Nasal itching and bleeding due to excessive exposure to air conditioners

Introduction: Nasal mucosa is very sensitive when it is exposed to extreme dry and cold weather conditions. Persistent or recurrent nasal itching due to such exposure is usually followed by the epistaxis. Objective of the study was to analyze effects of excessive exposure to dry and cold air of air conditioners on nose in terms of nasal itching and epistaxis

Methods: This prospective cohort study carried out on 144 healthy Pakistani individuals working in United Nations Hospital in Nyala, Sudan from February 2014 to May 2014. Individuals spending less than 8 hours daily inside air conditioners were compared to those spending more than 15 hours daily. Chi square tests were applied to compare the proportions of incidence of nasal itching and epistaxis between these two groups as well as between two age groups

Results: Mean age of all 144 subjects was 35.01 years [+/- 6.4]. Chi square test results confirmed that there was statistically significant difference of both the symptoms [nasal itching p-value 0.021 and nasal bleeding p-value 0.044] between two groups. Those spending more time in air conditioners were significantly more affected by dry and cold air. As for as the age group is concerned significantly higher number of subjects of ages more than 40 years had nasal bleeding compared to the younger age group [equal or less than 40 years]

Conclusion: Effects of exposure of dry air of air conditioners on nasal mucosa in terms of nasal itching and nasal bleeding were found to be significantly higher when subjects were exposed 15 hours or more per day. Furthermore nasal bleeding was more commonly seen in elderly subjects [more than 40 years] due to such exposure

Feasibility and safety of on table extubation after corrective surgical repair of tetralogy of Fallot in a developing country: A case series.

Fast‑track extubation is an established safe practice in pediatric congenital heart disease (CHD) surgical patients. On table extubation (OTE) in acyanotic CHD surgical patients is well established with validated safety profile. This practice is not yet reported in tetralogy of Fallot (TOF) cardiac surgical repair patients in developing countries. Evidence suggests that TOF total correction patients should be extubated early, as positive pressure ventilation has a negative impact on right ventricular function and the overall increase in post‑TOF repair complications such as low cardiac output state and arrhythmias. The objective of the case series was to determine the safety and feasibility of OTE in elective TOF total correction cardiac surgical patients with an integrated team approach. To the best of our knowledge, this is the first reported case series. A total of 8 elective male and female TOF patients were included. Standard anesthetic, surgical and perfusion techniques were used in these procedures. All patients were extubated in the operating room safely without any complications with the exception of one patient who continued to bleed for 3 h of postextubation at 2–3 ml/kg/h which was managed with transfusion of fresh frozen plasma at 15 mL/kg, packed red blood cells 10 mL/kg and bolus of transamine at 20 mg/kg. Apart from better surgical and bypass techniques, the most important factor leading to successful OTE was an excellent analgesia. On the basis of the case series, it is suggested to extubate selected TOF cardiac surgery repair patients on table safely with integrated multidisciplinary approach.

Frequency and mortality associated with Hyperglycemia in critically ill children

Objective: To determine the frequency of hyperglycemia in critically ill children admitted in PICU of a tertiary care hospital of Karachi and to compare the mortality of critically ill children with and without hyperglycemia

Study Design: Cross-sectional study

Place and Duration of Study: Paediatrics Intensive Care Unit [PICU] of National Institute of Child Health [NICH], Karachi, from November 2011 to April 2012

Methodology: One hundred fifty critically ill children admitted to PICU were included. Patients who had fasting blood sugar levels more than 126 mg/dl within 48 hours of admission were included in the hyperglycemic group. The normoglycemic and hyperglycemic groups were followed till 10 days to determine the mortality associated with hyperglycemia

Results: Out of 150 patients, 82 [54.7%] had hyperglycemia. Mortality rate was 48.7% [n=73/150]. However, mortality rate was significantly high 57.3% [n=47] in hyperglycemic patients than non-hyperglycemic patients [p=0.019]

Conclusion: The presence of stress-induced hyperglycemia in critically ill patients is a well established marker of poor outcome, and a very high mortality rate. Normoglycemia was associated with favorable outcomes in terms of hospital stay and mortality

