Comparison of early oral feeding and conventional oral feeding in cases of elective intestinal stoma reversal in terms of number of days of nasogastric decompression and hospital stay

Objective: To compare the efficacy of early oral feeding and conventional oral feeding in elective intestinal stoma reversal in terms of mean number of days of NG tube out and hospital stay. Study Design: Randomized Controlled Trials. Settings: Surgical Units of Allied/DHQ hospitals Faisalabad. Duration of Study: 1 year duration from February 2014 to January 2015. Sampling Technique: Non-probability consecutive sampling

Methodology: 60 patients were selected from OPD. Patients were randomly allocated to two groups. All stomas were closed in single layer extramucosal seromuscular fashion, intraperitonealy. In post-operative period, patients in group I were allowed oral feed in early post-operative period [6-8 hours] after the surgery. Initially, oral liquids [30ml/hr] was given and patients were observed for nausea and vomiting. Oral feed was increased gradually with the response of the patient with semi-solid to solid diet on 1[st] or 2[nd] post-operative day. Patients in group II were started oral sips of liquids once they pass flatus or audible bowel sounds. At least two follow up visits were advised within two weeks of discharge of patients, 1[st] on the 7[th] day and 2[nd] on the 14[th] day, for removal of skin stitches

Results: Out of 60 patients 37 [61.7%] were males and 23 [38.3%] were females. Among the variables under the study, for both groups, the minimum total number of days of nasogastric decompression was 0 days and maximum total number of days of nasogastric decompression was 5 days with mean of 1.17 days and standard deviation of 1.33. In group 1, the mean of the total number of days of nasogastric decompression was 0.13 +/- 0.35 days and in group 2, the mean of the total number of days of nasogastric decompression was 2.20 +/- 1.13 days with p-value of 0.0001 for both the groups, the minimum total number of days of hospital stay was 3 days and the maximum was 9 days, with mean of 4.82 days and Std. Deviation of 1.70 days. In group 1, the mean of the total number of days of hospital stay was 3.37 +/- 0.61 days and in group 2 the mean of the total number of days of hospital stay was 6.27 +/- 1.08 days with p-value of 0.000

Conclusion: Early oral feeding in cases of elective intestinal stoma reversal is better than conventional oral feeding in terms of number of days of nasogastric decompression and hospital stay

Damage to recurrent laryngeal nerve [RLN] with and without exposure in thyroidectomy

Objectives: To determine damage of RLN with and without exposure during thyroidectomy. Study design: Randomized control study Sampling technique: Non-probability consecutive sampling. Sample size: 150 patients. Setting: Surgical units of Allied Hospital Faisalabad

Methodology: With informed consent, study was conducted on two groups[75 in each group].Patients were distributed on alternate basis into group A and group B for thyroidectomy with and without identification of RLN respectively

Results: In group A 30[40%] patients were between 31-40 Years and 18[24%] between 41-50 Years. In group B 32[42.7%] were between 31-40 Years,13[17.3%] between 41-50 Years and 15[20%] between 50-60 Years. Mean of age was 38.5 +/- 10.9[standard deviation].In group A,28[37.3%] were male and 47[62.7%] females while in group B 25[33.3%] were males and 50 [66.7%] females. In group A 38[50.7%] patients were of MNG, 10 [13.3%] diffuse goiter, 7[9.3] solitary nodules, 13 [17.3%] suspicion of malignancy and 7[9.3%] malignanacy. In group B 33[44%] patients were having MNG, 15[20%] diffuse goiter, 10[13.3%] solitary nodule, 6[8%] suspicion of malignancy and 11[14.7%] malignant disease. In group A 39[52%] patients underwent STT, 20[26.7%] NTT, 10[13.3%] TT and 6[8%] hemi-thyroidectomy. In group B 35[46.7%] patients underwent STT, 21[28%] NTT, 12[16%] TT and 7 [9.3%] hemi-thyroidectomy. In group A 3 [4%] patients developed transient paralysis and 1[1.3%] permanent paralysis of RLN. In group B 7[9.3%] patients developed transient paralysis and 3[4%] permanent paralysis of RLN

