Frequency of acute complications of Hemodialysis in adult age group at a tertiary care center

Objective: To determine the frequency of acute complications of hemodialysis in adult age group at a tertiary care centre

Study Design: Descriptive study

Place and Duration of Study: Department of Medicine, Combined Military Hospital Lahore, from Apr 2012 to Oct 2012

Patients and Methods: We included 100 consecutive patients of chronic kidney disease on hemodialysis with age more than 12 years. Personal profile, comorbidities, intravenous access type and duration, hemodialysis parameters were recorded for each patient. Monitoring of blood pressure, temperature, pulse and history of palpitations, headache, nausea, vomiting, muscle cramps, fever, shivering, chest-pain, bleeding, fits, itching was recorded before and up till one hour post hemodialysis session

Results: In our study population fever was the commonest complication with frequency of 37 percent, followed by nausea and vomiting in 36 percent, muscle cramps in 28 percent, hypotension in 24 percent, headache in 23 percent, shivering in 22 percent, chest Pain in 15 percent, itching in 14 percent, hypertension in 10 percent, cardiac arrhythmias in 8 percent, hemorrhage in 7 percent and Seizures in 7 percent of patients

Conclusion: Infection related complications were more common in our set up as compared to international statistics which depicts that we should improve our antiseptic techniques

Mitral valve repair in a rheumatic population: an experience at AFIC/ NIHD

Objective: To analyze the outcome of mitral valve repair in rheumatic heart disease

Study Design: Retrospective analytical

Place and Duration of Study: Armed forces institute of cardiology/National institute of heart diseases Rawalpindi from Jan 2011 to June 2013

Material and Methods: In this retrospective study of 28 patients [15 females]. The mean age was 20.2 +/- 11.2 years [range, 11 to 55 years]. The cause of mitral regurgitation was rheumatic in all patients, with no congenital myxomatous, infective or ischemic cases. About 68% patients were in New York Heart Association [NYHA] functional class III or IV. In all the cases posterior ring annuloplasty was done with flexible C- Shape rings with size ranging from 20 to 26 mm. Repairs included anterior leaflet repair with cusp shortening and resuspension [n=17], posterior leaflet repair with quardranguloplasty and transpositioning [n=6], commissuroplasty [n=2] and mixed anterior posterior leaflet repair [n=3]

Results: There was no operative mortality. Follow-up was carried out for 10 months. The trivial mitral regurgitation was found in 3 cases [10.7%]. Four [14.2 %] patients required mitral valve replacement due to valve dysfunction

Conclusion: Mitral valve repair in rheumatic patients, with current techniques, can effectively correct functional and hemodynamic abnormalities with satisfactory results

Skeletonization of left internal mammary artery in coronary artery bypass grafting

Objective: To compare mean per-operative flow capacity between skeletonized and pedicled left internal mammary artery [LIMA] in patients undergoing coronary artery bypass grafting [CABG] surgery

Study Design: Randomized control trial

Place and Duration of Study: Department of Cardiac Surgery, Armed Forces Institute of Cardiology and National Institute of Heart Diseases [AFIC-NIHD], Rawalpindi, Pakistan from February to August, 2013

Methodology: Patients undergoing CABG for coronary artery disease, under 80 years, excluded by the exclusion criteria; and fulfilling the inclusion criteria were randomly assigned to two groups of 70 each. One group underwent skeletonized and the other underwent pedicled technique of LIMA harvesting. Free flow was checked just before anastamosis of each LIMA to the LAD, manually in blood flow in ml per minute during cardiopulmonary bypass by allowing it to bleed into a 100 ml container over 20 seconds. A specialized proforma was used to record the age, gender, weight, disease, type of IMA used, and free flow of the IMA. Data was analyzed using SPSS 18

Results: The mean age of the patients was 57.16 years in 40 patients, ranging from 36 to 75 years. Disease pattern analysis showed 5%, 10.7% and 84.3% single, double and triple vessel coronary artery disease, respectively. There was significantly higher free flow in the skeletonized group than the pedicled group [p=0.04]

Conclusion: Skeletonized IMA had superior flow to pedicled IMA in addition to its traditional proven advantages, which justifies its further use as a conduit for myocardial revascularization

Topical application of tranexamic acid reduces postoperative bleeding in open-heart surgery: myth or fact?

