gauze dressings

Residents-perceptions of their working conditions during residency training at PIMS

To determine the residents Persephone of their current working considerations by measuring their level of satisfaction with the existing pattern workload, working environment and residential / financial standards. Cross-sectional survey. The Department of Medical education, Pakistan Institute of Medical sciences [PIMS], Islamabad, during Sept. and Oct 2008 Residents of different specialties who had been undergoing residency one year were indicated. A questionnaire was employed which addressed three components of residency program including workload, working enorronment anal financial and residential as pear of training. Supplement question regarding impression of the overall working environment was asked. A five point response scale was used to rate responses to the questions in each of the three components of residency programme. Response rate was 73%. Among the 109 respondents, 74 [68%] were males while 35 [32%] were females. Seventy three [67%] were pursuing FCPS and 36 [27%] were pursuing other degree programmes including MS, MD, MCPS and M.Phil. The age range was 25 to 41 years with a mean of 31.60 +/- 4 years. Working environment was the highest rated area with index score of 67%. Financial and residential aspect of training was the lowest rated area with a score of 37%. Workload's index score was 46.78%. The overall working index score was 26.23%. Residents perceived marked problems with their working conditions as indicated by their unfavourable ratings of the various components of the residency programme. There were problems with workload, duty hours, working environment, income and accommodation. Further research is needed to confirm and improve upon these results

Pattern of satisfaction among neurosurgical inpatients

To measure satisfaction among patients receiving indoor neurosurgical care and analyse the profile of the dissatisfied patients. Cross-sectional study. This study was undertaken at the Department of Neurosurgery, Pakistan Institute of Medical Sciences [PIMS], Islamabad from March to April 2005. A total of 133 patients were included in the study by convenience sampling technique. All the patients, who received indoor care for a minimum of 24 hours and were discharged home, were included in the study. Patients who remained hospitalized for more than 4 weeks and those not consenting to participate were excluded. A questionnaire was used for the study that covered five fundamental areas of hospital care i.e. availability and behaviour of the staff, communication of information, residential and management issues. A five-point response scale was used to rate responses to the questions in each of these areas. The demographic profile of the patients and respondents, mode of admission, diagnosis, operation and duration of hospitalization were also recorded. The average of the responses to the questions in each of the five areas was taken as the fundamental area score [FAS] and the average of all these individual area scores was taken as the patient satisfaction score [PSS]. Overall satisfaction index [OSI] was measured by calculating the average of PSS, willingness to return score and willingness to recommend score. Response rate was 100%. Generally, patients were satisfied with care and rated various areas favourably. Behaviour of the staff was the highest rated area [95% score] while management was the lowest rated area [86.97% score]. Dissatisfaction was more frequent among the young, the educated, the male and the relatives. The PSS was 91.32%. Willingness to return score was 97.89% while willingness to recommend score was 95.48%. The OSI was 94.89%. Analysis of patients' dissatisfaction over specific aspects of health care serves to identify areas that could be improved by simple interventions, hence, patient satisfaction surveys should be conducted on regular basis in order to utilize patients' critical feedback for achieving service excellence and improved quality of care

Mesenteric lipoma leading to small gut strangulation and short gut syndrome

A rare case of mesenteric lipoma was presented to us as acute abdomen. His abdominal x-ray showed dilated small gut. Ultrasonography of abdomen revealed dilated small gut loops and minimal amount of free fluid in the peritoneal cavity. On exploration, most of the small gut was gangrenous and tightly twisted twice around its mesentery that contained a lump which was confirmed as lipoma on histopathology