Comparison of two dosages of Submucosal Dexamethasone to control Postoperative Trismus after surgical extraction of Mandibular impacted third molar

Objective: To compare the post surgical effects of two different concentrations' i.e. 4mg [milligram] and 8mg of sub mucosal dexamethasone to decrease trismus by comparing the mean decrease in interincisal distance in patients undergoing impacted mandibular third molar surgery

Study Design: Randomized controlled clinical trial

Place and Duration of Study: Outpatient department of oral and maxillofacial surgery unit, Mayo Hospital, Lahore. The study was completed in 6 months, from Jan 2012 to Jul 2012

Material and Methods: This randomized controlled clinical trial was conducted on 150 patients. Patients were divided into two groups A and B. Mean interincisal distance of all patients was recorded pre operatively and post operatively. All patients were advised to use a mouthwash clorhexidine 0.2 percent before surgery. Group A received 4 mg dexamethasone and group B received 8 mg dexamethasone in the buccal vestibular tissues. Standard surgical procedure was performed by the same operator under same conditions. Postoperative mean interincisal distance of all patients was recorded on day 2 [after 48 hours of surgery]

Results: Average age of patients was 32.62 +/- 7.86 years with minimum and maximum ages of 20 and 50 years respectively. Gender distribution was almost equal. Average [maximum interincisal] mouth opening distance was significantly higher in group B as compared to group A i.e. [36 +/- 3.928 mm [millimeter] versus 26.04 +/- 3.097 mm] with p-value=0.000

Conclusion: Eight mg dose of dexamethasone was statistically more significant in reducing the trismus as compare to 4mg [p-value=0.000]

Risks and benefits of giving early aspirin within 6 hoursof CABG: a retrospective analysis

Background and Objective: Antiplatelet drugs are frequently used after coronary artery bypass graft [CABG] surgery to prevent venous graft occlusion. The fear of bleeding complications prevents them to be given early post operatively, which is the time when antiplatelets use confers maximum benefit. Our objective was to determine the effect and influence of early aspirin therapy on fatal and nonfatal bleeding complications and blood requirements after coronary bypass surgery [CABG]

Methods: The patients who only underwent coronary artery bypass surgery for the first time in the past three years and did not have any bleeding diathesis were retrospectively analyzed from the cardiac surgery database of CPEIC Multan. The patients either received aspirin within six hours of CABG or had it given after 12 hours. The patients were analyzed for mean blood loss and number of blood units transfused. SPSS was used for statistical analysis. P value < 0.05 was considered significant

Results: Total 281 patients received aspirin within six hours while 326 patients did not. Mean blood loss in early aspirin group was 727ml as compared to 767ml in the other group [p value 0.74]. The median number of blood units transfused was 2 [p value 0.98]. Our results did not show any statistical difference in both the groups

Conclusion: Aspirin can safely be given early after CABG without the fear of bleeding complications thus conferring the advantage of increased graft patency

Clip-closure of appendix stump

An inadequate closure of the appendix stump leads to intra-abdominal surgical site infection. Many studies show that the use of costly high tech instruments such as Endo-loops, Endo-GIA for transaction and closure of the appendiceal stump lowers the risk of infection. The Aim of this study was to evaluate the use of clips for closure of appendix stump as a safe and cost-effective method. Descriptive Study. Oct 2009 to Jun 2010. Shalamar Hospital, Lahore. Over a period of 9 months 36 patients were selected to have laparoscopic appendicectomy. All patients had stump closure by clips as used for cystic duct and cystic artery in laparoscopic cholecystectomy. No patient had Endo-loop or Endo-GIA for closure of stump. All patients had follow-up at one week and six weeks after discharge from hospital. There was no clinical evidence of surgical site infection or leak from appendicular stump by this method. There was no discomfort in handling this instrument both for surgeon and scrub nurse. The price of the clips used was 4.30 Euros as compared to 112.00 and 232.77 Euros for the Endo-loops and Endo-GIA respectively. This study shows that clips can be used for stump closure without any additional risk to patient. It is also cost- effective. So appendiceal stump closure using clips is very convenient, an easy, safe, and cost-effective procedure

Reconstruction of mandibular defects with autogenous bone grafts: a review of 30 cases

