Patterns of Failure in Breast Cancer Patients of Kashmir Valley

Breast cancer is the most frequent cancer among women and also the leading cause of cancer related deaths in women. The patterns of failures in carcinoma breast seem to differ by cell type, pathological stage and by the treatment modality instituted. Breast cancers can recur locally, regionally and distantly. Survival rates decrease progressively as the stage of the disease increases. Aims & Objectives: To evaluate the patterns of failure in patients with Breast Carcinoma after definitive treatment modalities. Methods: We conducted an analytical, nonrandomized, cross-sectional study on the Patterns of Failure in 1238 patients with primary breast cancer who reported to our Regional Cancer Centre from 2002 to 2010. Results: A total of 1238 patients with 1189 females and 49 males were evaluated. Most of the patients were above fifty years of age with breast lump being the most common presentation. Infiltrating ductal carcinoma was the most common histology and stage II being the commonest stage of presentation. Most of the patients were hormone receptor positive and Her 2 neu receptor negative. Overall local failure was 3.9%, regional failure 2.7% and distant failure 22.5%. Overall 5 year disease free survival was 78.4%. Conclusion: The most common form of local failure is chest wall recurrence, regional failure is supraclavicular lymphadenopathy and distant failure is bone metastasis. The 5 year disease free survival is lower for all the stages when compared to world scenario. This may be attributed to more aggressive disease behaviour in our patients.

Level V Clearance in Neck Dissection for Papillary Thyroid Carcinoma: A Need for Homogeneous Studies

Abstract Introduction Papillary thyroid carcinoma has a very high rate of lateral neck node metastases, and there is almost unanimity concerning the fact that some sort of formal neck dissection must be performed to address the clinical neck disease in these cases. Although there is an agreement that levels II to IV need to be cleared in these patients, the clearance of level V is debatable. Objectives We herein have tried to analyze various papers that have documented a structured approach to neck dissection in these patients. Moreover, we have also tried to consider this issue through various aspects, like spinal accessory nerve injury and the impact of neck recurrence on survival. Data Synthesis The PubMed, Medline, Google Scholar, Surveillance, Epidemiology, and End Results (SEER), and Ovid databases were searched for studies written in English that focused on lateral neck dissection (levels II-IV or II-V) for papillary thyroid carcinoma. Case reports with 10 patients or less were excluded. Conclusions The current evidence is equivocal whether to clear level V or not, and the studies published on this issue are very heterogeneous. Level II-IV versus level II-V selective neck dissections in node-positive papillary thyroid carcinoma patients is far from categorical, with pros and cons for both approaches. Hence, we feel that there is a need for more robust homogeneous data in order to provide an answer to this question.

Efficacy of Drainless Total Thyroidectomy in Intrathyroidal Lesions of Thyroid

Abstract Introduction There is difference of opinion about the placement of the drain in thyroid surgeries, and, to the best of our knowledge, the efficacy of drainless total thyroidectomy regarding various parameters of thyroid lesions has not been well-established. Objective To report our experience with drainless total thyroidectomy, and to define an appropriate patient population for its performance. Methods This is a retrospective case analysis of the patients who underwent total thyroidectomy for intrathyroidal lesions with or without central neck dissection in a tertiary referral hospital (number = 74). The patients, who had undergone total thyroidectomy without any drain insertion, were analyzed, and the relationships among various parameters of thyroid lesions were noted in relation to seroma and hematoma formation. Results Seroma formation was noted only in 5 out of 74 patents (6.75%). All of the seromas that occurred were observed in patients with thyroid lesions < 4 cm, and 4 out of 5 seromas were observed in patients with a malignant pathology. There was no statistically significant difference in seroma formation between patients younger or older than 50 years of age. The nature of the lesion, whether benign or malignant, did not affect the formation of seroma. Of interest is the fact that none of the 10 patients who had central neck dissection performed as part of their treatment developed seroma. Conclusions Drainless total thyroidectomy is safe across all age groups for patients harboring either benign or malignant thyroid pathologies. However, caution is to be observed in opting for drainless total thyroidectomy in patients with large lesions (> 5 cm)

Sexual dimorphism using mandibular canine in establishing sex identity among Kashmiri population – A clinical study