Conclusion: Preservation of RLN is more likely with exposure and identification of RLN post-operatively

Radiation dose-rate reduction pattern in well-differentiated thyroid cancer treated with I[-131]

To determine the patterns of dose rate reduction in single and multiple radioiodine [I[-131]] therapies in cases of well differentiated thyroid cancer patients. Analytical series. Department of Nuclear Medicine and Radiation Physics, Multan Institute of Nuclear Medicine and Radiotherapy [MINAR], Multan, Pakistan, from December 2006 to December 2013. Ninety three patients [167 therapies] with well differentiated thyroid cancer treated with different doses of I[-131] as an in-patient were inducted. Fifty four patients were given only single I[-131] therapy dose ranging from 70 mCi [2590 MBq] to 150 mCi [5550 MBq]. Thirty nine patients were treated with multiple I[-131] radioisotope therapy doses ranging from 80 mCi [2960 MBq] to 250 mCi [9250 MBq]. T-test was applied on the sample data showed statistically significant difference between the two groups with p-value [p < 0.01] less than 0.05 taken as significant. There were 68 females and 25 males with an age range of 15 to 80 years. Mean age of the patients were 36 years. Among the 93 cases of first time Radio Active Iodine [RAI] therapy, 59 cases [63%] were discharged after 48 hours. Among 39 patients who received RAI therapy second time or more, most were discharged earlier after achieving acceptable discharge dose rate i.e 25 microSv/hour; 2 out of 39 [5%] were discharged after 48 hours. In 58% patients, given single I[-131] therapy dose, majority of these were discharged after 48 hours without any major complications. For well differentiated thyroid cancer patients, rapid dose rate reduction is seen in patients receiving second or subsequent radioiodine [RAI] therapy, as compared to first time receiving RAI therapy

Acute febrile illness; during the course of oral anticoagulation warrants immediate INR check

Oral anticoagulation is needed in many patients like after prosthetic valves insertion, in atrial fibrillation, clots in LA, clots in LV and DVT etc. It is mainly achieved by warfarin sodium which has many interactions with multiple other drugs and its action varies in different other chronic diseased states. to see the response of acute febrile illness on the chronic stable state of INR on a fixed dose of oral warfarin sodium. All the patients with acutely deranged INR who had a stable and controlled INR previously and a fixed dose of warfarin sodium were admitted in the cardiac surgical ward at FIC and their history was explored and recorded. A total of 966 patients were admitted in [CSW] during the period of April, 2012 to April, 2014 with deranged INR. INR was checked twice or sometimes thrice to rule out the laboratory error. 504 patients were female and 462 patients were male, 56 patients had repeated admission for their INR control, most of them were callous regarding taking dose of warfarin so they were excluded from the study. A total of 631 patients had low INR due to missed dose of warfarin sodium. Out of them 13 patients got stuck valve for which emergency redo prosthetic valve replacement was done. 06 patients died in emergency due to late presentation after the prosthetic valve got stuck. Only 279 patients had high INR on the previous dose of warfarin sodium, out of them 216 patients had out of range INR. They were treated by FFP transfusion and holding the Warfarin sodium dose for certain period of time.76% of the patients give H/o acute febrile states 101-103 with rigor and chills [Malaria, enteric fever, pharangitis, cellulitis, boils and UTI etc. etc.] since last 3-4 days for which they had got treatment from some local Gen. practitioners and gave the H/o bleeding gums, general body malaise, bruising, joint aches and pains. 24% of patients denied any acute febrile illness before their INR got out of range 2 patients died in emergency due to intra cerebral bleed after INR got uncontrolled. Any acute febrile illness even of short duration may cause sudden derangement of previously controlled INR on certain fixed dose of warfarin sodium which can create a life threatening situation like intra-cerebral bleed, haem-arthrosis, excessive menstrual blood loss leading to severe anemia. Other less dangerous situation are gum bleed, bruising, joint aches and pains and general malaise. So, it is always advisable and logical to get INR check when ever any acute febrile illness even of short duration is encountered to avoid grave situations

