Laparoscopic assisted appendectomy in children. Our experience of first 50 cases at tertiary care hospital Rawalpindi

Objective: To present an experience of the first 50 cases of appendectomy performed via laparoscopy assisted open technique

Study Design: Descriptive case series

Place and Duration of Study: This study was carried out at Pediatric Surgery department, Pak Emirates Military Hospital Rawalpindi, from Jan 2016 to Apr 2018

Material and Methods: Fifty patients [<12 years old] diagnosed as cases of acute appendicitis were enrolled after ethical committee approval. The procedure was performed via three ports [4 ports if required]. Appendix was brought out through the right iliac fossa port and appendectomy was performed by extracorporeal knotting technique. Operative time, position of appendix and postoperative complications were recorded. Data was expressed as means and frequency percentages

Results: Out of 50 patients, 31 were male and 19 were females. The mean age of the patients was 7.99 +/- 3.34 years. Forty one patients had acute appendicitis while 9 patients were diagnosed as appendicular mass. The mean operative time was 24.9 +/- 7.42 minutes. There were no cases of surgical site infection. Thirty eight patients were operated via three ports while 12 patients required four ports. Three patients required conversion to open appendicectomy due to extensive adhesions or abscess. Post-operatively drain was placed in only 6 patients

Conclusion: Laparoscopic assisted open appendectomy is a safe, quick and easy to learn technique in children which combines all the advantages of minimal access surgery with open appendectomy while reducing the number of complications associated with it. The technique has the added advantage of diagnostic laparoscopy over open surgery

Comparison of Onlay versus Sublay mesh repair for ventral abdominal hernias. a randomized controlled trial

Objective: To compare onlay versus sublay mesh repair for ventral abdominal hernias in terms of mean operative team, frequency of post-operative wound infection, seroma formation and hematoma formation

Study Design: Randomized controlled trial

Place and Duration of Study: Department of General Surgery, Pak Emirates Military Hospital Rawalpindi, from Apr 2017 to Dec 2017

Material and Methods: A total of 78 patients [39 in each group] diagnosed as a case of ventral abdominal hernia meeting the inclusion and exclusion criteria were included in the study. Patients with complicated hernias, recurrent hernias and bleeding disorders were excluded. Group-A patients underwent mesh repair by the onlay method while group-B patients underwent mesh hernioplasty via the sublay technique. All patients were followed for wound infection, seroma formation and hematoma formation. Data was analyzed by SPSS ver. 23.0

Results: The mean operation time in group A was 46.10 +/- 7.25 minutes while in group B, the mean operation time was 77.82 +/- 9.97 minutes [p<0.001]. The frequency of wound infection was 5.13 percent vs 0 percent [p=0.49] and hematoma formation was 5.13 percent vs 7.69 percent [p=0.999] between the two groups respectively which were statistically insignificant. However, seroma formation between the two groups was 23.08 percent vs 5.13 percent, which was statistically significant [p=0.023]

Conclusion: Sublay mesh repair for ventral hernias is better than onlay mesh repair for ventral abdominal wall hernias in terms of frequency of complications. However, it requires a longer operative time

Left-sided appendicitis in a 14-year girl with midgut malrotation

We present a case of 14-year girl with left-sided acute appendicitis who presented with lower abdominal pain. Midgut malrotation occurs at a rate of 1 in 500 live births. The condition is incidentally diagnosed during various radiological investigations done for other purposes. However, such patients may present with conditions like acute appendicitis, which poses a diagnostic dilemma if a high index of suspicion is not kept. The purpose of this case report is to increase awareness in the emergency physicians and young surgeons of this rare presentation; and the importance of radiological investigations in the diagnosis of left-sided appendicitis, to decrease morbidity and mortality

