Addition of 2 mg dexamethasone to improve the anesthetic efficacy of 2% lidocaine with 1:80,000 epinephrine administered for inferior alveolar nerve block to patients with symptomatic irreversible pulpitis in the mandibular molars: a randomized double-blind clinical trial

Methods@#In a double-blinded setup, 124 patients randomly received either of the following injections: 2% lidocaine with 1:80,000 epinephrine, 2% lidocaine with 1:80,000 epinephrine mixed with 2 mg dexamethasone, or plain 2% lidocaine mixed with 2 mg dexamethasone, which were injected as a primary IANB. Ten minutes after injection, patients with profound lip numbness underwent electric and thermal pulp sensibility tests. Patients who responded positively to the tests were categorized as “failed” anesthesia and received supplemental anesthesia. The remaining patients underwent endodontic treatment using a rubber dam. Anesthetic success was defined as “no pain or faint/weak/mild pain” during endodontic access preparation and instrumentation (HP visual analog scale score < 55 mm). The effect of the anesthetic solutions on the maximum change in heart rate was also evaluated. The Pearson chi-square test at 5% and 1% significance was used to analyze anesthetic success rates. @*Results@#The 2% lidocaine with 1:80,000 epinephrine, 2% lidocaine with 1:80,000 epinephrine mixed with 2 mg dexamethasone, and plain 2% lidocaine mixed with 2 mg dexamethasone groups had anesthetic success rates of 34%, 59%, and 29%, respectively. The addition of dexamethasone resulted in significantly better results (P < 0.001, χ 2 = 9.07, df = 2). @*Conclusions@#The addition of dexamethasone to 2% lidocaine with epinephrine, administered as an IANB, can improve the anesthetic success rates during the endodontic management of symptomatic mandibular molars with irreversible pulpitis.

Comparison between peak systolic velocity of the inferior thyroid artery and technetium-99m pertechnetate thyroid uptake in differentiating Graves' disease from thyroiditis

ABSTRACT Objectives The differentiation between the various etiologies of thyrotoxicosis, including those with hyperthyroidism (especially Graves' disease [GD], the most common cause of hyperthyroidism) and without hyperthyroidism (like thyroiditis), is an important step in planning specific therapy. Technetium-99m (99mTc) pertechnetate thyroid scanning is the gold standard in differentiating GD from thyroiditis. However, this technique has limited availability, is contraindicated in pregnancy and lactation, and is not helpful in cases with history of recent exposure to excess iodine. The aim of this study was to identify the diagnostic value of the peak systolic velocity of the inferior thyroid artery (PSV-ITA) assessed by color-flow Doppler ultrasound (CFDU) and compare the sensitivity and specificity of this method versus 99mTc pertechnetate thyroid uptake. Subjects and methods We prospectively analyzed 65 patients (46 with GD and 19 with thyroiditis). All patients were evaluated with clinical history and physical examination and underwent 99mTc pertechnetate scanning and measurement of TRAb levels and PSV-ITA values by CFDU. The diagnosis was based on findings from signs and symptoms, physical examination, and 99mTc pertechnetate uptake. Results Patients with GD had significantly higher mean PSV-ITA values than those with thyroiditis. At a mean PSV-ITA cutoff value of 30 cm/sec, PSV-ITA discriminated GD from thyroiditis with a sensitivity of 91% and specificity of 89%. Conclusion Measurement of PSV-ITA by CFDU is a good diagnostic approach to discriminate between GD and thyroiditis, with sensitivity and specificity values comparable to those of 99mTc pertechnetate thyroid uptake.

Comparative Study of Carrying Angle between Dominant and Non Dominanat Limb in Kashmiri Population

Introduction: Carrying angle (CA) is the angle subtendedby median axis of the arm with fully extended and supinatedforearm. There is scarcity of evidence in the literature regardingdifferences between the CA in both sexes depending uponthe ossification of arm and forearm bones and comparison ofCA between dominant and non dominant limb. Study aimedat comparison of data obtained by measuring CA by manualmethod between dominant and non dominant limb in agegroup 18 – 30 years.Material and Methods: CA was measured in 200 individualsof both sexes by clinical method with a manual goniometer.Results: Present study shows the significant gender differenceand significant difference between dominant and non dominantlimb.Conclusion: Unnecessary x ray exposure to children, youngadults and pregnant women can be avoided, by measuring CAby clinical methods.

