Hemodialysis internal jugular vein versus subclavian vein catheters: complications, patients' comfort, tolerance and cost-effectiveness

Objective: To compare hemodialysis [HD] internal jugular vein [IJV] versus subclavian vein [SCV] catheters in terms of procedural complications, patients' comfort, tolerance and cost effectiveness

Methods: Sixty six consecutive eligible adult patients planned for hemodialysis @ 3 sessions/ week for maximum 42 days in a private hospital at Sialkot, Pakistan were documented between March 2017 and April 2018. A group, IJV or SCV catheter was allotted to alternate subjects. The catheters were inserted as per practice guidelines. Record of catheter-related complications [CRCs] was computerized. Similarly, patients' uncomfortability and expenditures on management of CRCs were recorded

Results: Of 66 cases, 62 [93.9%, 31/group] successfully completed the study. Baseline information showed male predominance [n = 47, 75.8%], age [M = 47, range 24-75 years] or catheter stay time [M = 40 days]. The rate of vein damage or artery puncture was found higher in IJV than SCV group [[13.9 vs. 6.5%] or [9.7 vs. 3.2%], respectively] during catheterization. The difference also existed in late CRCs such as bacterial infection [32.3 vs. 16.1%], or device dysfunctioning [9.7 vs. 3.2%] with an exception of mechanical kinking. All the patients of IJV or SCV group with missed [19.4 vs. 6.5%] or shortened HD sessions [22.6 vs. 12.9%] reported CRCs-based discomfort as a cause of the regularity. Moreover, the participants of IJV group consumed 69% of the total expenditures on CRCs management

Conclusion: SCV is a better site for HD catheterization as it has comparatively lesser likelihood of complications, patients' feel comfortable and it is also cost-effective.than IJV

Molecular basis of quinolone resistance in clinical isolates of Klebsiella pneumoniae from Pakistan

Antibiotic resistant Klebsiella pneumoniae, is associated with various nosocomial infections that are difficult to treat. This study is designed to find out the patterns of resistance against commonly used antibiotics in K. pneumoniae clinical isolates with special attention to fluoroquinolones. A total number of 200 K. pneumoniae clinical isolates collected from various tertiary care hospitals of Punjab, Pakistan for a span of 1 year were investigated. Isolates were identified biochemically and genetically using VITEKR system and species-specific PCR, respectively. Antibiogram of isolates was studied by using disc diffusion and broth micro-dilution assays. Highest infection of K. pneumoniae detected in urinary tract [43%] followed by respiratory tract [25.5%]. Most of the isolates displayed strong resistance against ampicillin, cefotetan, tazobactam, cefuroxime, cefixime, ceftriaxone, ampicillin-sulbactam imipenem, meropenem, ciprofloxacin and moxifloxacin, while sensetive to cefotaxime. Chromosoaml mutation was deteted in gyrA gene, gyrA harbors a strong mutation which provides resistance against ciprofloxacin by substituting Ser83 -> Ile. However, no mutation was detected in gyrB gene. Moreover, qnrB1 plasmid born resistant gene was only detected among qnrA, qnrB and qnrS. The story depicts an alarming situation of antibiotic resistance among K. pneumoniae associated with various nosocomial infections

Molecular detection of blaVIM Metallo-beta-lactamase producing clinically isolated Pseudomonas aeruginosa from tertiary care hospital, Faisalabad

Metallo-beta-lactamases [MBLs] producing Pseudomonas aeruginosa are major threat for public health. They produce resistance against various antibiotics and remain low or no therapeutic options. A total of 200 clinical isolates of P. aeruginosa were collected from tertiary care hospital, Faisalabad. Isolates were sub-cultured on basic and selective media and confirmed by API 20NE. Phenotypic detection of carbapenamase, MBLs, antibiogram and MIC were determined as per CLSI guidelines. Molecular detection of blaVIM was performed using specific primers by PCR. Among 200 P. aeruginosa, majority [n=82] were isolated from pus samples followed by 28 from tracheal aspirates and 27 from sputum. Out of 110 [55%] MDR P. aeruginosa, 12 [11%] were positive for MHT and MBLs and blaVIM was identified in MBL positive isolates. Antibiogram revealed that all the isolates were resistant to beta-lactam drugs including carbapenems followed by 95% to levofloxacin, 67% to doxycycline and more effective drugs were tigecycline and colistin. MIC value for imipenem drug was 16micro g/mL and 8micro g/mL against 6 and 5 isolates respectively while MIC value for meropenem against 6 and 3 isolates were 8micro g/mL and 16micro g/mL respectively. Our study concluded the high prevalence of blaVIM producing P. aeruginosa in our clinical settings

