Diabetic foot ulcer; sequelae

Objective: The number of diabetic patients is increasing at a rapid rate1. Management of diabetic foot has been a challenge for medical professionals. This study was carried out to find the sequelae of diabetic foot ulcer management. Study design: Observational analytical study. Setting: Military Hospital, Combined Military Hospitals Rawalpindi and MIMC teaching Hospital, Mirpur [AJK]. Period: Sep 2009 to August 2013

Materials and methods: Total 310 patients were included in this study as outdoor and indoor cases. Out of these 184 were males and 126 were females. Age affected ranged from 20 years to 90 years. Average age was 50 years. Wagner's grading for diabetic foot ulcer was used as guideline for management

Results: Hyperglycemia was controlled in consultation with physicians in all these patients. Out of these 310patients 199 [64%] patients got their feet wounds healed on conservative management without amputation while 111[35.8%] patients had to undergo some amputation at some level

Conclusion: Diabetes mellitus, fore runner of so many diseases requires multidisciplinary approach. Well controlled diabetes mellitus, good feet hygiene, rational antibiotics in light of culture/sensitivity report and timely conservative or active surgical intervention produce good results in diabetic foot management

Frequency of acute kidney injury in patients undergoing coronory artery bypass grafting

Objective: To find the frequency of acute kidney injury in patients undergoing coronary artery bypass grafting

Methodology: The study was conducted in cardiovascular unit Lady Read-ing Hospital Peshawar. It was cross sectional study. Sampling technique was non probability convenient sampling. Data was collected from 20.2.2013 to 20.8.2013. Total 179 patients included in the study. All patients with known coronary artery disease were included in the study whom were planned for revascularization in the form of coronary artery bypass grafting [CABG]. Post-operatively all patients' serum creatinine till 48th post op hour was observed to detect acute kidney injury. Acute Kidney Injury [AKI] was defined as more than 50% or elevation of 0.3 mg/dl of creatinine level from base line

Results: A total of 179 patients undergoing coronary artery bypass grafting were included in the study. Average age of the patients was 46.88 years +/- 9.91 with range 20-60 years. Patients were divided into four groups according to age. The acute kidney injury after coronary artery bypass grafting was observed in 14 [7.82%] patients. Acute kidney injury was more common in old age and it was non significantly more common in male gender

Conclusion: In spite of current highly advance cardiac surgery techniques and post operative care still there is high incidence of acute kidney injury following revascularization and subsequent worst outcomes

Comparison of post circumcision complications and wound healing in infants by conventional open method and bone-cutter method

The objective of this study is to compare the frequency of post circumcision complications like bleeding and infection along with wound healing in infants by conventional open method and the bone-cutter method. Randomized controlled trial. Combined Military Hospital and Military Hospital Rawalpindi, from March 2009 to March 2010. A total of 400 patients were included in the study that underwent circumcision. Patients were randomly allotted to either group A in whom the circumcision was done with conventional open technique [n = 200] or to group B, in whom circumcision was done with bone-cutter [n = 200]. Patients were followed up in the surgical OPD after 5 days for assessment and earlier in case of any complication. Outcomes were measured by absence or presence of infection, post operative bleeding and cosmetic acceptance by the parents. Comparison between the two groups showed that the bleeding rate was 8% in group A and 7% in group B [p = 0.704]. Infection rate was 6% in group A and 5% in group B [p = 0.661]. Delayed wound healing was seen in 4% of circumcisions in group A as opposed to 2% in group B [p = 0.241]. Complication is a part of any surgical procedure. So is the case with circumcision however no significant difference was found between the two procedures in terms of bleeding, infection, trauma to the glans and the cosmetic outcome

Circumcision by bone cutter-Is it safe?

Objective: To determine the frequency of complications observed in circumcisions performed using closed method and to ascertain its safety in relation to pediatric penile trauma

Study Design: Quasi-experimental study

Place and Duration of Study: Study was conducted in departments of surgery of combined military hospitals of Cherat, Khuzdar and Malir from Jan 2008 to Dec 2009

Patients and Methods: Two hundred and fifty patients were included through the outpatient department for elective circumcision. Male children from 1 week of age to 1 year were included, circumcision being performed for ritual purpose. Exclusion criteria was those male children having deranged coagulation profile, neonatal jaundice, congenital urogenital abnormalities and any other disease. Circumcision was performed using closed technique by bone cutter

