Pattern of patients and diseases during mass transit: the day of Arafat experience

Every year 2-3 million Muslims gather for a few days around the Holy city of Makkah in Saudi Arabia to perform Hajj. Managing enormous health issues associated with such a mass gathering requires a very vibrant health delivery plan. Related research is part of the strategy. This study was done to assess the pattern of patients and illnesses encountered at one health facility at Arafat on the 2nd day of Hajj, when all the pilgrims move from Mina and stay in Arafat for a few hours . The objective of the study was to provide input so that recommendations can be given for future improvement of health care during this mass transit. All patients reporting sick to the Nimra Hospital on the Day of Arafat were included and documented on a detailed Performa and analyzed. We received 211 patients, essentially all of those were in need of acute medical intervention. Acute severe asthma and injures were the major problems encountered. There were two deaths both related to heat stroke. Patients received were predominantly Arabic speaking. Only those needing acute intervention seek medical advice during transit. Well equipped and staffed health facilities are, however, needed to cater these and for any mass casualties. Pre Hajj training and mandatory Flu vaccination can help

Aspiration of breast abscess through wide bore 14-gauge intravenous cannula

To aspirate breast abscess through a wide bore [14-gauge] intravenous [I/V] cannula and determine its efficacy in terms of the number of recurrences and number of aspirations. Case series. Dow University of Health Sciences and Civil Hospital and Bantva Hospital, Karachi, Pakistan, from January 2009 to December 2011. Patients with breast abscesses confirmed on ultrasound without skin ulceration were selected. The soft area of breast abscess with positive fluctuation was marked and fixed with index finger and thumb. A 14-gauge cannula was inserted. Pus was aspirated through a 50 cc syringe, repeated till no aspirate could be obtained. All patients were followed weekly for 4 weeks, clinically for size of lump, local tenderness and temperature, while complete resolution was confirmed on ultrasound, as resolution of the lesion. A total of 55 patients were included in this study. Mean age was 29 +/- 5.58 years while ranging from 20 - 40 years. Complete resolution of abscess was seen in 31 [56.4%] cases by single aspiration. Second aspiration was required in 24 [43.6%] patients and third aspiration in single setting was required in one case only. Recurrence after the second aspiration occurred in 08 [14.5%]. Incision drainage was required in 7 [12.7%] patients. Percutaneous aspiration of breast abscess through a wide bore [14-gauge] I/V cannula is a simple alternative to incision and drainage

Indications and outcome of small and large bowel stomas in emergency intestinal surgery

To evaluate the indications and outcome of small and large bowel stomas made during emergency intestinal surgery. Cross sectional study. Dow University of Health Sciences Civil Hospital Karachi, from January 2006 to December 2012. All emergency exploratory laparotomies performed for intestinal surgery, managed by stoma were included in this study. Decision for making stoma was based upon etiology, condition of the gut and judgment of the operating surgeon. Total numbers of patients were 200 [male 114, female 86] with mean age of 32.7 year. Trauma was the most common etiology. Firearm injury was the commonest mode [n=67, 33.5%] followed by stab wounds and blunt trauma [n= 12, 6.0%]. Patients also presented with perforation leading to peritonitis [n=65, 32.5%] and intestinal obstruction [n=52, 26%]. Tuberculosis was diagnosed in 5 [26.5%] patients, typhoid perforations in 35 [17.5%] and malignancy in 30 [15%] cases. The mortality in this series was 10%. Wound infection occurred in 42 [21%], burst abdomen in 10[5%] and enterocutaneous fistula and stoma retraction noticed in 6 [3%] patients. Stoma formation was a helpful adjunct surgical procedure performed in emergency intestinal surgery for various conditions with satisfactory outcome

Laparostomy: three year experience in a tertiary-care unit

Laparostomy is a temporary measure to avoid abdominal compartment syndrome as well as allow repeated and ready access to abdomen for lavage. This study was conducted to identify the indications and analyze the outcome of laparostomy in a tertiary care surgical ward. This prospective study was conducted on laparostomy cases between March 2008 and February 2011. Data was analyzed for the indication, clinical course and final outcome. Results were expressed as frequency-percentage, means, procedural morbidity and overall mortality. A total of 16 laparostomies were performed during the study period. All 16 patients were operated in emergency. Burst abdomen with impending intra-abdominal hypertension was the most common indication followed by "grossly edematous bowel" which made primary closure impossible. A delayed deep tension closure was possible only in eight patients. Four patients died in the postoperative period. Persistent wound sepsis was the most common morbidity. Laparostomy is often necessitated by the desperate situations encountered in emergency surgery

