Acute scrotal pain: a two year prospective cohort study

Objective: To determine the cause of acute scrotal pain and its subsequent treatment

Study Design: Prospective cohort study

Place and Duration of Study: This was carried out in Armed Forces Institute of Urology Rawalpindi and Combined Military Hospital Abbotabad from 1[st] Jan 2014 to 31[st] Dec 2015

Materials and Methods: A total of 116 patients who presented with acute scrotal pain were included in the study

Those presenting within six hrs and a history consistent with testicular torsion underwent urgent exploration. Those presenting with a history of more than six hours or within six hrs but clinically suggestive of testicular torsion underwent emergency Doppler ultrasonography before surgery

Results: The occurance of different conditions were as follows: testicular torsion 10, torsion of appendix testis 02, Epididymo-orchitis 4, orchitis 10, trauma 12, infected hydrocelei 12 ,strangulated inguinal hernia 3, and idiopathic scrotal pain 18. Mean age [in years] for testicular torsion was 13 +/- 5 for Torsion of appendix testis 16 +/- 8, and for epididymo-orchitis 50 +/- 22. Mean duration of symptoms [in hours] for testicular torsion was 10+/-4, torsion of appendix testis was 11 +/- 3 and epididymo-orchitis 18 +/- 14. During surgery for testicular torsion ,detorsion of the affected testis was done and bilateral orchidopexy was performed in 04 patients. Orchidectomy with orchidopexy of the contralateral side was done in 06 patients who had nonviable testis

Conclusion: Acute scrotal pain is a common presentation. Our study concluded that in such cases colour Doppler ultrasonography is important to reach a definitive diagnosis

The occurance of testicular torsion is very high in patients less than 18 years of age .Moreover if there is a clinically strong suspicion of testicular torsion then yield of immediate surgery is high, because delay in exploration proves detrimental to the efforts of salvaging the testis. Patients with epididymo-orchitis respond well to ciprofloxacin prescribed for two weeks

Disposal of syringes, needles, and lancets used by diabetic patients in Pakistan

To assess the use, handling and disposal of insulin injection equipment by diabetic patients in Pakistan. We conducted a cross-sectional study at diabetic clinics in five tertiary centers in Pakistan. All diabetic patients [type 1/type 2] who were on insulin for more than 1 month, were included. An Urdu [local language]-translated questionnaire was used to collect information on insulin administration equipment, the site and frequency of needle use, insulin syringe/pen/lancet disposal, sharing of needles and knowledge about diseases that are spread by sharing contaminated needles. Of 375 patients, 58% were female. The mean [SD] duration of diabetes was 12.3 [7.3] years, and the duration of insulin use was 4.4 [4.3] years. The majority of the patients used syringes [88.3%] for insulin administration. Additionally, the majority of the patients disposed of used devices [syringes, 92%; pens, 75%; and lancets, 91%] in the household garbage collection bin. About half of the patients [n = 185] reported being educated by their physicians about the disposal of sharps. Those who were educated by a physician [adjusted odds ratio [adjOR]: 0.36; 95%CI: 0.16-0.81] or could read/write English [adjOR: 0.32; 95%CI: 0.11-0.92] were less likely to dispose of syringes and needles in the household garbage. The common disposal of sharps in the household garbage has implications for disease transmission. Education on the safe disposal of sharps may improve the disposal practices

Multislice computed tomographic patterns of muscle bridging of left anterior descending artery and their relation to atheromatous coronary artery disease

To determine the frequency of atheromatous coronary artery disease in patients with myocardial bridge. Descriptive study. AFIC/NIHD Rawalpindi from September 2010 to November 2010. Patients undergoing MSCT angiography for diagnosis of CAD having an abnormal finding were included. Patients with history of prior coronary artery bypass grafting [CABG], coronary stenting and with chronic total occlusions were excluded. Computed Tomographic [CT] examinations were performed with a dual-source CT scanner. Scanning parameters: detector collimation, 2 x 32 x 0.6 mm; slice collimation, 2 x 64 x 0.6 mm; gantry rotation time, 330 milliseconds; tube current-time product, 350 mAs per rotation and tube potential 120 kV. Reconstructions done and data transmitted to workstations and analyzed. Myocardial bridge [MB] was diagnosed and evaluated when an intramuscular segment of LAD artery was visualized on axial, volume rendered and multiplanar reformation [MPR] images. Out of 232 patients 32% had MB. Males were three times more likely to have Myocardial bridge [MB]. Mid and distal LAD showed 54% and 45% MBs respectively. Fourteen percent had evidence of atherosclerosis proximal to MB segment. Mean length and depth of MB segment was 18mm and 1.8mm respectively. Superficial type was most common [44%], followed by deep type [33%] while RV type was least common [23%].Frequency of patients with myocardial bridge having concomitant atheromatous coronary artery disease was 14%

