Routine blood transfusion should not be [routine] in cardiac surgery

To determine if open-heart surgery can be performed in a public hospital in Pakistan without the use of routine blood transfusions. Considering the high prevalence of Hepatitis B and C in the donor population, decreased use of donated blood is the best protection against these and other transfusion transmitted infections. Cross sectional observational study. This study was conducted at cardiac surgery department, Mayo Hospital Lahore. It included patients operated from January 2006 to September 2006. Duration of study was 9 months. Total of 106 patients undergoing open-heart surgery were included in the study. These were all adult patients operated during the first nine months of 2006 by a single group of surgeons. Patients who were re explored for bleeding or had complicated postoperative course or who did not survive the operation were excluded. All the pump blood after cessation of cardiopulmonary bypass was transfused to the patient. Intra and post-operative allogeneic blood transfusions were given based upon strict transfusion criterion. Any patient who received 1 unit of blood[1] or 2 units of blood with post operative haemoglobin of 11 gram per 100 ml or more than 11 gram per 100 ml or more than 2 units of blood with post operative haemoglobin of 12 gram per 100 ml or more than 12 gram per 100 ml was considered to have received unnecessary transfusion[2]. 67 patients [63.21%] did not receive any blood transfusion. 32 patients, [30.19%] were transfused 2 units of blood. 7 [6.60%] patients received more than two units of blood. 8 [7.55%] patients received unnecessary transfusion. Blood transfusions can be eliminated in most routine cardiac operations. As appropriate drugs and technology like cell savers and in pump haemo-cocentration devices become available to us, the number of patients receiving blood transfusions can most likely be decreased further

Prevalence of hepatitis B and hepatitis C virus infection in multitransfused thalassaemia major patients in northwest frontier province

To determine the prevalence of hepatitis B and hepatitis C virus infection in multitransfused thalassaemia patients. A prospective study. Department of Pathology, Khyber Medical College Peshawar and Fatimid Foundation Peshawar from January 2000 to January 2001. This study was carried out on 250 multitransfused thalassaemia major patients. They were screened for hepatitis B surface antigen [HBsAg] and anti hepatitis C virus antibodies [anti-HCV antibodies] by Enzyme Linked Immunosorbent Assay [ELISA]. The patient's ages ranged from 1[1/2] year to 19 years. Majority of the patients included in the study had received more than 10 transfusions. The males were 180 [72%] and the females were 70 [28%]. Out of these 21 patients [8.4%] and 142 [56.8%] have been screened positive for HBsAg and anti HCV antibodies respectively. It has been recommended that properly screened blood, using a reliable method like ELISA, be only transfused to thalassaemic subjects in order to avoid / reduce transfusion associated infection

Surgery for pleuropulmonary tuberculosis

The purpose of our study was to analyze current indications for surgery in pleuropulmonary tuberculosis [TB]. We present our experience with TB patients presenting with indications for surgery between 1998 and 2003. Material and The indications for surgical intervention included 220 cases of empyema, mediastinal lymphadenopathy 48 cases, hemoptysis 25 cases, destroyed lung 24 cases, undiagnosed pleural effusion 24 cases, bronchiectasis 18 cases, cavitary lesion with MDRTB 13 cases and pulmonary aspergilloma 10 cases. Thirteen patients with multidrug-resistant tuberculosis required surgical intervention, although 26 were treated with second line drugs during this period. The techniques utilized included decortication in 152 cases, lobectomy in 62 cases, rib resection for pleural drainage in 50 cases, anterior mediastinotomy in 48 cases, pneumonectomy in 28 cases, open pleural biopsy in 24 cases, and thoracoplasty in 18 cases. In 12 patients [3.1%], two procedures were performed, and in one case, 3 procedures. In 65 cases [17%] there were complications, of which persistent air leakage after decortication and pulmonary resection was the most frequent [n=26]. There was a mortality rate of 2.8% [11 cases]. Conclusions: In our experience, surgery in the treatment of TB is indicated to resolve sequalae or complications, since cases of simple or multidrug-resistant TB can be managed pharmacologically. The morbidity and mortality rates in our series were acceptable