Rectal Duplication Cyst: a rare cause of Rectal Prolapse in a toddler

Rectal duplication cysts are rare congenital anomalies. They constitute only 4% of the total gastrointestinal anomalies. They usually present in childhood. The common presenting symptoms are mass or pressure effects like constipation, tenesmus, urinary retention, local infection or bleeding due to presence of ectopic gastric mucosa. We are reporting a rare presenting symptom of rectal duplication cyst in a 4-year-old boy/toddler who presented with rectal prolapse. He also had bleeding per rectum. Rectal examination revealed a soft mass palpable in the posterior rectal wall. CT scan showed a cystic mass in the posterior wall of the rectum. It was excised trans-anally and the postoperative recovery was uneventful. Biopsy report showed rectal duplication cyst

Clinical comparative study of efficacy of Epley manoeuvre and Semont manoeuvre in benign paroxysmal positional vertigo

To compare the efficacy of Epley manoeuvre and Semont manoeuvre in the management of benign paroxysmal positional vertigo. Randomized controlled trials. ENT Department Combined Military Hospital [CMH] Kharian and Gilgit from March 2005 to February 2010. Hundred cases of benign paroxysmal positional vertigo [BPPV] were selected on Dix-Hallpike test by non probability convenient sampling technique and randomly divided into two groups of 50 cases each. Patients in group-1 were treated by Epley manoeuvre and patients in group-2 were treated by Semont manoeuvre. The patients were examined on first day, 3[rd]30 day, 7[th] day and after 01 month and clinical results were observed. In group-l, 68% cases showed immediate resolution of symptoms, 74% cases on 3[rd] day, 80% cases on 7[th] day and total 82% cases recovered completely after one month. In group-2, 62% cases showed immediate resolution of symptoms, 68% cases on 3[rd] day, 74% cases on 7[th] day and total 78% cases showed complete recovery after 1 month. There was insignificant difference between the two groups regarding recovery at different follow ups. It was concluded that Epley and Semont manoeuvres are equally effective in the management of BPPV

Immune response of tuberculin test and diagnostic BCG test in children suffering from tuberculosis

To compare the immunological response of tuberculin test and diagnostic BCG test inoculation given simultaneously to children suffering from tuberculosis. Comparative - Cross sectional. This study was carried out at the Department of Paediatric Medicine, Nishtar Hospital Multan from 6 April 2011 to 5 Oct 2011. Fifty patients with tuberculosis were selected. Relevant data of cases including personal data, presenting complaints, physical examination finding and results of all the relevant investigations were collected. We injected 0.1 ml tuberculin intradermally on ulnar surface of right forearm and 0.1 ml BCG vaccine intradermally on deltoid muscle of left side. Both the BCG and tuberculin tests were performed at the same time by the same doctor. All information was recorded in a specifically designed proforma. 26 patients were male and 24 female. Out of 50 patients; BCG test was positive 36 patients and was negative in 14 patients. Mantoux test was positive in 26 patients and was negative in 24 patients. Both BCG and mantoux tests were positive in 26 patients. Ten patients had a positive BCG test where Mantoux test showed negative results. Both tests were negative in 14 patients. BCG skin test is more superior to Mantoux test as a diagnostic tool in paediatric age group patients suffering from various types of tuberculosis

Etiological determinants of pericardiocentesis in children

To look at etiology of pericardial effusion and association between etiology and need for pericardiocentesis. This retrospective study was conducted at the Department of Pediatrics at Aga Khan University Hospital Karachi from January 2002 - December 2010. It included children [age < 15 years] who were admitted with diagnosis of pericardial effusion. Relevant information regarding history, clinical examination, investigations and treatment were noted on a performa. Data was analyzed by using SPSS [statistical package for social science for window version 16.0]. Thirty six 36 patients admitted with moderate to large pericardial effusion were included in the study. Mean age of the patients was 79 +/- 10 months with male: female ratio of 3:1. Infections, postpericardiotomy syndrome, malignancy and connective tissue disorders were the most common causes of pericardial effusion. Seventy five percent [75%] patients required pericardial effusion drainage. Pericardial effusions secondary to infections and postpericardiotomy syndrome are more likely to require pericardiocentesis [p value 0.04]. There were two deaths in the study group which were unrelated to pericardial effusion. Infections and postpericardiotomy syndrome are the most common etiologies of pericardial effusion in our study group. Pericardial effusion secondary to infection and postpericardiotomy syndrome are more likely to require pericardiocentesis