Functional outcome of cemented versus uncemented hemiarthroplasty for intracapsular hip fractures

To determine the functional outcome of cemented versus uncementedhemiarthroplasty in displaced intracapsular fractures of the hip. Randomized control trial. This study was carried out at the Orthopaedics Department, Shaikh Zayed Hospital Lahore and Ibn e Siena Hospital and Research Institute Multan from August 2010 to August 2013. 1 10 patients with hip fractures fulfilling the criteria were included,55 patients in each group were randomized. Patients in group A were having cemented hemiarthroplasty and in group B were having uncementedhemiarthroplasty respectively. After surgery all patients were mobilized as soon as they were able. All patients were reviewed at 12 weeks follow up using a pain scale of one to six and a mobility scale of zero to nine. In group A, the preoperative mean pain score was 5.91 +/- 0.29 and postoperative mean residual pain score at 12 weeks was 2.73 +/- 0.45. In group B, the preoperative mean pain score was 5.91 +/- 0.29 and postoperative mean residual pain score at 12 weeks was 3.00 +/- 0.64. P value of 0.000 was significant in the favor of cemented hemiarthroplasty. In group A, the preoperative [before fracture] mean mobility score was 7.20 +/- 0.75 and postoperative mean reduction in mobility score at 12 weeks was 2.80 +/- 0.76. In group B, the preoperative [before fracture] mean mobility score was 7.20 +/- 0.75 and postoperative mean reduction in mobility score at 12 weeks was 3.20 +/- 0.76. P value Of 0.000 was significant in the favor of cemented hemiarthroplasty. The use of cemented hemiarthroplasty lead to less pain in the hip and improved return of mobility as compared to an uncemented prosthesis

Efficacy of intra articular injections in different grades of osteoarthritis of knee

To assess the efficacy of intra articular injections in different grades of osteoarthritis of knee. Descriptive study. This study was conducted at the Department of Orthopedics Railway Hospital Rawalpindi and Ibn-e-Seina Hospital and Research Institute Multan started from June 2008 to June 2012. This study included 90 patients of either sex having mild, moderate and severe grades of osteoarthritis of knee based on radiographic findings. A study proforma was designed in which bio-statics and results of the study were recorded. Five intra-articular injections of hyaluronic acid were given on weekly basis and patients were assessed for pain and functional activity at intervals of 0, 6 and 12 Weeks by KSKS, WOMAC and VAS scoring system. These patients were selected consecutively. In this study patients with mild and moderate grades of osteoarthritis of knee showed improvement but patients with severe grades of osteoarthritis either showed no response or less improvement. Intra-articular injection of hyaluronic acid is an effective modality in early stages of osteoarthritis of knee

Thoracoscopic evacuation of retained post-traumatic hemothorax

Post-traumatic retained hemothorax is a major risk factor for empyema thoracis leading to prolonged hospitalization, entrapped lung and a need for decortication. VATS [Video Assisted Thoracoscopy] for retained hemothorax shortens the duration of chest tube drainage and length of stay. From December 2004 to July 2009, 110 consecutive patients underwent VATS for retained or clotted hemothoraces at the Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi. Majority of the patients were males [n = 91; 82.7%]. Sixty-five patients [59.1%] underwent VATS within 6 days and 45 patients [40.9%] between 7 - 14 days of injury. In 8 patients [7.3%] VATS was abandoned for thoracotomy. Post VATS full lung expansion was achieved in 87 patients [79.0] with complete evacuation of hemothorax. Chest tubes were removed within the first week in 100 patients [90.9%]. In hemodynamically stable patients, VATS is a safe, reliable and effective technique for the evacuation of retained hemothorax. Early intervention within 6 days of injury avoids the need for a thoracotomy and is associated with a better short and long-term outcome

