prospective study of altered inflammatory response and its clinical outcome following laparoscopic and open cholecystectomy

Background: Inflammatory response following surgical trauma has long been a matter of study. Results, however, have been varied. We sought to assess changes in the levels of proinflammatory and anti-inflammatory cytokines in patients undergoing laparoscopic and open cholecystectomy and their impact on the clinical outcome of patients concerning the postoperative pain score

Methods:The study involved 90 cholecystectomies [55 laparoscopic and 35 open] for chronic cholecystitis. Blood samples were collected 2 hours preoperatively and at 4 and 24 hours post surgery. Sera were evaluated for the levels of interleukin-1beta, interleukin-10, and tumor necrosis factor-alpha. The independent sample t-test was used to compare the means of a variable between the 2 groups. Statistical analysis was done using SPSS, version 17

Results: The rise in the levels of interleukin-1beta, interleukin-10, and tumor necrosis factor-alpha was significantly more in the open cholecystectomy group at 4 hours [P<0.00]. At the 24[th] postoperative hour, the levels of all 3 cytokines were also higher in the open cholecystectomy group [P<0.001 for interleukin-1beta, P=0.185 for interleukin-10, and P<0.001 for tumor necrosis factor-alpha]. At the 4[th] postoperative hour, the patients in the laparoscopic cholecystectomy group had a significantly lower pain score [P<0.001] than the open group

Conclusion: Both laparoscopic and open cholecystectomy procedures altered the inflammatory milieu of our patients in the postoperative period. Inflammation caused by the laparoscopic procedure was significantly less. More research is needed to target specific inflammatory and anti-inflammatory cytokines to reduce surgical stress and improve patient outcomes

Comparison of conventional gauze therapy with vacuum assisted closure wound therapy in acute traumatic wounds

To compare the Vacuum Assisted Closure [VAC] wound therapy with Conventional Gauze Therapy [CGT] in management of acute traumatic wounds on the basis of time taken to achieve a vital red wound ready for definitive surgical closure. Randomized control trial. Department of Surgery Combined Military Hospital Rawalpindi from Mar 2009 to Sep 2009. This study included 82 patients of acute traumatic wounds. Patients were randomly allotted to group A, in which wound was treated with new method of vacuum assisted closure [VAC] wound therapy and to group B, in which wound was managed by conventional gauze therapy [CGT]. Outcomes were measured by the presence of vital red wound ready to be closed by surgical intervention. Patients with concomitant systemic pathology were not included in study. Comparison between the two groups revealed mean time for wound healing 13 days in group A and 16.9 days in group B with significant difference [p value =0.029]. Vacuum assisted closure wound therapy is an effective method in reducing time of wound healing for definitive surgical closure

Amniotic membrane transplantation in primary pterygium compared with bare sclera technique

To compare the excision of primary pterygium by bare sclera technique and excision combined with amniotic membrane transplantation [AMT]. An experimental study. Eye Department, Military Hospital, Rawalpindi, presently known as Armed Forces Institute of Ophthalmology, Rawalpindi, from May 2007 to July 2008. A pilot study of 70 patients was conducted. Patients were divided in two groups. In group I, pterygium excision was done by bare sclera technique while in group II, AMT was done after excision. Patients were followed for 6 months. Proportion of recurrence of pterygium was noted in each group and compared with chi-square test with significance at p < 0.05. Number of patients who presented with recurrence of pterygium in group-I were 12 [37.5%] and in group-II were 4 [12.9%]. Chi-square tests showed that there was a statistically significant difference in frequency of recurrence between the two groups [p = 0.025]. AMT after excision of pterygium appeared to be safe and effective way of treating primary pterygium as compared to bare sclera technique due to lesser recurrence at 6 months