Left radial artery approach for coronary artery intervention

To determine the success rate of left radial artery approach for coronary intervention. Descriptive study. Armed Forces Institute of Cardiology/ National Institute of Heart Diseases Rawalpindi. Study Period spanned from 15 January 2010 to 15 July 2010. The study was conducted on a total of 41 patients, out of these 41 patients, 25[61%] had undergone diagnostic coronary angiography using left radial artery approach and 16[39%] underwent percutaneus coronary intervention. Left radial artery route was selected after Positive Allen Test. Injection Verapamil 5mg was given through side connection of radial artery sheath to prevent spasm. No conversion to femoral artery route was done, establishing 100% success rate, without any bleeding or haematoma. Left radial artery approach for coronary angiography and percutaneus intervention in convenient and safe for the patient and almost free from major access site complication

Dual source multislice computed tomography for pulmonary embolism: initial experience at AFIC/NIHD Rawalpindi

Observation of different computed tomography findings in patients suffering from pulmonary embolism. All patients who underwent computed tomography for pulmonary embolism and had positive findings of pulmonary embolism, were included in the study. Armed Forces Institute of Cardiology/ National Institute of Heart Disease, between April 2009 and October 2010. Patients on mechanical ventilation were excluded from the study. CT pulmonary angiograms were obtained with 64 slice dual source computed tomography [DSCT] machine [Somatom definition] from Siemens. Before scanning breath holding was taught. A craniocaudal acquisition was obtained with a collimation of 64 x 0.6 mm and a pitch of 1.2-1.4. Total number of patients included in the study were 34 with mean age 50 years. The mean of Score by Miller was 10 +/- 5.532 and the mean percentage obstruction by method of Miller was 62.5%. The mean of Score by Qanadli was 19.62 +/- 12.32 and the mean percentage obstruction by method of Qanadli was 49.04%. The mean of Score by Mastora was 54.53 +/- 33.27 and the mean percentage obstruction by method of Mastora was 35.18%. Calculated mean and SD of right ventricular [RV] diameters was 44 +/- 7.75mm, left ventricular [LV] diameter was 32 +/- 8.06mm, RV/LV ratio was 1.508 +/- 0.58 mm, main pulmonary artery [PA] luminal diameter was 29 +/- 4.16mm, ascending aorta size was 32.46 +/- 5.14mm, PA/Aorta ratio was 0.913 +/- 0.188mm, Azygos Vein diameter was 11.14 +/- 1.88mm and superior vena cava [SVC] diameter [at azygos arch] was 18.93 +/- 3.37 mm. Correlation between methods was generally significant. Reflux of contrast injection was noted in 24 out of 34 patients, leftward bowing of inter-ventricular septum was observed in 21 patients, pleural effusion was noted in 10 patients and pericardial effusion was seen in only 3 patients. CT pulmonary angiography has emerged as a reliable non invasive tool for not only confirmation of diagnosis of pulmonary embolism in short time but also gives valuable information about prognosis of these critically ill patients. Further it can provide accurate follow up of thrombolytic therapy and can help plan an interventional strategy

Comparison of lateral anal sphincterotomy [closed method] versus anal dilatation

To compare lateral anal sphincterotomy [closed method] with anal dilatation in the management of primary chronic anal fissure. A prospective, comparative, interventional study. Department of Surgery Combined Military Hospital Kohat from Jan 2001 to Mar 2002. During the period, all patients with primary type of chronic anal fissure, who were above 12 years of age and were fit for surgery, were selected for study. They were divided into two groups for both surgical procedures in a randomized manner. After their respective surgical procedures patients were followed up for four weeks on weekly basis. The changes in signs and symptoms were thoroughly reassessed and noted in a separate proforma maintained for each patient for the purpose of comparison. The total number of patients was 49 with an average age of 40 years. Male to female ratio was 7:1. In 44 [89.79%] patients the fissure was located posteriorly while in 5 [10.20%] patients it was located anteriorly. Closed lateral anal sphincterotomy [LAS] was done in 28 [57.14%] patients, of which 25 [51.02%] were males and 3 [6.12%] females. While anal dilatation [AD] was done in 21 [42.85%] patients, 18 [36.73%] males and 3 [6.12%] females. In all the patients in whom LAS was done, there was disappearance of all the symptoms and complete healing of ulcer. Those operated by AD, there was disappearance of all the symptoms and complete healing of ulcer in only 8 [38%] patients. Incontinence was present in 9 [18.36%] patients. Three [14.2%] patients had persistence of ulcer while one [4.76%] was having recurrence of ulcer. Lateral anal sphincterotomy, especially close method gives excellent results as compared to anal dilatation in terms of ulcer healing, disappearance of symptoms and lower rate of ulcer recurrence or incontinence

