Renal allograft rejection:role of Tc99m-DTP a renal scan

Objective: Tc99m- diethylene triamine pentaacitic acid [DTP A] renal renography has been used to evaluate renal transplant function with variable results. In this study we compared the results of renal scan with biopsies of renal ailograft to evaluate the ability of renography to differentiate acute rejection from other causes of allograft dysfunction including acute tubular necrosis [ATN] and medication toxicity

Study Design: Observational / cross sectional study

Place and Duration of Study: This study was carried out in the Hope Kidney Clinic, Texas, USA from January 1, 201 1 to December 31, 2012 Materials and Methods: All nenal transplant patients at Hope Kidney Clinic, Laredo, Texas, USA who had Tc99m- DTPA ratal scan for elevated serum creatinine and subsequent biopsy within 48 hours were included

A total of eighteen patients underwent allograft biopsy. We tested the hypothesis that decreased flow and function would predict acute rejection and in other etiologies such as ATN normal flow with or without impaired function would be seen

Results: Four of 9 patients [44%] with impaired flow and function on renography had acute rejection, three of which has vascular component. Four of 9 patients [44%] with normal flow with or without normal function had rejection, none of which has a vascular component

Conclusion: Based on these findings, it was concluded that Tc99m-DTPA renography is neither sensitive nor specific for the detection of acute allograft rejection butTc99m-DTPA renography may be more sensitive for detecting rejections with vascular component as all of those in this study demonstrated

Hypoglycemic and hypolipidemic effects of Lactobacillus fermentum, fruit extracts of Syzygium cumini and Momordica charantia on diabetes induced mice

A lot of treatment strategies available for diabetes but its complications are still a medical problem around the globe. It demands to find out some alternative therapeutic measures. In order to investigate the anti-diabetic potential of probiotics and natural extracts, this study was designed. Accordingly, a local source of yogurt probiotic strain Lactobacillus fermentum was isolated and characterized that showed its probiotic properties. Besides this, natural extracts of plants fruits like java plum [Syzygium cumini] and bitter gourd [M. charantia] were made. Lactobacillus fermentum and the extracts were administered individually as well as in combination to diabetes induced mice. Different parameters like body weight, blood glucose level and lipid profile including total cholesterol, HDL and LDL were analyzed before and after treatment. The results showed that Lactobacillus fermentum and natural extracts have hypoglycemic as well hypolipidemic activity against diabetic mice. This study can further investigated to screen potential compounds from these extracts to control the glucose and the lipid levels in diabetic patients

Unusual histopathological findings of appendectomy specimens

Background: Appendicitis is a very common surgical clinical condition and appendectomy is a frequently performed procedure worldwide. Although obstruction caused by fecoliths or lymphoid aggregation is a common reason for appendicitis, unusual histopathological findings can be a cause too. Unusual findings can range from benign conditions like worm infestation and cysts to malignant conditions like carcinoid tumors and adenocarcinomas. Enterobius vermicularis infection, tuberculosis, ascaris lumbricoides infestation, carcinoid tumors and cystadenomas are some of the commonly appearing unusual findings

Objective: To document the number of rare histopathological findings of appendectomy specimens

Methods: A 7 year retrospective study was conducted at Ziauddin University Hospital from March 2005 to December 2012. From accumulated information for 2157 appendectomies, 138 appendectomy specimens had rare histopathological findings. Incidental and negative appendectomies were excluded from this study

Results: 58% of the patients with unusual histopathological findings were males [n=80] and 42% were females [n=58]. Most common findings included: Enterobius vermicularis48.5% [n=67], Tuberculosis13% [n=18], Carcinoid tumors 9% [n=13] and cystadenomas 8% [n=11]. Other findings include: peri appendicular abscess, adenocarcinoma of colonic origin, necrotizing lymphadenitis, ascaris lumbroides, Meckel's diverticulum, taenia saginata, pheochromocytoma and mucocele

Conclusion: Appendectomy specimens should be routinely sent for histopathological examinations as this practice can help in diagnosing rare tumors and conditions