Incidence of anemia in pregnancy. A randomized study at PMC hospital Nawabshah

In this part of the world anemia is one of the major public health problems especially in pregnant women. In our country the most important cause of anemia is poor diet repeated pregnancies and lack of awareness about contraception. Anemia can easily be managed with well nourish diet, with supplements of iron folic acid and multivitamin tablets. In our areas socio-economic problem is one of the causes which can be cope with help of Government and Non- Governmental Organizations by providing iron tablets and iron fortified foods to the population as a prophylaxis. To improve their health, pregnant women should regularly visit the clinics of Obs and Gynae and follow instructions of attending doctors and practice birth spacing in between the pregnancies. To determine the incidence of anemia in pregnant women in different socioeconomic classes in rural areas. Cross-sectional observational study. This study was conducted at the Department of Gynae and Obs, Peoples Medical College Nawabshah, and Sindh Pakistan from 1[st] March 2009to 30[th] June 2009. 850 pregnant ladies were included in the study who came to attend the antenatal clinic; where their history and clinical examination were recorded on a Performa. The ladies were divided into three socioeconomic classes, the higher, middle and lower class. 3ml of blood sample was taken from all the ladies for hemoglobin estimation and other necessary Lab test. A total number of 850 participants were included in this study, out of those 329 pregnant women were having hemoglobin [Hb] below 9 gm/dl, declared as anemic, the incidence as observed was 38.77% and the highest incidence was found in lower socioeconomic class. It can be concluded from this study that anemia is one of the major problem in pregnant women of rural areas. The incidence observed was 38.77% which was least [0.6%] in higher class and was highest [60.2%] in lower socioeconomic class

Analysis of causes and treatment modality in non-union of long bones diaphyseal fractures

The purpose of this study was to analyze the causes of nonunion leading to modification in treatment modalities in long bones diaphyseal fractures. Descriptive Study. Combined Military Hospital Quetta, Combined Military Hospital Sialkot, Pakistan, from 5th Sep 2005 to 26th Dec 2008. Non-healing long bones diaphyseal fractures > 6 months were included with exclusion of pathological fractures, delayed union < 6 months. Patients general profile and fracture details with non-union causes were recorded. Old failed surgery with re-do surgical intervention was analyzed. Infected cases were treated with removal of implant, thorough debridment, appropriate antibiotics followed by delayed stabilization while non-infected cases with stable fixation and bone grafting. Out of fifty six patients, tibial fractures were maximum 17[30.4%], femur 16[28.6%], radius ulna 15[26.6%], and humerus 8[14.3%]. Most patients were young 37[66.07%] and male 48[85.7%]. Road traffic accident caused 43[76.8%] fractures. Causes of non-union were high energy trauma 37[66%], insufficient stabilization 31[55.4%], followed by smoking, soft tissue interposition, poor nutrition, NSAIDs, broken implants, infection, intact fellow bone, multiple segment fracture, repeated manipulation, chronic illness and neurovascular impairment in descending order. Plates failed more than K nails. Complications like superficial and deep infection, neuroprexia and delayed healing settled with bone healing in mean time 4.76 months. Nonunion of long bones diaphyseal fractures can be prevented by avoiding causative agents, early intervention, tissue protection and stable fixation. Interlock nailing is best for femur, good for tibia, may be useful in humerus but not suitable for radius and ulna. Bone graft accelerates healing process. Early re do surgery must be considered because of manageable rate of complications

Varicocelectomy high ligation versus low ligation

To find out the outcome of two modalities in management of varicocele comparing high ligation [Paloma's procedure] and low ligation [Ivanissivich's procedure] This observational descriptive study was carried out in Surgical units of People's Medical College Hospital Nawabshah on 60 patients, belonging to age group of 15 to 36 years from January 2002 to December 2006. Patients with varicocele were divided in two groups of treatment modality equally. Group I comprising 30 patients for high ligation whereas 30 patients were kept in Group II for low ligation. Follow up was carried out for two years but response was poor. Varicocele had been observed on left side in most of the cases [95%]. Three cases [5%] presented in Grade-I, 21 [35%] in Grade-II and 36 [60%] in Grade-III varicoceles. Oligospermia was detected in 15% of cases. Group I patients were apprehensive regarding disappearance of dilatation and hanging veins postoperatively seen in 70% of cases whereas disappearance of veins were seen in 93.34% in Group II patients. Complications like haematoma and hydrocele are seen in Group II patients as compared to Group I. Wound infection and recurrence remained almost the same in both groups. High ligation was better tolerated with less complication but did require more counseling regarding disappearance of dilated veins. Paloma's procedure also does not disturb the normal anatomy of inguinal canal