Seasonal variation of acute appendicitis

Objective: To determine the seasonal variation of acute appendicitis

Methods: A total of 320 patients fulfilling the inclusion criteria were enrolled in the study after getting the written informed consent. Appendectomies were performed by consultant surgeons and residents. After surgery histopathological examination of specimens was performed by consultant Histopathologists at Armed Forces Institute of Pathology Rawalpindi and CMH Peshawar. The patients presenting in different four seasons September to November as autumn, December to February as winter, March to May as spring, June to August as summer, were compared to determine seasonal variations

Results: In our study out of all 320 patients 188 [58.75%] were males and 132 [41.25%] were females. Sixty patients [18.75%] presented in autumn season [Sep-Nov], 52 patients [16.25%] in winter season [Dec-Feb], 78 [24.25%] patients in Spring season [Mar-May].130 [40.62%] patients presented in Summer season [Jun-Aug]. There was almost 24.37% increased incidence in summer as compared to winter season, 21.87% increased incidence as compared to autumn season, 16.37% increased incidence as compared to spring season

Conclusion: Acute appendicitis incidence is increased in summer months in Pakistan. Preventive measures can be taken during summer season [June to Aug] to decrease morbidity and mortality associated with this disease

Efficacy of early oral refeeding in patients of mild acute pancreatitis

Objective: To compare Early Oral Refeeding [EORF] with Routine Oral Refeeding [RORF] on outcome of patients of mild Acute Pancreatitis [AP] in terms of Mean Length of Hospital Stay [LOHS]

Methods: This randomized controlled trial was conducted at Surgical Department CMH Rawalpindi, from 1[st] Feb 2015 to 01st Aug 2016. A total of 60 patients with pain epigastrium were enrolled in the study. Severity of pancreatitis was assessed using Glasgow Scale. Patients were randomly divided in two groups. Group-A was started feeding within 12 hours [EORF group] and Group-B after 12 hours [RORF group]. Demographic details and data were recorded on a structured proforma. After discharge, LOHS was measured for both groups and outcome was compared

Results: The groups were comparable with respect to age, sex, etiology, Glasgow Scale, time from onset of pain and Serum Amylase levels at admission. Treatment was standardized according to international guidelines for both groups. The mean LOHS was 7.8 +/- 2.14 days in the Group-A and 10.03 +/- 1.75 days in Group-B. The difference in the mean LOHS between the two groups was statistically significant [p<0.05]

Conclusion: In patients of mild acute pancreatitis, early oral feeding is feasible and safe and has better outcome then those with routine oral refeeding

Effects of surgery duration on post-extraction sequelae following impacted third molar surgery by using two different bone cutting methods; a double blind randomized trial

The objective of this research was to analyze the impact of duration of surgery on post-operative pain and swelling after surgical removal ofmandibular third molars

This study was planned as double blind randomized clinical trial that comprised of 60 patients experiencing unilateral mandibular third molar extraction who were recruited into two groups before surgery on the basis of bone cutting method. The study duration was three months, executed at Department of Oral and Maxillofacial Surgery, Dow International Dental College, Dow University of Health Sciences, Karachi. Post-operative complications [pain and swelling] were assessed pre operatively and then on 3rd and 7th day post operatively using visual analogue scale and objective scale for swelling measurement using five anatomical points on face. Surgery duration was divided into two groups, 10-20 minutes group and 20 minutes onwards

Mann Whitney test was used to assess the impact of duration on pain and swelling in both groups. In 10-20 minutes group, mean difference for pain on day one, day 3 and day 7 was calculated with p-value of 0.15, 0.641 and 0.081 respectively while in group having surgery duration of 20 minutes and more, the computed p-value were 0.002, 0.0168 and 0.02 respectively. Mean difference for swelling was calculated in both bone cutting groups with p-value of 0.0916 in 10- 20 minute group and 0.004 in 20 minute onward group

Increasing time duration was associated with more pain and swelling irrespective of the method used for bone cutting. Conventional slow speed hand piece used for bone cutting was associated with less post-operative complications

