Economic Burden of Rabies: An Experience from a Tertiary Care Hospital in Kashmir, India

Background:Post-exposureprophylaxis(PEP) is the mainstay of prevention in suspected exposure to rabies virus.Exposedpatients are able to obtain anti-rabies vaccine in the anti-rabies clinicpro bono butthey have to pay forpassive immunization and cover otherassociated costs.Aim:To estimate and analyze the direct and indirect costs of rabies PEP.Methods: This study was conducted on 429 patients, who were exposed to bites from various animals and reported to Shri Mahraja Hari Singh Hospital (SMHS), an associated tertiary hospital of Government Medical College, Srinagar, Kashmir. Patient socio-demographic profile, details of animal bite exposure, the cost incurred for PEP wascollected. The data were analyzed using a descriptive statistic.Results: The study revealed a total median cost incurred on patients for receiving a PEP as 29.3 USD (United States Dollar), with an Inter-quartile Range (IQR) of 0.2 USD to 43.1USD. The direct median cost was 20.5 USD with an IQR of 6.2 USD to 29.4USD, while the indirect median cost was 20.3USD with an IQR of 13.5USD to 24.4USD.Conclusion:Post-exposure prophylaxis imposesa significant economic burden to bite victims especially those of low socio-economic strata for whom the cost issubstantial.Original ResearchArticle

Assessment of immunization coverage in district Srinagar of Kashmir

Background: Immunization is till now most safe, cost effective and powerful intervention that has decreased the burden of vaccine preventable infectious diseases all over the world. The aim of this study was to estimate the immunization coverage among children aged 12-23 months in district Srinagar of Jammu and Kashmir.Methods: The study sample included 30 clusters from district Srinagar selected as per the 30×7 cluster sampling method.Results: It was found that fully immunized children were 87.14% and 12.26% of children were partially immunized and none was unimmunized. Regarding the individual vaccine coverage, it was highest for OPV1 (99.52%) followed by BCG and OPV0 (99.05%) and lowest for Hepatitis birth dose (95.24%). The dropout was found highest (6.22%) for OPV1-OPV3 and lowest (1.47%) for LPV1 - measles/MCV (1.47%).Conclusions: The immunization of district Srinagar is above 85% and this gives a positive hope for better future to reach coverage of 100%.

Acute meningitis complicated by transverse myelitis

Myelopathy is an infrequently reported complication of bacterial meningitis. We report the case of 32-year old Nepali male who developed acute transverse myelopathy, confirmed by MRI, subsequent to acute bacterial meningitis

Off-flavors removal and storage improvement of mackerel viscera by supercritical carbon dioxide extraction.

The oil in mackerel viscera was extracted by supercritical carbon dioxide (SCO2) at a semi-batch flow extraction process and the fatty acids composition in the oil was identified. Also the off-flavors removal in mackerel viscera and the storage improvement of the oils were carried out. As results obtained, by increasing pressure and temperature, quantity was increased. The maximum yield of oils obtained from mackerel viscera by SCO, extraction was 118 mgg(-1) (base on dry weight of freeze-dried raw anchovy) at 50 degrees C, 350 bar And the extracted oil contained high concentration of EPA and DHA. Also it was found that the autoxidation of the oils using SCO2 extraction occurred very slowly compared to the oils by organic solvent extraction. The off-flavors in the powder after SCO2 extraction were significantly removed. Especially complete removal of the trimethylamine which influences a negative compound to the products showed. Also other significant off-flavors such as aldehydes, sulfur-containing compounds, ketones, acids or alcohols were removed by the extraction.