Background: Multitudes of options are available for reconstruction of functional and cosmetic defects of the mandible, caused by various ailments. At the present time, autogenous bone grafting is the gold standard by which all other techniques of reconstruction of the mandible can be judged. The purpose of this study was to evaluate the outcome of different osseous reconstruction options using autogenous bone grafts for mandibular reconstruction. Methods: This Interventional study was conducted at Department of Oral and Maxillofacial Surgery, King Edward Medical University/Mayo Hospital Lahore, from January 2008 to July 2009 including one year follow-up. The study was carried out on thirty patients having bony mandibular defects. They were reconstructed with the autogenous bone grafts from different graft donor sites. On post-operative visits they were evaluated for outcome variables. Results: Success rate of autogenous bone grafts in this study was 90%. Only 10% of the cases showed poor results regarding infection, resorption and graft failure. Conclusion: Autogenous bone grafts, non-vascularised or vascularised, are a reliable treatment modality for the reconstruction of the bony mandibular defects with predictable functional and aesthetic outcome

Surgical apparels comparison of some physical parameters

Around the world, majority of the public and private sector hospitals are using reusable gowns and scrubs whereas only a few hospitals are using disposable ones. Protection during surgery is very important both for the patient as well as for the surgeon. The reasons are not only hygienic but also creating a barrier so that the bacteria and the viruses do not transfer from patient to doctor and vice versa. The surgical gowns have been in use for many decades. With the advancements in the field of manufacturing [weaving and finishing], the quality of gowns has been improving over the period of time. In Pakistan, there is no awareness yet regarding the construction of surgical apparels viz. surgical gowns and scrubs so no standards are being followed as such during the manufacturing [weaving and finishing] of surgical apparels. For effective barrier function of surgical gowns and scrubs, it is necessary for them to comply with certain standards in terms of physical characteristics viz. mass per unit area, number of threads per unit length, tensile strength etc. The idea behind this study was to evaluate the physical characteristics of surgical gowns and scrubs currently being used in different public sector hospitals of Lahore. After which, necessary guidelines can be formulated and proposed to the concerned departments of various hospitals, in the light of which they can design some specifications and select appropriate materials for surgical apparels in future. 1]. To evaluate the physical characteristics of surgical apparels [gowns and scrubs] currently being used in different public sector hospitals of Lahore. 2]. Comparison of results with existing/available performance requirements. Experimental study design. April 2010-June 2010. Samples of fabric used for making surgical gowns and scrubs were collected from different hospitals of Lahore and evaluated for different fabric properties viz. mass per unit area, construction analysis [number of threads per unit length] and tensile properties in accordance with EN and ISO standards, in standard atmosphere for testing textiles. The results obtained were compared with the available international standards and limited research studies done in the area of surgical apparels yet. It was found that none of the samples collected meet the minimal requirements available yet. So, there is a dire need of some minimal criteria of surgical apparels for the safety of the patients as well as of the health care personnel

Coronary artery by pass graftingearly morbidity and mortality in patients with tight glycaemic control versus standard control

Several studies have suggested superiority of tight glycaemic control in reducing the incidence of surgical site infection and mortality after cardiac surgery. To compare the frequency of post operative surgical site infections after CABG in patients with tight glycamic control and those with standard glycamic control. Shaikh Zayed Hospital, Lahore. June 2008 to March 2010. Total of 496 patients were included, they were randomized to tight glycaemic control group [TGC, n =248] or standard control group[SC, n=248].In TGC group blood glucose was maintained between 90 - 130 mg/dl, while in SC group blood glucose was maintained between 131- 190mg/dl for 48 hours post surgery. Results were prospectively evaluated. Demographic and surgical data was similar in both groups. Patients in TGC group showed significant reduction in post operative superficial sternal wound infection [4 vs 12, p < 0.05], deep sternal wound infection [1 vs 7, p <0.05] and leg wound infection [2vs 9, p<0.05].There was also non significant reduction in the incidence of post operative mediastinitis [1 vs 3], new myocardial infarction [2 vs 3],and atrial fibrillation [10 vs 12]. Mortality was equal in both groups [1 in each]. Significant reduction in SSI was observed in TGC group and no change was seen in other morbidities and short term mortality in the study

Optimal dose of prophylactic intravenous ephedrine for spinal-induced hypotension during cesarean section