To determine the efficacy of topical application of Tranexamic acid in controlling postoperative bleeding in open-heart surgery. Double blind randomized control trial. Departments of Cardiac Surgery and Intensive Care of Armed Forces Institute of Cardiology and National Institute of Heart Diseases [AFIC-NIHD], Rawalpindi, Pakistan, from May to October 2011. A total of 100 consecutive adult patients fulfilling the inclusion criteria undergoing elective on-pump cardiac surgeries were randomly divided in groups [A] and [B]. A study solution that contained 2.5 g of Tranexamic acid in 250 ml normal saline in group-A and equal amount of normal saline [placebo] in group-B was poured in the pericardial cavity over the mediastinal tissues before sternal closure. Postoperative bleeding was measured in both groups for 24 hours in the cardiac surgical ICU. Efficacy of Topical Tranexamic Acid / Placebo was measured in terms of mean postoperative bleeding in ml. Kindly again include these lines which seem to have been omitted in the final proof. There was significant difference in the mean postoperative bleeding within 24 hours among the two groups 340.1 +/- 112.4 ml in Tranexamic acid group vs. 665 +/- 187.28 ml in placebo group [p < 0.001]. Patients who did not have topical Tranexamic acid before chest closure had a significantly higher postoperative bleeding. Topical Tranexamic acid application is an effective and economical way for controlling non-surgical bleeding in patients undergoing cardiac surgery with cardiopulmonary bypass

Correlation between serum ferritin level and liver function tests in thalassemic patients receiving multiple blood transfusions.

Background: Multiple blood transfusions are the mainstay of thalassemic patients in order to combat the severe anemia. These frequent blood transfusions result in the excessive iron deposition, leading to multiple injuries to a variety of organs in the body. In response to these injuries, the levels of various enzymes are disturbed. The whole phenomena usually involve the interrelation of one parameter with some other. The present study aimed to estimate the levels of serum ferritin and hepatic enzymes and to find out any possible correlation between them in thalassemic patients receiving multiple blood transfusions. Methods: A total number of 90 thalassemic patients of both sexes ranging from 10-15 years, receiving multiple blood transfusions were included in the present study. Blood samples from all the patients were withdrawn and analyzed for the values of serum ferritin, hemoglobin and hepatic enzymes (serum alanine transaminase, serum aspartate transaminase, serum alkaline phosphatase). Pearson correlation coefficient was applied to observe correlation between serum ferritin level and hepatic enzymes. A P value of ≤0.05 was considered statistically significant. Results: The overall values of serum ferritin, and hepatic enzymes (serum Alanine Transaminase, serum Aspartate Transaminase, serum Alkaline Phosphatase) were remarkably increased than their normal values. However, hemoglobin level was considerably decreased in thalassemic patients. A weak positive insignificant correlation was observed between serum ferritin with hepatic enzymes and hemoglobin in thalassemic patients. Conclusion: Multiple blood transfusions cause iron overload in the body, which in turn, lead to increased serum ferritin levels in thalassemic patients. High levels of hepatic enzymes are somewhat correlated to serum ferritin concentration. However, the exact reason of elevated levels is still unclear. Further detailed studies should be conducted in order to identify the exact mechanism behind this and to search for the promising correlations of various parameters in thalassemic patients receiving multiple blood transfusions.

2011 dengue haemorrhagic fever outbreak in Lahore - an account of clinical parameters and pattern of haemorrhagic complications

To describe the frequency and outcome of dengue haemorrhagic fever [DHF] cases and determine the association of clinical and laboratory parameters with haemorrhagic complications. A descriptive study. Combined Military Hospital, Lahore, from August to November 2011. Clinical profile and outcome of 640 adult patients hospitalized with a strong clinical suspicion of dengue fever [DF] was evaluated. Based on serological confirmation, these patients were divided into confirmed DF and probable DF cases. They were also categorized according to severity into dengue fever [DF], dengue haemorrhagic fever [DHF] and dengue shock syndrome [DSS] cases according to WHO guidelines. After detailed clinical evaluation, blood samples were taken for a complete blood count, urea, creatinine, sodium, potassium, bilirubin, alanine aminotransferase [ALT], prothrombin time [PT] and activated partial thromboplastin time [APTT]. Patients were managed according to standard protocols with intravenous fluids and symptomatic treatment. SPSS 18 was used for statistical analysis of clinical data. Comparison of features among the groups was made using chi-square or t-test with significance at p < 0.05. There was 359 probable DF and 281 confirmed DF cases. The development of DHF, neurological manifestations and overall mortality was more frequent in confirmed DF group. Comparison between DHF/DSS and DF cases revealed a significant difference in vomiting [p = 0.04], purpuric rash [p < 0.001], systolic blood pressure [p = 0.002], serum ALT [p < 0.001], hospital stay [p < 0.001], neurological involvement [p < 0.001] and coagulopathy [p < 0.001] between the two groups. Among 159 DHF patients, 108 [67.9%] had bleeding from gums and oral cavity, 73 [45.9%] had haemetemesis and 82 [51.5%] malaena, 41 [25.8%] had epistaxis, 12 [7.5%] developed intracranial bleeding, 18 [11%] had hematuria, 12 [7.5%] had fresh bleeding per rectum and 37 [23%] developed haemoptysis. Overall mortality was 3%, but mortality in DHF/DSS cases was 6% and 41.6% for DSS cases. Logistic regression analysis showed that abdominal pain, purpuric rash, ascites, thrombocytopenia, coagulopathy and raised ALT had a statistically significant predictability for developing DHF. A variety of manifestations including that abdominal pain, purpuric rash, ascites, thrombocytopenia, coagulopathy and raised ALT had a statistically significant predictability for developing DHF. A knowledge and understanging of these complictions would be useful for the management of patients if such outbreaks of DHF are encountered again