Medical ethics in ICU patients: conflicts and their resolution

The patients admitted to an ICU are special in many respects; they may have one or more than one organ failure, old age or an irreversible or a terminal illness. The cost of standardized intensive care is high and many families find it impossible to sustain the cost of prolonged intensive care of their near and dear ones. Difficult decisions may have to be taken by the patient, families or the treating physician. This is the point when medical ethics get involved into it. This special article addresses some of the dilemmas related to ethical issues

Ethical Dilemma in multiple co-morbid respiratory failure patient: Patient autonomy against family wishes?

An 82 years old patient with background history of severe COPD, heart failure, multiple co-morbidities and poor quality of life was admitted with pneumonia and subsequently developed acute respiratory distress. There was an obvious conflict of opinion among her family members regarding decision making in her case. The patient time and again insisted against being resuscitated if she ever became seriously ill. However, she did not appoint a proxy decision maker or give an advance directive. This created an ethical dilemma, resulting a clash among the family members as well as her treating physicians concerning the withholding of active treatment and DNR orders in case of cardiorespiratory arrest. In the end the clinicians took lead and, with effective communication with the patient and the family members, made a final decision of withholding treatment in respect of the patient's dignity and autonomy

Frequency of hepatocellular carcinoma in cirrhosis

To find the frequency of hepatocellular carcinoma in cirrhotic patients of our population. Prospective observational study. Medical A Unit Hayat Abad Medical Complex Peshawar. Period: 1st January 2010 to 31st July 2011. Material and All patients were screened for presence of Hepatocellular carcinoma [HCC] by performing Alpha fetoprotein and ultra sound [U/S] abdomen. Contrast enhanced computed tomography scan [CT] of abdomen was done in selective cases. European Association for the Study of Liver Diseases [EASLD] Noninvasive criteria [limited to patients with underlying cirrhosis] was used for diagnosis of HCC i.e. Two coincident imaging techniques that identify a focal lesion more than 2 cm showing arterial hypervascularization or one imaging modality that identifies a focal lesion more than 2 cm in diameter showing arterial hypervascularization and serum AFP levels greater than 400 ng/Ml. A total of 370 patients cirrhotic patients were enrolled in this study. Thirty nine patients [10.5%] were diagnosed as having HCC. Male patients were 30 [77%] and 9[23%] were female. Mean age was 49.2% [range 18 to 72 years]. Abdominal discomfort was predominant symptom present in 94% patients, followed by anorexia present in 90% patients, abdominal distension in 76%, weight loss in 62%, jaundice was present in 46% patients, altered mental status was notice in 36% patients and history of upper gastrointestinal [GI] bleed and malena was extracted from 26% patients. Ultrasound abdomen and CT abdomen showed unifocal lesion in 48.7% patients, multifocal lesion in 30.7% patients and massive lesion in 20.5% patients. Alpha fetoprotein ranged from 45ng/dl to 630ng/dl. Hepatitis C [HCV] was the commonest cause present in 51% patients, Hepatitis B [HBV] in 15.3% patients and HBV and HCV co-infection in 10.25% patients, history of alcoholism was revealed in 5% patients and in 2.5% patients alcoholism was present along with HCV and HBV each, while in 10% cases the cause of cirrhosis remained unknown. Hepatocellular carcinoma is the most common primary hepatic tumor and one of the most common cancers worldwide. It is concluded that HCC is more common in males compared to female cirrhotic patients. Hepatitis C followed by HBV are the leading causes of HCC related cirrhosis in local Population of Khyber pakhtoonkhwa

Intra vaginal wooden foreign body causing multiple internal fistulae and bladder stone in a 12 years girl