Results: Out of the total 250 cases, the success rate of circumcision without any complication was recorded in 229 [91.6%] cases. The remaining 21 [8.4%] cases developed minor complications. Infection was recorded in 7 children [2.8%].Some degree of bleeding was observed in 10 [4%] cases which require change of dressing in 8 cases and haemostasis by application of stitches in 2 cases. Redo surgery was done in 4 [1.6%] cases for unsatisfactory cosmetic reasons. None of the patients in our study sustained trauma to glans

Conclusion: Although it is not a standard procedure, Close method of circumcision by bone cutter is an established and safe technique if it is performed by trained practitioners. We suggest that training workshops should be organized to adequately train all practitioners of circumcision on the safe methods available

Frequency of complete heart block after surgical closure of perimembranous ventricular septal defect

Objective: to find the frequency of complete heart block [CHB] in patients undergoing surgical perimembranous Ventricular septal defect [VSD] closure

Methodology: this was a Descriptive cross sectional study performed in Cardiovascular Department Lady Reading Hospital Peshawar. Data was collected from 28 January 2013 to 28 July 2013 with sample size of 103.Sampling technique was non probability consecutive. All patients with perimembranous ventricular septal defect, aged 5 years to 25 years with any gender were included in the study

Results:-mean age was 12.63 years +/- 6.63. Patients were divided in four categories according to their age. Over all complete heart block in the perimembranous ventricular septal defect after surgical closure was 10[9.71%]. Age wise distribution of complete heart block shows that majority of the complete heart block 6[12.8%] were found in age less than or equal to 10 years

Conclusion:-VSD closure is less often associated with CHB but there should be arrangements for pace maker to timely pace the patient in case of any emergency

Polio vaccination; knowledge, attitude, and practice in district Abbottabad, Khyber Pakhtunkhwa, Pakistan

To assess knowledge, attitude and practice [KAP] about poliomyelitis [polio] vaccination in District Abbottabad, province Khyber Pakhtunkhwa [KPK], Pakistan, to identify reasons of failure of polio vaccination/ eradication campaign and to make recommendations in the light of the study. District Abbottabad, province KPK, Pakistan including both urban and rural areas. Three months from 1st June to 31st August 2012. This cross-sectional descriptive explorative study was conducted in District Abbottabad, of province KPK, Pakistan. A structured questionnaire was submitted to people in the urban and rural population using convenient sampling. Out of 200, only 142 questionnaires were filled by interviewing parents and guardians of the children followed by focused group discussions with the community heads and the parents of the children. Majority [61.78%] of respondents were of low income category with the mean age of 31 years. Amongst those [75%] were earning Rs.7,000-12,000 per month. Literacy rate was low with 45.77%. Out of which 40.67% fathers and 59.33% mothers were illiterate. Therefore a few respondents were aware about the mode of transmission of polio. Majority [80%] said that polio could be prevented by polio drops and about 86% said that this vaccine had no side effects. About 45% respondents refused to cooperate with polio teams, and 28% respondents believed, that Abbottabad Operation had bad effect on anti-polio campaign. Regarding the use of boiled drinking water, 95.8% respondents knew that it was good for health. While only 4.20% were using boiled water for drinking. Advice of the health professionals [69.71%] and other family members [7.74%] was respected in making health care decisions, therefore it was an opportunity for the government to involve these persons as well as media men in conveying message to the community to achieve ultimate goal of polio free Pakistan. Unawareness among the population of District Abbottabad, especially the knowledge about the disease, mode of transmission and its prevention are the most deficient areas. Secondly misconceptions about the nature of polio drops, and religious misinterpretations in masses, created by general public and religious leaders, are the major obstacles in the real success of vaccination campaign

Non-invasive positive pressure ventilation facilitates early extubation in post operative cardiac patients

To assess the use of NIPPV [non-invasive positive pressure ventilation] during weaning from mechanical ventilation in post-op patients in an ICU and compared this procedure with intermittent mandatory ventilation [IMV] by analyzing cardiac and respiratory parameters and complications. A randomized clinical trial was conducted from June 2009 to July 2010 on Post-operative surgical patients that were on IMV for more than 48 hours, who failed at 30 minutes of spontaneous breathing T-piece trial [SBT]. If failure occurred before the 30th minute, he/she was included in the group previously defined by random assignment. Patients in the experimental group were extubated and placed on NIPPV, whereas other patients [the control group] returned to IMV. Daily SBT was carried out thereafter in order to evaluate the possibility of extubation in control group. Of 60 patients who failed T-piece trials, 30 patients were placed on NIPPV and 30 on [IMV]. The ages of patients in the NIPPV and IMV groups were 45.7 +/- 18.11 and 47.10 +/- 18.45 years respectively. In both groups, ventilation time before T-piece trial was 2-3 days. Patients of the NIPPV group had a shorter stay in the ICU and in the hospital i.e., 2.93 +/- 0.785 days versus 7.4+1.11 days for IMV group. No serious complications were observed in both groups. The results of this study suggest that the combination of early extubation and NIPPV is a good alternative