Intraperitoneal mesh plasty

Incisional hernia is a common surgical condition with a reported incidence of 2-11% following laparotomy. Various modalities of repair have been advocated but the overall results still remain disappointing. To evaluate in incisional hernias the efficacy and safety of intraperitoneal mesh repair with conventional Polypropylene mesh. In CMH Muzaffarabad, CMH Sialkot and PAC Hospital Kamra. From January 2000 to January 2007. 90 cases of incisional hernia with a minimal defect size of 4 inches were included; there was no limitation to age and sex. Patients with comorbid conditions like Diabetes Mellitus, Hypertension, Bronchial Asthma, and lschemic Heart Disease etc: were also included if there was no other contraindications for surgery. Observations were made with regard to duration and ease of the operation, wound complications, hospital stay, recurrence and delayed complications. In our series of 90 patients, females [92.22%, n=83] outnumbered males [7.77%, n=7] and the highest incidence was in the 4[th] decade of life in females and the 3[rd] decade of life in males. Gynecological operations accounted for 61.44% [n=51] of the index operations. 77.7% [n=70] of patients had a BMI >30. Comorbid conditions were present in 36.66% [n=33] of patients. The polypropylene mesh placed intraperitoneal varied from 15x7.5 cm to 30x20 cm. The mean operating time was 60 +/- 20 minutes; operating time was extended when the procedure was accompanied by Dermolipectomy 80 +/- 10 minutes. 85.55% patients [n=77] attended our follow-up, ranging from 12 months to five years. Method of follow-up in outpatients department [OPD]/Clinics: 71.11% [n=64], by telephonic conversation: 12.22% [n=11]. 14.44% [n=13] were lost in follow up. All patients in follow up had serial abdominal sonograms at 3, 6, 9 and 12 months postoperatively respectively to evaluate bowel motility, adhesion formation and any locally associated complication. No recurrence was noted in the follow-up group. Historically intraperitoneal mesh placement of conventional polypropylene has been avoided as it was associated with significant postoperative complications. Based on our analysis, we believe that intraperitoneal mesh repair is still an effective option for incisional hernias, especially in difficult cases and with patients having comorbid conditions. The associated high incidence of complications associated with intraperitoneal mesh placement in the literature were not seen in our experience

Bicycle passenger injuries in children

To find out types of traumatic injuries in bicycle passenger children. At PAC hospital Kamra. Period: From October 2005 to October 2007. The children between the ages of 03 to 10 years were included in this study. They were divided into two groups. First group[Gp-I] sustained injuries due to ankle or foot entrapment in rear running wheel while the second group [Gp-II] sustained injuries due to fall of bicycle, while child sitting alone either at front bar or rear luggage carrier unattended. Gp-I sustained mostly frictional injuries ranging from simple abrasion to deep lacerated wounds of lower leg, ankle and foot. While in Gp-II severe injuries like fractures of upper and lower limbs, visceral abdominal injuries and head injuries were observed. Bicycle passenger injuries are common injuries of the children in less developed countries. These injuries range from simple "road rash" to serious head injuries

Pattern of anterolateral cervical lymph nodes involvement in papillary thyroid carcinoma

To determine the pattern of metastatic involvement of anterolateral cervical lymph nodes in papillary thyroid carcinoma. Retrospective, descriptive study. Department of Surgery, Khyber Teaching Hospital, Peshawar, from July 1998 to July 2005. The clinical and pathological record of 38 patients who underwent neck surgery for cervical metastasis from papillary thyroid carcinoma was reviewed. Neck dissections were done and 85 lymph nodes were taken. Forty lymph nodes were histologically positive and were classified in 3 groups based on dissection procedure. The neck level [levels I-V] of the positive nodes of all the 3 groups was identified. The mean age of patients was 32+2.5 years. The positive nodes in neck level III were the most involved followed by level II, IV, V and then I. Modified neck dissection should be adopted for papillary thyroid carcinoma. Papillary thyroid carcinoma usually involves the neck level II, III and IV with the level III being the most frequently involved