Oesophagectomy for carcinoma esophagus- Peshawar experience of 270 cases in 4 years

To audit the results of 270 Oesophagectomies done for Carcinoma Oesophagus over a 4 year period. This observational descriptive study was conducted at Department of Cardiothoracic Surgery, Lady Reading Hospital and Khyber Medical Centre Peshawar from Sep 2002 to Sep 2006. Computerized clinical data of 270 cases of Oesophagectomy for Carcinoma Oesophagus was retrospectively analyzed. All patients had apart from routine investigations, Barium studies, Endoscopy and biopsy, CT Thorax/Upper abdomen with Oral and I/V Contrast and Abdominal ultrasound. Detailed examination of clinical record was made to determine the surgical outcome. Out of 270 cases 189 were Males 81 were Females with a mean age of 51.6 years. The age range was 17-80 years. In out of two hundred and seventy cases one hundred and sixty two [162/270] [60%] cases had lower one third tumors, one hundred and five [105/ 270] [38.88%] cases had middle one third tumors while three [3/270] [1.11%] tumors were just below the thoracic inlet. Of the one hundred and sixty two lower one third tumors stomach involvement was present in eighty one [81/162] [30%] cases. Adenocarcinoma was present in one hundred and seventeen [117/270] [43.33%] cases, Squamous cell carcinoma was present in one hundred and forty four [144/270] [53.33%], Adenosquamous was six [6/270] [2.22%], Carcinoma in situ was two [2/270] [0.74%] and Leiomyoma was one [1/270] [0.370%]. Morbidity was 28/270 [10.370%] and comprised anastomotic leaks 09, aspiration pneumonia 06, wound infection 03, hoarseness 03, and strictures 03,. Thirty day mortality was 14/270 [5.185%] and included aspiration pneumonia-respiratory failure 02, myocardial infarction 03, anastomotic leak 03, tracheal injury 02 and presumed pulmonary embolism 04. Two hundred and seventy cases in four years is a very high volume of Oesophageal work load for malignancy. Our morbidity of 10.370% and mortality of 5.18% shows that such major operations can be done safely in thoracic centers

Surgical management of pericardial diseases

Tuberculosis and purulent pericarditis are the most common causes of pericardial effusion and constriction. Chronic constrictive pericarditis is a chronic inflammatory process that involves both fibrous and serous layers of the pericardium and leads to pericardial thickening and compression of the ventricles. The resultant impairment in diastolic filling reduces cardiac function. Pericardiectomy remains the treatment of choice for chronic constriction. A review of 72 cases at department of Cardiothoracic Surgery, Lady Reading Hospital is presented. There was a mortality of 12% and a morbidity of 20%. Forty seven of the 72 cases were tuberculous. The surgical excision of pericardium remains the only available curative treatment for constrictive pericarditis, while open pericardial drainage is required for cardiac tamponade resulting from pericardial effusion

Collapse therapy in 21 century an experience of 50 cases

To observe the various indications of thoracoplasty and evaluate their management and outcome. Study Design: An observational descriptive study. Place and Duration: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital from July 2001 to January 2004. Subjects and During two and a half years study period fifty patients needed thoracoplasty. M: F ratio was 36:14. Aged distribution was 23 - 57 with a mean age of 36.3 years. Indications for surgery were tubercular or parapenumonic empyema in 25[50%] patients, post lobectomy space infection, and broncho pleural fistula [BPF] in 10[20%], destroyed lung with hemoptysis in 8[16%], post pneumonectomy space infection in 4[8%] and upper lobe hemoptysis with poor PFTs in three [6%] cases. A standard subperiosteal extra pleural paravertebral surgical technique was used in all cases. Out of 50 cases 28 [56%] required full thoracoplasty and 22[44%] cases underwent partial thoracoplasty. Postoperatively all patients had a single chest drain on suction for 7 days. Both the drain and stitches were removed after 2 weeks and patients were advised to attend out patient department for follow-up. Patients symptoms index showed remarkable improvement. 100% improvement was needed in patients regarding chest pain, fever, cough, weight loss, hemoptysis and ATT. Postoperative complications were noted in 10 [20%] cases. Four patients had wound infection, 2 had wound dehiscence, residual space in 3 and restricted shoulder mobility in one. There was 1[2%] mortality. This patient had borderline pulmonary functions and had to be ventilated for ventilatory failure. With the persistent problem of pulmonary tuberculosis in the developing countries, thoracoplasty is still an operation of continued relevance for space obliteration in cachectic patients, and as collapse therapy for bleeding lungs with poor PFTs. Most patients are definitively and rapidly cured with limited sequelae

