Postpancreatitis abscess of falciform ligament: an unusual presentation

Pathologies of the falciform ligament are extremely rare entities ranging from cyst and hematoma to abscess and gangrene. Intestinal obstruction, secondary to extensive falciform ligament abscess, has not been reported to date. On account of being rare, diseases of falciform ligament have perplexing presentations leading to unwanted delays in diagnosis and management. These may present with abdominal wall ecchymoses [Cullen's sign - pancreatitis, portal hypertension], an abdominal mass, features of abscess, intestinal obstruction or peritonitis. Abscess may be an indicator of underlying liver or biliary pathology. Appreciating these as important differentials while working up patients with similar features, would markedly reduce missed diagnoses and improve surgical management. We present the case of a 40-year Pakistani gentleman who had duodenal obstruction owing to the presence of falciform ligament abscess resulting from a rather ignored episode of pancreatitis, mimicking malignancy

Comparison of BISAP score with Ranson's score in determining the severity of acute pancreatitis

To determine the accuracy of BISAP score in finding out the frequency of severity and mortality in patients with acute pancreatitis by comparing it with Ranson's score. Crosse-sectional study. Department of Surgery, Pakistan Institute of Medical Sciences, Islamabad, from April to December 2010. A total of 80 patients who presented in emergency with acute pancreatitis were included by consecutive non probability sampling technique. Cases of acute pancreatitis were classified as mild or severe based on the organ failure criteria and/or local complications according to the Atlanta Symposium. All patients were scored according to both Ranson's score and BISAPscore. Out of 80 patients, 35 [44%] were males and 45 [56%] were females. The mean age was 46.89 +/- 15.75 years. Twenty five patients [31.25%] were classified as severe acute pancreatitis and 3 patients [3.75%] had evidence of pancreatic necrosis on CT scan. The duration of hospital stay was 1 - 54 days with a mean of 13.12 +/- 12.83 days and mortality rate was 5%. The number of patients with a BISAPscore of >/=3 was 15 and Ranson's score >/=3 was 25. The observed incidence of severe disease stratified by the BISAP score has [p < 0.001] and by Ranson's score has [p < 0.001]. In regards to mortality, patients having BISAPscore >/=3 has p=0.003, while patients having Ranson's score >/=3 has p=0.002, both are statistically significant. The newly proposed BISAP score is a simple and accurate tool for severity stratification and is equally effective in finding out frequency of severity and in turns mortality in patients with acute pancreatitis as Ranson's score

Perceptions of post-graduate medical stuents, regarding effectiveness of telemedicine [TM] as an instructional tool

To determine post-graduate medical students perceptions regarding effectiveneess of telemedicine as an instructional tool. It was a pragmatic, sequential mixed method study. The data collection was by distribution of questionnaire to groups present both at holy family hospital rawalpindi and NORI hospital islamabad. Variables of interest were perceptions of medical students and effectiveness of telemedicine [TM] as an instructional tool. Ethical committee approval was taken before the study. Out of 384 post-graduate students [PGS], 360 filled the questionnaire performa [response rate 93.75%], age range was 25 to34 years. Responding to different questions; 95.56% respondents agreed/strongly agreed thatTM was a good mode of information transfer [MIT]. Another72.2% respondents understood well the information given through this MTE; 64.4% participants were satisfied with the technical quality of services provided. Some 71.11% preferred TM over lectures and demonstrations, and 85.56% participants agreed/strongly agreed that TM should be accessible to all doctors working in various setups, throughout the country. Responding to the open ended questions; 61.95% participants stated that TM was more effective due to multidisciplinary approach. Regarding the main strengths of TM,30.83% voted for its multidisciplinary approach and 21% for its interactive nature. Considering the weaknesses of TM40.83% pointed towards technical problems and23.89% noted that this MIT lacked face to face exposure. The perceptions of overwhelming number of participants were in favor of telemedicine as an instructional tool

Impact of constructive feedback on the undergraduate medical students' attitude towards psychiatry

To determine the impact of constructive feedback, during clinical attachment, on the undergraduate medical students' attitude towards psychiatry. Quasi-experimental study. CMH Lahore Medical College, Lahore, Pakistan from December 2012 to October 2013. Participants were 107 students of final year MBBS. They were divided into study and control groups. Demographic data was recorded and attitude towards psychiatry [ATP-30] questionnaire was administered to all the students before the clinical attachment. Both the groups underwent 3 weeks clinical attachment. However, only the students in study group received constructive feedback. ATP-30 was re-administered to students of both groups soon after completion of attachment. Because of errors and omissions in data, forms of two students were excluded. Statistical analysis was carried out on data of 105 students, which consisted of 53 students in the study group and 52 in control groups. The mean age of study group was 22.21 years [SD=0.885], while that of control group was 22.19 years [SD=0.886]; with 32.1% and 34.6% males in the study and control group respectively. Both the groups had comparable demographic features. Pre-attachment ATP30 scores of both groups were comparable i.e. 84.47 +/- 5.29 versus 84.56 +/- 5.30 [p-value < 0.934]. However, post-attachment scores of both groups increased i.e. 103.11 +/- 5.98 versus 85.85 +/- 4.31 [p-value < 0.001]. This increase in score was statistically highly significant in the study group. Constructive feedback during clinical attachment has a significantly positive impact on the undergraduate medical students' attitude towards psychiatry