Carcinoid tumors: an ignored cause of appendicitis

Background: Many conditions related to appendix present as appendicitis. These conditions can range from fecolith obstruction to tumors .Carcinoid tumors are most common tumors to present in appendix. Most of the carcinoid tumors in appendix present as appendicitis. Majority of the cases are diagnosed after histopathological examination, with 90% of the tumors measuring smaller than 1 cm with excellent prognosis after appendectomies. Tumors with the size of 2cm are treated with right hemicolectomy

Objective: To determine the frequency of carcinoid tumors in appendectomies using histopathological data

Methods: This was a retrospective study conducted at Ziauddin University Hospital, Nazimabad for a time period of 7 years from March 2005 to December 2012. 2,157 appendectomies were analyzed, out of which 13 appendectomy specimens were diagnosed as carcinoid tumors. Incidental and negative appendectomies were excluded from this study

Results: 0.60% of the appendectomy specimens were diagnosed as carcinoid tumors [n=13], male to female ratio was [5.5:1], 77% [n=10] of the tumors were up to 1 cm in size and 23% [n=3] of the tumors were of 1.5 cm in size. Majority of the tumors [n=9] had well differentiated cell types. 77% of the tumors were localized to the tip of the appendix, 15% of the tumors spread locally to the distal half of the appendix and 8% spread to the mesentery

Conclusion: Carcinoid tumors of the appendix, mostly present as appendicitis in early stage. While 90% of the cases show excellent prognosis with appendectomy, 10% of the cases might need further management

Retro-peritoneal extra-adrenal ganglioneuroma encasing major blood vessels

Ganglioneuroma is a rare, benign, slow-growing asymptomatic tumor of the neural crest cells. It occurs in one per million population with female predominance. It most commonly occurs in the retro=peritoneum. Although CT scan and other imaging modalities can be used, its diagnosis is essentially based on histopathology. We report a case of 18 year old male who presented with abdominal pain and a mass in the left lumbar quadrant. CT scan abdomen showed a retroperitoneal mass encasing aorta, IVC and left common iliac artery. A diagnosis of Ganglioneuroma was established on ultrasound guided Trucut biopsy. He underwent laparotomy for total excision of mass. Per-operatively the mass was separated from the vital structures and the major blood vessels. His post-operative course was uneventful and he was discharged on 7th post-operative day. His final histopathology confirmed the initial diagnosis of ganglioneuroma. Nonetheless, a possibility of ganglioneuroma should be kept under consideration in cases of all retroperitoneal extra-adrenal masses

Morgagni hernia - presenting as vague abdominal pain since 8 years

Morgagni hernia is the rarest type of Congenital Diaphragmatic Hernia[CHD]. It accounts for 2% of all CHD cases and is detected incidentally through a chest xray The hernia occurs mostly on right side of diaphragm with incidence of 90%, 8% occur bilaterally and 2% limited to left side. It is predominant in females presenting symptom of abdominal pain. The presence of colonic sounds on chest examination is a significant finding in diagnosis. CT scans usually reveal a retrosternal or parasternal mass or fat density which represents omentum and air containing viscus. A case of a middle aged lady presenting with vague abdominal pain for the last eight years is reported. Suspicion was raised over a chest xray which highlighted the right dome of diaphragm being pushed up and the presence of gaseous shadow under the right dome. Subsequent computed tomography showed morgagani hernia. The patient underwent open transabdominal of the stomach and omentum, where the hernia sac not resected and a primary closure of the defect was performed. The post operative course was uneventful. Morgagni though rare, often remains undiagnosed and can lead to life threatening complications. Surgical intervention regardless of patient's asymptomatic state should be offered to avoid complications

Surgical handover in an era of reduced working hours: an audit of current practice