Clinical and ultrasound correlation in first trimester abortion

To compare the diagnostic accuracy of clinical and ultrasound evaluation in first trimester abortions and assess the impact of ultrasound on patient management. Non-interventional comparative study conducted on 100 patients, selected on simple random basis from Gynae Outpatient Department. Department of Obstetrics and Gynaecology, Allama Iqbal Medical College and Jinnah Hospital, Lahore Materials and All the patients with symptoms of first trimester abortion were evaluated clinically and by ultrasound to formulate a diagnostic and management plan. Both Modalities were compared for diagnostic accuracy, positive and negative correlation in different types of abortions. 34% of the patients were at 10 weeks of gestation, 28% were unsure of dates, 17% were at 11 weeks of gestation, 13% of the patients were at 9 weeks of gestation, 5% were at 6 weeks while 3% were at 7 weeks of gestation. Clinical diagnosis was made in 42% of cases; in 39% definite diagnosis was possible with combined clinical and ultrasound evaluation while in 19% no diagnosis was established with either modality In 89% of the cases the diagnosis was made on single ultrasound scan, while 11% required a repeat scan. Correlation between two modalities was present in 81% of the cases. Positive correlation was obtained in 59% and negative correlation was seen in 22%. The correlation was not possible in 19% of cases. Ultrasonography is an essential tool in diagnosis of early pregnancy failures especially where clinical evaluation is inconclusive

Plasma concentrations of non-esterified fatty acids in chronic renal failure in the United Arab Emirates

In end-stage renal failure, dyslipoproteinemia is linked to risk of cardiovascular disease. Increased concentrations of triacylglycerol-rich, very low density lipoproteins [VLDL] and decreased concentrations of high density lipoproteins [HDL] are usual, whilst total cholesterol and low density lipoprotein [LDL] concentrations are not increased. Non-esterified fatty acids [NEFA] are not transported by lipoproteins, but increased concentrations may also be associated with cardiovascular disease risk. In this study, plasma concentrations of NEFA and other lipids were compared in healthy subjects and patients with end-stage chronic renal failure who were either undialyzed or undergoing peritoneal dialysis or hemodialysis. Fasted blood samples for measurement of albumin, total, free and HDL-cholesterol, triacylglycerols and NEFA were taken from 56 apparently healthy subjects and from 48, 28 and 46 patients from the United Arab Emirates during 2002 who were either untreated or on peritoneal or hemodialysis. Hemodialysis subjects were studied immediately before and after a single treatment session. For all groups of patients, total, and LDL-cholesterol were unchanged, triacylglycerols and free cholesterol were raised and HDL-cholesterol concentrations and the percentage of esterified cholesterol were significantly decreased compared to controls. Plasma NEFA concentrations for untreated patients were similar to controls, but were decreased in peritoneal dialysis patients and markedly increased both before and, even more so, after dialysis in hemodialysis patients. Patients with end-stage renal failure share common features of dyslipoproteinemia irrespective of whether they are untreated or on peritoneal dialysis or hemodialysis. However, only hemodialysis patients show significantly increased concentrations of NEFA

Pregnancy with previous mitral valve replacement

Mitral valve replacement has changed many lives of patients with severe mitral stenosis who were doomed due to severe haemodynamic complications. Successful pregnancy outcomes are now numerous. The study was carried out at Services hospital involving 7 pregnant patients with mitral valve replacement, as regards to its antepartum, intrapartum and postpartum management. The study showed the incidence to be 0.2% of all deliveries. StarrEdwards was the most common [71.5%] prosthetic valve with good haemodynamic outcomes. Five [71.5%] patients remained in NYHA class II, showing the efficacy of valvular surgery and I. Five [71.5%] patients ended in vaginal delivery of healthy infants and 2 [28.5%] had evacuation. Six [85.7%] patients received anticoagulants. Oral warfarin was used in all of these six cases throughout the first trimester. One [14.3%] of these patients ended in spontaneous abortion. One [14.3%] patient had blighted ovum and intravenous heparin was replaced for warfarin 24 hours before evacuation at 12 weeks of gestation. The remaining 4 [57%] patients continued warfarin through second trimester, and replaced by subcutaneous heparin at 34 weeks in 3[42.8%] patients and at 36 weeks in one [14.3%] patient. Coagulation monitoring, which was carried out in only 3 [42.8%] cases, revealed ineffective thromboprophylaxis. Ampicillin and gentamycin was given intravenously at start of labour and then 8 hourly for 48 hours in 6 [85.7%] patients. Antenatal antibiotic prophylaxis was provided only to 1 [14.3%] patient by benzathaine penicillin [penidure-LA, Wythe] 1.2 x 106 units per month. Diuretics, digoxin and beta blockers were prescribed according to individual requirements of patients. Two patients developed pulmonary oedema treated effectively in the intensive care unitI.C.U. There was no mortality in this study. A concerted effort by all the concerned specialities in patients management is necessary to ensure safe outcome. The role of subcutaneous instead of intravenous heparin for prophylaxis in pregnancy should be evaluated by further studies