The objective of this study was to compare the efficacy of 10, 15, and 20mg bolus doses of prophylactic IV ephedrine for prevention of maternal hypotension associated with spinal anesthesia for cesarean section. A prospective, quasi experimental study. The study was conducted at Department of Anesthesiology and Intensive Care, Shalamar Hospital Lahore [Pakistan], and was completed in six months period from January to June 2008. Ninety parturients of ASA grade I and II, receiving spinal anesthesia for elective C-section were included in this study. They were randomly divided into three groups. Group-I received lOmg, Group-II 15mg, and Group-Ill 20mg prophylactic IV ephedrine immediately after administration of spinal anesthesia. Intra operative hemodynamic changes were recorded and the data were analyzed. Incidence of hypotension was significantly higher in Group-I parturients receiving a lOmg prophylactic dose of ephedrine than in Group-II and Group-Ill parturients receiving 15mg or 20mg of ephedrine respectively [53.3% versus 13.3% and 3.3% respectively]. There was however, a significantly higher incidence of reactive hypertension in Group-II parturients [46.7%]. 15mg bolus dose of prophylactic IV ephedrine can effectively prevent spinal induced maternal hypotension during cesarean section without adverse effects like reactive hypertension

Contralateral limb weakness after intrathecal chemical neurolysis for cancer pain

The treatment of cancer pain encompasses both pharmacological and interventional techniques. In certain situations, patients may have intractable pain despite use of optimal doses of oral or parenteral analgesics. Interventional procedures, like intrathecal chemical neurolysis [ICN], play an important role in the management of such intractable cancer pains. The goal is to achieve segmental block that is purely sensory, without causing any motor weakness in the patient. Potential problems related to ICN include inadequate pain control with the progression of tumour size, short duration of effect, lower limb weakness on the ipsilateral side and rectal or bladder sphincter dysfunction. We present a case report in which the patient developed unexpected weakness of contralateral limb after ICN for management of cancer pain

Management of refractory secondary glossopharyngeal neuralgia with percutaneous radiofrequency thermocoagulation

Glossopharyngeal neuralgia [GN] can present as an orofacial pain syndrome in which there are repeated episodes of intractable pain in the tongue, throat, tonsils and ears. Primary GN is idiopathic, whereas secondary GN has some identifiable cause like tumor invasion that leads to constant irritation of the nerve. Current therapies include pharmacological management, nerve blocks, decompression surgery, and neuromodulation by either medications or pulsed mode radiofrequency. Radiofrequency lesioning of the glossopharyngeal nerve is a minimally invasive technique, which can effectively manage the pain in such patients. Here, we report a case in which secondary GN due to invasive tongue tumor, unresponsive to pulsed mode radiofrequency treatment, was treated with radiofrequency thermocoagulation [RFT]

Tubular duplication of esophagus: rare congenital malformations require individualized and innovative procedures

Rare congenital problems generally have no standardized diagnostic or operative technique. Because of some variation within the spectrum, diagnosis and management has to be individualized and tailored according to the local findings to relieve the symptoms. We report a diagnostic dilemma and surgical management of a child with proximal tubular duplication of esophagus with complete remission of symptoms after surgery. To diagnose rare malformations a high index of suspicion is required when differential diagnoses are being considered

Bilateral adrenal abscesses - A rare entity: a case report with review of literature

To report a very rare condition of bilateral adrenal abscesses in an infant. From literature it appears to be the third case being reported. On ultrasound imaging on several occasions it was considered to be bilateral adrenal hemorrhage. Hence our objective is to highlight the possibility of such masses to be adrenal abscesses. Design: Report of an unusual problem in an infant. Setting: Department of Pediatric Surgery, Children's Hospital, PIMS, Islamabad. Successfully treated with surgical drainage. Bilateral suprarenal abscesses usually results as an uncommon complication of bilateral adrenal hemorrhage. Ultrasound is the most helpful examination in distinguishing a suprarenal lesion from an intrarenal pathology and in demonstrating the morphology of an abscess. Percutaneous biopsy of supra renal mass should be avoided if pheochromocytoma is in the differential as was in our case

Tracheobronchial foreign bodies: a review and analysis during past one year at children's hospital, PIMS, Islamabad

