Kawasaki disease experience at tertiary care hospital Rawalpindi, Pakistan

Objective: To study the clinical features, investigations, cardiac complications, effects of treatment and demographic profiles in patients with classical Kawasaki disease [KD]

Study Design: Descriptive study

Place and Duration of Study: Pak Emirates Military Hospital Rawalpindi, from Jan 2007 to Dec 2011

Patients and Methods: Twenty five children of either gender aged 2 months to 12 years diagnosed with KD based on the international diagnostic criteria were included in this study. Collected data included patient demographics, clinical features, investigations, echo-cardio graphic findings, treatment and follow-up

Results: A total of 25 patients were evaluated during the above mentioned duration. Mean age at diagnosis was 3.7 years [SD +/- 3.05]. Fever was present in 100 percent of the patients with the other major diagnostic features present in more than 90 percent of the patients. Seventeen [68 percent] patients presented after ten days of fever. Coronary aneurysms were seen in 40 percent of the patients. We administered intravenous immune-globulins [IVIG] in 100 percent of the patients. 12 percent of the patients still had coronary aneurysms after 1 year of diagnosis. There was no mortality

Conclusion: KD needs to be considered in the differential diagnosis of all children with persistent unexplained fever with rash. A great number of cases of KD are missed and treated as common cold or flu. Diagnostic criteria used for KD is helpful in diagnosis of KD and can help in early prompt treatment with IVIG to prevent the life threatening complication of coronary aneurysms

Outcome and Prognostic factors of stroke in children presenting at an Army hospital in Pakistan

Objective: To determine the outcome and prognostic factors of stroke in children presenting at Military Hospital Rawalpindi

Study Design: Cross-sectional study

Place and Duration of Study: This study was conducted at the department of Pediatrics, Military Hospital Rawalpindi, from Oct 2012 to Mar 2014

Patients and Methods: Sixty consecutive children presenting with stroke were included in this study after taking written informed consent from the guardians/parents. A predesigned proforma was used to record patient's demographic details along with the presenting complaints, type of stroke, underlying cause and outcome

Results: The mean age of the patients was 3.49 +/- 3.29 [Mean +/- SD] years. There were 35 [58.3 percent] male and 25 [41.7 percent] female children. Ischemic stroke was the most frequent and was observed in 37 [61.7 percent] patients followed by hemorrhagic [16.7 percent], sinovenous thrombosis [8.3 percent] and ischemia with hemorrhagic findings [6.7 percent]. Mixed lesions and transient ischemic attacks were reported in 2 [3.3 percent] patient each. Mean length of hospital stay was 9 +/- 6 [Mean +/- SD] days. Sixteen [26.7 percent] children recovered completely while 41 [68.3 percent] children had some neurological deficit at discharge. Mild to moderate deficit was recorded in 21 [35.0 percent] children while 20 [33.3 percent] children had severe deficit. Three [5.0 percent] patients expired during hospital stay

Conclusion: Ischemic stroke was the most common cause of paediatric stroke. Important risk factors of peadiatric stroke included congenital heart diseases and intracranial infections. Poor prognostic factors included male gender, age less 5 years and congenital heart disease

Compliance and effectiveness of who surgical safety check list: a JPMC audit

Objective: To assess World Health Organization [WHO] Surgical Safety Checklist [SSC] compliance and its effectiveness in reducing complications and final outcome of patients

Methods: This was a prospective study done in Department of General Surgery [Ward 02], Jinnah Postgraduate Medical Centre [JPMC], Karachi. The study included Total 3638 patients who underwent surgical procedure in elective theatre in four years from November 2011 to October 2015 since the SSC was included as part of history sheets in ward. Files were checked to confirm the compliance with regards to filling the three stage checklist properly and complications were noted

Results: In 1st year, out of 840 surgical procedures, SSC was properly marked in 172 [20.4%] cases. In 2[nd] year, out of 857 surgical procedures 303 [35.3%] cases were marked which increased in 3rd year out of 935 surgical procedures 757 [80.9%] cases and in 4th year out of 932 surgical procedures 838 [89.9%] cases were marked. No significant change in site and side [left or right] complications were noted in all four years

Surgical Site Infection [SSI] was noted in 59 [7.50%], 52 [6.47%], 44 [4.70%] and 20 [2.12%] cases in 1st, 2nd, 3rd and 4th year respectively. SSI in laparoscopic cholecystectomies was 41 [20.8 %], 45 [13%], 20 [5.68%] and 4 [1.12%] in 1st, 2nd, 3rd and 4th year respectively. No significant change in chest complications were noted in all four years. Mortality rate also remained same in all four years

