Endovascular treatment of carotid-internal jugular venous fistula in a bomb blast victim

Carotid-internal jugular venous fistula is one of the rarest presentations among victims of bomb blast injuries. Treatment of such fistula is open surgery with high mortality and morbidity. Endovascular treatment with covered stent seems to have an optimal result with low complications. We present a case report of a bomb blast victim having carotid-jugular venous fistula with hemodynamic compromise. The patient was successfully managed with endovascular graft stent. There was an optimal result with no immediate and long-term complications

Management of diaphyseal femur fractures in adults with intramedullary interlocking nail

Fracture of femur in adult patients presents special problems. Orthopaedic surgeons often encounter diaphyseal femur fractures, because these fractures most often result from high - energy trauma, one must have high index of suspicion for complications. Currently reamed interlocking nailing is indicated for most femur fractures because of high rate of union, low rate of complications and advantage of early stabilisation which decreases the morbidity and mortality rate in patients. The objective was to determine the functional outcome of intra-medullary interlocking nailing in diaphyseal fracture of femur in adults in terms of early rehabilitation and fracture healing. This prospective study was carried out from 1.9.2008 to 31.3.2010 in the Department of Orthopaedics, Social Security Teaching Hospital, Lahore. Twenty five patients aged between 20 - 50 years having fracture diaphysis of femur were included. Patients less than 18 years of age, open grade III fractures and pathological fractures were excluded from the study. Routine preoperative investigations were done. Radiological assessment included AP and lateral radiograph of thigh with hip and knee and chest PA/AP view. There were 21 males and 4 females with male to female ratio 5.25:1. The age ranges from 20 - 50 years with mean age of 31.2 years. Majority of the fractures were spiral fractures seen in 9 cases. Comminuted fracture seen in 8 cases, oblique fracture seen in 5 cases and transverse fractures were seen in 3 cases. The results obtained were excellent in 13 patients, good in 9 patients, fair in 2 patients and poor in 1 patient. Mean time of fracture healing was observed 14.3 +/- 1.3 with range of 12 - 16 weeks. The most preferred treatment in the management of fracture diaphysis of femur is intra-medullary interlocking nail especially in skeletally mature patients as regards early rehabilitation and fracture healing

frequency of nonunion and avascular necrosis in fracture neck of femur in young adults, treated with cannulated screws

Objectives:- The objective of the study was to document frequency of nonunion and avascular necrosis in fracture neck of femur [NOF] in the young adults, treated with cannulated screws

Methodology: It is a descriptive case series study, carried out at Department of Orthopaedic Surgery Sheikh Zayed Hospital [PGMI] Lahore. Forty patients were included in this study, reported within two weeks of injury. All patients with Garden type I, II, III and IV fractures neck of femur, aged from 18 to 55 years, from May 2012 to November 2012 were included with the consent to undergo osteosynthesis with cannulated screws

Results: KOFU [Japan] hip scoring system was used to evaluate results. Total 34 fractures [85%] achieved radiological union on an average of 3 months. Out of these 34 patients, 11 patients were with Garden type I, 10 patients Garden type II, 8 patients with Garden type III and 5 patients with garden type IV fractures had union of fracture. Total 6 patients [15.0%] had complications. Out of these total 6 patients, 2 patients were Garden type III and 4 patients were Garden type IV. All these 6 patients [15%] had nonunion, and 2[5%] patients ended in avascular necrosis of head of femur also but in 4 patients head of femur remained viable. There was no case reported with implant loosening in our all treated cases

Conclusion: With cannulated screw fixation all garden type I and II fractures achieved union and garden type III fractures have minimal frequency of nonunion and garden type IV fractures have variable frequency of nonunion. So cannulated screw fixation is best method of treatment in fracture neck of femur in young adults

Vesico-vaginal fistula: interposition flap, a key to success

Vesico-vaginal Fistula [VVF] is an abnormal communication between bladder and vagina that causes continuous discharge of urine into vaginal vault. The objective of this study is to describe current trends of aetiology and repair of Vesico-vaginal Fistulae. This is a Descriptive Study, conducted at Armed Forces Institute of Urology, Rawalpindi and Combined Military Hospital, Kharian between May 2001 and May 2007. All patients diagnosed as cases of vesico-vaginal fistulae were included in the study. Their demographic profile and repair success was determined. A total of 86 patients were included in the study. The mean age of the patients was 35.5 years [range 25-46]. Total abdominal hysterectomy was the most common cause [53% of the cases] followed by obstetric causes [43.92% of the cases]. Success rate of the surgery in the study was 97.5%. The common causes of vesico-vaginal fistula in this study were total abdominal hysterectomy and obstetric causes. The success rate was high, yet the attempt should be made to prevent this socially distressing condition