Valvular patients; post operative course, size of the left atrium can predict the cost effectiveness

Cost effectiveness in any surgical procedure is a major contributory factor in the continuation of medical services in developing countries. Limited data is available in assessing the factors related with the duration of ICU stay and treatment after valvular replacement surgeries. Our aim was to see the correlation of pre operative Left Atrial size of the patient and duration of post operative stay in ICU. Observational Study. March 2010 to April 2014. Faisalabad Institute of Cardialogoy, Faisalabad. A total of 550 consecutive patients with valvular lesions were included in the study. Their Left Atrial size was measured echocardiographically pre-operatively and their stay /course in the ICU was monitored. Three categories were identified in regard with the Left Atrial size and the ICU stay. If LA size is below 60 cm2, the post operative course and stay in ICU is normal and lasts for about 1-2 days. If LA size is between 60-65 mm2, the post operative course may be complicated and prolonged by the atrial fibrillation / flutter for which pharmacological cardio version may be needed and the stay in ICU is prolonged and may last for about 2-3 days. And if pre-operative LA size is more the 65 mm2 the patient may behave in entirely different way. His atrial fibrillation persists in spite of electro cardiovertion or pharmacological cardiovertion and his stay in ICU may last up to 4-5 days and thus the cost of treatment is raised. LA size can predict the post operative behavior of the patient in ICU and duration of stay and expected cost of the treatment. Smaller is the size of LA, shorter is the stay in ICU and thus lesser is the post operative cost and vice versa

Early postoperative valvular patient; modified devaga's repair for moderate to sever TR is a cost-effective maneuver

Rheumatic Heart Disease is affecting the tricuspid valve almost as equally as it affects the other valves of the heart and the fact is that the single valvular disease of the heart is rare in our population. Objectives: To determine the cost effectiveness of modified devagia repair in relief of post operative valvular patient. Period: 2009-2014. Setting: Faisalabad Institute of cardiology Faisalabad, Method: All the patients with mitral valve disease having concomitant tricuspid valve regurgitation operated upon. Average age of 14 years to 45 years without gender discrimination. Result: A total of 380 patients were studied having concomitant mitral and tricuspid disease. Out of which 276 patients had moderate to severe tricuspid regurgitation on per-operative digital assessment for which modified DeVaga's repair was essential and done. Only 104 patients had moderate tricuspid regurgitation on per-operative digital assessment which was the main population of address in our study. Out of these, 76 patients were decided for modified DeVaga's repair due to their moderate tricuspid regurgitation and 28 patients were left alone without modified DeVaga's repair due to their mild to moderate tricuspid regurgitation. Then their early post operative course was monitored in terms of ICU stay and their functional recovery after operation. Patients with modified DeVaga's repair for moderate tricuspid regurgitation showed 30-42 hours early weaning of inotropes and mobilization from ICU than the patients without modified DeVaga's repair for mild to moderate tricuspid regurgitation. It is thus evident that modified DeVaga's repair for moderate tricuspid regurgitation saved hours of ICU stay, cost of ICU treatment, man hours of doctors, nurses and paramedical staff showing good post surgical functional recovery as well. Conclusions: Modified DeVaga's repair for moderate tricuspid regurgitation has a cost effective impact in the treatment of valvular patients causing early and good functional recovery after valvular replacement procedures, saving man hours of Cardiac surgeons, Nurses, Paramedical staff, patients and thus their cost of treatment.