Gender determination in forensic investigation is of immense medico legal importance especially in mass disaster. Teeth are excellent tools for identification as they are resistant to physical and chemical agents. The aim of the present study was to investigate gender dimorphism by measuring the linear dimensions of mandibular canine width and inter canine width among Kashmiri population. The study consists of 125 subjects selected from outpatient clinic of oral medicine and radiology, 64 were males and 61 were females. The age groups selected were in range from 18-24 years. There was statistically significant difference in canine width on right and left sides and inter canine distance between males and females (p value less than 0.05). These parameters can be helpful in determining the gender of the unknown deceased person in forensic investigations among Kashmiri population

Comparison of silastic and acrylic interpositioning for the treatment of temporomandibular joint ankylosis

The aim of this study was to compare the treatment outcome of thirty unilateral temporomandibular joint [TMJ] ankylosis cases treated in Pakistan Institute of Medical Sciences [PIMS], Islamabad within four years by either silastic or acrylic interpositional arthoplasty. Patients having bilateral TMJ ankylosis, age less than 16 years, coronoidectomy required during procedure, already operated cases and medically compromised patients were excluded from the study. Pre and post-operative assessment was done by thorough history, physical examination and radiographic evaluation [OPG and CT scan] to determine the cause of ankylosis, the maximal inter-incisal opening, complications including infection, presence of facial nerve paralysis and recurrence rate. The maximal inter-incisal opening in the pre-operative period ranged from 0-11mm and was recorded at a mean of 32.7+/-5.8mm for cases treated with silastic interposition and 29.5+/-6.8mm for the ones treated with acrylic one year after surgery. Infections, swelling, pain and nerve injuries were reported in both the groups post-operatively. Both silastic and acrylic were found to be statistically similar in terms of maximal inter-incisal opening, complications and recurrence rates. Recurrence was observed in only one patient treated by acrylic inter-positioning. Silastic however demonstrated itself to be a better choice in terms of handling and patient tolerability

Outcome and cost comparison of laparoscopic transabdominal preperitoneal hernia repair versus open Lichtenstein technique

To compare the outcome and cost of laparoscopic inguinal hernia repair versus open repair. This was a randomized controlled study conducted on 100 patients from January 2011 till April 2012, in Surgical 'A' unit, Lady Reading Hospital, Peshawar. A total of 100 patients were randomized and were allocated into two groups i.e. open repair [Lichenstein procedure] and laparoscopic repair [Trans-abdominal pre-peritoneal mesh repair, TAPP] group using lottery method. Type of hernia, type of procedure done, total cost of surgery, duration of hospital stay, post operative pain rating by visual analogue score and post operative complications were assessed. Significant difference was observed between the two groups in relation to the perioperative complications. Mean operative time was short in open repair 55.40 +/- 10.73 minutes compared to TAPP 87.10 +/- 11.60 minutes but the mean length of hospital stay was less in TAPP [2.78 +/- 0.64 days] compared to open [3.5 +/- 0.67 days]. Regarding postoperative complication urinary retention was 22% and 10%, wound discharge was 20% and 08%, recurrence was observed in 12% and 06% in open repair and TAPP respectively. The difference was statistically insignificant. Laparoscopic repair showed significantly less post operative surgical pain compared to open repair. This trial showed no statistical difference between the open and laparoscopic procedures regarding post operative complications but laparoscopic repair showed statistically lower post surgical operative pain and hospital stay with greater operative time and cost. This study supports the use of the laparoscopic repair techniques for the treatment of inguinal hernia

Safety of ultrasonic dissection versus conventional electrocautery dissection during laproscopic cholecystectomy in terms of gall bladder perforation

To compare the safety of ultrasonic and electrocautery method of dissection in terms of gallbladder perforation. This randomized controlled trial included 128 patients, which were divided into two groups, ultrasonic dissection [A] and electrocautery dissection [B]. GB perforation [if any] was noted intraoperatively, and all the data was recorded on a structured questionnaire. Data was analyzed using SPSS. The incidence of GB perforation was significantly lower in ultrasonic dissection [10.9%] than electrocautery methods of dissection [29.7%], hence the safety of ultrasonic dissection in terms of gallbladder perforation, was significantly higher than electrocautery dissection [89.1% vs. 70.3% p-value=0.007]. Ultrasonic dissection is safer modality of dissection in terms of gall bladder perforation and its use should be encouraged as routine method of dissection during LC

Can computerized tomographic angiography be used to triage patients with chest pain presenting to the emergency department?