Vaginal foreign bodies in girls may be accidental, self-inflicted or secondary to child abuse. These may causes a number of complications like Infections, abscess formation, intestinal perforation, vaginal discharge and internal fistulae. We are presenting a case of a 13 years old girl who presented with a supra-pubic mass and dysuria. X-ray showed a radio-opaque shadow in pelvis. The child was admitted in medical ward with the diagnosis of bladder stone and UTI. She was pouring frank pus from the vagina. On rectal digital examination a hard foreign body was felt in the rectum. Investigations revealed that she had a large pelvic collection, a sharp wooden Foreign Body [FB] extending from the rectum through the vagina in to the urinary bladder forming a bladder stone. Patient also developed recto-vaginal and vesico-vaginal fistulae. Foreign body was removed along with the bladder stone, pelvic abscess drained and colostomy was performed. Later repair of vesico-vaginal fistula were performed, recto-vaginal fistula closed spontaneously and colostomy closed. Patient became fully continent for urine and feces after completion of surgical procedures. A careful history from the child revealed that she had inserted the foreign body herself as a self-exploring practice

Multiple myeloma in younger age

A Multiple Myeloma [MM] is rare in younger age group. We report MM in a 30-year-old female, who presented with multiple lytic areas upon skeletal survey, but with negative Bence Jones protein. Bone marrow biopsy confirmed it to be a case of multiple myeloma. Patient was put on chemotherapy and radiography to which she responded and now is ambulatory

Comparison of complications of septal surgery with and without use of intra-nasal splints

To compare the adhesion formation and post-operative pain with and without intranasal splints in patients undergoing septal surgery with inferior turbinectomy. Comparative study. The study was carried out in CMH Rawalpindi from April2005 to Oct 2005. Total 60 patients undergoing septal surgery were randomly divided into two groups. In Group A intranasal splints [made from plastic infusion bottles] were placed with paraffin gauze packing and in Group B, paraffin gauze packing was done without intranasal splints. Follow-up was carried out at 48 hours and 01 week after surgery for assessment of pain scores, while adhesion formation was monitored for two months after surgery. Mean age of patients in Group A [with splints] was 26.43 years and of Group B [without splints] was 25.77 years. There was marked difference of pain scores at 48 hrs after surgery between two groups and difference was found highly significant [p value 0.001]. The p-value of pain score for data at one week was 0.022, still significantly different but lesser than the one at 48 hrs. Only two patients both without splints were found to have adhesions [p value 0.150]. It is concluded that intranasal splints increased post-operative pain significantly and there was no significant benefit in reducing the post-operative adhesion formation with splints

Factors affecting survival in patients with oesophageal atresia and tracheo-oesophageal fistula

To evaluate the various factors affecting survival in babies with oesophageal atresia and tracheo-oesophageal fistula. Descriptive study. The study was carried out at the Department of Paediatric Surgery, The Children's Hospital, Pakistan Institute of Medical Sciences [PIMS], Islamabad from March 2004 to March 2005. All neonates with oesophageal atresia [EA] and tracheo-oesophageal fistula [TEF] during the study period were included in the study. Patients having isolated EA were excluded. A total of 80 patients were included in the study. Patients were received from the emergency department, OPD and Neonatal ICU. Diagnosis was confirmed by passing a radio opaque orogastric tube. Investigations were done to look for other associations. After stabilisation, right thoracotomy was performed, fistula was ligated and divided. An attempt was made to do a primary oesophago-oesopahgostomy. Nasogastric feeding was started on 2nd post-operative day. A contrast oesophagogram was performed on the 7th postoperative day and having ruled out leak, oral feeding was started. Out of the total, 33 [41%] survived and 47 [58%] patients died. Out of 47 deaths 20 [25%] died before surgery and 27 [34%] died after surgery. Mean follow up period was 6 months. Sixteen [20%] patients had anastomotic leak, 24 [30%] had anastomotic stricture, and 64 [80%] patients had postoperative pneumonia. We conclude that proper antenatal check ups will detect the problem early, avoid home deliveries and hence improve survival. Pneumonitis and septicaemia significantly affect survival. Availability of ICU is one of the main determinants of survival. The likely cause of high mortality rate in pre-operative patients in our series is non-availability of NICU due to limited space in our setup