Appendectomy; comparison of outcomes of laparoscopic versus open

The aim of this study was to compare the outcomes and morbidities of laparoscopic appendicectomy [LA] and open appendicectomy [OA] in patients with acute appendicitis. Interventional study. The study was conducted at Madina Teaching Hospital, University Medical and Dental College, Faisalabad. From June 2007 to August 2009. The study group consisted of two hundred patients suffering from acute appendicitis. One hundred patients underwent LA and one hundred patients underwent OA. Comparison was based on operating time, complications, requirements for postoperative analgesia, time until resumption to regular diet, hospital stay, and return to full activity in days. Comparisons were made between continuous variables using Student's t test of the means and were made between proportions using Fischer's exact or chi-square testing where appropriate. Statistical significance was taken to be a p value of .05 or less. Of the hundred patients, five patients [5%] had the procedure converted to open surgery. The rate of infection was significantly lower in patients undergoing LA. The median length of stay was significantly shorter after LA [2 days after LA, 5 days after OA, P < 0.05] than after OA. The operating time was shorter [OA: 25 min [median], LA: 30 min [median], P > .05] in patients undergoing open appendicectomy compared to laparoscopic appendicectomy. LA is associated with increased clinical comfort in terms of fewer wound infections, faster recovery, earlier return to work and improved cosmesis

Radiological feature of hepatic cirrhosis hepatitis "c" in Pakistan our experience at department of radiology, services institute of medical sciences

Objects: to evaluate the accuracy of liver fibrosis stage by utilizing the techniques of advanced ultrasound performance in patients with chronic liver disease with Hepatitis C

Material and Method: this cross-sectional study was prospectively designed by including 101 consecutive patients with a diagnosis of chronic liver disease including liver cirrhosis between January and December 2010. The ultrasound score was determined from both hepatic lobes and the average scoring was calculated for liver edge, liver surface and liver parenchymal texture. A score of O was given when no abnormality was observed; score 1 for mild abnormality; score of 2 for moderate abnormality; and a score of 3 for severe abnormality. Scoring was given for a blunted edge and severe irregular surface or a highly coarse texture only when these characteristics were clearly confirmed by the low frequency probe

Results: out of 101 subjects, 63.4 % were male and 36.6 % were female with age range of.23-70 years [mean age 50.73 years SD+/- 10]. 17.8 % subjects were between age group 20-40 years, 67 .3 % between age group 41- 60 years and 14.9 % between 61 years and above. Mean duration of illness was 2.86 years [minimum 1 year and maximum 15 years]. Mean liver size was 12.261 with SD+ 2.7145. Mean portal vein size was 1.662 SD+ 2.3247. Mean spleen size was 71.71 SD+ 32.226. 62.4 % had splenomegaly, 66.3 % had ascites, 56.4 % had bruising and bleeding, 62.4% had varices. 20.8 % had sharp edge 48.5 % had mildly blunted edge and 30.7 % had blunt edge, '11.9% had smooth edge. 33.7% had mildly irregular edge, 39.6 % had irregular edge and 14.9 % had highly irregular edge. Regarding liver parenchymal structure 13.9 % had fine, 22.8 % had mildly coarse, 48.5 had coarse and 14.9 % had highly coarse liver parenchymal. structure.15.8 % of subjects had mild fibrosis [score 0-2], 55.4 % had moderate fibrosis [score 3-5], 28.7 % had severe fibrosis [score 6-8]

Conclusion: US scoring system is clinically useful for differentiating patients with minimal or no fibrosis from those with mild to severe fibrosis. This is also useful for prognostic information and determining the optimal therapeutic options during the follow-up of chronic liver disease