De vega's tricuspid annuloplasty for severe tricuspid regurgitation - early and midterm follow up

To assess early and midterm outcome of De Vega's Repair of Tricuspid Valve in Severe Tricuspid Regurgitation [TR]. This was a prospective observational study conducted from January 2007 to June 2011, at Cardiovascular department PGMI, Lady Reading Hospital Peshawar. De Vega's surgical repair of tricuspid valve was done in severe tricuspid regurgitation patients with mitral valve replacement [MVR] or with double valve replacement [DVR=MVR+ AVR [Aortic valve replacement]]. Pre operative and post operative early [with in 1month] and midterm [at 6 month] follow up data was collected and analyzed on the basis of New York Heart Association [NYHA] functional status and echocardiographic finding. The outcome of De Vega's repair was assessed. Total study population was 160, with age ranging from 14-52 years [mean age 21 years]. Out of these 160 patients 89 [55.60%] patients were female and 71 [44.40%] were male. Preoperative diagnosis of 118 patients was related to pure mitral valve disease, and 42 cases were having aortic valve disease along with mitral disease. All patients had severe TR. Patients who were free from TR in MVR group were 81.3% and 75.0% patient were TR free in DVR group at 6 months follow up and the repair was intact on echocardiography. De Vega's repair in Severe TR is a safe and economical procedure in our setup

Pattern of combat casualties in war against terror among soldiers wearing body armor at CMH Peshawar

To determine the pattern of gun shot and explosive injuries in soldiers equipped with body armor and helmet. Descriptive study Combined Military Hospital Peshawar, from 1st June 2008 to 30th May 2010. All combat casualties received in 'Emergency reception' of Combined Military Hospital, Peshawar were included. Data was taken from the patient's medical charts and by personal evaluation and entered in a proforma. The variables used were age, use of helmet, cause of the injury, site of injury, Haemo-dynamic Status, conscious level, intensive care treatment duration, total hospital stay, return to work and mortality. A total of 516 combat casualties were received in 'Emergency reception' of Combined Military Hospital, Peshawar, Pakistan. All patients were males with a mean age of 31.22 +/- 7.858 years. Sixty nine percent [356] cases had injury due to splinters from Improvised Explosive Devices [IED] and 31% [160] had gunshot wounds. Seventy five percent [391] patients were haemodynamically stable while 24.2% [125] were unstable. Penetrating Extremity Injury [PEI] was the commonest injury [71.9%] followed by Penetrating Injury of Face or Neck [PNFI] in 12.0% [62], Penetrating Torso Injury [PTI] in 8.9% [46] and Penetrating Injury of Cranial Vault [PCI] in 7.2% [37]. Overall mortality was 64 [12.4%] IEDs have become the weapon of choice in gorilla warfare by the terrorists in addition to guns, bombs, and anti-personnel mines. The use of body armor has decreased the mortality but the morbidity in terms of limb injuries has increased

Comparison of 0.2 % glyceryl trinitrate and open lateral internal anal sphincterotomy in treatment of chronic anal fissures

To compare lateral internal sphincterotomy with 0.2 percent glyceryl trinitrate in the treatment of chronic anal fissure in terms of fissure healing and complications. Randomised Controlled Trials [RCT] Place and duration of the study: The study was of 6 months duration conducted at surgical unit Combined Military Hospital Rawalpindi from August 2006 to February 2007. Subjects and Seventy Patients were randomly assigned to two treatment groups. Group 1 was assigned to apply glyceryl trinitrate 0.2 percent paste while, in group 2 lateral internal sphincterotomy was done. Response to the treatment was assessed in terms of fissure healing and occurrence of complications. Follow up of the patients was carried out at the end of 2nd, 4th, and 6th week of treatment. In this study overall healing rate after 6 weeks with GTN was 71.4% and 100% with LIS [p< 0.001]. Conclusions: lateral internal sphincterotomy is better than GTN in fissure healing