Acute bronchiolitis in children; epidemiologic and clinical features

To study the epidemiological and clinical features of acute bronchiolitis in children < 2 years of age with mild to moderate acute bronchiolitis. Outpatient department of Department of Pediatrics, independent university hospital, Faisalabad, Pakistan, from October 2010 to March 2011. 200 children diagnosed clinically with mild or moderate acute bronchiolitis were included in the study using convenient sampling technique. Epidemiologic variables of interest included age, gestational age at birth, sex, weight, breastfed or not, parental or caregiver tobacco smoking and socioeconomic status. Clinical variables of interest included cough, fever, breathlessness, wheeze, Rhonchi, feeding and sleep pattern and severity of disease. Predominant age group was between 2 to 12 months [76.5%] with mean age of 7.6 +/- 4.7. 95.5% of children were full term at birth. Male predominance with male to female ratio of 1.4:1 was noted. Mean weight was 7.2 +/- 1.8 kg. Predominantly mixed feeding pattern [45%] was observed. Most of the parents/caregivers [70%] were nonsmokers. Majority of children [81.5%] belonged to families with poor socioeconomic status. Results of clinical variables revealed Cough [100%], breathlessness [69.5%], audible wheeze [59.5%] and rhonchi on chest auscultation [100%], disturbed sleep [80%] and decreased oral feeding [78%]. Majority of children [79.5%] were afebrile. Mild acute bronchiolitis [73.5%] was predominant as compared to moderate acute bronchiolitis [26.5%]. Acute bronchiolitis is more prevalent in children <1 year of age with male predominance and in children from families with poor socioeconomic status. Mild form of acute bronchiolitis is more common. A relative lack of fever along with cough, breathlessness, wheeze and/or rhonchi are major presenting clinical features of acute bronchiolitis

Ossification of Posterior Longitudinal Ligament of spine- a recognizable cause of Myelopathy in Pakistan

Ossification of the Posterior Longitudinal Ligament [OPLL] is not so rare disorder in spine. We reviewed retrospectively three cases of cervical stenosis complicated by Myelopathy in two men and one woman. All patients presented with signs of cervical myelo-radiculopathy of varying degrees. Diagnosis was made clinically and confirmed radiologically with plain radiographs, MRI scan, and CT 3D reconstruction. Surgical decompression was done, two patients underwent laminoplasty and one patient was treated by laminectomy. They all showed favourable outcome following surgical decompression

Dengue fever; assessment of knowledge, attitude and practices of community medicine of Aziz Bhatti town Lahore during recent epidemic

Dengue infection is one of the most common mosquito borne viral diseases of public health significance. It has been identified as a clinical entity since 1780. Dengue is caused by viruses that are small enveloped viruses and are members of the family Flaviviridae genus Flavivirus. It is a vector borne disease and is a global health threat. In Pakistan first epidemic was reported in 1994 and since then cases are reported every years. This year dengue infection raised the number of patients and increased the deaths. To assess the knowledge, attitude and practices of the people regarding Dengue fever. Cross Sectional Study. Aziz Bhatti Town, Lahore. One Month. Convenient sampling. The investigator himself collected the information from the sample under study. First of all, an informed consent was obtained from the respondent under study and secrecy of the information was ensured. Data was entered and cleaned using Epi Data version 3. Data was analyzed using Epi info version 3.5.1. Out of 41 respondent families only 2.4% did not hear about dengue fever while 97.6% respondents were well aware of the dengue fever. 80.5% were aware of high grade fever in dengue fever, 73.2% were aware of associated body aches. 92.7% were aware that dengue fever is preventable. 95.1% were using mats, coils and repellents while 2.4% were using smoke of wet wood.36.6% were covering the water containers. 75.6% were keeping environment dry and clean.68.3% were having opinion that they will consult GP in case of illness.85.4% told that TV/Radio were the source of above mentioned knowledge while 9.8% doctor and 4.9% got information through newspapers. Only 4.9% respondents were having opinion that government had sprayed for dengue fever.7.3% families experienced the patient of dengue fever in their family. In this study the results are the almost same with little variations as found in other studies. The knowledge, attitude and practice are the almost same in every studies with little variation. Majority of the families were well aware of dengue fever

in vitro evaluation of apical microleakage of single cone obturation versus lateral condensation obturation technique