Conclusion: WHO SSC is an effective tool in reducing in-hospital complications thus producing a favorable outcome. Realization its efficacy would improve compliance

Trans-sternal thymectomy in myasthenia gravis patients with laryngeal mask airway

TUIP is as effective as TURP in achieving maximum flow rate but TUIP was superior in terms of shorter operative time, less retrograde ejaculation and less need of blood transfusion. A descriptive case series. Department of Anaesthesia, Jinnah Postgraduate Medical Centre Karachi, from June 2006 to December 2010. All patients who underwent trans-sternal thymectomy for myasthenia gravis under laryngeal mask airway [Prosea] were included. They were maintained with inhalation agent and analgesics. Muscle relaxants were avoided in all the patients. The haemodynamics and blood gases were monitored perioperatively. A total of sixteen patients underwent the procedure using laryngeal mask airway [Proseal]. There were ten females and 6 males. Mean age at presentation was 26.5 +/- 10.4 year. The haemodynamics and blood gases were well maintained perioperatively. Fourteen patients [87.5%] could be extubated successfully. Two patients needed intubation and ventilation; one for 9 hours and other for 24 hours. These patients were identified as those who were on higher doses of pyridostigmine [>240 mg] and had severe pre-operative muscle weakness. The use of laryngeal mask airway [Prosea] for patients undergoing trans-sternal thymectomy is a satisfactory alternative to tracheal intubation for those patients of myasthenia gravis who do not require airway protection. Avoidance of muscle relaxants and use of laryngeal mask airway [prosea] in facilitate rapid emergence and allowed early extubation

Abdominal pregnancy

Abdominal pregnancy is a rare form of ectopic pregnancy associated with high maternal [0.20%] and perinatal [40-95%] mortality; surprisingly we had three consecutive cases of this condition. Case 1: Was referred from Taulka hospital where the patient presented as, four months gestational amenorrhea with acute diarrhea vomiting and severe anemia. She was treated symptomatically, transfused two units of blood and referred to Liaquat University Hospital with Ultrasound report showing suspicion of abdominal pregnancy. Case 2: Was newly married primipara who presented with four months gestational amenorrhea and severe lower abdominal pain. Ultrasound report showed a complex mass of 8.0cm just below the anterior abdominal wall [over the uterus] with alive fetus. The uterus was empty, so the diagnosis of abdominal pregnancy was made. Case 3: Was a young 19 years old lady, initially admitted in surgical unit as case of acute abdomen with history of five months pregnancy followed by D and C two weeks back by LHV [Lady Health Visitor], they collaborated with gynae unit due to this history. Examination showed septic, tender on palpation, on P/V examination some dry shrunken cord like structure with foul smelling discharge hanging out from vagina, identified a gut loop with uterine perforation. In this case abdominal pregnancy was diagnosed on surgery as ultrasound report could not give the clear picture. All cases were managed with surgical intervention. In first two cases fetuses were delivered alive but non viable, in third case fetus was dead macerated found within abdominal cavity in right side. In first case placenta was removed completely and in second case, it was adherent with adjacent structures not actively bleeding so left in situ and post operatively three doses of injection methotrexate were given. First two cases recovered completely while in third case patient required ICU care after surgery. All three cases who had different clinical presentations were diagnosed and managed successfully

Pattern of obstructed labour at a public sector University Hospital of Sindh, Pakistan

Objective: to determine the frequency, risk factors, complications and outcome of obstructed labour in our setup

Study design: a retrospective study

Setting: obstetrics and Gynaecology Unit IV, Liaquat University Hospital, Jamshoro - Pakistan from January 2004 to December 2006 [three years]

Methods: patients' records, labour room registers, operation theatre books and perinatal records were reviewed retrospectively to gather information about patients admitted with obstructed labour

Results: out of 2126 hospital deliveries during the study period, 44 [2.1%] were admitted with obstructed labour as an emergency. Only 13 [29.5%] had received antenatal care at some stage of pregnancy. Thirty-two [72.2%] patients belonged to rural areas. Mean duration of labour was 15.9+/-11.6 hours. Cephalo-pelvic disproportion in 22 [49.3%] cases was the most common risk factor of obstruction, followed by malposition/malpresentation in 19 [43.3%] cases. Caesarean section was the most common mode of delivery [81.1%]. Three [6.8%] patients had ruptured uterus. Still birth rate was very high i.e. 14 [31%] and neonatal deaths were 4 [9%], while 26 [49%] babies survived with minor problems

Conclusion: obstructed labour still poses a great maternal and foetal problem in our setup. Malpractice by untrained persons is a major factor. Most of these cases are preventable by proper antenatal care provided by properly trained persons