Gall-stone ileus with multiple tuberculous strictures

Gall-stone ileus associated with tuberculous strictures is an uncommon cause of bowel obstruction related to a cholecystoenteric fistula. The stone usually obstructs the narrowest part of the intestine. The patient whose intestine is strictured due to tuberculosis or other disease, the stone can impact that part of the strictured area. We report such a case of gall-stone ileus in a patient of 80 years with multiple tuberculous strictures. After surgery, she responded to antituberculous drugs and did well

Results of primary closure in the management of gangrenous and viable sigmoid volvulus

To compare the outcome of primary repair, both in viable and gangrenous cases of Sigmoid Volvulus. Retrospective study conducted from August 2001 to April 2006. District Headquarter Hospital, Bannu, North West Frontier Province. All patients admitted with large gut obstruction due to Sigmoid Volvulus. After initial investigations and resuscitation, the patients were shifted to the operation theatre where the vascular status of the sigmoid colon was noted, and resection and primary anastomosis was done in all the cases. Patients were allowed orally after 3-5 days, when their bowel sounds returned and they were able to pass flatus and/ or faeces. All patients were discharged home after recovery, and were followed up for a minimum of four months. The outcome of both the gangrenous and the viable gut patients was compared in terms of anastomotic leakage, wound infection, hospital stay and long term complications. The findings were entered onto a proforma and the results compiled and analyzed. Amongst the total 83 patients, there were 72 [86.7%] males and 11[13.3%] females, with an age range of 35-80 years [mean 55 years]. All patients presented with the typical symptoms of intestinal obstruction. Local and systemic signs of toxicity were more common in the gangrenous group. Postoperatively 17 [53.12%] patients in the gangrenous group and 9 [17.64%] cases in the viable group developed paralytic ileus; 2 [6.25%] patients in the gangrenous group developed anastomotic leakage leading to peritonitis; 2 [6.25%] patients in the gangrenous group and one [1.96%] in the viable group developed intra abdominal abscess; eight patients in the gangrenous group and five in the viable group developed wound infection, two of these patients late on developed incisional hernia. The mean hospital stay in the gangrenous group was 10 days as compared to eight days in the viable group. The difference in the outcome of primary anastomosis in both the viable and non viable groups was insignificant. Primary anastomosis can be safely done for acute sigmoid volvulus in both gangrenous and viable gut

Penetrating colonic injuries: management by primary repair

To assess the out come of primary repair in Penetrating Colonic Injuries. Prospective, interventional study from August 2001 to February 2004. Setting: This study was conducted at DHQ Hospital, Bannu. All patients who sustained colonic injury either by gunshot or stab injury were included in the study. Only those patients were included who were hemodynamically stable, did not have life threatening co-existing injuries and on operation were found to have mild to moderate peritoneal fecal contamination. All patients were operated after initial resuscitation and colonic injuries found were repaired primarily without fecal diversion. During the immediate and early postoperative period, these patients were observed for any complications like peritonitis, wound infection, peri-anastomotic abscess, pelvic, sub-diaphragmatic or interloop abscesses and colocutaneous fistulae. Patients were discharged home after they passed stools and their postoperative period remained uneventful for few days. Out of the 35 patients, majority were young males [80%]. The commonest mode of injury was fire arm, seen in 80% of the cases. The time interval between injury and repair was 4-12 hours [mean 6 hours]. Simple repair with interrupted suture was the commonest procedure performed, followed by right hemicolectomy. Twelve [34%] patients developed complications in the form of wound infection, intra abdominal abscesses and fecal fistulae. The total hospital stay was 7-21 days with the mean [9 +/- 2 days]. Primary anastomosis is safe and has excellent results in Penetrating Colonic Injuries

Monkey bite

Monkey bites have been reported less frequently in medical literature as compared to other animal bites. An animal keeper of a zoo was bitten by a monkey resulting in multiple would all over body more so on genital area. They were in form of lacerations and crushing with puncturing patterns. Wounds were irrigated and debridement done. Antibiotics cover with tetanus and rabies prophylaxis were given Secondary suturing was done later. The recovery was smooth without any residual defect

Takayasu's arteritis

Takayasu's arteritis is an uncommon disease. A case of Takayasu's arteritis in a young soldier is reported, who presented with generalized weakness, easy fatigability and claudication of upper limbs. On clinical examination the brachial and radial pulses were absent bilaterally while carotids were palpable. Doppler studies and angiogram confirmed occlusion of right and left subclavian arteries