To confirm the findings of Computerized Tomography Angiography by invasive angiography. This comparative study on 50 patients fulfilling the inclusion criteria were admitted in cardiology ward. Then they were shifted to catheterization lab of Lady Reading Hospital Peshawar for invasive angiography and segmental analysis of all four vessels i.e. right coronary, left coronary circumflex and left anterior descending artery was done. A total of 50 patients were studied both with CT angio and invasive angio and 750 segments were analyzed for the 4 main arteries that is LMS, LAD, RCA and Circumflex. The sensitivity of CT angiography for the LMS was 87.5%, Specificity 100%, PPV 100% and NPV 97.6%, PPV was 100% and NPV was also 100%. Similarly the diagnostic accuracy of CT angiography for the circumflex was sensitivity 100%, PPV 100% and NPV 97.91 to 100%. For RCA the sensitivity was from 60 to 100%, specificity 100%, PPV 100% and NPV 95 to 100%. Coronary CT angio with the highest resolution scanners could be a suitable means for rapid triage of patients presenting to emergency departments with chest pain and for evaluation of patients with equivocal stress test results who might otherwise need invasive angiography

An audit of the complications of dual and single chamber pacemaker in adult patients followed over a period of one year

To determine the frequency of dual and single chamber pacemaker complications in adults. This study was conducted in 151 pacemaker implanted patients and they were followed every month for 1 year, for evaluation /programming of pacemaker function and examining for device related complications. Out of 151 patients with pacemaker, 111[73.5%] patients received single chamber pacemaker and 40[26.5%] patients were implanted with dual chamber pacemakers. In one year follow up 21[13.9%] patients developed different complications while 130 patients had uneventful follow up. The different complications seen were infection 9[6%] patients, lead displacement 4[2.6%] patients, heart failure 3[2.0%] patients, Pacemaker syndrome, lead fracture, diaphragmatic twitching, pocket hematoma and keloid formation at scar site was noted in 1[0.7%] patient each. As a whole complications in single chamber was 73.5% compared to patient with dual chamber pacemaker which was 26.5%.The rate of complications associated with PPM is not significant, but the rate of complications were more in single chamber pacemaker compared to dual chamber pacemaker. Infection was the major complication seen

Myositis ossificans traumatica of lateral and medial pterygoid muscles: a case report

A 19 years male patient came to the Oral and Maxillofacial Surgery outpatient department with chief complaint of progressively reducing mouth opening for the past four months. History, clinical and radiological examination strongly suggested it to be a rare case ofmyositis ossificans traumatica which was subsequently confirmed histopathologically. The patient was managed by extirpation of the ossified left lateral and medial pterygoid muscles with inter positioning of split thickness temporalis muscle and fascia flap and post-operative mouth opening exercises. Satisfactory mouth opening was achieved. However recurrence relapse was noted soon after

Hyperkalemia as a medical emergency in patients with ESRD on hemodialysis

To see the incidence and clinical presentation of hyperkalemia as a medical emergency in patients with ESRD on hemodialysis and to determine the safety and efficacy of two hours hemodialysis session as an emergency measure for the treatment of this emergency. This observational study was conducted in emergency department [ED] and hemodialysis unit [HDU] of Qilwah General Hospital Albaha, Saudi Arabia from Feb.2001 till Jan.2009 [8years].Twenty two patients with ESRD on hemodialysis presenting to ED as a medical emergency due to hyperkalemia were studied to know the clinical presentation of hyperkalemia and ECG changes. Salbutamol nebulisation along with DW 50% 50 ml with regular insulin was used to buy time for dialysis. Calcium gluconate 10% 10ml was given for cardioprotection if indicated. All patients were monitored closely. Serum potassium levels were measured at arrival, after one hour, at completion of two hours of hemodialysis and at 12 hours later. Total 20848 dialysis sessions were done in HDU and 192[0.92%] were as emergency dialysis sessions. Twenty two dialysis were done for hyperkalemia. Shortness of breath was the most common symptom and mean time since last dialysis session was 65.91 +/- 16.08 hours. Mean serum potassium at arrival to ED, one hour later after 2 hours of dialysis and 12 hours later was 7.10 +/- 0.39 mmol/L, 6.41 +/- 0.38 mmol/L, 3.48 +/- 0.37 mmol/L and 4.53 +/- 0.47 mmol/L respectively. The mean decrease in serum potassium after medical treatment in ED and after two hours of dialysis was 0.69 +/- 0.13 [p value<0.0001] and 2.93 +/- 0.12 mmol/L [p value <0.0001] respectively. Two patients died in ED before dialysis could be started. ESRD patients may come to ED with hyperkalemia. If serum potassium is more than 6.0 mmol/L or ECG findings of hyperkalemia are there in these patients, ventolin nebulisation and dextrose-insulin infusion should be given in ED to buy time for an emergency session of dialysis. Calcium gluconate has cardioprotective effect. A two hour dialysis session as an emergency measure is effective and safe in such situations provided it is followed by a scheduled session of dialysis next day. Any delay may prove fatal

evaluation of use of Trans-Obturator Tape [TOT] sling procedure in the current surgical management of female stress urinary incontinence