Efficacy of tamsulosin alone versus tamsulosin phloroglucinol combination therapy for medical expulsion of lower ureteral calculi

Objective: To see whether phloroglucinol-added tamsulosin therapy exhibits better efficacy than tamsulosin alone in medical expulsion of lower ureteral stone [LUS]

Methods: Sixty four consecutive adult patients presented in a urological setting at Sialkot, Pakistan between January 2015 and December 2016 with solitary, unilateral 3-8mm sized lower ureteral stone [reported by noncontrast computed tomography of the kidney-ureter-bladder] were documented. Group either study or control was allotted, randomly. Same 0.4 mg tamsulosin, once daily was given to all the participants. However, additional 40 mg phloroglucinol, thrice daily was advised for study group [n = 32]. The therapy terminated on confirmation of stone expulsion otherwise continued for 6 weeks. Patients were asked to use 50 mg diclophenac Na on colic episode

Results: Demographic characteristics revealed 81.2% [n = 52] male patients while age statistics as M = 42.3, SD = 5.93 [range 32-60] years. The study group showed higher stone expulsion rate [100%] and time to expulsion [M = 10.34 days] than control. The values were statistically significant [p = .02 and p = .0001; X2 test in SPSS]. Similarly, combination therapy had advantage on mono therapy for reporting statistically lesser numbers of colic episode [p = .03] and consumption of analgesic [p = .02]. A marked difference in rate of adverse effects i.e. 68.8 vs. 90.6% was observed in study and control groups

Conclusion: Phloroglucinol-added therapy is a better choice for expulsion of LUS than tamsulosin alone with reference to stone expulsion rate and medication time

Multi drug resistant salmonella typhi resistant to ceftriaxone isolated in a tertiary care hospital

Enteric fever is a systemic infection caused by Salmonella typhi and Salmonella para-typhi A and B. It is a major cause of morbidity and mortality worldwide. Multi-drug resistant [MDR]S. typhihas been reported since 1997 rendering the primary anti-typhoidal drugs and the fluoroquinolones as no longer a choice for typhoid treatment, thus leaving Ceftriaxone as the mainstay for enteric fever treatment. There are reports of emerging resistance to Ceftriaxone from many Asian countries. We report the first case of Ceftriaxone ResistantS. typhi from Children hospital, PIMS.A four-and-a-half-year-old girl presented with fever, abdominal pain and loss of appetite for last one month. Systemic examination revealed abdominal tenderness and mild hepatomegaly. The Typhidot test was positive for IgM. Blood culture was initially done in BACTEC 9050, [Automated blood culture system by B.D.] and was positive after 24 hours' incubation at 35[degree]C. This sample was later sub culturedon Blood and MacConkey'sagarand showed S. typhi colonies which were further confirmed by api, [analytical profile index, by Biomeurex, Italy]. Sensitivity was applied according to Kirby Bauer's Disc diffusion method using CLSI 2016 guidelines,and the organism was found sensitive to only three drugs: Augmentin, Chloramphenicol and Imipenem. The patient was treated with Imipenem intravenously and recovered.MDRS. typhi is on the rise worldwide and effective surveillance methods need to be brought into action to curtail these resistance trends

Serum lipids - a modifiable risk factor for senile cataract

To identify the role of serum lipids in patients with different types of senile cataract. It was an observational case control study in a tertiary care centre in the city of Lahore, Pakistan. Fifty patients with senile cataract and fifty control individuals were selected. History taking with ophthalmic and systemic examinations were done. Fasting serum samples were taken for estimation of lipid profile from all the subjects. In the patient group, female to male ratio was 1.63:1. 78% patients had nuclear cataract, 16% had cortical and 6% had posterior sub capsular type of senile cataract. Serum Triglycerides, cholesterol, LDL, HDL and VLDL of patients were compared with controls. The p-value of cholesterol, LDL and HDL was non-significant. Serum triglycerides and VLDL were significantly raised in patients of senile cataract [p. <0.001]. Serum Triglycerides and VLDL are modifiable risk factors in the development of senile cataract in Pakistani patients. Serum Triglycerides is the only lipid, which has shown consistent results related to cataract development in different parts of the world. Other lipids show variable results in different countries

