Spontaneous bacterial peritonitis in cases with liver cirrhosis

Objective: To determine the frequency of spontaneous bacterial peritonitis [SBP] in cases with liver cirrhosis

Study design: Cross-sectional study

Place of study: Department of Medicine, Shaikh Zayed Hospital, Lahore

Period of study: From March 2016 to November 2016

Methodology: In this study there were total 100 cases included of liver cirrhosis of both genders with age range of 12 to 70 years. Cirrhosis was labelled depending upon the ultrasonography findings of decreased liver size, parenchymal changes with or without portal vein dilatation with deranged liver functions. SBP was labelled where the ascites albumin gradient was more than 1.1 with TLC count more than 500 with neutrophils more than 250/ml

Results: In the present study there were total 100 cases of liver cirrhosis. There were 69 [69%] males and 31 [31%] females. The mean age of the cases was 49.21+/-8.14 years. Spontaneous bacterial peritonitis was seen in 40 [40%] of the cases. There was no significant different in term of duration of cirrhosis with p= 0.98. SBP was seen in 32 [47.05%] in child pugh class C and 08 [33.33%] in class B with p= 0.04

Conclusion: Spontaneous bacterial peritonitis is seen in almost half of the cases of liver cirrhosis and is significantly associated with child pugh class C

Raised homocysteine level in ischemic stroke

Objectives: To determine the frequency of raised homocysteine level in ischemic stroke

Methodology: This was a cross sectional study. This was carried out at Department of Medicine, Shaikh Zayed Hospital, Lahore during March 2016 to November 2016. The 100 cases of either gender falling in the age range of 40-80 years were included. ischemic infarct was labeled on the basis of hypodense area on CT brain. Raised homocysteine level was labeled when the levels were more than 15 Mumol/L

Results: In the present study there were total 100 cases of ischemic stroke, there were 60 [60%] males and 40 [40%] females. The mean age of the cases was 52.34+/- 6.57 years. Raised homocysteine levels was seen in 60 [60%] of the cases. It was seen more in females affecting 24 [63.15%] cases with p= 0.48. It was near significantly high in age group 60-80 years where it was seen in 34 [65.38%] of cases with p= 0.09

Conclusion: Ischemic stroke is one of the fatal complication of raised homocysteine levels and it is near significantly associated with higher age

Association of BRCA1 185 del AG with early age onset of breast cancer patients in selected cohort from Pakistani population

Objective: Large spectrum of pathogenic BRCA mutations is known as a major cause of hereditary breast ovarian cancer in human all over the world. The objective of present study was to find out the association of mutations185-del-AG and 185Ins.A at BRCA1 exon-2 with age of onset and family history of gynecological cancer among the selected cohort of breast cancer patients in Pakistani population and to provide guidelines for treatment strategies

Methods: For the present study 115 subjects were recruited from different hospitals of Punjab, Pakistan, during May, 2017 to February, 2018. The inclusion criteria were age =30, without any previous BRCA testing and willingness to participate in present study. Subjects were interviewed for various demographic factors. Out of 115 subjects, 46 were selected on the basis of findings of previous studies and approximately 3 ml of blood was collected in EDTA coated vials for analysis of BRCA1 exon-2. Column based DNA extraction was performed by using commercial kit and exon specific primers were used to amplify BRCA1 exon 2 and PCR products were sent for sequencing to Eurofins Genomics. Sequences were analyzed through the BLAST program at National Center for Biotechnology Information (NCBI) and Bio Edit software. Accession numbers were obtained on submission of sequences in GenBank

Results: BRCA1-185-del AG mutation was found in one of the breast cancer patient who was 33 years of age at diagnosis. None of the samples revealed positive results for BRCA1-185 Ins. A

Conclusion: BRCA1-185 Del AG mutation has association with early age onset of breast cancer. The direct sequencing is very useful approach for BRCA analysis and exon specific selected cohort from Pakistani population

Fuctional outcome of acute Disseminated Encephalomyelitis in children

Objective: To determine functional outcome of acute disseminated encephalomyelitis in children and factors affecting outcome at The Children's Hospital, Lahore

Study Design: Cross-sectional observational study

Place and Duration of Study: Department of Pediatric Neurology, The Children's Hospital and Institute of Child Health, Lahore from Nov 2014 to Oct 2015

Material and Methods: Fifteen patients with acute disseminated encephalomyelitis fulfilling the inclusion criteria were enrolled. Detailed history, examination, prior febrile illness and modified Rankin scale score for functional disability at presentation and discharge were recorded through study proforma. All patients underwent lumbar puncture and neuroimaging. Data were analysed in SPSS [v.20] and Chi-square test was applied to find p-value