Rapid detection of methicillin resistant staphylococci from the nasal screening swabs by mannitol salt agar with cefoxitin and oxacillin disks

To assess the reliability of Manitol salt agar [MSA] for directly identifying Methicillin Resistant Staphylococcus aureus [MRSA] and Methicillin Resistant Coagulase negative Staphylococci, [MRCoNS] in nasal swabs for screening purposes using cefoxitin and oxacillin disks. Descriptive and Quasi-experimental. The study was done in the two surgical units of Combined Military Hospital, Rawalpindi and all the samples were processed at the Department of Microbiology, Armed forces Institute of Pathology, Rawalpindi during July 2007. A total of eighty four duplicate swabs were taken from the anterior nares of various staff members of the two surgical units and were directly inoculated on Mannitol salt agar with Cefoxitin disc 30 micro g [MSAFOX] and oxacillin disc 1 micro g [MSAOX]. All the samples were simultaneously inoculated on blood and MacConkey agar for conventional testing, using standard conditions, and confirmed as MRSA or MRCoNS by oxacillin disk diffusion technique. The staphylococcal isolates were later confirmed as MRSA/MRCoNS by polymerase chain reaction [PCR] for mec A gene analysis. There were 45 staphylococci which revealed mec A gene [40 MRCoNS and 5 MRSA] by PCR. Both the disks with MSA effectively identified the methicillin resistance. MSA with cefoxitin could identify 40 methicillin resistant staphylococci [35 MRCoNS and 5 MRSA] where as MSA with oxacillin could identify 39 methicillin resistant staphylococci [34 MRCoNS and 4 MRSA]. There was no significant difference between the two disks in sensitivity, specificity, positive and negative predictive values and overall efficacy of the procedures. MSA with cefoxitin 30 micro g and oxacillin 1 micro g appear to be highly accurate, easy to perform and beneficial for quick and reliable detection of methicillin resistant staphylococci from the nasal carriers in a routine microbiology laboratory

Management of typhoid ileal perforation: a surgical experience of 44 cases

Typhoid perforation of ileum is a serious complication of typhoid fever. There are different surgical methods of repairing the perforation. The aim of this study was to report the surgical experience regarding treatment of typhoid ileal perforation in our setup. It wa a retrospective, observational study carried out at Departments of Surgery Unit I and Pathology, Peoples Medical College and Hospital Nawabshah from July 2003 to June 2008. Forty-four patients were admitted through causality as cases of acute abdomen, 28 [63.63%] were males and 16 [36.36%] females, with age range of 10-45 years. The diagnosis of typhoid perforation was made on clinical grounds, laboratory investigations, x-ray, ultrasound examination, and operative findings. Exploratory laparotomy was carried out and perforations were managed. The variables studied in the post operative period were wound infection, wound dehiscence, entero-cutaneous fistula, residual abscess, mortality, hospital stay and incisional hernia. Fever with abdominal pain and distension were the symptoms in all subjects followed by diarrhoea, vomiting and constipation Widal test more than 1:320 was positive in 35[79.45%] cases and typhi dot [IgM in all cases and IgG in 15] was positive in all cases. Blood culture was positive in 32 [72.7%] cases. X-ray abdomen revealed pneumoperitoneum in 22 [50%] cases. Ultrasound shows free peritoneal collection in 40 [90.90%] cases. On operation the abdominal cavity was heavily contaminated in 12 [27.27%] patients while in 32 [72.72%] patients the peritoneal cavity was having moderate contamination. 36 [81.81%] patients had single perforation and 8 [18.18%] patients had more than one perforation. In 32 [72.72%] patients perforations after freshening the ulcer were closed by single layered interrupted extra mucosal technique with vicryle 2/0, 4 [9.09%] needed resection and anastomosis and in remaining 8 [18.18%] loop ileostomy was made. The typhoid ileal perforation still carries high morbidity and mortality. The typhoid ileal perforation should always be treated surgically. There are many operative techniques to deal typhoid ileal perforation but no one is fool proof. Regardless of the operative technique timely surgery within 24 hours with adequate and aggressive resuscitation is a way to decrease the morbidity and mortality