Rare case of Spigelian Hernia, diagnosis and treatment

As it stands, Spigelian hernias are rare and generally overlooked or misdiagnosed. We report a case in which a Spigelian hernia presented to us as a painless abdominal swelling in a 39 year old obese female with no known co-morbids The hernia appeared as swelling in the right lower quadrant, which was non tender at the time of admission and showed no signs of strangulation. Diagnosis of the hernia was made on CT-scan and an open technique was adapted to repair it. The post op period was insignificant in the patient

Survival of a malignant hyperthermia patient

Malignant hyperthermia is an inherited autosomal life threatening skeletal muscle disorder usually triggered by certain general anesthetic drugs like volatile anesthetics and depolarizing muscle relaxants [succinylcholine]. Only early recognition and prompt accurate treatment can save life in an otherwise fatal situation. We present a case of a young boy in whom malignant hyperthermia was recognized within 10 minutes of induction of anesthesia and life was saved by prompt treatment even in the absence of dantrolene

Hypertrophic cardiomyopathy in the Saudi Arabian population: clinical and echocardiographic characteristics and outcome analysis

Current published literature on hypertrophic cardiomyopathy [HCM] comes primarily from Western populations. There is no published data on clinical and echocardiographic characteristics and long-term outcome of HCM in an Arab population. We conducted a retrospective analysis of all patients 16 years or older diagnosed with HCM at our institution. Detailed clinical and echocardiographic data were collected and outcome was analyzed. A total of 69 patients were identified as having HCM. The mean age was 42 +/- 16 years with 71% male patients. All patients were Saudi citizens with Arab ancestry. Details about family history and presenting symptoms were available for 44 and 48 patients consecutively. Nine [18%] patients were asymptomatic and were diagnosed based on abnormal cardiac auscultation. The commonest presenting symptoms were dyspnea with or without chest pain and palpitations occurring in 40 [81%] patients. Only four [9%] of 44 patients had a family history of HCM and /or sudden cardiac death [SCD]. The most common ECG abnormality was left ventricular hypertrophy [LVH] present in 60 [86%] patients. The commonest septal hypertrophy morphology was mid-septal [catenoid] in 30 [43%] followed by neutral in 23 [33%], basal septal [sigmoid] in 3 [4%] and apical in 6 [8%] patients. Twenty [28%] patients had evidence of resting left ventricular cavity gradient of >/= 30mmHg. Eleven [16%] patients had evidence of biventricular hypertrophy. Left ventricular ejection fraction was normal in 65 [94%] patients. Over a median [25-75 percentile] follow-up of 7 years [4.5-10], only three patients died, all of non-cardiac causes. There were no cases of SCD during the follow-up period. Six patients required an implantable cardioverter-defibrillator [ICD]; five for primary prevention and one for secondary prevention. Only one patient progressed to end stage dilated cardiomyopathy. The natural history of hypertrophic cardiomyopathy in the Saudi population appears to be benign with catenoid morphology being the most common septal hypertrophy pattern. Risk of SCD appears to be quite low in this population

High heel shoes; outcome of wearing in young generation: a cross sectional study

Outcome of wearing high heel shoes in young generation: A Cross Sectional Study. Introduction/ High heels increase the heel height, thus increasing the pressure under the metatarsal head in forefoot, they push the center of mass of the body forward taking the hips and spine out of alignment moreover the altered posture of walking 1-5 in high heels places excessive forces on the inside of the knee joint. All these factors contribute in causing deleterious pathologic deformities. The studies carried out previously were more focused on the adult population furthermore there isn't much work done to investigate the effect of heels in Pakistan therefore, this was a non-invasive study the purpose of which was to evaluate these complications particularly targeting the medical students of medical colleges, Karachi. A total of 220 respondents aged between 15 to 25 years were selected as potential respondents meeting the criteria for selection. A convenience based randomized sampling method was adopted, where the participants were required to fill questionnaires and give their demographic details. They were inquired about the presence of any co morbidities which was an essential part of the exclusion criteria. They were also inquired about their usage of high heel shoes, their size, duration and frequency of usage, and if they had been causing any complications such as bunions, heel spur, callosities or pain in soles, calf or back. The data obtained was analyzed through SPSS and the graphs of frequency for all the complications were computed. After analyzing the 220 participants it was found that 7.7% were males while 92.3% were females, and 61.8% were found to be within 21 to 23 years of age. After the analyses of data for the complications it was found that out of the total participants 18.8% experience foot swelling, 19.4% blisters, 16.4% foot numbness, 12.3% foot callosities, 2.8% heel spur, and 3.7% experience bunions. From this study conducted on the students of medical college it was found that wearing high heel shoes is not associated with any significant complications among most of the students