The aim of this in-vitro study was to use dye penetration method to compare the apical microleakage of matched taper single-cone and cold lateral condensation technique in teeth prepared with ProTaper instruments. Eighty [80] human extracted single rooted teeth were used. The teeth were randomly divided into two experimental groups of thirty [30] teeth each and two negative and positive control groups of ten [10] teeth each. The groups were as follows: Group I, Teeth were obturated using single cone obturation technique; Group II, Teeth were obturated using a cold lateral condensation technique. In positive control Group; teeth were instrumented and left unobturated, where as in negative control Group, teeth were instrumented and five [5] teeth were obturated with single cone obturation technique and five [5] teeth with the Lateral condensation technique. The access cavities of all teeth were obturated with Ketac Molar [3M ESPE] to ensure a coronal seal. The specimens were stored for 24 hours in 100% humidity at 37°C to allow the sealer to set. After that the surface of all roots in experimental and positive control groups were then covered with two layers of nail polish, except for the apical area [2mm]. In the negative control group all surfaces of the roots, including the apical area, were covered with two layers of nail polish. Each tooth was subsequently immersed in a freshly prepared 5% aqueous methylene blue dye solution [PH 7.0] at 37°C for seven days, and stored in incubator. Following storage, the roots were cut along their long axis and evaluated under a stereomicroscope to measure the depth of dye penetration. The negative controls showed no dye penetration while, the positive controls showed completely dye penetration. Mean and standard deviation of leakage for experimental groups were, for Single Cone Obturation, 6.42 [SD +/- 3.18], for Lateral Condensation Obturation, 6.44 [SD +/- 1.8]. There was no significant difference between the two groups [p=0.245]. Both the single cone and the lateral condensation obturation techniques proved equally effective in achieving the apical seal

To evaluate the effect of shef life on depth of cure of polyacid-modified composite - an in vitro study

The present study aimed to compare the curing depth of chemically similar Polyacid-modified composite resins [PAM-C] having different expiry periods. The curing depth of the PAM-C, Dyract Extra [Dentsply, U.K.] was determined for a near expiry and a long expiry material using a scraping method based on ISO 4049:2000. Samples were light-cured [800 mW/cm[2] at 40 seconds] in plastic mould. Immediately after light-curing the cylinder shaped material was removed from the mould, height of the cylinder of cured material was measured by using digital caliper and taken as the curing depth. The means of the curing depth of two materials were subjected to two sample independent t test using SPSS. The mean value of depth of cure for near expiry PAM-C [Group-A] was 6.389 mm [sd +/- .202] and that of long expiry material PAM-C [Group-B] was 7.087 mm [sd +/- .149]. The curing depth differed significantly between the materials of the two groups [P<0.001]. The curing depth greatly varies between the materials. It may be inferred that the curing depth of the two assigned groups of PAM-Cs depend on the period of expiry of the material

Neurological outcome after coronary artery bypass surgery

Neurological dysfunction is a common complication after cardiac surgery. Despite significant advances in cardiopulmonary bypass [CPB] technology, surgical techniques and anaesthetic management, central nervous system complications occur in a large number of patients undergoing surgery requiring CPB. The objective of this study was to determine neurocognitive status of the patients undergoing coronary artery bypass grafting [CABG] and to find any causative or associated factor. We evaluated 1000 consecutive patients undergoing primary isolated coronary artery bypass grafting [CABG] at a tertiary care cardiac institute from July 2000 to December 2001 to determine the neurological outcome after CABG and risk factors involved. The demographic and perioperative data were analyzed by X2 analysis. A history of diabetes, hypertension, increased age, preoperative neurological event, aortic atheromatous / calcific disease, bilateral carotid artery disease, intermittent aortic cross clamping and evidence of mural thrombi are all co-related with increased risk of neurological damage after CABG. When analyzed in a stepwise logistic regression model, diabetes mellitus, aortic disease increased age and mural thrombi carried a higher probability that the patient would have a postoperative neurological deficit. Conclusions: We conclude that although these factors are individually involved in the adverse neurological outcome after CABG but the combination of these factors greatly increases the risk of postoperative neurological consequences and only few of them are avoidable

Papillon-lefevre syndrome. all about palms, soles and gums: a brief review

Papillon-Lefevre syndrome [PLS] is an autosomal recessive disorder of keratinization characterized by palmoplantar keratoderma and periodontitis with subsequent loss of teeth. The exact etiology of the diseases remains to be unraveled. Nonetheless cathepsin C gene mutations may be involved. The present review focuses on the recent advances about role of cathepsin C gene in the causation of PLS and other disorders