Reliability of results produced through objectively structured assessment of technical skills [OSATS] for endotracheal intubation [ETI]

To estimate the reliability of an objectively structured assessment of technical skills [OSATS] in patients for Endotracheal Intubation [ETI], using task-specific checklists during administration of general anaesthesia. Co-relational reliability study. Department of Anaesthesia and Medical Education, Pakistan Institute of Medical Sciences, Islamabad, from September to November 2010. Ten first year residents of the department of anaesthesia who had successfully completed a one-day course of ETI on mannequins and had performed 25 ETI in actual patients under supervision, were asked to perform ETI on anaesthetized patients in the operation theater after consent. The procedure was directly observed by two expert observers [ER1 and ER2] and one inexperienced observer [novice, NR] using a validated task oriented checklist. Each trainee repeated the procedure on another patient and was reassessed using the same checklist. Inter-rater for test and retest, and expert to novice reliabilities along with internal consistency were calculated. The inter-rater reliability was 0.92 in test and was 0.98 in retest [Ebel's calculation]. Spearman Rank Correlation Coefficient [SRCC] for ER 1 and NR was 0.76 in test and 0.89 in retest. Cronbach's alpha for internal consistency was 0.93 for first test and 0.97 for retest. The OSATS for ETI in real patients demonstrated excellent inter-rater test reliability, inter-rater retest reliability, expert-novice reliability and internal consistency. This instrument, therefore, proves promising as a tool for competency-based evaluations

Sentinel node localization in breast carcinoma

To determine the success rate of sentinel node dissection and the sensitivity of sentinel node to determine the presence of axillary node metastasis in women with clinically node negative breast cancer. Case series. Place and Duration of Study: The study was conducted at Department of General Surgery Pakistan Institute of Medical Sciences, Islamabad [PIMS] and Nuclear Oncology and Radiotherapy Institute, Islamabad [NORI] from January 2002 to December 2003. A total of 15 patients of early carcinoma breast were recruited in the study. Five patients were injected with radiocolloid and later with isosulfan blue in the subareolar region. Ten patients were given isosulfan blue only. All the patients were subjected to standard axillary clearance after sentinel node biopsy through separate incisions. Sentinel node was examined by intra-operative frozen section and all of the dissected lymph nodes were examined histopathologically for tumour deposits. Sentinel lymph node was successfully excised in all the cases 15/15 [100%]. In 14 of the patients the sentinel node pathology was truly predictive of axillary nodal status. Sensitivity of the test was 93.33% and the positive predictive value was 100%. Sentinel node biopsy should be followed by standard axillary lymph adenectomy until the results of multiple prospective randomized trials define the role of this technique in the management of carcinoma breast

Peripheral vascular injuries due to trauma: pims experience

Peripheral vascular injuries due to trauma are on the rise in Pakistan. Morbidity in the form of amputation is very high because of late presentation of the patients to a centre where facilities for vascular surgery are available. The purpose of this study was to identify the factors responsible for late presentation, and poor outcome of vascular repair in such cases. Clinical and operative details of 51 patients with peripheral vascular trauma, who underwent surgical intervention between 1994 to 1998 at PIMS, were reviewed. Type of injury, mode of presentation, time between injury and arrival to the hospital, methods of vascular repair, use of graft or vein, and outcome of the procedure were analyzed.Patients with late presentation, combined arterial and venous injuries involving the popliteal artery and its branches were associated with high amputation rate, There were 45 arterial and 6 isolated venous injuries. After surgical repair, 9 [17.5 percent] patients required amputation due to various reasons. Time is the key factor in determining the final outcome of vascular repair. The delay can be avoided by rapid transfer of such patients to a major hospital

Transverse ectopia of the testis: a case report

A case of transverse ectopia of the testis in a man of 30 years is presented. The patient was admitted for a right inguinal herniorraphy and the finding of ectopic testis was accidental

Intussusception of an appendiceal mucocele: a case report and review of literature

A fifty year old female was admitted with a painful mass in the right iliac fossa, bleeding per rectum and occasional vomiting. A presumptive diagnosis of ileocecal intussusception due to colonic polyp was made on the basis of barium enema and abdominal ultrasound. However, exploratory laparotomy revealed intussusception of a benign mucocele of the appendix, which was later confirmed on histopathological examination. It is a rare entity and the first to be reported in Pakistan. A review of relevant literature follows the case report

Surgical management of nodular goitre: a review of 210 cases

In a 2 1/2 years period, we operated upon 210 patients referred to us with nodular goiter. Among them, 160 patients [76%] were women. 120 [57 percent] had multinodular goiter and 90 patients [43 percent] had a solitary nodule. The preoperative examination proceure is discussed. Radionucleide thyroid scan was performed in all cases. 120 patients [57%] had multiple cold and functioning nodules, 79 patients [37%] had cold and 11 [5%] had a warm nodule. The accuracy of fine needle aspiration biopsy and cytology [FNABC] performed in 79 patient with a cold nodule is assessed. 24 patients [11.4%] had a malignant tumour. The histologic features of the benign and malignant tumours are described. The operative procedures in benign goiter consisted of subtotal or total lobectomy and subtotal thyroidectomy. In the patients with malignant tumours, a more radical operation was performed consisting of near total or total thyroidectomy. Radical neck dissection was done when it was indicated. The operative complications are discussed