Knowledge and practices of basic life support amongst the ambulatory staff in Karachi

To assess the Knowledge and Practice of Basic Life Support in the ambulatory staff services in Karachi. Cross Sectional Study This study was conducted at Sindh Medical University [JSMU] from March 1st to October 30[th], 2011. Sample size of 283 was drawn using non- probability purposive sampling, ambulance staff members belonging to 10 ambulance services in the city, mainly Aman Foundation, Edhi, Chippa, Khidmat-e-Khalq Foundation were interviewed through structured questionnaire. The data was collected and analyzed on SPSS version 17. Out of the 283 ambulatory staff members, 72.5% of the staff had no knowledge of Basic Life Support, 27.4% had knowledge. 14% answered correctly about the position in which a heart attack patient should be placed, 90% answered wrongly about patient whose clavicle had been fractured. 72% of the ambulatory staff actually checked oxygen flow in the tank after they had put the mask on the patient, 65% of the staff had removed the helmet of accident patients.64.8% had no idea about the respiratory rate, pulse count of an adult, 76.2% didn't know about the complications of an Intravenous installation. The study proved major lapses in knowledge and practices in Basic Life Support for ambulatory staff. Implementation of first aid's protocol are fully neglected, yielding an ambulance service that might let the patients suffer undue circumstances and also directly affects major indicators of primary health care

Seroprevalence of bordetella pertussis antibodies to pertussis toxin among healthy children

Pertussis or whooping cough is a highly communicable, vaccine-preventable acute respiratory tract disease, caused mainly by Bordetella pertussis. In this study, serosurveillance of IgG antibodies against pertussis toxin was carried out in healthy children, aged 3 months to 12 years, from the multiethnic cities of Islamabad and Rawalpindi, Pakistan. Kruskal- Wallis test was applied to determine the difference among groups. The results showed that the average values of pertussis toxin IgG dropped down significantly with age after getting the first dose in first 2 years [p < 0.001]. Therefore, the researchers suggest introduction of booster vaccination with DTaP at second year of life and school going age to reduce the risk of getting B. pertussis infection

Hemodynamic response of low dose bupivacaine with fentanyl spinal anesthesia in elderly patients

To determine whether a reduced dose of bupivacaine in combination with fentanyl could give reliable block with greater hemodynamic stability in elderly patients. Quasi experimental study. Department of Anaesthesiology, Intensive Care and Pain Management Combined Military Hospital Rawalpindi. One year duration, from May 2006 to April 2007. ASA I-III elderly patients [n=60] undergoing surgery for fracture neck of femur, meeting the inclusion and exclusion criteria. Sixty elderly patients were randomized in two groups. The study group [group-A] received spinal anesthesia as a combination of hyperbaric bupivacaine 7.5 mg and fentanyl 15 µgm while the control group [group-B] received hyperbaric bupivacaine 15 mg. The hemodynamic stability of the patients and the quality of the blocks were compared. All patients had adequate duration of block. There was no significant difference in the change of heart rate between the two groups. Fall in blood pressure was more pronounced in the control group [group-B] patients requiring more ephedrine as compared with the study group [group-A] patients which remained more hemodynamically stable. A reduced dose of hyperbaric bupivacaine in combination with fentanyl provides reliable spinal anesthesia in elderly patients with few events of hypotension and little need for vasopressor support of blood pressure.