significance of alanine aminotransferase level in chronic hepatitis C infection

To determine the significance of alanine aminotransferase [ALT] level in tfirbftib hepatitis C infection in our setup. A prospective cross-sectional, observational study carried out from August 2006 to June 2008. Departments of Pathology, Nawabshah Medical College Nawabshah and research institute of LUMHS Jamshoro. A total of 344 HCV-PCR positive patients having histological evidence of chronic hepatitis with either fibrosis or inflammatory activity by biopsy were evaluated 239 men and 105 women with ages between 18-55 years of age were included in the study. All the patients went for FLISA test for the presence of HCV antibodies by ELISA kit of Biokit Spain, and then a 5.0 ml of blood was collected in a tube with separating gel, to obtain serum, which was stored at room temperature for the determination of alanine aminotransferase by Ecoline kit on Slectra automatic chemical analyzer of Merck, Germany. The ALT was estimated in 344 patients and was 4.4 times higher [mean level

54.5 U/L] than normal in 335 [97.38%] patients, while 09 [2.61%] patients showed ALT level with in normal limit. The data in the current study indicates importance of ALT in chronic hepatitis C infection, and shows that ALT is the major liver enzyme and is a marker of liver infection or hepatitis, as majority [97.38%] of patient in our study showed a high level of ALT

Otolaryngologic manifestations of gastroesophageal reflux disease

To determine frequency of endoscopic oesophagitis in the patients who complain the chronic laryngopharyngeal disorders in the absence of typical gastroesophageal Reflux Disease [GERD] symptoms. Descriptive study The study was carried out in the department of E.N.T at Nawabshah Medical Centre, Nawabshah over the period of two years [2004 to 2006]. One hundred patients of either sex and in the age group between 25-79 years with symptoms of chronic laryngopharyngeal disorders were selected for study. All patients had physical examination of upper aero digestive tract. Direct laryngoscopy was done to evaluate the status of larynx, however rigid esophagoscopy was done to evaluate the status of esophageal mucosa and biopsies from lower part of esophagus were taken in all patients. Eighty percent of patients with symptoms of chronic laryrigopharyngitis were also suffering from microscopic Oesophagitis. Among the 80% patients 87.5% were having non-erosive oesophagitis while 12.5% were having erosive oesophagitis. In significant number of patients with chronic upper respiratory symptoms resistant to the treatment, there was co existing gastroesophageal disease which could be the cause of the symptoms

audit of peripheral lymphadenopathy

To evaluate the causes of Peripheral Lymphadenopathy. A descriptive and cross sectional study conducted from July 2004 to June 2006. Department of Surgery and Pathology, Nawabshah Medical College and Hospital, Nawabshah. A total of 116 patients with Peripheral Lymphadenopathy. The patients were evaluated for outcome parameters in relation to age, sex. Site and specific cause of peripheral lymphadenopathy. A total of 116 patients including 64 [55.17%] females and 52[44.82%] males were evaluated for peripheral lymphadenopathy. Their ages ranged between nine months to 70 years with a mean age of 27.14 years; majority belonged to the age group 11 to 20 years. Forty seven [40.51%] patients had cervical lymph nodes enlargement, 42 [36.20%] mesenteric, 24 [20.86%] axillary and 3 [2.85%] inguinal nodes enlargement. Tuberculosis and malignancy were the main causes of lymphadenopathy with an incidence of 53.44% and 13.79% respectively. Nine [7.75%] cases had acute lymphadenitis and 27 [23.25%] reactive hyperplasia, while in tow [1.72%] cases no pathology was detected. Peripheral Lymphadenopathy without any obvious cause presents a diagnostic dilemma