To examine the current practice of handover and to record trainees' assessment of handover process. An audit study. Department of General Surgery, Scarborough General Hospital, Scarborough, United Kingdom, from January to April 2010. A paper-based questionnaire containing instruments pertaining to handover guidelines was disseminated to trainees on surgical on-call rota at the hospital. Trainees' responses regarding handover process including information transferred, designated location, duration, structure, senior supervision, awareness of guidelines, formal training, and rating of current handover practice were analysed. A total of 42 questionnaires were returned [response rate = 100%]. The trainees included were; registrars 21% [n=9], core surgical trainees 38% [n=16], and foundation trainees 41% [n=17]. Satisfactory compliance [> 80% handover sessions] to RCS guidelines was observed for only five out of nine components. Ninety-five percent of hand over sessions took place at a designated place and two-third lasted less than 20-minutes. Computer generated handover sheet 57% [n=24] was the most commonly practised method of handover. Specialist registrar 69% [n=29] remained the supervising person in majority of handover sessions. None of the respondents received formal teaching or training in handover, whereas only half of them 48% [n=20] were aware of handover guidelines. Twenty-one percent of the trainees expressed dissatisfaction with the current practice of handover. Current practice of surgical handover lacks structure despite a fair degree of compliance to RCS handover guidelines. A computerised-sheet based structured handover process, subjected to regular audit, would ensure patient safety and continuity of care

Operative notes at surgical units of a tertiary care hospital

To assess the quality of operative notes in general surgery procedures. Descriptive study. Civil Hospital Karachi. Operative notes for all procedures were typed and saved in a data retrieval system [Health Management and Information system, DOTS'78]. A proforma was designed in accordance with the standards prescribed by Royal College of Surgeons of Edinburgh [RCSE] for taking down surgical case notes. The operative notes were studied and a proforma was filled for each. These were then compared with the prescribed standard for completion of documentation. The data was analyzed on SPSS 13. Out of a total of 100 notes, 99 had operating surgeons name mentioned, however, the time of surgery was missing in all. Approximately half of the notes surveyed did not mention the incision type, while operative diagnosis was mentioned in 92% of the notes. Post operative instructions were mentioned in 89% of the notes reviewed. Standardized notes documentation was not found in the present study in most of the cases

Maternal factors associated with intrauterine growth restriction

Intrauterine growth restriction is a major neonatal health issue. Maternal factors have been found to have greater impact on IUGR. Studying these factors can help in reducing the mortality and morbidity associated with IUGR. This Case-control study was conducted at the department of Paediatrics Post-graduate medical institute Lady Reading Hospital Peshawar from March 2008-April 2009. Small-for-gestational age [SGA, i.e., IUGR cases and n=200] live born babies were compared with appropriate-for-gestational age [AGA, i.e., controls and n=200] babies. Information regarding socio-demographics of mothers, gestational age and birth weight of baby, maternal clinical characteristics, and medical and obstetric complications during pregnancy was recorded on a predesigned proforma. Data analysis was done through SPSS-16. To find the maternal factors associated with the intrauterine growth restriction, multivariable logistic regression was used. We also did two different sets of logistic regression analysis for Symmetric and Asymmetric SGA babies as Cases. After adjusting for other variables in the multivariable model we found that the mothers of IUGR babies were of younger age [OR=0.8, CI=0.7-0.9], were poor [OR=2.5, CI=1.4-4.4] and underweight [OR=3.5, CI=1.1-5.7] and had anaemia [OR=2.7, CI=1.3-5.4] in the index pregnancy, and had history of Previous IUGR birth [OR=9.7, CI=3.3-18.3] and placenta previa [OR=3.2, CI=1.1-6.6]. There was an interaction between pregnancy induced hypertension and parity of mother with a primary-para mother with pregnancy induced hypertension [PIH] having an increased risk for IUGR babies [OR=10.1, CI=1.0-23.2]. The studied factors need special attention in hospital based settings in order to improve the perinatal outcome in IUGR babies