MR imaging of the knee - an audit of practice

Magnetic resonance imaging [MRI] scan has shown constant accuracy in diagnosing various knee pathologies. A positive predictive value of upto 98% has been documented in various studies. It is completely non-invasive non radioactive and diagnostic accuracy is comparable to arthroscopy [64-94%]. We present an audit of 217 consecutive patients from the waiting list on knee arthroscopy who underwent MRI scan. The scans were reported by one consultant radiologist. The results of MRI were compared against preoperative diagnosis and the influence of this investigation on decision making was evaluated. Significant number of patients had a change in diagnosis [54.4%] and alteration in treatment plan [36.4%] because of inaccuracies in the clinical diagnosis. We believe that MRI scan can help the clinician in making an accurate preoperative diagnosis and target the arthroscopy to specific lesions. This is a non-invasive investigation which can replace diagnostic arthroscopy

Strongyloidiasis in an immunocompromised patient with nephrotic syndrome, complicated by intestinal obstruction, perforated appendix and ARDS

A case of strongyloidiasis in a 65-year old Omani male with nephrotic syndrome, who was on steroid therapy [prednisolone 70 mg/day] is presented. The patient presented with symptoms of gastric outlet obstruction, septicemia and respiratory failure, and a laparotomy showed perforated appendix, the histology of which showed a mucinous tumor of borderline malignancy and peritoneal strongyloidiasis

Scalp defects

Scalp defects can result from trauma, tumors or infection. Whereas small defects can be closed with wide undermining and local flap coverage, large full thickness defects with exposed calvarium cannot be treated as such. Twenty patients with scalp defects were treated in the department of plastic and reconstructive surgery Mayo Hospital Lahore from 8.10.89 to 17.9.95. Fourteen [70%] of the patients were females. Thirteen [65%] belonged to rural areas. Trauma [65%], burns [25%], infection [5%] and tumors [5%] were the main causes of defects. Five [25%] patients [all females] had avulsion injury of the scalp. The size of defects varied from a minimum of 9 cm[2] to a maximum of 615 cm[2]. Nineteen [95%] had skin grafting with eighteen [90%] requiring split and one [5%] full thickness graft. Three [15%] required local flap rotation and seven [35%] bone chiselling. Majority [80%] of patients required two or less operations. The mean hospital stay was 38.5 days. There was only one mortality, which was related to burn injuries. It is concluded that bone chiselling followed by skin grafting is a safe and effective way of treating very large scalp defects and should be offered to patients where microsurgery is not feasible or available

Calcium channel blockers in the treatment of hypertension

Calcium channel blockers [CCBs] have gained increasing importance in the treatment of hypertension during recent years. These drugs lower the blood pressure by their cardiac and vascular effects. Possible cardio protection and a favorable influence on progression of atherosclerosis may be the additional advantages. Some aspects of basic and clinical pharmacology of CCBs are reviewed in this article

Transperitioneal drainage in liver abscesses

The clinical features and surgical management of 64 consecutive cases of liver abscess admitted over a period of 18 months were reviewed and form the basis of this retrospective study. The incidence of liver abscess was 0.358% of all hospital admissions. Ages varied from one to 72 with a mean age of 38.8 years +/- standard deviation 13.36 [S.D.] There were 53 [83%] single lobe abscesses in the right lobe, 4 [6%] in the left lobe and present bilaterally in 7 cases [11%]. Fever was the commonest symptom, present in 57 cases [89%], pain in 50 [78%] cases and leucocytosis in 47 [73%] patients. Eleven patients [17%] responded to antimicrobial therapy and were excluded. All the other 53 patients [82%] underwent transperitoneal drainage. Ultrasound scan was successfully used in confirming the diagnosis. There were no deaths and 6 patients [11.7%] developed wound infection. Eight [15.6%] patients had controlled biliary fistulae, one of whom had a prolonged stay

Surgery in acute cholecystitis

Eighty eight patients presented with symptoms leading to an initial diagnosis of acute cholecystitis over a 12 month period [1986-1987]. Forty eight presented with a palpable gallbladder [Group 1], eight with a vague tender mass in the right upper quadrant [Group 2], and thirty two presented with biliary colic, with minimal abdominal signs, which settled within 24 hours [Group 3]. Jaundice was present in 8 patients [6 in group 1, in group 2]. All patients in group 2, but only 19% in group 3, and 23% in group 1, had a past history of right upper quadrant pain. Surgery was required in 40 Pakistan [46%]. Seventy four and 94% of patients in group 2 and 3 respectively, had fever as against only 6% of patients in group 1. Seventy percent of group 1 patients and 62% of group 2 were operated and during their current admission. Initially, all group 3 patients were treated conservatively, but 2 developed distended gallbladder, and were operated on. Organisms grew from the gall bladder aspirate in only 8 [9%], and only when the bile was dark green. Acute gallbladder disease is more causally related to pressure changes resulting from obstruction than infection. Early operation relieves obstruction and allows and progression of the disease