Early surgery for pulmonary tuberculosis

The purpose of our study was to analyze current indications for surgery in tuberculosis and evaluate the outcome of early surgical intervention. Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar from June 2000 to July 2004. Total number of cases was 132; M: F 105: 27. Age range was 20 to 79 years. Mean age was 48.4 years. The indications for surgical intervention included 5 cases of pulmonary aspergillioma, 9 cases of pneumothorax; 3 cases of pulmonary nodes and masses without histological diagnosis, 15 cases bronchiectasis, 12 cases of massive hemoptysis and 82 cases of pleural empyema while six patients with multi drug-resistant tuberculosis required surgical intervention. The techniques utilized included lobectomy in 45 cases, pleural drainage in 20 cases, segmented pulmonary resection in 32 cases, surgical procedures on the chest wall in 17 cases, pneumonectomy in 10 cases, decortication in 8 cases. In 22 cases two or more procedures were performed on the same patient. In 26[19.6%] cases various complications were noted of which wound infection was the most frequent. There was a mortality rate of 3.3% [4 cases]. Surgical treatment is indicated for the complication of TB and management of MDR TB. Early surgery is beneficial in patients whose disease is still localized and who can tolerate resection surgery; of particular importance is a healthy opposite lung, on which the patient would be dependent during and immediately after surgery

Management of empyema thoracis-Peshawar experience of 450 patients

To observe the various clinical presentations of empyema thoracis and evaluate its management and outcome. An observational descriptive study. Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital from June 2001 to June 2004. Clinical record of 450 patients who underwent various surgical procedures during 3 years were retrospectively analyzed. Detailed scrutiny of record was carried out to analyze the clinical presentation; various surgical procedures and outcome. There were 270 [60%] male and 180 [40%] female patients. Majority of the patients 310 [68.8%] were in the age range of 20 - 40 years. Common presentation was fever [62%]; cough [26%] and chest pain [11%]. The duration of symptoms was less than 8 weeks in 57% and more than 8 weeks in 42% cases. Common etiologies were pneumonia [31%], post tuberculous [37.7%], traumatic [24%] and iatrogenic [6.6%]. Tube thoracostomy was the initial l ine of management in 200 patients. Decortication was required in 200 patients while 50 patients needed thoracoplasty to obliterate persistent residual pleural space. The mortality was 4% [18/450]. Thirty one [7%] had wound infection, air leak in 18 [4%], wound dehiscence in 9 [2%] and septicemia in 14 [3%] cases. Depending upon the stage, various surgical options exist for the treatment of thoracic empyema. Selection of the most appropriate procedure must be individualized but the basic principle is evacuation of pus from the pleural space, appropriate antibiotic therapy and obliteration of empyema cavity

Diaphragmatic injuries, a retospective analysis of 50 patients

This study seeks to define the clinical presentation, the usefulness of diagnostic tests, surgical management approach and outcome of treatment of diaphragmatic injuries in our trauma patients. An observational descriptive study. Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital, Peshawar from March 2001 to April 2005. In this retrospective study, 50 patients admitted to our department with diaphragmatic injury were evaluated according to the type of injury, diagnostic methods, associated organ injury, treatment, modality, morbidity and mortality. The average age of patients was 32 years. There were 35 [70%] male and 15 [30%0 female patients, 38 [76%] of these patients sustained blunt and 12 [24%] had penetrating chest injury. The diaphragmatic injury was right sided in 4 and left sided in 46 patients. Thirty nine [78%] patients presented in respiratory distress within 48 hours of in jury while 11 [22%] presented with bowel obstructive symptoms months and years after injury. A chest x-ray on admission suggested the diagnosis in 70% of the cases while chest ultrasonography and contrast studies were required in others. Surgery was emergent in 35 [70%], semi-emergent in 9 [18%] and effective in 6 [12%] cases. Surgical approaches were left thoracotomy [40 patients], left thoracolaprotomy [6 patients] and right thoracotomy [4 patients]. The diaphragmatic repair was achieved by direct suture in 45 cases while prolene Mesh was required in 5 cases. The mortality rate was 6% [n = 3]. Recurrence occurred in one [2%], wound infection in 3 [6%], pleural, space, problem in 1 and chest infection in 2 [4%] patients. A high index of suspicion and early surgical treatment determine the successful management of traumatic diaphragmatic injury with or without the herniation of abdominal organs. The surgical approach is individualized. We prefer the thoracic approach adding laporotomy when necess ary