Acute renal failure after cardiopulmonary bypass surgery

Acute renal failure [urine output <0.5ml/kg/hr.] following cardiopulmonary bypass is an uncommon but highly lethal complication which arises in the setting of inadequate cardiac function and may be associated with multi-organ failure. Acute renal failure [ARF] after cardiopulmonary bypass occurs in about 8% of adult cardiac surgical patients with some preoperative renal impairment and in about 3-4% of patients with normal preoperative renal parameters. This study was conducted to determine the frequency of acute renal failure after cardiopulmonary bypass operations and to find possible risks factors. We analyzed the data of 500 consecutive patients who survived the first 24 hours after open heart surgery at Punjab Institute of Cardiology, Lahore as this is the minimum time to evaluate post-operative renal function, their morbidity, mortality and the main contributing risk factors, from July 2000 to Dec. 2000. The association between preoperative, intra-operative and postoperative variables and the development of ARF was assessed by multivariate logistic regression. Of the 500 consecutive patients 35 [7%] patients developed acute renal failure [serum creatinine>2.5 mg/dl] and 102 [20.4%] patients developed acute renal dysfunction [serum creatinine 1.6-2.4 mg/dl]. Positive risk factors noted in the development of ARF were age, raised preoperative blood urea and creatinine, diabetes mellitus, low cardiac output state, oligurea, total CPB time, total cross clamp time and significant hypotension during the procedure or during intensive care unit [ICU] stay. Mortality rate for established ARF was extremely poor [88.8%] and there were only four [4] survivors among those requiring dialysis. Conclusions: Prevention of this disastrous complication appears to be better than treatment once it is fully established. However newer aggressive forms of early renal replacement / transplant therapies may have some promise

Tuberous sclerosis complex: bourneville's disease

Tuberous sclerosis complex is an autosomal dominant neurocutaneous syndrome due to mutations in two genes, tuberin and hamartin, involved in tissue growth. It is characterized by hamartomas in multiple organs including skin. Cutaneous lesions e.g. angiofibromas, ash-leaf macules, shagreen patches, ungual fibromas are quite characteristic and may herald other systemic features. The present article reviews the clinical profile, laboratory work-up, diagnosis and management of this multisystem disease

Evaluation of AST/ALT ratio in patients with liver disease

To assess AST/ALT ratio in patients with liver disease, i.e. hepatitis and cirrhosis and to evaluate its significance as predictor of cirrhosis in our population. Place and Duration of Study: The study was carried out in the Department of Medicine and Gastroentero logy Medical Unit-I Post Graduate Medical Institute/Services Hospital, Lahore and Department of Pathology PGMI Lahore Pakistan. The period of study was from July 1999 to July 2000. Subject and This study comprised 75 patients suffering from liver disease. All the patients were thoroughly examined clinically and ultrasound was performed. They were divided into two groups; Group I: It included 50 [35 male, 15 female] patients with cirrhosis of the liver confirmed clinically and by ultrasonography. Group II: It comprised of 25 [18 male, 7 female] patients with acute hepatitis confirmed by serology. The blood sample were sent to department of pathology Postgraduate Medical Institutes Lahore. HBs Ag and anti-HCV were performed using the commercially available kits based on ELISA techniques. AST and ALT were determined using the kits based on photometric methods in which the Oxo-acids are assayed by coupling with 2-4 dinitrophenyl hydrazine. The mean AST and ALT concentrations of the patients with hepatitis [Group II] were elevated significantly [P<0.001] as compared to those of the cirrhotic patients [Group I]. In contrast, the mean AST/ALT ratios of the cirrhotic patients [Group I] were elevated significantly [P<0.001] than the patients with hepatitis. Conclusions: The present study shows that the mean AST/ALT ratios of the cirrhotic patients were significantly higher [P < 0.001] as compared to those with hepatitis. Hence, the AST/ALT ratio can be considered as a dependable marker of fibrosis in patients with chronic liver disease in Pakistan, even though liver biopsy remains the most definitive diagnostic measure for cirrhosis