Indications and complications of bronchoscopy: an experience of 100 cases in a tertiary care hospital

To enlist the frequency of indications and complications of flexible fibreoptic bronchoscopy in a tertiary care hospital. A total of 100 patients admitted to Chest and medical units of Lady Reading hospital Peshawar who needed bronchoscopy were selected irrespective of their age, sex, occupation. All patients in whom bronchoscopy was indicated were included in the study. After detailed clinical history with thorough physical examination and relevant investigations, Bronchoscopy was performed with Olympus fibreoptic bronchoscope. Relevant data were recorded for analysis. Out of 100 patients, 64 [64%] were male, and 36 [36%] were female. Majority of patients [55%] were above 50 years of age. In 60% patients, there was radiographic abnormality on chest X-ray and C.T scan. In 25 [25%], the indication was unexplained hemoptysis and 2 [2%] patients had hoarseness. Another 13 [13%] patients were bronchos coped to see Acid Fast Bacilli in bronchial wash. These patients were suspected to have Tuberculosis but sputum smears were reported negative on repeated examinations. Complications which occurred in these patients included Pneumothorax [1%], hemorrhage [1%], hypoxemia [4%], Atrial tachycardia [3%], bronchospasm [2%], and post-bronchoscopy fever [2%]. These complications were managed accordingly and all patients recovered without any serious consequences. Most of the indications for Bronchoscopy in this hospital are diagnostic rather than therapeutic. Most common indications include radiographic abnormalities, hemoptysis, hoarseness and for isolation of ABF

PONV-A comparative study of meto-clopramide alone and with dexamethasone in strabismus surgery

To determine the efficacy of intravenous metoclopramide alone and in combination with dexamethasone in preventing postoperative nausea and vomiting [PONV] in patients undergoing strabismus surgery. Single blinded, randomized, interventional study. This study was conducted in the department of Anaesthesiology at Nishtar Hospital, Multan from October 2005 to October 2006. After the approval of the hospital's ethical committee, the study was conducted on 60 patients who were randomly divided into two groups, each group containing 30 patients. All of the patients were between 2-14 years of age and were A.S.A-I. Randomization was done by envelope draw method. The patients received either metoclopramide 150 micro g/kg or dexamethasone 150 micro g/kg with metoclopramide 150 micro g/kg combination IV, 30 minutes before the induction of anesthesia. General anesthesia was induced with thiopentone sodium, nalbuphine, succinylcholine and maintained with isoflurane and N[2]O+O[2] in both groups. PONV were evulated postoperatively. Patients in group II who received metoclopramide plus dexamethasone experienced significantly less PONV during the first 24 h after surgery. In this study, a single dose of metoclopramide plus dexamethasone [150 micro g/kg of each drug] produced better antiemetic effects after strabismus surgery than metoclopramide alone

Dural sinus thrombosis: frequency and imaging diagnosis

To determine the frequency of dural sinus thrombosis [DST] and highlight diagnostic importance of its subtle imaging findings in patients presenting for workup of their varied neurologic complaints and symptoms. Observational case series. Study Period: June 2002- May 2005. All new patients undergoing cranial computed tomography [CT] and magnetic resonance [MR] imaging were included in this study which consisted of 1676 consecutive subjects with 1780 examinations. These were reviewed in real time on monitors [as they were being performed] for evidence of DST before printing of hard copies prior to disposition of patients. CT studies were performed on Toshiba Auklet scanner with 5 mm thick axial slices and 1cm inter slice gap. MR imaging was performed on 1.5 Tesla Toshiba Visart scanner with T1 and T2 weighted [T1 and T2W], spin echo, FLAIR and post contrast T1 weighted [T1W] imaging in multiple planes. Subjects with inconclusive but suspicious conventional imaging [CT, MR] were evaluated by magnetic resonance venography [MRV]. Patients presenting for follow-up of established diagnoses including neoplasia, arterial infarcts, hypertensive parenchymal haemorrhages and postsurgical status were excluded. Delta and empty delta were the most commonly observed CT and MR signs diagnostic of DST on pre and postcontrast images and were present in 43 patients. Thrombus was also directly visible within lumen of superior sagittal, transverse and sigmoid sinuses on T1W MR images in 21 individuals. In 12 patients, these signs were either absent or too subtle to be conclusive. However, presence of venous haemorrhagic or non-haemorrhagic brain parenchymal edematous lesions prompted further evaluation by MRV, which confirmed presence of DST in these subjects as well. As a result, a total of 55 patients with a frequency of 3.3% were diagnosed and treated for DST. Frequency of DST in patients with neurological complaints and symptoms is 3.3%, which is significantly higher than has been clinically suspected or recognized. On routine CT and MR studies, diagnostic imaging signs, while highly specific for DST, can be absent or may be masked due to technical factors or associated complications. Presence of brain parenchymal venous haemorrhagic or non-haemorrhagic edematous lesions should prompt judicious and close scrutiny of images on monitors by changing viewing parameters to detect subtle signs of DST. If still in doubt, MRV must be pursued for definitive diagnosis