Spontaneous splenic rupture secondary to metastatic malignant spindle cell tumour

We report a case of pathological splenic rupture as a manifestation of malignant metastatic spindle cell tumour. To the best of our knowledge, this is the first case report of an atraumatic-pathological rupture of the spleen secondary to metastatic malignant spindle cell tumour. A 63-year-old man with a previous history of right upper limb amputation for an axillary malignant spindle cell tumour was admitted with an acute abdomen. Computed tomography showed a ruptured spleen. The patient subsequently underwent splenectomy. Histopathology confirmed the presence of malignant metastatic spindle cell tumour. Pathological splenic rupture is a rare manifestation of metastatic malignant spindle cell tumour. Background oncological history and thorough examination of the musculoskeletal system may provide important clues to make a prompt diagnosis.

The role of perioperative warming in surgery: a systematic review / O papel do aquecimento perioperatório em cirurgia: uma revisão sistemática

OBJECTIVE: The objective of this review was to systematically analyze the trials on the effectiveness of perioperative warming in surgical patients. METHODS: A systematic review of the literature was undertaken. Clinical trials on perioperative warming were selected according to specific criteria and analyzed to generate summative data expressed as standardized mean difference (SMD). RESULTS: Twenty-five studies encompassing 3,599 patients in various surgical disciplines were retrieved from the electronic databases. Nineteen randomized trials on 1785 patients qualified for this review. The no-warming group developed statistically significant hypothermia. In the fixed effect model, the warming group had significantly less pain and lower incidence of wound infection, compared with the no-warming group. In the random effect model, the warming group was also associated with lower risk of post-anesthetic shivering. Both in the random and the fixed effect models, the warming group was associated with significantly less blood loss. However, there was significant heterogeneity among the trials. CONCLUSION: Perioperative warming of surgical patients is effective in reducing postoperative wound pain, wound infection and shivering. Systemic warming of the surgical patient is also associated with less perioperative blood loss through preventing hypothermia-induced coagulopathy. Perioperative warming may be given routinely to all patients of various surgical disciplines in order to counteract the consequences of hypothermia.

OBJETIVO: O objetivo desta revisão é analisar sistematicamente os ensaios sobre a eficácia do aquecimento perioperatório em pacientes cirúrgicos. MÉTODOS: Uma revisão sistemática da literatura foi realizada. Ensaios clínicos sobre aquecimento perioperatório foram selecionados segundo critérios específicos e analisados para gerar dados sumativo expresso na diferença média padronizada (standardized mean difference, SMD). RESULTADOS: Vinte e cinco estudos englobando 3.599 pacientes de várias disciplinas de cirurgia foram obtidos a partir de bases de dados eletrônicas. Dezenove ensaios aleatórios em 1.785 pacientes qualificados para esta revisão. Nenhum grupo de aquecimento desenvolveu estatisticamente significativa hipotermia. No modelo de efeito fixo, grupo de aquecimento tiveram significativamente menos dor e menor incidência de infecção na ferida quando comparado com o grupo de não-aquecimento. No modelo de efeito aleatório, grupo de aquecimento também foi associado a um menor risco de tremores pós-anestesia. Em ambos os modelos de efeitos fixos e aleatórios, o aquecimento foi significativamente associado com menor perda de sangue. No entanto, houve significativa heterogeneidade entre os ensaios. CONCLUSÃO: O aquecimento perioperatório de pacientes cirúrgicos é eficaz na redução da dor pós-operatória ferida, infecção ferida, e tremores. O aquecimento sistêmico do paciente cirúrgico também está associado com menor perda de sangue no perioperatório prevenindo hipotermia e induzindo coagulopatia. O aquecimento perioperatório pode ser administrado rotineiramente a todos os pacientes cirúrgicos de diversas disciplinas, a fim de neutralizar as consequências da hipotermia.