DFT for exploring the antioxidant potential of homogentisic and orsellinic acids

In recent years, much attention has been focused on the antioxidant potential of different phenolic acids. But still no theoretical investigation is reported on the antioxidant potential of Homogentisic and Orsellinic acids. In this study, computational investigation based on the density functional theory [DFT] has been carried out to understand the antioxidant potential of Homogentisic and Orsellinic acids. The bond dissociation enthalpy [BDE] of O-H, spin densities and electronic properties such as dipole moment, ionization potential, electron affinity, HOMO and LUMO energies, electronegativity, electrophilic index, energy gap, softness and hardness have been calculated. These properties show that both phenolic acids are good antioxidants. Comparison of BDE of Homogentisic and Orsellinic acids with many other phenolic acids also indicate the good antioxidant potential of these compounds. Homogentisic acid has very high antioxidant potential due to the presence of semiquinone structure. This study will be helpful for the better utilization of these compounds in pharmaceutical and food industry

Effects of hot shot [non cardioplegic blood based] on cardiac contractility and rhythm as parameters of myocardial protection in CABG surgery

To compare the effects of warm blood cardioplegia along with hot shot [non-cardioplegic blood based] at the end of ischemic time to warm blood cardioplegia without hot shot to assess resumption of effective electromechanical activity and need for internal electrical cardioversion as indicators of myocardial protection and preservation. Randomized control trial. The study was conducted at Armed Forces Institute of Cardiology [AFIC], Rawalpindi for a period of 10 months [March 2009 - Dec 2009]. Total 100 patients of coronary artery disease having coronary artery bypass grafting [CABG] surgery were equally and randomly divided into two groups using random numbers table. Group A [n=50], consisted of warm blood cardioplegia with non cardioplegic blood based hot shot and group B [n=50], consisted of warm blood cardioplegia only. The adequacy of myocardial protection techniques was assessed by noting the time interval [in seconds] between declamping of the ascending aorta and patient regaining electromechanical activity. Additional parameters were rhythm, use of internal cardiac defibrillation, inotropes, IABP requirement and ECG evidenced peri-op MI. Average age in group A was 56.98 +/- 9.47 years and in Group B it was 59.14 +/- 9.35 years. In group A there were 48 [96%] males and group B there were 43 [86%] males with p-value of 0.081. Comparison of preoperative variables of both the groups revealed no difference in cross clamp time [p=0.52], CPB time [p = 0.68] and endarterectomy [p=0.55]. The electromechanical activity [contractility of heart] returned within 7.53 +/- 2.09min in group A as compared to 9.81 +/- 2.6min in group B [p<0.001]. Significantly high frequency was observed for defibrillation [p=0.025], inotropic support [p=0.045] and IABP insertion [p=0.041] in group B as compared to group A. In CABG surgery the additional use of hot shot [non cardioplegic blood based] during cardiopulmonary bypass [CPB] is effective in myocardial protection and preservation by resuming early contractility of heart, benefit of no detrimental effects like dysrhythmias and less requirement of chemical or mechanical cardiac support

Optimization of extraction conditions for the extraction of phenolic compounds from Moringa oleifera leaves