Management of patients with esophageal artesia with or without tracheoesophageal fistula, a 7 years experience

To see the short term outcome in patients treated for esophageal artesia with or without tracheo-esophageal fistula in our setup. Descriptive and retrospective. Department of Paediatric Surgery and Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital Peshawar from January 1998 to December 2004 with duration of 7 years. After diagnosis, patients were put on broad-spectrum intravenous antibiotics, intravenous fluids, vitamin K injection and throat suction in a normothermic environment. Diagnosis was established mainly on clinical grounds and supported by passing a big size nasogastric suction tube [size 10 Fr] through the mouth into the esophagus and taking a plain X-ray chest of the patient. After adequate preparation, through a right thoracotomy in 5th intercostals space, fistula repair and esophageal anastomosis was performed extrapleurally in patients with tracheoesophageal fistula while gastrostomy and ce rvical esophagostomy was performed in patients with pure esophageal atresia. Transanastomotic tube was passed as a nasogastric tube size 10 to act as a stent and later on used for tube feeding. A total of 60 patients with esophageal artesia with or without tracheoesophageal fist ula were admitted. There were 40 males and 20 females. Age ranged from 1-7 days. Weight of the newborn patients was in the range of 2 - 3Kg. Four patients had cyanotic congenital heart disease, two were with imperforate anus and two with spina bifida. All patients had some form of bronchopneumonia due to aspiration of upper pouch contents out of whom 30 patients had severe pneumonia. Six patients left the hospital against medical advice and 6 patients died before operation. Forty-eight patients were operated. Esophagostomy and astrostomy was performed for pure esophageal atresia [10 Patients], while in 38 patients, a right thoracotomy in the 5" inter costal space with fistula ligation and esophageal anastomosis was performed. Three out of ten patients with pure esophageal atresia died, while eighteen patients with tracheoesophageal fistula died after surgery. Twenty-seven out of total 48 patients survived and were discharged to home after an average hospital stay of 7 days after surgery. Eleven patients were s een in follow up and treated accordingly. This study shows that majority of these patients presented late because of improper referral system. Delay in diagnosis and management led to various complications such as aspiration pneumonia, dehydration and septicemia with great mortality which is further increased due to nonavailability of the neonatal intensive care facility in our setup. Survival of these patients can be improved by early and proper referral system, specialized medical and surgical team, specialized anesthesia with personnel trained in neonatal anesthesia

Growth and ionic relations of foderbeet and seabeet under saline environments

Growth and ionic relations of fodderbeet [Beta vulgaris] and seabeet [B.maritima] were studied in a greenhouse experiment using garden soil salinized with 200 mM NaCl. Both the species tolerated salinity level of 200 mM NaCl, but seabeet performed better than fodderbeet. Fresh weight of shoot increased significantly [P< 0.01] under higher salt concentration in both the species. Fodderbeet accumulated more biomass under saline conditions than seabeet. Salt treated plants accumulated significantly higher Na+ and Cl- content in shoot compared to untreated control plants. Chloride [Cl-] of seabeet root was significantly higher than shoot; however, chloride content of shoot was significantly lower in fodderbeet. The concentration of these ions was comparatively higher in seabeet root than fodderbeet in the later growth period. Potassium K+ content was low and revealed antagonistic effect with that of Na+ content. Calcium [Ca+2] ions were not significantly absorbed by shoot of both species. A significant effect of treatment by the root has been observed in both species. Magnesium [Mg+2] content of shoot were increased with the time. Seabeet has absorbed more Mg+2 than fodderbeet. The fodderbeet showed a significant salt tolerance during five week growth period. Seabeet is comparatively more salt tolerant. Domesticated cultivars of fodderbeet like Majoral have considerable adaptability in the inland salt affected areas of Pakistan