Pattern of injuries inflicted on troops fighting, on the western front

To determine the pattern of fatal and non fatal injuries in soldiers and officers during the present war on Western front. Descriptive study with partly retrospective data collection. The study was carried out at Combined Military Hospital [CMH] Peshawar, the tertiary care centre for Pakistan Armed Forces serving FATA and NWFP from March 2004 to May 2009. Data of non-fatal injuries was collected by noting down the wounds inflicted on injured soldiers and officers evacuated from forward areas while the record of non-fatal injuries was noted from the hospital papers prepared for each patient. Due to reasons of confidentiality the analyses is based on percentages only, while actual figures can be provided by the authors on appropriate security cleared requests. The Lethality Index [LI] of wounds, calculated by dividing the fatal injuries by the total injuries, was 18% during these six years. Out of the total fatal injuries in all six years highest number occurred in 2008 [40%] while LI was highest in 2005 [25%]. Only a small number of patients [1.86%], who were evacuated alive, died in the hospital. Fifty one percent soldiers received multiple [>two] fatal injuries. Head [46%] and Chest [44%] were the commonest sites of fatal injuries while limbs were the commonest sites of non-fatal injuries. Gun shot wounds were the commonest [68%] mode of fatal and non-fatal injuries. Head and chest injuries are the commonest sites of fatal injuries, while limbs injuries constituted the major portion of the non-fatal injuries indicating potential areas in need of improved protective

Association of aetiology, presentation and post-operative complications of post-traumatic peripheral artery pseudoaneurysm

To describe post traumatic pseudoaneurysms and its association to causes, presentation and conventional surgical treatment modalities. This Descriptive study carried out in the Department of Cardiovascular Surgery, Lady Reading Hospital, Peshawar from January 2003 to December 2007. Patients with associated arteriovenous fistula were excluded from this study. All the demographics including age, sex, type of injury, site, associated complications operative details, pen operative morbidity and mortality were prospectively recorded in a data base. The total number of patients was seventy five. All the patients underwent conventional surgical procedures. Reverse saphenous graft was received by 34%, 24% had end to end anastomosis, 12% had interposition synthetic graft, 8% had rent repair while 21.33% had primary ligation of the involved artery. There was no pen operative mortality. Six patients had post operative complication in the form of graft, thrombosis and or infection. Three patients had amputation, two in lower limb and one in the upper limb. Majority of them were male 90.66%. Age ranged from 7 years to 75 years. Most of the patients [77.3%] were in second to fourth decade of life. The most common cause of injury was gunshot wound [56%] followed by stab wounds [13.33%] and road traffic accidents [12%]. Few cases of bomb blast [6.66%], Post cardiac catheterization [4%], glass injury [4%] and intravenous drug abusers [2.66%] were also reported. The commonest site of injury was fern oral artery [37.33%].In this study majority of patients were male with gunshot wound as commonest cause. Reverse saphenous vein graft was treatment of choice. Infection and thrombosis were the commonest postoperative complications

Should we say good bye to closed mitral commissurotomy in our setup

To study the short-term results of closed mitral commissurotomy in patients with rheumatic mitral stenosis. Material and This study was conducted at the department of cardiovascular surgery, Lady Reading Hospital, Peshawar from January 2003 to December 2003. Data was collected on a preformed proforma. Mitral valve characteristics were evaluated according to the scoring system devised by Wilkins and Associates. All those patients who had severe mitral stenosis and echo score of < 12, raised pulmonary hypertension or patients with atrial fibrillation were included in this study. Patients having echo score > 12, left atrial and left atrial appendage clot, moderate mitral regurgitation were excluded from the study. After operation patients were followed up for six months for haemodynamic stability. During this time period, 76 patients with rheumatic mitral stenosis underwent closed mitral commissurotomy. Total patients were 76 [male 18, female 58] with age range of 10 to 60 years. Pre-op 2 2 mitral valve area ranged from 0.6 to 01 cm a mean of 0.74 + 0.13 cm. Mean mitral valve gradient was 19.7 + 6.3 mm Hg. Pulmonary artery systolic pressure ranged from 35-110 mmHg. Five patients had associated severe tricuspid regurgitation. Twenty patients had controlled atrial fibrillation. At two weeks follow-up in the out patients department after closed mitral commissurotomy the mean mitral valve 2 gradient was 9.4 + 4.2 mmHg and mitral valve area was 1.6 +/- 0.7 cm. One patient developed severe mitral regurgitation and one had left hemperesis. Pulmonary artery systolic pressure assessed by Doppler, dropped to a mean of 40 mmHg. There was no death. At six months follow-up the improved haemodynamics were maintained. Cost of the whole procedure was less than the cost of the percutaneous transmitral commissurotomy catheter alone. Closed Mitral Commissurotomy is a safe procedure. It is cost effective in developing countries with limited health budget, closed mitral commissurotomy still has a role to play