Antisperms antibodies in infertile males attending a tertiary care hospital in Karachi

To estimate the levels of anti-sperm antibodies in infertile males attending a tertiary care hospital in Karachi. Out of 160 males studied, 132 met the criteria and were included in the study. Semen analysis was done by proper standardized procedures as mentioned in WHO manual for examination of human semen and sperm cervical mucus interaction. A blood sample was drawn to detect the presence of anti-sperm antibodies. Antisperm antibodies were found positive in 8 males suggesting that antisperm antibodies are the etiologic factor causing infertility in 6% infertile male subjects. A positive correlation was found between the ages of patients and antisperm antibodies greater than 70 IU/ml. Direct correlation of circulating antisperm antibodies with male infertility suggests the role of immunologic infertility as an etiologic cause of infertility in idiopathic infertile males of Pakistan

Recurrent abscesses following an intra muscular injection of diclofenac sodium

Two young females and one obese male presented with multiple discharging sinuses due to recurrent injection abscesses that burst spontaneously following intramuscular [IM] injections of diclofenac sodium. These abscesses were formed in relation to repeated IM injections given in order to relieve the pain. Multiple discharging sinuses led to disfigurement of the arm that was managed by wide local excision. Skin loss was dealt with skin grafting. Learning the proper technique of administering an intramuscular injection, alternating the injection site and change of analgesic can help to minimize the possibility of these complications from tissue necrosis

Minimal access surgery training of general surgical residents in Karachi, Pakistan; where do we stand?

To evaluate post graduate surgical residents' training in minimal access surgery. This cross sectional survey was based on a 16-item self reporting questionnaire that was provided to 48 third, fourth and fifth year postgraduate general surgical trainees doing residency in seven Karachi institutions accredited by College of Physicians and Surgeons Pakistan for Fellowship training. All 48 trainees completed and returned the given questionnaire. Eleven were 3[rd] year, 33 were 4[th] year and four trainees were 5[th] year residents. Mean age of the trainees was 30.31[SD 2.8] years [range 27 to 43], Males were 35 [72.92%], females were 13 [27.08%]. Forty six [95.83%] answered that laparoscopic surgery was performed in their department, while two [4.17%] replied in negative. Nine [18.75%] said that they had performed Laparoscopic Cholecystectomy under supervision, while 39 [81.25%] responded "no". Regarding "Dry Lab" access 18[37.5%] responded "yes" while 30 [62.5%] said no. Similarly regarding "Wet Lab" none said "yes", all [100%] responded by saying "No" as was the case of Virtual Reality Simulator where 45 [93.75%] said "No" while three [6.25%] did not answer this question and none responded "Yes". Out of the 48 trainees questioned only nine [18.75%] had ever attended a Basic Laparoscopy workshop while 39 [81.25%] had not. Trainees own perception regarding their skills and status in laparoscopic surgery training was such that none said Excellent, 7[14.58%] said Good, eight [16.67%] labelled themselves as Average while nine [18.75%] thought they were below average, 23 [47.92%] said they were Poor in this Skill and one[2.08%] did not respond. Most 41 [85.42%] would prefer to do a One Year Fellowship in Minimal Access Training following FCPS, while one[2.08%] said "No" and six [12.5%] were not sure. Education and training in Minimal Access Surgery within Institutions of Karachi is not standardized and access to training facilities is limited

Chest trauma management: good outcomes possible in a general surgical unit

To determine the predominant pattern of injuries following chest trauma and assess the adequacy of the management strategies employed in a general surgical unit of a trauma care hospital. This Case Series study with prospective data collection was conducted in Surgical Unit-Il ft Unit-VI of Civil Hospital Karachi, from September 2007 to February 2009. One hundred and three consecutive patients with thoracic trauma presenting in emergency department were evaluated. Patients above 12 years of age, who presented with chest trauma either alone or associated with multiple trauma were included. A total of 103 patients were studied for various chest injuries during eighteen months period. As a whole 58% of patients had blunt chest injury as compared to 42% who had penetrating injuries. Thirty patients [29%] had chest wall injuries [rib fracture, mild lung contusion] without haemothorax or pneumothorax, who were managed conservatively. Chest intubation was required in 64 patients [62%] having hemothorax I pneumothorax. Thoracotomy was required in nine patients [9%], in which only two were emergency thoracotomy and seven were elective. Over all mortality rate was 8%.Penetrating injury of chest is rising with time due to gunshot injuries although blunt trauma is still more common. Majority of chest trauma patients can be managed in a general surgical unit satisfactorily and few patients need major operative management