Use of continuous low pressure suction on chest drain in thoracic surgical unit

To assess the merits and demerits of continuous Low Pressure Suction applied to the chest drain in both preoperative and postoperative thoracic patients. Department of Cardiothoracic Surgery, Postgraduate Medical Institute, ady Reading Hospital Peshawar from Jan 2005 to March 2005. It was a prospective study carried out over the period of three months to assess the benefits of Low Pressure Suction. Patients with Chest trauma, inflammatory disease of the lung and pleura, carcinomas and postoperative patients were included in the study. Patients with multiple trauma and moribund patients were excluded from the study. Postoperative patients were given priority for suction beds. The suction applied to the chest drain ranged from -05 to -20 KPa. It was continuously applied to the chest drain 24hrs a day and 7 days a week and only interrupted at the time of bottle change or patients going to toilets. A total of 180 patients were included in the study, which were divided into two groups depending upon the availability of suction beds. Group I: Included those patients who were put on Continuous Low Pressure Suction. Group II: Included those patients who were not put on Continuous Low Pressure Suction because lack of suction beds. Ninety patients were included in group I and similar number of patients into group II. In group I out of 90 patients 40 were non-operative and 50 were operative. In group II out of 90 patients 55 were non-operative while 35 were operative. Out of operated patients [total 85] full lung expansion was achieved in 42 [84%] in group I and 25 [71.4%] in group II while partial lung expansion was achieved in 08 [16%] in group I and 10 [28.6%] patients in group II. Out of non-operated patients [total 95] full expansion was achieved in 35 [87.5%] in group I and 42 [76.4%] in group II while partial expansion was achieved in 05 [12.5%] patients in group I and 13 [23.6%] in group II. Out of 5 partial expansions in group I suction had to be discontinued in 2 patients because of increasing air leak. Continuous low pressure suction helps to decrease the need for surgery in patients following chest trauma, inflammatory lung disease and decreases morbidity in postoperative patients

Two years audit of thoracic surgery department at Peshawar

The aim of the study was to audit all admissions for significant adverse events as well as to assess academic and research activities of our department during last two years. Design: A descriptive audit comprising of surgical, academic and research aspects. Place and Duration: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital Peshawar from June 2002 to June 2004. Materials and Data comprising of patients demographics, number and type of various surgical procedures, hospital stay, various complications and number of deaths that occurred were entered into database. A computerized record of all academic and research projects was kept. Data base analysis was carried out for determining morbidity and mortality. Analysis of surgical audit showed 2160 procedures. Tube thoracostomy was required in 1030 patients while elective procedures were 1130. Elective thoracic procedures were 969 [85.5%] while elective cardiac procedures were 161 [14.2%]. Various procedures performed included, decortication 103 [9.1%], esophagectomy 73 [6.46%], Hydatid cystectomy 38 [3.36%], closed mitral volvotomy 51 [4.5%], PDA ligation 46 [4.07%], pericardectomy 17 [1.5%], lobectomy 59[5.22%], pneumonectomy 11 [0.97%], thoracoplasty 21 [1.85%], while other thoracic and cardiac procedures were 13.3% and 5.6% respectively. Overall mortality was 3% while morbidity was 3.4%. During this period our department had 17 publications; presented 22 papers in various conferences; has produced three fellows in thoracic surgery, one fellow in general surgery and conducted "First National Thoracic Surgery Course". One assistant professor and one senior registrar have been appointed during these two years. Highest priority should be accorded to surgical audit to determine various risk factors for mortality and morbidity and ultimately to improve patient care. Moreover, all academic and research projects should be completed through mutual efforts of all teaching staff to achieve desired standards of teaching and learning. Accountability of the medical profession can only be achieved through surgical audit. It is high time that this becomes a part of our ward routine and teaching programmes

Primary focal segmental glomerulosclerosis in Iraq

Aim: to study primary focal segmental glomerulosclerosis in Iraq Sixty-nine cases of focal segmental glomerulosclerosis[FSGS]

Results: a total of 850 renal biopsies[12,3%],taken from adult patients[46 males and 13 fema1es]presented with nephrotic syndrome;42[61 %],protienuria;24 cases[35%],impaired renal function; 14[20%]and hypertension;l7cases[25%]. Serial and level sections were required for light