Level of interferon gamma in the blood of tuberculosis patients

Interferon gamma [IFN- gamma], a cytokine produced by a variety of cells is involved in the immune response against M. tuberculosis. It activates the production of other cytokines and molecules that kill mycobacterium. IFN- gamma also has diagnostic role in identification of active and latent tuberculosis. To determine the level of IFN- gamma in the blood of TB patients. Ninety-one subjects were selected, including 54 active TB patients and 37 healthy controls. Among 54 TB patients, 27 had confirmed TB and 27 were clinically diagnosed as having TB. IFN- gamma concentration was determined in their blood by an ELISA technique. In TB patients, Mean +/- SD of IFN- gamma was 48.69 +/- 28.78 pg/ml while it was 12.99 +/- 5.70pg/ml in the control group [p <0.001]. Significant differences in the level of IFN- gamma were observed among confirmed TB patients, clinically diagnosed TB patients and the control group [Mean +/- SD 59.68 +/- 28.78, 36.85 +/- 24.76 and 12.99 +/- 5.70 pg/ml, respectively]. Furthermore, a significant negative correlation was observed between the concentration of IFN- gamma in TB patients and the duration of anti-tuberculosis therapy. IFN- gamma level was high in both clinically diagnosed and confirmed TB patients as compared to a control group. Measurement of IFN- gamma production is helpful to diagnose active tuberculosis, but further research is required

Clinical profile and postoperative outcome in patients with simple and complex aspergilloma of lung

To compare the clinical presentation and results of pulmonary resection in simple and complex aspergilloma of the lung. Observational study. The Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, from January 2003 to December 2008. Fifty-one adult patients with unilateral aspergilloma lung were included in this study. Patients were divided into two groups: A [simple aspergilloma-SA, n=14] and B [complex aspergilloma-CA, n=37], based on the radiological and operative characteristics of the cavitatory lesion and the presence or absence of extensive adhesions with the chest wall. Suitability for resection was assessed with arterial gases, pulmonary function tests and echocardiogram. Results were compared using Fishers exact test. Recurrent hemoptysis was the predominant symptom in both the groups. Exertional dyspnea [A=21.4%; B=56.8%; p=0.03], chest pain [A=21.4%; B=59.5%; p=0.027], cough [A=35.7%; B=70.3%; p <0.05] and postoperative complications like residual pleural space A=14.2%; B=54%; p=0.013] and pleural collection [A=7.1%; B=37.8%; p=0.041] were predominant in group B. Lobectomy was the most common procedure performed in group B [A=28.6%; B=59.5%], while wedge excision was performed in the majority of patients in group A [A=42.9%; B=29.7%]. Recurrence of aspergilloma was seen in 3 patients [8.1%] in group B only. Total number of early and late complications in SA and CA were 7, and 60, respectively. Early mortality was 8.1% and 0.0% in group A and group B, respectively [p=0.552]. The overall mortality was 5.4%. Symptoms were more frequently associated with CA as compared to SA. Surgery for CA was associated with low mortality but significant morbidity, whereas SA had low postoperative morbidity and no mortality

Postoperative nausea and vomiting [PONV]; preoperative dexamethasone in laparoscopic cholecystectomy patients

To evaluate the effect of preoperative single dose injection dexamethasone for prevention of PONV in patients undergoing laparoscopic cholecystectomy and comparing it with normal saline [placebo]. Experimental RCT study. The study was conducted at Madina Teaching hospital, University Medical and Dental College, Faisalabad from January, 2008 to October 2009. After approval from the hospital ethical committee, 200 patients with ASA I and II were included in the study. We divided the patients into two groups; group I received preoperative dexamethasone [8mg] and the group II received normal saline [placebo] 90 minutes before the surgery. Patients were observed for any episodes of nausea or vomiting, need for rescue antiemetics, and complete responses in the postoperative period. The complete response was defined as no nausea, no vomiting, and no ant emetic medication during a 24-h postoperative period. This was also the primary efficacy end point of the study. The data was analyzed using Pearson's Chi square test with P<0.05 taken as significant. Nineteen patients [19%] in the dexamethasone group reported nausea, compared with 43 [43%] in placebo group [p<0.05]. Eight patients [8%] in the dexamethasone group reported vomiting and twenty two patients [22%] in the placebo group reported vomiting [P<0.05]. In group I, thirteen patients [13%] asked for rescue anti-emetic where as in group II [placebo group] thirty six patients [36%] asked for rescue anti-emetic [p<0.05]. Seventy three patients [73%] in the dexamethasone group showed a complete response, compared with 35 [35%] in placebo group [p<0.05]. We concluded that preoperative dexamethasone [8mg] reduces the incidence of PONV as compared to placebo. As it is a cheap, freely available drug causing no complications, it should be used in otherwise fit selected patients undergoing laparoscopic cholecystctomy