Frequency of risk factors for breast cancer

[awaissabir2000@yahoo.com] To evaluate the frequency of risk factors for breast cancer. Main outcome measures were the above-mentioned risk factors in 50 diagnosed cases of breast cancer. Descriptive study. Surgical Unit-III, Nishter Hospital Multan. 50 female patients with proven diagnosis of breast cancer were evaluated with special emphasis on etiological risk factors. Findings were recorded in the proforma and results obtained were compared with national and international studies. 60% patients were in age group of 35-55 years, 50% had age of menarche 11 years, age of first full term pregnancy was between 15-25 years in 64% cases 60% patients belonged to lower middle class. 8% patients had family history of breast cancer. 56% patients had age at menopause above 50 years. No patient gave past history of breast cancer. It was concluded that in area of Multan, breast cancer is more common in patients having age between 35-55 years, early age of menarche, lower middle socio-economic status and late menopause

Risk factors in the causation of duodenal ulcer perforation in region of Southern Punjab

Despite the wide spread use of gastric antisecretory agents and eradication therapy, the incidence of perforation of duodenal ulcer remains more or less the same [5 10%]. There are certain well-defined risk factors that indicate, an increased liability to develop the disease The association of various probable risk factors such as H. Pylon, inadequate dietary intake, smoking, alcohol, ABO blood group and non-steroidal anti-inflammatory drugs has been studied. To evaluate the probable risk factors for perforation of duodenal ulcer, highlighting any prevalent one in the occurrence of perforation in our region. Study design:-Descriptive/Retrospective study. 3[rd] surgical unit Nishter Hospital Multan. Subjects:-All the patients having DU perforation were included. 62 patients with DU perforation were evaluated with special emphasis on etiological risk factors. Findings were recorded in the proforma and results obtained were compared with national and international studies. Stress, Smoking, NSAIDs and H. Pylori are the important factors in the causation of duodenal ulcer perforation. In our series stress is involved in 80% of cases. Followed by smoking [69%], H. Pylon [64%] and NSAIDs [55%]. Stress, smoking; H-Pylon infection and NSAIDS abuse are the factors in southern Punjab which cause perforation of duodenal ulcer

Application of alvarado scoring system in diagnosis of acute appendicitis

Appendicitis is an important differential diagnosis in patients with right iliac fossa pain. Acute appendicitis is one of the most common surgical emergencies with a life time prevalence of approximately 1 in 7[2]. To analyze the Alvarado score in relation to the diagnosis and management of acute appendicitis. This study was carried out in Surgical Unit III, Nishtar Medical College/hospital Multan. The study period was from January 2003 to December 2005. Sample size consisted of 100 patients. All these patients presented in A and E department Nishtar Medical College. Hospital Multan. Patients of any age group and both genders presenting to the emergency department with pain in right lower quadrant of abdomen were included in the study. Patients with presentation of urological, gynecological or surgical problems other than appendicitis and especially patients with mass in right iliac fossa were excluded from the study. Only 11 patients had increased severity of symptoms with score 7 or more on reevaluation with in first 24 hours. These 11 patients underwent appendicectomy. Operative findings and histopathological reports showed that 6 patients had inflammed appendix and the remaining 5 patients had normal appendix. Total number of surgeries performed in our study was 73 [73%]. Among these patients 42 were males and 31 were female. Operative findings and histopathological reports showed that 64 patients [87.68%] had inflammed appendix. Negative appendicectomy rate in our study was 12.32%. In our study we found the positive predictive value for Alvarado Score is 87%. The Alvarado score can be used as an objective criterion in selecting patients for admission. Its application improves diagnostic accuracy and consequently reduces negative exploration and complication rates

Beneficial effects of magnesium supplementation in diabetes mellitus - an animal study

The study was carried out on alloxan - induced diabetic rabbits to demonstrate the effects of oral magnesium salt on metabolic homeostasis. Eight days after alloxan administration to rabbits, sufficient hyperglycemia [259 + 26mg/dl] was detected. With the passage of days, we observed severe hypomagnesemia and as well as hypokalemia in diabetic placebo group. Serum calcium levels, however, remained within the normal limits. Supplementation of oral magnesium salt upto 10 days, corrected the abnormal deficiencies of the electrolytes. Compared with 5mg magnesium, 10 mg magnesium/kg body weight/day was found to be the better oral dose for normalizing the mineral homeostatis. Clinically the lipid profile was also improved significantly by magnesium supplements. Furthermore, the highest glucose concentration [301 + 35 mg/dl] was found in diabetic placebo group in the end of the study. However, in groups of diabetic animals receiving magnesium salts, though the glucose levels could not be controlled but did not increase and remained within constant moderate hyperglycemic states as had been observed in the beginning after alloxan administration. The study concludes that oral magnesium has beneficial effects on biochemical homeostasis and should be supplemented in hypomagnesemic diabetics along with classic hypoglycemic agents