Methods: microscopy by which glomerular lesions were represented by segmental mesangial matrix accentuation, segmental fusion to Bowman's capsule, hyalinosis atthese areas were present in 19 cases sometimes segmental basement membrane thickening, rest of glomeruli with normal cellularity, and normal basement membrane thickening. All cases showed interstitial changes: tubular atrophy 40 cases[57.4%],tubular hyaline cast 21cases[30.4%],fibrous tissue dwposition in 47[68.1%],thickened small blood vessel wall in 17[24.6%]and all cases[100%]showed localized mononuclear cell infiltrations. Clinic pathological aspects and diagnostic problems of FSGS are discussed

Surgery for hemoptysis - one year experience of 72 patients

To determine aetiology of patients presenting with hemoptysis and evaluate their management and outcome. Study Design: An observational prospective descriptive study. Place and Duration: Department of Cardiothoracic Surgery, Postgraduate Medical Institute, Lady Reading Hospital from 1st Jan 2003 to 31st December 2003. Materials and This prospective study included 72 patients; 51[71%] were males and 21[29%] were females. Male: female ratio was 2.5:1 Age range was from 7 years to 81 years with a mean age of 36.3 years. All the patients had hemoptysis o n presentation while 25[35%] also experienced dyspnoea. Chest radiograph was obtained in all, CT Thorax in 60 [83%] while pulmonary function tests were performed in 68[94%] patients. Out of 72 cases 09 patients had to undergo immediate surgery, 27 underwent surgery within one week after initial stabilization and 36 were operated upon electively. All patients, except 6 pediatrics cases, had one lung ventilation during surgery. The mean operative time was 55[ +/- 20] minutes. Out of 72 patients 30 had lobectomy, 24 had hydatid cystectomy, 9 had wedge excision, 3 had pneumonectomy and 6 had thoracoplasty. Mortality was 2/72 while morbidity was 6/72 comprising 4 wound infections [in the emergency group] and 2 each had persistent air leak and empyema. Hospital stay ranged from 7 - 36 days with mean of 12.6 days. Pathological breakup of the 72 cases was bronchiectasis 30, mycetoma 2, lung abscess 9, hydatid cysts 24, carcinoma 6 and AV malformation 1. Inflammatory lung disease, especially TB and its sequelae is the commonest cause of hemoptysis. Elective surgery with one lung ventilation after initial stabilization in a well equipped and well staffed cardiothoracic unit [OT and ICU] is a safe option for hemoptysis, not responding to medical management

Congenital infection of rabbits with Schistosoma japonicum and protective immunity of offspring / 中华医学杂志(英文版)

<p><b>BACKGROUND</b>Recently congenital infection with Schistosoma japonicum (S. japonicum) has been demonstrated in pigs, rabbits, mice and dogs. We explored the rabbit as an animal model for the congenital infection of schistosomiasis japonica and assessed the effect of a congenital S. japonicum infection on the resistance of rabbit kittens to a postnatal challenge infection.</p><p><b>METHODS</b>Sixteen pregnant New Zealand white rabbits were infected with a single dose of S. japonicum cercariae. The exposed animals were divided into three groups according to the gestation age at the time of infection. Diagnosis of prenatally acquired S. japonicum infection in the rabbit kittens was primarily based on serological tests in combination with parasitological and histopathological findings. Congenitally infected kittens were challenged percutaneously with 100 S. japonicum cercariae to assess the effect of a congenital S. japonicum infection on kitten resistance to a postnatal challenge infection.</p><p><b>RESULTS</b>The overall prevalence of congenital infection in offspring of infected mothers was 20% (12/60). The congenital infection rate in group L (late gestation) was much higher than in group E (early gestation) and group M (mid-gestation) (P <0.05). After a postnatal challenge infection, prenatally infected kittens had a 54.66% worm reduction rate, 41.45% egg reduction rate, and 51.76% granuloma size reduction rate compared to naïve kittens.</p><p><b>CONCLUSIONS</b>This study demonstrates the possibility of congenital infection of S. japonicum in rabbits and the resistance of congenitally infected kittens to a postnatal challenge infection. These results have important implications not only for epidemiological investigations, but also in designing government control programs for schistosomiasis.</p>