Malpractices of hand hygiene in nursing staff: a global threat for increasing incidence of infections

This study assessed the knowledge, practice of standard hand hygiene in nursing staff to identify the causes of not adapting hand hygiene techniques during routine patient care. A cross sectional study. This study was carried out in Karachi in various public sector hospitals i.e. Jinnah Postgraduate and Medical Centre, National Institute of Child Health, Civil Hospital Karachi, Sindh Institute of Urology Transplantation, National Institute of Cardiovascular Diseases. The study completed in six months from May to November 2010. A sample of 335 nursing staff was selected, convenient sampling was used, consent was taken. They were asked about their practices of hand hygiene through structured questionnaire at five major public sector hospitals of Karachi, Pakistan. Out of 335 nursing personnel. 71.9% were unaware that washing hands under running water for 30sec to 1min remove most of the germs. 74.62% knows that hand washing is necessary. Regarding practices, 35.5% use sanitizers while 47.2% use antiseptic, normal soap for washing hands. 67.1% practice hand washing before and after coming in contact with patients. 43.7% took some treatment after needle prick while others [56.3%] didn't feel the necessity to take any treatment, regardless of the risk of Hepatitis, IHV. 36.1% adopted sterile techniques after hand washing. Surveillance was below average [46.6%]. Hand hygiene knowledge, practices of nursing staff is part and parcel for minimizing infections. Adequate hand washing facilities, positive attitude towards hand hygiene, adherence to practice, strict surveillance system for hand hygiene is essential to combat increasing incidence of infections

Human papilloma virus and oral lesions in Gutka eating subjects in Karachi

To determine the frequency of HPV in eaters of Gutka [betel, areca, lime and tobacco concoction], presenting with oral lesions. A descriptive study. Ziauddin University Research Laboratory, from February to July 2010. Subjects munching Gutka fulfilled the inclusion criteria. Samples were collected in the form of 20 - 40 ml oral rinse from 262 subjects who were habitual eaters of Gutka after an informed consent. Gentle brushings from the lesion were taken from subjects with the help of a brush at the other end of dental floss and the oral rinse was stored at 4[degree sign] C until DNA extraction. DNA was extracted and PCR was performed using HPV consensus primers Gp5+/Gp6+. Oral cavity was examined for the presence of ulcer, trismus, sub-mucosal fibrosis, leukoplakia and/or warts. Out of 262 subjects, 42 were females and 220 males with an average age of 27 +/- 10 years. HPV was positive in 47 subjects [17.9%]. HPV frequency was 2.7% greater in chewers with more than 10 years of habit compared to less than 10 years. Examination of oral cavity showed 78% presenting with more than one complaint including oral ulcers [25%], rough mucosa [62%], sub-mucosal fibrosis [24%], leukoplakia [20%] and erythroplakia [10.6%]. Highest frequency of HPV was observed in erythroplakia [25%]. Association between presence of symptoms and HPV shows an ODDS RATIO: ad/bc= 4982/430=11.6. Oral lesions caused by constant exposure to Gutka are associated with high frequency of HPV infection, which may be a risk factor for squamous cell carcinoma of the oral cavity. People should be educated about the consequences of Gutka abuse

Knowledge of doctors working in Karachi about vitamin D deficiency

To assess the knowledge of doctors working in Karachi about Vitamin D deficiency. This descriptive cross-sectional study was carried out at public and private hospitals and clinics in Karachi from January 2010 to March 2010. Four hundred doctors registered with the Pakistan Medical and Dental Council [PMDC] working in Karachi were included in the study. A well structured, pre-tested questionnaire was designed to gather data. Each interview was completed by an investigator. Questions included the sources and metabolism of vitamin D, deficiency of vitamin D, its presentation in clinics and its management. Questionnaires were completed by 400 doctors. The results indicate that doctors are aware of the sources and metabolism of vitamin D but lack information about the duration and factors regarding sunlight exposure. The physicians generally have good information about the signs and symptoms of vitamin D deficiency and the factors causing it, but do not have sound information about deficiency management. The results support the fact that doctors need more knowledge and training about vitamin D deficiency