Perforation operation interval as a prognostic factor in typhoid ileal perforation

To find out significance of perforation-operation interval [POI] in relation to early prognosis in patients with peritonitis due to typhoid Heal perforation [TIP]. Case series. Department of General Surgery, Jinnah Postgraduate Medical Centre [JPMC] Karachi, from October, 2004 to March, 2007. The study included 92 patients with generalized peritonitis diagnosed as typhoid Heal perforation Methods fulfilling the inclusion criteria. All non typhoidal and traumatic perforations were excluded from the study. Data was collected in the proforma designed for the study. The diagnosis of typhoid Heal perforation was established on the basis of history, clinical examination, radiology, isolation of Salmonella Typhi, and a positive Widal test. Histopathological confirmation of the diagnosis was also made. Out of 92 patients, 75 were males [81.5%] and 17 [18.5%] females, with male to female ratio of 4.4:1. The ages ranged between 15 to 50 years. The most common symptoms were fever [100%], abdominal pain [100%], constipation [81.5%], vomiting [76%] and distension of abdomen [69.5%]. The most common signs elicited on abdominal examination were tenderness [100%], guarding [72.8%] and absent gut sounds [65.2%] Out of 92 patients 12 patients [13%] presented within 24 hours of onset of severe abdominal pain [Group A]. Among late presenters, My nine [64.1%] patients presented 25-72 hours after severe abdominal pain [Group B] and twenty one patients [23%] presented after 72 hours [Group C]. Mortality was highest among group C patients [8/21 ;38%], while the mortality among the late presenters [Group B] was 10.2% [6/59]. There r was no mortality in the early presenters [Group A]. Overall mortality was 15.2% [14/92]. The average perforation operation interval in survivors was 44.2 hours as compared to average of non-survivors- 63.9 hours [p <0.01]. Prolonged presentation time leads to a high mortality rate. Once intestinal perforation occurs, early recognition, early referral and aggressive management could decrease the high mortality

Role of urgent thoracotomy in improving the survival of patients with severe chest trauma

To determine the frequency of survival in patients with thoracic trauma, undergoing Urgent Thoracotomy [UT]. Quasi-experimental study. The study was carried out in the Department of Thoracic Surgery, JPMC, Karachi, from January 2005 to June 2007 [30 months]. Fifty two patients, who presented with chest trauma and underwent UT within 48 hours of sustaining thoracic trauma, were included in the study. All patients were assessed by history, physical examination and relevant investigations. A total of 475 patients with acute thoracic trauma needing admission during the study period presented to the Accidents and Emergency Department. Fifty-two [52/475; 10.9%] patients were indicated for UT. The most common indication for UT was massive hemothorax [43/52; 82.6%]. The mean age of the patients was 34.36 +/- 11.02 years. There were 22 [42.2%] blunt injuries and 30 [57.8%] penetrating injuries. Road Traffic Accidents [RTA] were the most frequent cause of blunt chest injuries [15 patients; 75%], while firearm injury was the commonest [21 patients; 70%] cause of penetrating chest trauma. Post thoracotomy mortality was 13.3% [4 out of 30] in patients with penetrating injuries and 18.2% [4 out of 22] in patients with blunt injuries [p < 0.01]. Mortality of UT was 15.3% with survival of 84.7%. Overall survival in 475 patients was 95.58%. Early recognition of treatable injuries and an aggressive approach in management with Urgent Thoracotomy can increase chances of survival of patients suffering from severe chest trauma

Lead exposure in children living around the automobile and battery repair workshops