Primary closure of common bile duct after open choledochotomy

To assess the outcome of primary closure of common bile duct after open choledochotomy. Descriptive case series. Department of surgery, unit II, III and VI, Dow University of Health Sciences and Civil Hospital Karachi from June 2005 to May 2009. Clinical records of all the patients who underwent bile duct exploration followed by primary closure were reviewed. Main outcome measures were operating time, duration of hospital stay and postoperative complication; including bile leakage, subphrenic abscess, biliary peritonitis and postoperative jaundice. The SPSS version 11 was applied to the data for analysis. A total of 38 patients were found from clinical records having male to female ratio of 1:6.6. Mean [ +/- SD] operating time was 95 [ +/- 7] minutes. The overall complication rate was 10.52%. Bile leak was encountered in three [7.89%] patients whereas small subphrenic collection was noticed in one [2.63%] patient who was treated conservatively. None of the patients experienced postoperative jaundice and biliary peritonitis. Mean [ +/- SD] duration of hospital stay was 7.63 [ +/- 1.63] days. Primary repair of common bile duct after open choledochotomy is safe and associated with low complication rate

Heart failure patients are prone to develop magnesium deficiency as a result of diuretic/digoxin therapy

To evaluate serum magnesium level in chronic heart failure [CIIF] patients receiving diuretic and digoxin therapy. Study Design: A case-control study. The study was conducted at the Basic Medical Sciences Institute [BMSI]. Jinnah ostgraduate Medical Centre [JPMC], Karachi with collaboration ofNational Institute of Cardiovascular Diseases [NICVD], Karachi from April to December 2003. Serum magnesium levels were evaluated in 65 subjects including 45 patients of heart failure admitted in the NICVD, Karachi. Twenty subjects were healthy, age and gender matched controls [group l]. Patients were divided into two groups [groups-II and III] according to treatment with diuretics or combination of diuretic and digoxin. Other electrolytes including sodium, potassium, chloride and calcium were also evaluated. Student't' test at ranging p-values of [<0.05. <0.01, <0.001] were used to determine the statistical significance. The cardiac failure patients showed lower [1.72 +/- 0.07 mg/dl] level of serum magnesium when compared with normal [0.53 +/- 0.19 mg/dl] control subjects and even more significantly lowered [1.65 +/- 0.09 mg/dl] in patients who were receiving diuretics and digoxin as compared to patients [1.80 +/- 0.10 mgidl] who were on diuretics only [p<0.001]. Patients with chronic heart failure were characteristically prone to develop magnesium deficiency along with other electrolytes [potassium. calcium, and chloride] due to administration of diuretics and digoxin

Patients experiences and satisfaction from surgical out patient department of a tertiary care teaching hospital

To find out patients experiences and satisfaction from the Surgical Out Patient Department [OPD] of Civil Hospital, Karachi. This cross-sectional study was done in surgical OPD of Civil Hospital, Karachi from January to March 2008. Patients were asked questions regarding general condition of the OPD, administrative procedure, waiting time, consultation time, doctors attitude and ethical behaviour, their professionalism, overall satisfaction, future reutilization and recommendation to others apart some demographic information. Total 490 patients were interviewed after taking verbal consent. More than three fourth of the patients agreed with good atmosphere [administrative procedure, receptionist attitude, waiting room] of the OPD department, but only 64[13.1%] said that inside the hospital the surgical OPD sign was clearly visible. Mean waiting time was 47.47 +/- 15.29 minutes [Range: 15-150]. Three hundred one[61.4%] patients were examined and treatment advised by Residents only while 189[38.6] patients received treatment by Consultants. Mean consultation time was 6.03 +/- 3.34 minutes [2 - 20] and 246 [50.2%] patients said that consultation time was adequate. From only 287 [58.6%] patients consent was taken before examination but patients privacy was maintained while examining 306 [62.4%] patients. Sixty five [13.2%] patients experienced subsequent visit problem with other units. Four hundred seventy three [96.5] patients said they will utilize the OPD in future and 461 [94.1%] said they will recommend it to other. Overall patient's experiences and satisfaction from Surgical OPD were fair to good. We have highlighted number of areas in which improvement can be made to increase the quality of care and patient satisfaction

Mesh hernioplasty: surgeons' training ground?