Spectrum of breast tuberculosis

To determine the presentation of breast tuberculosis, diagnostic methods and surgical treatments. A case series. This study was conducted at Dow University of Health Sciences and Tuberculosis Clinic at Bantwa Hospital, Kharadar, Karachi, from April 1999 to March 2007. Clinically diagnosed patients of breast tuberculosis, confirmed by laboratory work-up, were included in this study. Detailed history and examination of both breast and axillae were the primary diagnostic measures. Complete blood counts, ESR, Mantoux test, ultrasound, mammogram, fine needle aspiration cytology, staining for acid-fast bacilli both smear and culture were performed. Core biopsy for lumps more than 5 cm and wide excision biopsy for the lump less than 5 cm were the methods applied. Pre-designed research proforma was filled and descriptive statistics of age, site, side, clinical presentations, investigations were recorded and surgical treatment done. Anti-tuberculosis treatment was given to all patients. Thirty patients were studied with mean age of 28.4 years ranging from 16-48 years. Bilateral breast involvement was seen in 2 patients with 14 cases involving the right and left breast. Lymph node involvement was present in 7. Pulmonary tuberculosis was seen in 4 patients. Multifocal disease was present in 27 patients. The clinical presentation was with lump in 6, discharging sinuses in 14, cold abscess in 8, and non-healing ulcer in 2 patients. There were 5 lactating mothers. Montoux test was positive in 5, AFB smear and culture were positive in 3. Only AFB culture was positive in 4. Five patients required core biopsy for diagnosis of confirmation of lump more than 5 cm and wide excision biopsy was required in 7 patients with lump less than 5 cm. Despite antituberculous treatment, surgical management was required in 21 [70%] cases. Tuberculosis of the breast, simulating the carcinoma breast and granulomatous mastitis very closely and are difficult to be differentiated without tissue diagnosis. Surgical management is more often required

Factors causing non-breastfeeding in children under six months of age in district Nowshera, Pakistan

In developing countries bottle feeding has emerged a big public health problem while in developed countries the trend is opposite. Prevalence of breast feeding in Pakistan is 90-98% but in some subgroups of population it is as low as 60-80%. The objectives of the study were to determine the causes of non breast feeding in children less than six months of age in district Nowshera, and assess practice of starting first breast feeding to the newborn. A cross sectional study was conducted in ten union councils of district Nowshera. A total of 305 children under six month age were selected by simple random method. Data was collected on pre-designed questionnaire and analysed by descriptive statistics. The study included 198 children from rural and 107 from urban areas. Mothers/guardians of 71.8% children were uneducated. Causes of non breast feeding included perception of mothers of having insufficient milk [45.9%], working mothers [18.4%], mothers with chronic diseases [13.1%], children with congenital or acquired diseases [17%], mothers having next pregnancy [3.61%] whose mothers have been died [0.98%] and twin babies [0.98%]. On the other hand, 61% babies started breast feeding on first day, 19% on second, 10.8% on third and 3.9% after third day while 5.2% babies got no breast feeding at all. Main causes of non-breastfeeding in less than six month age are perception of having insufficient milk, working women and twin babies

Bile duct injuries during open and laproscopic cholecystectomy:management and outcome

To evaluate the management of twenty two patients, with bile duct injuries during open and laproscopic cholecystectomy who were referred to the tertiary center. It is a prospective cohort study conducted at Department of Surgery, Sindh Government Lyari General Hospital, affiliated with Dow University of Health Science Karachi. Patients who sustained bile duct injuries following open cholecystectomy and laproscopic cholecystectomy were included. Time between cholecystectomy and recognition of injury, method of repair and post operative outcome was recorded. Strassburg classification was used to delineate the type of bile duct injury. Twenty two patients of bile duct injuries following open cholecystectomy and laproscopic cholecystectomy were managed. Mean age of patients was forty six [thirty four - fifty six] years. Injury was sustained in fifteen patients during laproscopic cholecystectomy and in seven patients during open cholecystectomy. Overall fourteen patients had Strassburg E1 and E2 and eight patients had E3 and E4 injuries. In nineteen patients, Roux-en-Yhepaticojejunostomy was done, while three patients underwent lateral choledochorraphy with T-tube drainage. One patient died of septicemia, while one patient was re-explored for revision of hepaticojejunostomy for stenosis of bilioenteric anastomosis. Other minor complications were treated conservatively. Bile duct injury after open and laproscopic cholecystectomy can be successfully managed in a tertiary center by hepatobiliary surgeon. Principles of management include anatomic definition of injury, control of sepsis, staged approach involving interventional radiology and refined operative technique