The aim of this study was to optimize the extraction conditions for the extraction of phenolic compounds from Moringa oleifera leaves using response surface methodology [RSM]. A user- defined design was applied to determine the effects of extraction time [min], extraction temperature [C] and ethanol concentration [%], on total phenolic content [TPC] from Moringa oleifera leaves dried by three methods [oven, sunlight and ambient air]. The RSM was used to optimize the extraction conditions for the extraction of TPC of Moringa oleifera leaves. The optimum conditions that maximize the extraction of TPC were extraction time, 60 min; extraction temperature, 90°C and% of methanol, 50% [v/v]. TPC extracted under these conditions were 12.28, 12.65 and 13.14 mg GAE/g DW for samples dried by different methods. Significant difference between drying methods was found [p<0.001]. Pair wise significant difference was found only between oven and ambient air drying methods [p<0.001]

Double flap patch closure of VSD with elevated pulmonary vascular resistance: an experience at AFIC/NIHD

To determine the 30 days outcome measured in terms of morbidity and mortality in cases of ventricular septal defect [VSD] with increased pulmonary vascular resistance [PVR] managed with double flap patch closure. Case series. Armed Forces Institute of Cardiology [AFIC/NIHD], Rawalpindi, from December 2005 to December 2008. Forty patients with VSD having PVR 9.58 + 4.33 wood units underwent double flap patch closure. The patch was fenestrated as one half of the expected aortic annulus diameter. A separate flap patch 5 mm larger than fenestration was attached to superior upper one third margins of fenestration. The patch was placed with flap to open towards the left ventricular apex. Modified ultra filtration [MUF] was employed in every case and sildenafil was given postoperatively. The age of patients ranged from 1 to 28 years with a mean of 6.66 + 5.70 years. There were 22 males and 18 females. All patients were weaned off from inotropic and ventilatory support as earlier as possible postoperatively with intensive care unit [ICU] stay of 77.15 + 54.56 hours. Postoperative pulmonary artery pressures were reduced to 42.63 + 10.86 mmHg as compared to pre-operative pulmonary artery pressures of 88.3 + 15.2 mmHg. Postoperatively 11 patients with suprasystemic pulmonary artery pressures and desaturation went into pulmonary hypertensive crisis in which immediate 2D echo evidenced the functioning flap valve with right to left shunt. There was only one death [early] out of 40 patients with an overall mortality of 2.5% along with limited morbidity. Double flap patch is an inexpensive, easy to construct technique with low morbidity and mortality in cases of VSD with raised PVR

Spontaneous spinal epidural hematoma; a rare entity report of two cases

Spontaneous spinal epidural hematomas are very rare. These generally occur in adult males and are most frequently located in the lower cervical region. Most common symptoms are sudden onset cervical or thoracic pain followed by features of cord compression. MRI is the diagnostic investigation of choice. Early diagnosis and prompt surgical evacuation are of paramount importance for a better neurological recovery. We present a report of two cases of spontaneous acute spinal epidural hematoma who presented with sudden onset of very severe pain in the neck and interscapular region followed by acute onset quadriparesis. They were diagnosed on MRI and were operated

Frequency, presentation and postintervention prognosis of chondroblastoma

To evaluate the frequency of clinico-radiological presentation and the prognosis after treatment of chondroblastoma. Design: A descriptive, observational study. Place and Duration of Study :The study was carried out at the Department of Orthopaedic Surgery, JPMC, Karachi over the period of 16 years, January 1986 to June 2002. Methodology: Patients in teenage, presenting with signs and symptoms of a primary bone tumours, were included by retrospectively reviewing the tumour registry record. Detailed scrutiny of clinical record was carried out to analyze the clinico radiological presentation and posttreatment prognosis criteria of healing was symptom-free centripetal and homogenous ossification. Seven [1.24%] out of 563 primary bone tumour cases were chondroblastoma. The clinico-radiological presentation in the 2 out of 7 [28.57%] cases was classical, 2 simulated osteomyelitis and other 3 as chondromyxoid fibroma, aneurysmal bone cyst and giant cell tumour. Lesions were treated with curettage and bone grafting. One patient [14.28%] developed recurrence within 2 years after curettage and healed after re-curettage and bone grafting. Five out of 7 [71,42%] tumours showed good response and 2 out of 7[28.57%] showed satisfactory response. Chondroblastoma is very rare benign primary bone tumour with high local recurrence rate. The lesions confined to epiphysis of weight-bearing bone present early with symptoms of mild arthritis. Lesions in non-weight -bearing bones often present late and simulates epiphysio-metaphyseal tumours. Lesions heals with centripetal healing and need more than 2 years follow-up to achieve recurrence-free healing