To clinically evaluate the outcome of Inguinal Hernioplasty in terms haematoma, wound infection and recurrence, with special reference to surgery done by trainee surgeons. Case control study with prospective data collection, conducted from Sep. 2005 to August 2006. Surgical Unit two, Civil Hospital, Karacho. All male patients above 30 years of age with Inguinal hernia were included in the study. Patients presenting in emergency and those with age less than 30 years were excluded, as they did not undergo Mesh Hernioplasty. Patients with symptoms like chronic cough and constipation, and those with conditions like anaemia, diabetes and hypertension were optimized before surgery. Anaesthesia fitness was taken after necessary investigations. Patients were mostly operated under Regional [Spinal] anaesthesia. Two doses of a first generation cephalosporin or co-amoxiclav were used as a prophylactic antibiotic. Data was collected on a pre-designed proforma; record was also duplicated on the computer in the SPSS Version 10. Out patient follow-up was done for 6 months as a minimum. A total of 75 males with 78 inguinal hernias were operated during the study period; three patients had bilateral hernia. Sixty five percent of our patients had hernia on the right side and 31% on the left side, while 4% were bilateral. The ages of the patients ranged from 30 to 81 years; majority [72%] were under the age of 60 years. Sixty percent of the patients were manual workers. Sixty nine [88.5%] inguinal hernias were reducible and 9 [11.5%] irreducible; 6[7.7%] were recurrent. Trainee surgeons did 70% of the operations. Haematoma occurred in five cases, seroma in nine, urinary retention in four, wound infection in four and recurrence in one case. No mortality occurred during the study. In our set-up Mesh Hernioplasty has proven to be effective with low complication and recurrence rates. It is easily learnt by trainee surgeons. Early ambulation should be the aim. Cost of the mesh is a minor stumbling block, but the long term benefits of this hernia repair makes it the benchmark for all

Audit of a general surgical unit: reed for self evaluation

To find out the pattern of admissions and the outcome of patients in a general surgical unit of a major teaching hospital. Observational, descriptive study covering the year 2006 with retrospective data collection. Surgical Unit three, Dow Medical College and Civil Hospital Karachi. All patients admitted to the unit during 2006 either through Out-patient Department or Emergency Department or transferred/referred from other units/departments. Detailed data regarding the patients was collected and analyzed. A total of 779 patients, 492 males and 287 females, were admitted during the study period; 489 from the Out-patients Department [OPD] and 276 from the Emergency [Casualty] Dept., while 14 were transferred from other departments as they had general surgical problems. Inguinal hernias accounted for the highest number of admissions i.e. 15.5% followed by Acute Appendicitis [11 9%] and Chronic Cholecystitis [10.7%]. Trauma constituted 11.2% of the total admissions, including 46 [5.5%] cases of gunshot injuries. There is a dire need of local studies on the topic of Surgical Audit because for proper and better health care planning of the country, a knowledge of the current pattern of admissions and diseases spectrum are essential

Post operative wound infection: a surgeon's dilemma

Keeping in view the prevalence of wound infection in our set up, this study was designed to evaluate the frequency, clinical presentation, common risk factors and different organisms involved in cases of clean and cleancontaminated surgery. Observational descriptive study from March 2005 to February 2006. Surgical Unit III, Civil Hospital, Karachi. One hundred patients who underwent clean and clean-contaminated surgery. Biodata of the patients together with their clinical features, diagnosis, type of surgery performed and the development of any complications including wound infection was noted and the data analyzed. Out of the 100 patients [52 males and 48 females] in the study, 69 belonged to the clean surgery group and 31 to the clean-contaminated surgery group. The overall incidence of surgical site infection [SSI] in the study was 11%; 5[7.2%] cases in the clean surgical group and 6[19.4%] cases in the clean-contaminated group developed infection. Patients in the age group 51-60 years were infected more than those in the younger age groups. The incidence of wound infection was more in male patients [11.5%] as compared to female patients [10.4%]. Obesity was also a main cause of SSI as evident from the fact that patients with more than 60kg/m2 were infected more [20%] as compared to 30-40kg/m2 [7.1%]. Surgical site infection was found more in patients with extended pre-operative hospital stay. Anaemia, smoking, diabetes mellitus, prolonged surgery, operations by junior surgeons and operations late in the list were also associated with more surgical site infection. The usual time of presentation of SSI was within three weeks following surgery and most patients presented with wound abscess and cellulitis, while two patients had wound dehiscence. The common organisms involved in the SSI were Staphylococcus aureus, E. coli, Streptococcus pyogenes and Pseudomonas group. Meticulous surgical technique, proper sterilization, judicious use of antibiotics, improvement of operation theatre and ward environments, control of malnutrition and obesity, treatment of infective foci and diseases like diabetes, and avoidance of smoking helps control the morbidity of surgical wound infections