In view of changing patterns, to identify most common type of foreign bodies in tracheobronchial tree of children. To make recommendations for appropriate measures to prevent the incidence of inhalation. This descriptive study was carried out between April 2001 to March 2002 on 108 children. Department of Pediatric Surgery, Children Hospital, Pakistan Institute of Medical Sciences [PIMS], Islamabad. We studied 108 patients out of whom 68 were male [63%] and 40 were female [37%]. The mean age was 3.97 years. Most common symptoms were dyspnoea in 88 [81%]. 35 patients [32%] had insignificant X-ray findings. 65 patients [60%] had hyperinflation. 3 patients [2.7%] had atelectasis. One patient had bronchiectasis, one with emphysematous change and one had pleural effusion. The most common organic foreign bodies 28 had pieces of peanuts [26%] and next most common 11 had beetle nuts [10%]. Most common inorganic foreign bodies 26 in our series was a whistle [24%], followed by 13 metallic rings [12.2%], metal nails, safety pins, pallets, watch batteries and ring stones. Aspiration of foreign body into tracheobronchial tree in children carries a high risk to life but adequate and prompt treatment is associated with very low mortality. Health care education is the key to prevention. Industrial manufacturing laws with regard to quality control and safety of production of various toys to which children are commonly exposed should be forcefully implemented

Twin fetus in fetu-a very rare entity: a case report with review of literature

1] To report a very rare condition of conjoined twining in fetus in fetu in an infant. From literature it appears to be the 4th case being reported. 2] To emphasize the importance of proper examination of the fetus in fetu grossly by doing extensive dissection, radiologically and detailed histological tissue examination from several sites. Design: Detailed report of an unusual intra-abdominal mass in an infant. Setting: Department of Pediatric Surgery, Children Hospital, PIMS, Islamabad. Successfully treated with surgical removal and interesting diagnosis emerged. Twin fetus in fetu [FIF] is a very rare anomaly due to an abnormal embryogenesis of fetus during pregnancy. Malformed fetus grows in the body of co-twin and it is frequently detected as an abdominal mass. There is no clear distinction between the term of FIF and fetiform teratoma [FT]. We are reporting a case in which a girl was referred as a case of nephroblastoma but at operation and on detailed examination of the specimen it turned out to be a case of twin fetus in fetu

Prostatic phabdomyosarcoma in an infant with neurofibromatosis

we are reporting an unusual case of a tumor in early infancy causing complete urinary obstruction. The patient was an infant with external signs of neurofibromatosis who presented with acute urinary retention prostatic rhabdomyosarcoma and was managed by total cystectomy and urinary diversion

Glant sacrococcygeal teratomas

This is a report of two cases of giant sacrococcygeal teratoma [SCT] with completely different clinical appearance, histological pattern, and hematological findings. In the first case, the malignant nature of the tumor was apparent at birth, whereas the second patient had mature, non-malignant tumor and presented after eight months of birth. In the first case early and complete excision cured him completely of his tumor as was evident in his three years follow up with normal alpha-fetoprotein levels. Whereas in the second patient, the benign and mature nature of the tumor prevented malignant change although patient presented late. In both patients reconstruction of anatomical structures was performed. Early and late postoperative appearance was comparable to normal

Histopathological interpretative difficulties of a soft tissue tumour. a case report

This case is reported to explain the histological difficulties in differentiating soft tissue tumours. A childhood fibrosarcoma is reported which was misdiagnosed even on several reviews of histopathology slides. Though prognosis and treatment of soft tissue tumours are almost the same, there is still a need for proper histologic diagnosis, to place them in an appropriate group

Omphalocele major: conservative management

In our community, majority of deliveries are at home and most have no intra-uterine fetal monitoring. Many congenital anomalies, including omphaloceles, are diagnosed after birth. Almost all such cases are transported to health facilities, wrapped in dirty clothing, and are heavily contaminated with established sepsis. Even in tertiary centers like ours, resuscitative and ventilatory facilities have several limitations. Under these circumstances, we have devised a line of management on conservative lines and in stages, for contaminated omphalocele major. This seems to offer the best chance of survival to the infants. The present report is of three children presented at the Children's Hospital PIMS, Islamabad. Their mode and state of presentation and method of management are discussed, which highlights several important features of this condition in our set-up. A review of literature is also presented

Management of an ancurysmal bone cyst

Aneurysmal bone cyst is a rare, non-neoplastic, expansile bony lesion that mainly affects children and young adults. It may cause diagnostic confusion with a bone tumor. These cysts are frequently treated surgically, but recurrence is very common and surgery is hazardous, especially when the lesion is adjacent to the growth plate. A case report of an aneurysmal bone cyst in an 11 year old child is presented with serial radiographic changes and discussion on its management