To assess the role of TOT sling procedure in current surgical management of female Stress Urinary Incontinence [SUI] in terms of post-operative results, cost effectiveness, pt acceptance and complications. From June 2006 to September 2008, 30 patients of SUI were treated surgically by TOT-sling procedure. Pre-operatively the patients were evaluated by thorough history taking, clinical examination and different diagnostic test depending upon the individual clinical scenario. Patients were explained in their own language the nature of procedure and the principle behind it. Any complication[s] [intra/postoperative] were noted. After discharging the patients they were followed up by at least 3 visits [follow-up visits] at 1,3 and 6 month interval. Any complications of the procedure and patient acceptance were evaluated at each follow-up. The mean age of the total patients [n=30] was 39.5 yrs and 28 [93.33%] were multiparous. Involuntary loss of urine on straining was the most common complaint present in 25 [83.33%] patients and 22 [73.33] patients were having duration of symptoms less than 3 yrs. 9 [30%] patients were having mild cystocele pre-operatively which resolved after surgery. All the 30 [100%] patients were continent post-operatively while 7 [23.33%] were having lower urinary tract symptoms [LUTS]. No major intra/post-operative complication was seen but, urgency, dysuria, fever and haematuria was seen post-operatively which resolved after few days. The operative time was 24 +/- 3.8 months and catheter was removed on 2.7 +/- 1.7 days post-operatively. Hospital stay was 6 +/- 2.4 days [3-11] and app. Cost of the treatment was Rs 3253 +/- 360 [2700,3900]. TOT Sling procedure is currently the Gold Standard for management of female SUI. It is very important to diagnose SUI and rule out other causes of incontinence because only the former one [Genuine SUI] is improved by TOT sling and other types may be even worsened by this procedure

Pattern of lipid profile in type-2 diabetes mellitus patients

To know the pattern of lipid profile in obese and non-obese type-2 diabetes mellitus patients as compared to a control group One hundred [50 obese and 50 non-obese] diagnosed patients having diabetes mellitus minimum for the last three years were randomly selected from the outdoor patient department of medicine, Khyber teaching hospital, Peshawar during the year 2002. Obesity was taken as body mass index of more than 25 kg/m[2]. One hundred healthy individuals were selected from among the staff of Khyber medical college, Khyber College of Dentistry, and Khyber Teaching Hospital, Peshawar to constitute the control group. They had no history of any chronic illness. Subjects suffering from cardiovascular diseases, kidney disorder and hepatic disorders were excluded from the study. Fasting serum triglyceride, total cholesterol, HDL-C, LDL-C, and VLDL-C were determined by enzymatic calorimetric method and calculated by using Friedewald [1972] formula. The levels of serum triglycerides [170.15 +/- 10.3 mg/dl vs 159.01 +/- 10.11mg/dl], total cholesterol, [191.61 +/- 18.61 mg/dl vs 182.61 +/- 17.6 mg/dl], LDL-C [113.12 +/- 11.01mg/dl vs 102.69 +/- 11.17 mg/dl] and VLDL-C [34.03 +/- 2.03 mg/dl vs. 31.80 +/- 0.2mg/dl] were higher in diabetic patients as compared to the control group, while HDL-C [43.39 +/- 6.41 mg/dl vs. 57.69 +/- 7.06 mg/dl] was lower as compared to the control group. Dyslipidemia is a significant finding in type-2 diabetes mellitus patients

Growth hormone deficiency coexisting with insulin dependent diabetes mellitus

This is a case report of a boy, 13 years of age, referred from Yemen for cataract surgery. He was known to have IDDM and was admitted with DKA precipitated by psychological stress and inadequate insulin doses. He also had short stature [below 3rd percentile], later discovered to be due to GH deficiency. DKA was adequately controlled with standard lines of management. After the cataract surgery, GH replacement therapy was given without any interference in the control of diabetes [the dose of insulin had to month and HbAIC level was also satisfactory at the time of discharge on 89th day