The aim of this study was to screen children 1-12 years of age for lead exposure living around automobile and battery repair workshops. A total of 190 children living in one kilometer areas around the automobile and battery repair workshops were selected from houses and schools. These were divided into two groups: group A comprised of the children living around the automobile repair workshops and group B comprised of the children living around the battery repair workshops. Among the 190 children, 115 [60.5%] were males and 75 [39.5%] were females. The mean age of the children was 8.7 years. Majority of the children was less than 4 years of age [55.8%]. The blood lead levels were between the range of 1.3 - 34.2 mg/dl [mean 11.4 mg/dl]. Children living around the battery repair workshops [mean +/- SD 12.85 +/- 6.02] had high blood lead levels [p 0.020] as compared to the children living around the automobile repair workshops [mean +/- SD 10.19 +/- 6.13]. There was a significant negative correlation of blood lead levels and haemoglobin [r = - 0.400 and p 0.001]. Children living around automobile and battery repair workshops had significantly high blood lead levels according to WHO and CDC criteria. Blood lead level [BLL] is a good screening and diagnostic test for the assessment of lead exposure in children living in lead contaminated high risk areas

Role of video assisted thoracoscopy in the management of clotted hemothorax

To evaluate therapeutic value of videothoracoscopy in chest trauma patients with residual clotted hemothorax. Prospective study Sixty five patients included in the study were seen at the Department of Thoracic Surgery, Jinnah Postgraduate Medical Centre, Karachi, after careful assessment of their haemodynamic status and the extent of injuries. Out of these, 15 presented in our casualty, while 50 were referred to the Department from elsewhere. Inclusion criterion for the study was x-ray chest showing a retained haemothorax 72 hours after tube thoracostomy. They underwent therapeutic VATS on the next available operation day. One lung anaesthesia was used with collapse of the lung on the ipsilateral side. Two or three ports were used keeping the concept of triangulation in mind. The pleural cavity was washed with warm normal saline and one or two 36 Fr. thoracostomy tubes were inserted under vision. Sixty-five hemodynamically stable patients [54 males and 11 females] with chest trauma [blunt 46, penetrating 19] were examined and treated videothoracoscopically over a period of 3 years from November 2001 to October 2004. The indication in this group of patients was clotted hemothorax, which failed to evacuate with a conventional large bore [36 F] thoracostomy tube. Most [77%] of the patients underwent VATS in the first week after injury, while 23% patients had video assisted thoracoscopy [VATS] in the second week. The rate of conversion to thoracotomy was 7.7% [5 patients]. It was seen that in these 5 patients requiring thoracotomy, an increased time interval between injury and VATS was a significant factor in determining the outcome [p<0.005]. In all these patients the time interval was more than 7 days. Post VATS full lung expansion was achieved in 51 [78.5%] patients. The average duration of VATS was 70.16 minutes [minimum 60 minutes; max 100 minutes]. Most patients [90.8%] had the thoracostomy tube removed in the first week after surgery. In 6 patients the tube was kept for a longer duration. Therapeutic video assisted thoracoscopy is a safe and reliable operative technique for the evacuation of post traumatic clotted hemothorax in hemodynamically stable patients. VATS, if performed within the first 7 days of injury, obviates the need for later thoracotomy and decortication avoiding prolonged hospital stay and morbidity of an empyema thoracis

Degloving injuries

Early identification of degloving injuries and to emphasize their management. DESIGN: Retrospective study. SETTING: Department of surgery Allied and DHQ Hospitals Faisalabad. PERIOD:May 1986 to April 1996. PATIENTS AND METHODS: 120 patients 96 males [80%] and 24 female ranging between 4 to 75 years mean 39.5 years. RESULTS AND CONCLUSIONS: The etiological factors were Road Traffic Accident in 56% [67 patients], rotatory machine accident in the remaining 44% [53 patients]. Degloving most commonly occurred in the lower limb 44% [53 patients], following by in the descending order Peno scrotal 20% [24 patients] upper limb 17.5% [21 patients] scalp 14.1% [17 patients] and miscellaneous group 4.16% [5 patients]. Associated skeletal fracture were seen in 7 patients 4 of which had multiple fracture