Utilization of blood in elective cholecystectomy

To evaluate Blood Ordering and Transfusion ratios for elective cholecystectomy. All patients who underwent elective cholocystectomy in Surgical Unit III, Civil Hospital, Karachi from December 2005 to November 2006 were included in this study. Blood units cross matched and units transfused intra-operative and post-operatively were recorded apart from patient demography and hepatitis profile. A total of 132 patients underwent elective open cholecystectomy during the study period. Total 181 blood units arranged, among these only nine units of blood were transfused. This means only only 4.9% of blood was utilized while 95.1% of blood was not utilized. Cross-match to transfusion ratio=20.11, Transfusion probability=6.8 and Transfusion index=0.06. For elective cholecystectomy, there is no need for routine cross matching of blood. However, one must confirm the availability of blood for Hepatitis B and Hepatitis C reactive patients, and for cases with recurrent acute cholecystitic attacks

Manifestations of tuberculosis in breast

The aim of this study was to highlight the importance of tuberculosis as a cause of breast diseases. Retrospective study from 2000 to 2005. This study was conducted at Sarfaraz Rafiquee Shaheed Hospital and Civil Hospital, Karachi. All patients who were diagnosed as cases of tuberculous mastitis were included in the study. In all patients the biodata and a detailed history was taken and a thorough examination performed. Relevant investigations that were done included CP and ESR, X-ray Chest, Mammography, Mantoux Test, Sputum for acid fast bacilli, Discharge from sinuses for detection of acid fast bacilli and culture, Biopsy and histopathological examination. All patients underwent surgery with removal of the infected breast tissues, combined with anti-tuberculous chemotherapy. A total of seven cases were detected during the study period with tuberculosis of the breast. All were females with an age range from 17 to 50 years, but the majority were under 30 years of age. The duration a/their symptoms ranged from six months to two years. The main symptoms and signs were multiple discharging sinuses over the breast [n=3], painless lump [n=2], painful lump [n=1], ulcer [n=1], ipsilateral axillary lymphadenitis [n=3] and pulmonary tuberculosis [n=2]. The diagnosis was made on histopathology in all the cases; six cases belonged to the nodular tuberculous group, while one had disseminated tuberculous mastitis. Acid fast bacilli were detected in only two specimen, while positive culture was obtained in only one patient. Successful outcome was seen following treatment comprising of anti-tuberculosis drug therapy with removal of the infected breast tissue in six and mastectomy in one patient. This study establishes the importance of including and remembering tuberculosis in the list of the causes of breast diseases, specially in cases of recurrent abscesses, sinuses and lumps

Blunt abdominal trauma; does clinical evaluation suffice?

To correlate preoperative clinical diagnosis with per-operative findings in cases of Blunt Abdominal Trauma. Observational study with prospective data collection from Jan. 2004 to Dec. 2005. Surgical Unit III of Civil Hospital, Karachi. All patients over 12 years of age who underwent surgery for admitted with Blunt Abdominal Trauma. The patients were resuscitated and prepared for surgery: starting. blood transfusion in haemodynamically unstable patients, passage of nasogastric tube, bladder catheterization and doing appropriate investigations where conditions permitted. Pulse, Blood pressure, Temperature, Respiratory rate, Oxygen saturation and Urinary output monitoring started. As soon as possible surgical exploration was carried out through a midline incision under general anaesthesia. The surgical procedures performed depended upon the laprotomy findings. The data collection was done on a standard performa. During the two-year study period 25 patients, 21 males and 4 females, aged 16-52 years [mean 27 years] were admitted with Blunt Abdominal Trauma. At the time of presentation in the Casualty Dept. most of the patients [64%] were in a state of circulatory shock. Road Traffic Accident [RTA] was the commonest cause of Blunt Abdominal Trauma in our study, accounting for 16 [64%] patients, followed by fall from height in six [25%] and assault in three [12%] cases. A clinical diagnosis of splenic injury was made in 11 [44%] cases, liver injury in eight [32%],intestinal perforation in five [20%] and bladder injury in one [4%] case. Our pre-operative clinical diagnosis correlated with the operative findings in 22 [88%] cases. However in three [12%] cases, the operative findings did not correlate with clinical diagnosis. An early examination of Blunt Abdominal Trauma patients, enables the surgeon to reach a correct working diagnosis in the majority of cases