Tuberculosis of the breast: a cytomorphological study of nine cases

To determine the role of FNAC with histological confirmation in the diagnosis of tuberculous mastitis, and to highlights its importance by determination of frequency, clinical history, clinical presentation and laboratory investigations in our setup. A retrospective case series from Jan. 1997 to Dec. 2006. Department of Pathology, Nawabshah Medical College, Nawabshah. Nine patients with mammary tuberculosis. The data was collected from patients files and other record, and the results tabulated. All were married multiparous women, aged 18-42 years, belonging to poor socio-economical class. One was pregnant, while three were lactating mothers. Associated pulmonary tuberculosis was present in three cases. Previous history of tuberculosis was present in one case, though five patients had a family history of tuberculosis. Lump in the breast, with or without ulceration/ abscess/ discharging sinus was the clinical presentation of all the cases, as was low grade fever and pain. All patients had anemia and weight loss, though axillary lymphadenopathy was seen in five cases. ESR was raised in all the cases and the Mantoux test was positive. The glutaraldehyde test was positive, though it was performed in three cases only. AFB were seen in one case only. The diagnosis was made on FNAC by the presence of chronic granulomatous inflammation having caseating epithelioid granulomas and Langhan's type of giant cells. The cytological diagnosis was confirmed by histopathologicaI findings of excisional biopsy specimen in all the cases. The present study highlights the importance of tuberculous mastitis; its frequency being 2.3% in breast diseases. FNAC is an important initial diagnostic tool in patients having tuberculous mastitis, specially in the rural areas. It is safe, rapid, simple, cost effective and accurate, the accuracy being 100%

Gleason grading of carcinoma prostate at Nawabshah medical college / Hospital

To evaluate the Gleason Score and pathological grading of patients with Carcinoma of the Prostate amongst prostatectomy specimen. A retrospective study from January 1996 to December 2005. Nawabshah Medical College Hospital, Nawabshah. A total 4595 patients who underwent prostatectomy. Detailed data of the patients was retrieved from the case sheets, ward records and the Pathology Department by manual search, and analyzed. Amongst the total 595 cases, the age range was 50-90 years with a mean age 465.08 years. Out of the 595 prostatectomy specimen submitted during the study period, 46 [7.73%] had adenocarcinoma. According to the Gleason Score 18 [39.13%] cases had well differentiated [Score 2-4], 24 [52.17%] had moderately differentiated [Score 5-7] and four [8.69%] cases had poorly differentiated [Score8-10] adenocarcinoma. Gleason Score is a universally accepted prognostic indicator of Carcinoma Prostate. Pathologists must report consistently for the better management of the condition

Significance of HER-2/neu oncoprotein overexpression in invassive ductal breast cancer

To asses the frequency of HER-2/neu Oncoprotein over expression in invasive ductal breast cancer and correlate it with various prognostic parameters. Comparitive cross-sectional study was carriedout at department of pathology Basic Medical Sciences Institute, Jinnah Postgraduate Medical Centre, Karachi. Seventy two [72] formalin fixed paraffin embedded blocks of diagnosed invasive ductal carcinoma were retrieved and 5 m.m thick sections were cut and stained with H and E for the review of diagnosis and grading. The immunohistochemical staining was done on 4m.m thick sections by using Polyclonal rabbit anti HER-2 ZYMED USA, and ZYMED 2nd generation LAB-SA immunodetection system, to see the HER-/neu over expression. Section containing > 50% of tumor cells exhibiting intense circumferential cell membrane staining scored as positive. Thirty one [31%] positive over expression was observed. A statistically significant result [P<.05] was found between HER-2/neu over-expression and lymph node status and size of tumor. Oncoprotein HER-2/neu over expression is directly related to the lymph node status and size of the tumor. These patients may benefit from a more aggressive therapy like Herceptin and can also be used as a prognostic marker in the follow up of these patients