Injuries and fatalities resulting from the 2005 south Asia earthquake. A hospital experience

The South Asia quake struck South Asia with its epicentre in Pakistan on 8[th] October 2005, originating from a previously recognized fault line but of unsuspecting magnitude of death and destruction. The Earthquake measured 7.6 on the Richter scale and caused massive loss of life and extensive damage to property never seen before in the history of Pakistan. Earthquake related admissions and deaths to one of the two major tertiary care hospitals receiving casualties from the quake zone from 8[th] October 2005 through 1[st] November 2005 were analysed. All medical data from the hospital records was reviewed for quake related injuries and information about pattern of injuries received and treatment administered. A total of 3128 earthquake related admissions were recorded in the hospital with 39 in-hospital deaths. Admission rates were approximately 2:1 by gender, males affected more. Earthquake related injuries are varied and multifactorial. Comprehensive surveillance and a well developed plan for all Medicare setups need to be in place and when actively rehearsed, can help lead to better management preparedness

Devega's tricuspid valve annuloplasty: Still a good alternative in our setup

To assess the durability of Devega's repair of tricuspid valve in severe tricuspid regurgitation [TR]. From January 2002 to December 2003. 22 Devega's surgical repairs of tricuspid valve in severe TR were done either with mitral valve replacement or with Atrial Septal Defect [Secundum Type] repair. Clinical data was retrieved from hospital records and analyzed post-operatively on the basis of NYHA status and echocardiographic findings at the interval of 6, 12 and 24 weeks. The durability of Devega's repair was assessed. Out of 22 Devega's repair, over 80% of the patients having severe TR+3 reverted to no TR and about 20% patients had mild TR postoperatively at the interval of 6 months and the repair was intact on echocardiography. Devega's repair of tricuspid valve in severe TR is a safe and economical procedure in our setup

Mortality and morbidity of abdominal inferior vena-caval injuries

To evaluate the outcome of abdominal inferior vena-caval [IVC] injuries in patients presented to Accident and Emergency Department, Lady Reading Hospital, Peshawar. Design: An observational study. Place and Duration of Study: The study was conducted at Postgraduate Medical Institute [PGMI]/Lady Reading Hospital, Peshawar, from January 1995 to January 2003, Patients and Case records of all patients operated within specified period for vascular trauma having injuries to the abdominal inferior vena cava. In all cases vascular trauma management was done mainly on clinical assessment in a low equipped set up. Data on age, gender, mechanism, nature and location of inferior vena-caval injuries, other vascular and non-vascular injuries were recorded. There were 22 patients, 77.27% male and 22.72% female. Age ranged from 10 to 40 years with mean age of 25.09 years. Majority of injuries were caused by penetrating injury [77.27%], blunt injury in 04.54% and 18.87% were iatrogenic. Majority [95.45%] were having single laceration of inferior vena cava and 04.54% were having more than one laceration. Associated vascular injuries involved aortic 9.09%, internal iliac in 4.54% and renal vein in 4.54%. Most common associated non-vascular injury involved small intestine [72.72%] and large gut [50%]. Inferior vena-caval injuries carries high mortality rate. When associated with multiple organ injuries and retrohepatic inferior vena-caval injuries are almost fatal

Abdominal aortic aneurysm surgery - local experience

The aim of this study was to evaluate the outcome of AAA referred to our unit by general surgeons/physicians.This study was conducted from Jan 1996 to Dec 2001. 25 AAA were referred. Age range 18-75 years [mean 54 years] male 19, female 6. Eight out of 25 patients presented with dissecting leaking AAA while 16 presented with non-specific symptoms. Diagnoses were made only by doppler ultrasound. Out of 8 leaking AAA 2 patients were not operated because of low pressure and no response to resuscitative measures. Six patients underwent surgery but we lost 4 out of which 1 had table death, 2 patients died on 3rd and 5th post operation day because of Acute MI, 4th patient died on 4th post operative day because of graft thrombosis. Two patients survived the operation and went home on the 10th post operation day. Out of the non-dissected group of AAA all the patients survived surgery and discharged home on the average 10th post operation day. Non-specific abdominal pains radiating to back especially in the elderly should be thoroughly investigated keeping in mind the AAA and they may be referred to the respective center for proper management