Magnesium levels and diabetic retinopathy

We measured magnesium levels in 85 diabetic patients with diabetic retinopathy. Compared with controls, these patients showed a significant decrease in plasma magnesium level [P<0.02] and an increase in urinary magnesium level [P<0.05]. This tendency was most significant in the sub-group of poorly controlled diabetics, whose fasting plasma glucose was above 250 mg/dl. Reduced levels of magnesium in plasma and in erythrocytes were found to be more pronounced in patients with proliferative diabetic retinopathy than in those with no retinopathy or with background retinopathy only. [Pakistan Journal of Ophthalmology 9:3-5, January, 1993]

Role of magnesium in the management of hypertension

Twenty-two patients receiving long term diuretic treatment for arterial hypertension [19] and congestive heart failure [3] received magnesium chloride 10 mmol/day for four months. Both systolic and diastolic pressures decreased significantly, by a mean of 13 +/- 9 mmHg. No significant changes were recorded in serum or urinary electrolytes except for magnesium

Effect of alloxan-induced diabetes on serum electrolytes and lipids in rabbits

Effect of alloxan on serum glucose, electrolytes and lipids was observed in 20 induced-diabetic rabbits. Thirteen days after alloxan administration sufficient hyperglycemia was detected and the serum levels of magnesium and sodium were lower significantly. Out of 20, eight Rabbits [40%] developed marked hypomagnesemia and hyponatremia which were inversely associated with the degree of hyperglycemia. Serum HDL-cholesterol was also decreased and triglycerides increased statistically. However, the difference in the mean values of total cholesterol, calcium and potassium were found to be non-significant after alloxan injection

Study of magnesium and its correlations in diabetic patients

Fasting concentrations of magnesium and related parameters were measured in 90 diabetic patients categorizing into insulin treated [34], non-insulin treated [40] and untreated diabetics [16]. Compared with age and weight matched 42 control group, serum concentrations of magnesium were significantly lower in untreated [P<0.02] and overall diabetic patients [P<0.05]. The concentration was the lowest in the insulin-treated group [P<0.01]. There was significant increase in the values of urine magnesium/day in non-insulin treated [P<0.02] and overall diabetics [P<0.02] as compared to controls. Maximum urinary loss of magnesium [7.4 mEq/day, P<0.01] was found in patients of untreated diabetes mellitus. In all diabetics, serum magnesium concentrations were inversely related to serum glucose values [Sigma = -0.34, p < 0.02] and in non-insulin treated and overall diabetics to insulin concentrations [Sigma = -0.21, p < 0.05] and Sigma = -0.19, P < 0.05 respectively]. There was again a negative correlation of serum magnesium with glycosylated haemoglobin [HbAic] in insulin treated [r = -0.61, p < 0.02] and overall diabetics [r = -0.46, p < 0.02]. Serum magnesium was positively correlated with age [Sigma = -0.36, p < 0.02] and inversely related with ketone bodies [Sigma = - 0.28, p < 0.05] when results for all groups of diabetics were pooled

Effect of oral and injectable contraceptives on low density and high density lipoproteins

Low density and high density lipoproteins [LDL] were measured in 50 women taking oral contraceptives and 40 women taking injectable contraceptives for the period of 2-12 months regularly. Compared with control group of 20 women, oral contraceptive users were found to have significantly higher serum levels of total LDL, LDL - cholesterol and significantly lower levels of HDL-cholesterol. However, the mean values of these parameters in group of women on injectable contraceptive, were almost identical with the controls

Psychiatric symptomatology in climacterium

A study of Psychiatric Symptomatology in 20 women in Climacterium is presented. Apart from the vasomotor symptoms they complained of sadness, nervousness, insomnia, headache, irritability and anorexia. None of them had any such complaints before. The menstruation, pregnancies and puerpeure of these women were uneventful. Characteristics of a flush have been documented. The cultural beliefs as reported by the patients concerning the effects of menopause on women's health have been described