Surgical ligation of patent ductus arteriosus in a non-cardiac surgical centre

Surgery for Patent Ductus Arteriosus [PDA] is usually performed in specialized cardiac centres with either open surgery of percutaneous embolisation using different materials and devices. This involves high cost of treatment especially for those poor patients who have grown up to several years of age without seeking any treatment for their disease. The objective of this study is to evaluate the safety of surgery for PDA in a non cardiac paediatric surgical setup. A total of 89 patients of 8 months to 12 years [mean 3 years] age were operated over a period of 13 years [from 1993 to 2006]. Fifty-five cases were females and 34 were males. Investigations included x-ray chest, ECG and echocardiography. All patients with PDA were included in the study except those who had other associated cardiac anomaly and those who had a calcified ductus. The ductus was dissected out and ligated with non-absorbable suture [Silk No. 1 or 2]. The patients were discharged by the 5[th] postoperative day. In majority of the patients the recovery was smooth and uneventful. Eight patients had minor complications which were treated conservatively. There were 3 mortalities in this series; 2 patients were over 10 years of age and had calcified ductus. They died during surgery due to primary haemorrhage and 1 died after 24 hours in the intensive care unit. All patients were reviewed at 1 week, 1 month, 3 months and 1 year after surgery. In majority, the typical machinery murmur disappeared immediately or a soft systolic murmur persisted for up to 4 weeks and then disappeared. With proper patient selection, the procedure can safely be performed in a paediatric surgical setup with facilities for cardiac monitoring. The surgeon needs to receive some additional training in the cardiac institution for safe surgery on these children. This will significantly reduce the cost with minimal complications especially for those poor patients who cannot afford the modern procedures due to monitory constraints. Children older than 10 years are not suitable for open surgery because of calcification of the duct

Bilateral lung collapse due to aspirated nasal packing

An aspirated foreign body continues to present serious challenge of airway management to anesthesiologists perioperatively. These patients usually present with respiratory distress and require a high index of suspicion; need prompt assessment and recognition of the potential cause, and emergency management to obtain the best possible outcome. Nasal packing after ENT surgery has been previously reported to result in complications. A nasal pack obstructing left bronchus completely and right bronchus partially, resulting in post obstructive pulmonary edema is reported. This patient had aspirated the nasal pack in recovery room after tracheal extubation. The case highlights the need for close postoperative monitoring in patients with nasal packs, the diagnostic role of fibroptic bronchoscope and therapeutic role of rigid bronchoscope in airway obstruction

Emergency surgical management of a massive anterior mediastinal teratoma in a neonate

Generally an anterior mediastinal teratoma is diagnosed because of space occupying effect which produces respiratory distress and pneumonic episodes. However there have been few reports where there was the need to address the problem soon after birth [Fig. 1] because of severe respiratory compromise 2, 3. This was also the case in our patient. A full term baby who had to be transferred from 1000 Km. distance because of none availability of neonatal surgical facility there. He was transported with respiratory support after having been diagnosed on a plain x-ray and on MRI. [Fig. 2, 3, 4]. Emergency resuscitation and management resulted in successful outcome. Details of treatment are presented in this care report

Presentation of retinoblastoma in South Punjab

To study the mode of presentation of retinoblastoma in South Punjab. Department of Ophthalmology, Nishtar Hospital, Maltan. A retrospective study was carried out on children who visited Eye Department, Nishtar Hospital, Multan from March 2005 to February 2007. Forty patients were included in the study. The age of children ranged from 6 months to 6 years. The most children presented were with proptosis. A total of 40 patients were included in the study. Out of these 40 patients, 24 [60%] were male and 16 [40%] were female. Their mean age was 3-5 years. Children [45%] presented with proptosis. Therefore it is mandatory that all the children must be screened keenly and referred to tertiary hospital for proper evaluation and management. The late presentation of retinoblastoma is due to unawareness of people living in far flung areas where people are uneducated and poor and go to hakeems, peers and believe on jaddu and tona etc. Arrangement should be made for early screening of children and education of people for early symptoms and signs of the disease