Effects of transurethral resection of prostate on flow rate and voided volume on patients with benign prostatic hyperplasia

Objective: to assess urinary flow rate/uroflowmetry in patients undergoing transurethral resection of the prostate [TURP] for benign prostatic hyperplasia [BPH], during three postoperative months

Study design: prospective observational study

Materials and methods: this study was conducted at Department of Urological Surgery and Transplantation, Jinnah Postgraduate Medical Centre [JPMC] Karachi-Pakistan, between March 2002 and March 2005. Fifty consecutive clinically diagnosed cases of BPH who never went in retention of urine and underwent TURP were included in this study. Preoperative urinary flow rate was measured. Uroflowmetry was postoperatively carried out after every month for three months period and observations were analyzed

Results: mean +/- SD age of the subjects was 63.62 +/- 6.75 years. Preoperatively mean +/- SD values were maximum flow rate 7.60 +/- 2.41 ml/sec, average flow rate 4.44 +/- 1.28 ml/sec and voided volume 165.54 +/- 49.60 ml. Post-TURP mean +/- SD values after three months were maximum flow rate 27.24 +/- 5.11 ml/sec, average flow rate 13.48 +/- 2.08 ml/sec and voided volume 240.32 +/- 49.91 ml. The variation in means of uroflowmetry parameters from first to third post-TURP month found statistically significant [P<0.001]

Conclusion: we conclude that the effects of post-transurethral resection of prostate, all the obstructive uroflowmetry parameters return towards normal levels. It indicates that there is excellent improvement relief in both obstructive and irrelative symptoms

Outcome of surgery for pilonidal sinus: karydakis versis open procedure

To compare and analyze the outcome of Karydaki's procedure with Open excision technique for Pilonidal sinus especially in term of recovery time, period off work, complications and recurrence. Prospective, randomized and comparative study from April 2004 to Sept. 2006. Dept. of Surgery [Unit-I], Sindh Government Lyari General Hospital, Karachi. Twenty six patients with Pilonidal sinus of the natal cleft were included in the study. Biodata, symptoms and signs of all the patients were recorded and appropriate investigations performed. They were randomized into two groups. Group-K underwent Karydaki's procedure in which a wedge of tissue including the simus and its ramifications were excised with primary asymmetrical closure of the wound. In Group-O patients, wide excision of the Pilonidal sinus tract was done and the wound was left open. Amongst the 26 patients included in the study, majority [25] were males in the third decade of life [52.85%]. Their mean duration of symptoms was 8.53 months. The mean operating time for K-Group [45 +/- 10 mins.] cases a bit longer than the O-Group patients [25 +/- 5 mins.] however the former group was associated with fewer postoperative complications, lesser recovery period [2.46 weeks], lesser period off-work [3.53 weeks] and low recurrence rate [7.69%]. In contradiction, amongst the O-Group patients the mean recovery period was 6.69 weeks, mean period off-work was 8.15 weeks and recurrence was seen in 15.38% patients. The Karydakis procedure is superior to Open excision in terms of post-operative morbidity, recurrence rate and recovery period, though it takes a big longer to perform