Comparative study of intubating conditions after Rocuronium and Suxamethonium [study of 50 cases]

To compare the Intubating Conditions and Changes in heart rate [HR] achieved after suxamethonium chloride and rocuronium bromide, during intubation, in patients between ages 11-50 years out of which 4 were in paediatric age group [11-12 years] and 46 in adult group [19-50 years]. This study was conducted at the Armed Forces Hospital Sharourah kingdom of Saudi Arabia during six months period starting from 01/02/09. Fifty patients aged between 11-50 years, 4 including in paediatric age group [11-12 years] and 46 in adult age group [19-50 years], requiring general anesthesia for various surgical procedures, were randomly divided into two groups, i.e. Group A in which Rocuronium bromide, 0.9 mg kg-1 was given for intubation [[n=25] [23 adults, 2 children]] Group B in which Suxamethonium chloride 1.5 mg kg -1 was used for intubation [[n=25] [23 adults, 2 children]] Intubating conditions were observed at 60 seconds after intravenous bolus administration of suxamethonium or Rocuronium. HR was also observed immediately before induction [Pre-Op], at 60 seconds after bolus of Suxamethonium or Rocuronium [Immediately after relaxation], Immediately after intubation and then five minutes after intubation. Intubating conditions were rated as excellent in 96% [n=24 Twenty two adults two children] and good in 4% [n=1 Adult] of the patients who received Rocuronium and excellent in 100% of the patients who received Suxamethonium. There were no statistically significant changes observed in HR at all observation times between the two groups. It is concluded from this study that intubation can be performed under good to excellent conditions at 60 seconds after a bolus dose of Rocuronium of 0.9 mg kg-1. As far as affect on HR are concerned, our study indicate no significant difference between the two drugs. The result of this study indicates that to facilitate intubation using rapid sequence induction technique Rocuronium is a reasonably good alternative to Suxamethonium

Modified Alvarado Score; accuracy in diagnosis of acute appendicitis in adults

To compare the frequency of inflamed appendix in suspected patients of acute appendicitis having Modified Alvarado Score [MAS] of 7 or more with patients having MAS of 6 or below. Comparative cross sectional study. The study was carried out at Surgical Departments of Combined Military Hospital [CMH] and Military Hospital [MH] Rawalpindi from April 2006 to April 2007. This study involved 100 patients who were operated with provisional diagnosis of acute appendicitis. Preoperatively MAS of each patient was calculated and the patients were divided in two groups. Group-l had MAS of 7 or more while Group-ll had MAS of 6 or below. Postoperatively appendices of all the patients were sent for histopathological examination and its result regarding presence or absence of acute appendicitis was then compared with MAS of respective group. [a] Group-l :- A total of 72 patients with 64 [88.9%] positive inflamed appendices on histology. Negative appendicectomy rate 8 [11.1%], [b] Group-ll:-A total of 28 patients with 8 [28.6] positive inflamed appendices. Negative appendicectomy rate 20 [71.4%]. There is statistical significant difference of positive appendicectomy rate between two groups with [p-value<0.001]. Frequency of inflamed appendix is more in patients having MAS of seven or above. The number of negative appendicectomies can be reduced by using MAS in clinical practice

Rapidly progressive effusive constrictive pericarditis caused by methicillin sensitive staphylococcus aureus [MSSA]

Effusive-constnctive pericarditis is a clinical syndrome characterized by concurrent pericardial effusion and pericardial constriction, where constrictive hemodynamics are persistent after effusion is drained. It may present at any point along the clinical course, from the occurrence of an effusion to the development of chronic pericardial constriction. We refer an unusual case of effusive constrictive pericarditis developing rapidly within days, following purulent pericarditis secondary to chest trauma