Survey of chest specialists and trainees knowledge and practice of TB guidelines

To investigate the fundamental knowledge of TB guidelines and their application in day to day practice by the chest specialists and trainees working in teaching hospitals. A questionnaire-based survey was conducted among the participants of 5th biennial chest conference. The data of 195 doctors was analyzed. 96% of doctors said they were treating their TB patients according to guidelines and categorize their patients for treatment, but only 54% knew the correct number of categories for treatment as recommended by the guidelines. Only 49% knew about the components of DOTS. 85% doctors considered sputum microscopy most important diagnostic test for TB and 61% would use it for monitoring of their patients. 88% would advise sputum AFB culture and sensitivity in suspected cases of suspected drug resistance, 59% doctors would treat MDR TB patients themselves and 33% would refer to specialized centers. 5 declared them incurable. 47% and 30% doctors respectively recommended changes in WHO recommended fixed drug combination FDC during pregnancy and lactation. 58% doctors recommended chemoprophylaxis for tuberculosis in our setting. Overall fundamental knowledge of consultants regarding management of TB was good. Knowledge about DOTS and TB guidelines among all the doctors was average and needs improvement. Management of MDR TB by trainees is alarming in the absence of adequate knowledge and experience

Survey of awareness and management attitudes of chest specialist and trainees towards asthma

The study was aimed at three objectives: i. To know about doctors understanding of pathophysiology of Asthma. ii: To assess the knowledge of treatment of asthma and actual treatment practices by Chest specialists and Postgraduate trainees. iii: To assess the baseline knowledge, attitude and treatment practice in the absence of any local treatment guidelines and then see the effectiveness of the guidelines in changing their practice. A preset questionnaire was distributed among doctors from all over Pakistan, during 5th Biennial Conference on Lung Health in 2002. Each question was followed by a set of answers, of which one was to be tick marked. 66 doctors participated, 14 teaching consultants, 24 chest specialists, 14 postgraduate students, and 14 other doctors. 82% doctors would treat their patients on long-term basis and 18% would treat them acutely. 71% thought asthma was chronic inflammation of the airways whereas 28% thought it was due to bronchoconstriction and mucus plugging. Airways remodeling was considered to be partially or fully reversible by 90% and not reversible by 8%, 2% did not respond. 89% were fully aware of stepwise management of asthma and 11% were little aware. The grading of asthma severity was done by clinical examination 44% and clinical plus spirometery 56%. Inhalers were prescribed always by 35%, frequently by 57% and sometimes by 6%. 78% prescribed steroid inhalers alone or in combination with Beta 2 agonist, whereas 12% used only Beta 2 agonist. 93% would teach inhaler technique by themselves or by trained technician and 7% would leave it to chemists or patients. 88% would check inhaler technique on follow-up visit. 92% used oral drugs with inhalers. The choice of oral drugs varied between steroid [8%], theophylline [28%], Beta 2 agonist [37%], and leukotriene inhibitors [18%], no response [9%]. 47% sometimes and 50% never advised desensitization while 3% recommended it frequently. A significant proportion of doctors lacked a good understanding of pathophysiology of asthma. Although the majority of chest physicians and trainees were fully aware and correctly practiced, a significant number [i.e. one fourth] of doctors were not managing their patients with asthma correctly according to the guidelines

open label evaluation of amlodipine in the treatment of mild to moderate essential hypertension

Twenty-five outpatients with mean baseline sitting diastolic blood pressure of 97.3 mmHg and mean age of 46 years completed 12-week active treatment period with amlodipine following a 2-week screening phase. Treatment was started with 5mg amlodipine once daily [excepting 3 patients started on 10mg once daily]. The dose was increased to 10mg once after 4 weeks in patients who failed to achieve a target DBP of