Hepatico-Munostomy For high biliary obstruction

To determine the efficacy of hepatico-jejunostomy as a method of successful decompression of the binary tree in cases of proximal bile duct obstruction. Descriptive, retrospective study from 1993 to 2003.Civil Hospital, Karachi. 77 patients who presented with proximal bile duct obstruction during the above mentioned period. The data of all the 77 patients was analyzed as regards to presentation, treatment, and the outcome. Proximal bile duct obstruction was seen in 44 benign and 33 malignant cases. The benign cases were due to post-cholecystectomy trauma while the malignant cases were due to cholangiocarcinoma. Hepatico-jejunostomy with different approaches like anastomosis of Common Hepatic Duct[CHD] to jejunum [n-40], Right and Left Hepatic Duct[HD] to jejunum [n-28], only Left Hepatic Duct to jejunum - Segment III approach [n-6] and Ligamentum Teres approach [n-3] were adopted after curative resection in 52 [67.53%] and palliative resection in 25 [32.47%] patients. A marked decrease in cholestasis to almost normal level was achieved when CHD or/and LHD both were involved, whereas significant decrease was observed when only LHD was used for anastomosis; 79% cases had little or no clinical symptoms like jaundice or pruritis. The overall 5-year survival in malignant cases was around 15%. Hepatico-jejunostomy is a feasible and reasonably effective treatment procedure following curative or palliative resection. The patients were significantly relievedfrom cholestasis and symptoms of jaundice or pruritis. Although complete decompression was rarely achieved in malignant cases, near normal levels were achieved in benign cases

Extra Hepatic portal vein obstruction leading to variceal bleed due to portal hypertension

Portal Hypertension can be due to many causes other than cirrhosis. We report a case of extra hepatic portal vein obstruction leading to portal hypertension and varices, managed successfully by creating a Porto Caval shunt

Management of hilar malignant biliary strictures

To determine the etiology of Hilar malignant biliary strictures and the efficacy of hepaticojejunostomy in it's management with or without segmental liver resection. A retrospective study of 33 patients was carried out at Civil Hospital and Lyari General Hospital Karachi. They presented with signs and symptoms of mechanical cholestasis. Study was conducted to find the etiology, level of obstruction and the extent of the disease together with approaches to either cure the disease or to relieve the symptoms. Curative resection was attempted where possible in all 33 patients but decision of curative resection or palliative bypass with or without liver resection was made per operatively after accessing the level of obstruction and extent of local, parenchymal or vascular infiltration. Of the 33 patients studied, 72.73% [n=24] had cholangiocarcinoma and 27.27% [n=9] had gall bladder Ca with local bile duct extension. Four different sites of biliary tree [i] common hepatic duct [CHD], [ii] confluence of common hepatic duct [CCHD], [iii] right and left hepatic duct [R and LHD] separately, and [iv] left hepatic duct [LHD] were anastamosed with jejunum. Normal liver functions with complete relieve from symptoms was achieved where CHD or CCHD was anastamosed whereas only a significant decrease was observed when R and LHD and only LHD were anastamosed with jejunum. Surgical resection of the tumor together with biliary decompression using different approaches of hepaticojejunostomy is an effective way of managing malignant Hilar bile duct obstruction as well as significantly decreasing the severity of symptoms in irresectable tumours

Acute abdomen in malaria

This is a study of seven cases [11%] of acute mesenteric ischaemia presenting as acute abdomen in a cohart of 60, of blood smear proven Malaria. Their presentation, diagnosis and management were recorded. Pathophysiology of occlusion of mesenteric vessels and the uncommon presentations of gut ischaemia due to malaria are discussed. In conclusion patients with short history of high grade fever followed by abdominal pain, malaria should be considered in the differential diagnosis

Role of octreotide in postoperative enterocutaneous fistula

Postoperative enterocutaneous fistulae, a serious complication of gastrointestinal surgery are associated with significant morbidity and mortality. Its management is based on nutritional support, control of sepsis, skin and wound care while waiting for fistula to close. Octreotide, a long acting somatostatin analogue, reduces gastrointestinal secretions and motility, hence reducing fistula output. Thirty one patients with postoperative enterocutaneous fistulae were administered octreotide subcutaneously and its effect on fistula output, till closing time were noted. There was a significant reduction in the fistula output, in 23[74%] patients fistula closed spontaneously in second week. Skin and wound were also easily managed. Although fistulahealing time was apparently reduced but, it was not possible to prove reduction in healing time convincingly, as to this end, controlled double blind trials are required. It is however, concluded that octreotide significantly reduces the morbidity by reducing - fistula output and assists in better skin and wound care