Correlation of age with histopathological type of testicular tumors

The aim of the study was to find out the frequency and histopathologic type of various testicular tumors in correlation with age of the patients in our setup. It was a retrospective, descriptive study carried out at the Department of Pathology, Peoples Medical College, Nawabshah, Pakistan. All testicular tumors diagnosed from January 1991 to December 2005 were included in the study. The clinical data and surgical pathology reports with haematoxylin and eosin stained slides were obtained from the record. All the cases were reviewed and results tabulated. The patients were divided into six age groups and the tumors classified according to the pathological classification of testicular tumors. During this period 73 cases of testicular tumors were diagnosed in the department. All cases were diagnosed as germ cell tumors [100%]; consisting of 57 [78.1%] cases of single histologic type and 16 [21.9%] cases of mixed germ cell tumors. Most of the cases presented in the 3[rd] and 4[th] decades. Seminoma was found to be the commonest tumor in 27 [37%] cases, embryonal carcinoma in 29 [27.4%] cases, teratocarcinoma in 11 [15.1%] cases, yolk sac tumor and teratoma each in 5 [6.8%] cases, embryonal carcinoma with seminoma in 3 [4.1%] cases and teratoma with seminoma in 2 [2.8%] cases. In this study the ages of the patients and the frequency and histopathological findings in testicular tumors, with few exceptions are similar to other studies from different parts of the world, confirming the worldwide similarity of these parameters

Percutaneous use of stone punch in the management of vesical calculi in children: a new treatment modality

To evaluate the efficacy, safety and results of a newer technique, using Mauermayer stone punch for percutaneous bladder stone removal in children. It was a prospective study from November 2000 to November 2004, in the Department of Urology, Peoples Medical college hospital Nawabshah, Pakistan. One hundred and thirty children having vesical calculi of various sizes were included in this study. The procedure is based on principal of percutaneous removal of bladder stones, using ordinary trocar cannula under video-cystoscopic visualization and Stone punch to extract/fragment the stones. These children were evaluated by detailed history, clinical examination, ultrasonography, Radiography of urinary tract, urine routine examination, urine culture and blood urea. These patients, who were otherwise candidates for open cystolithotomy, were treated percutaneously using suprapubic approach. Satisfactory results were obtained in almost all cases having solitary and multiple stones. In selected cases urethral damage, operating time, hospital stay and cost can be decreased to minimum with this simple technique. This study shows that suprapubic percutaneous route can be employed as an alternative procedure to previously reported different percutaneous modalities where percutaneous nephrolithotomy instruments, laparoscopic instruments, percutaneous vacuum sheaths and other trocar and stone forceps have been utilized for removal of vesical calculi

unusual foreign body in the urinary bladder

Foreign body in urinary bladder being unusual in clinical setting presents as a diagnostic dilemma with vague history. Bladder calculi are uncommon in adults and usually result either from obstruction or foreign bodies. The present case report describes a young girl presenting with cysticism. Investigations revealed a bladder calculus encrusted on trans-urethrally inserted abortion stick in the urinary bladder that warranted surgery. Endoscopic manipulation was successful. Postoperative period was uneventful

Aneroid sphygmomanometer; assessment of accuracy in hospital and general practice

To assess the accuracy of aneroid sphygmomanometer. MATERIAL AND METHODS: One hundred and two [102] aneroid sphygmomanometers were inspected, their accuracy was compared against a standard mercury manometer at five different pressure points. An aneroid was defined as being intolerant if it deviated from the standard mercury menometer by greater than +/- 4 mm Hg at one or more of the test points. 54 [52.9%] of 102 manometers were intolerant deviating greater than +/- 4 mm Hg. 64.8% of the intolerant manometers read lower than standard and 35.2% read higher than the standard. Majority of the aneroid manometers was inaccurate and had physical defects. Assuming that an aneroid manometers is accurate simply because the equipment appears in otherwise good condition, may also be misleading. Aneroid sphygmomanometers can easily be calibrated using a standard mercury manometer and a Y connector. CONCLUSIONS: Mercury sphygmomanometers should be bought in preference to aneroid models, as they are more accurate. We recommend that owners should inspect their aneroid apparatus for physical defects and calibration every six months interval. They should buy a standard apparatus as a large number of unbranded and uncertified aneroid sphygmomanometers are available in the market