Results: Out of 15 patients, there was male predominance [10 male 66.7 percent] with mean age 7.4 +/- 2.5 years. Encephalopathy 100 percent [n=15] followed by fever, fits 73.3 percent [n=11] and motor deficit 60 percent [n=9] were common presentation. About 46.7 percent [n=7] cases had prior febrile illness. MRI brain had >5 lesions in 86.7 percent [n=13] with sub-cortical area 93.3 percent [n=14] periventricular area 86.7 percent [n=13]. Functional outcome was good in 80 percent [modified Rankin scale of 2 or less at time of discharge]. Consciousness level and disability score at presentation were statistically significant factors affecting the outcome [p-value 0.004 and 0.002 respectively]

Conclusion: Acute disseminated encephalomyelitis in children had variable clinical presentation. It has good outcome with level of consciousness and disability score being significant factors affecting outcome

The cause and neuroimaging findings in pediatric Arterial Ischemic stroke

Objective: To determine the causes of arterial ischemic stroke and neuroimaging findings in children

Study Design: An observational, prospective, cross-sectional study

Place and Dration of Study: Department of Paediatirc Neurology, Children's Hospital and Institute of Child Health, Lahore for a period of six months from Nov 2014 to Apr 2015

Material and Methods: Children from 1 month to 18 years of age with radiologically confirmed arterial ischemic stroke, occurring 1st time in life, were included in the study. Arterial ischemic stroke [AIS] was confirmed on the basis of history, examination and neuroimaging findings of the brain. Further investigations were done according to the cause of arterial ischemic stroke and neuroimaging brain findings

Results: A total of 72 patients of arterial ischemic stroke were identified over a period of 6 months. Among these, male predominance was found in 53 [73 percent] children. Outpatient department patients outnumbered the indoor patients with stroke in 38 [53 percent] children. Children between 1-5 years of age were the most affected ones [65 percent]. Hemiplagia, fits, hemiparesis and aphasia were the most common presenting features affecting 60 [83 percent], 27 [38 percent], 14 [19 percent] and 8 [11 percent] children respectively. The commonest cause of arterial ischemic stroke was iron deficiency anemia, found in 30 percent [n=22] of the children followed by anemia due to other causes in 27 percent [n=20] and congenital heart diseases in 8.3 percent [n=6] of the children. On neuroimaging studies, parietal lobe was the most affected part of the brain in 23 percent of the children [n=16]. Middle cerebral artery was the major artery affecting 57 percent [n=12] of the patients

Conclusion: Iron deficiency anemia, anemia due to other causes and congenital heart diseases were common etiologies in children with arterial ischemic stroke in our study. Parietal lobe and middle cerebral artery were the most affected areas of the brain on neuroimaging

Frequency of persistent intradialytic hypertension in patients undergoing hemodialysis

Objective: To determine the frequency of persistent intradialytic hypertension in Pakistani end stage renal disease patients on hemodialysis

Methods: A total of 150 patients undergoing hemodialysis were included in the study after informed consent. After enrollment, pre- and post-dialysis systolic blood pressurewas measured using standard techniques. Persistent intradialytic hypertension was labeled. All data was collected on predesigned proforma. Anti-hypertensive medicines being used and duration of dialysis in months were used as effect modifier

Results: From one hundred and fifty patients the minimum age was found as 18 years and maximum age was found as 60 years with mean + standard deviation as 47.04 +10.64 years. There were 56 % male patients and 44% patients were female. Persistent intradialytic hypertension was found in 12% patients. 84% patients used anti-hypertensive. By using chi-square test, there was no significant association between age and presence of persistent intradialytic hypertension with p-value = 0.546. Significant association was not found between gender and presence of persistent intradialytic hypertension with p-value = 0.139. Usage of Anti-hypertensive was significantly associated with presence of persistent intradialytic hypertension with p-value = 0.048. Duration of dialysis was not significantly associated with presence of persistent intradialytic hypertension with p-value = 0.706

Conclusion: The frequency of persistent intradialytic hypertension was found in 12% end stage renal disease patients on hemodialysis. Effect modifiers were not significantly associated with presence of persistent intradialytic hypertension except usage of Anti-hypertensive

Evaluation of patients with coronary artery disease for major modifiable risk factors for ischemic heart disease

Incidence of cardiovascular diseases is on the rise in developing countries. Deaths due to ischemic heart disease can be reduced by modifying the risk factors. The present study was conducted to evaluate the patients scheduled for Coronary Artery Bypass Surgery for the presence of major modifiable risk factors for ischemic heart disease [IHD]. It was a descriptive study. All patients who underwent elective Coronary Artery Bypass cardiac surgery between November 1, 2008 and February 28, 2009 at Rehman Medical Institute, Peshawar, were included in the study. Presence of Diabetes, Hypertension, Smoking, Dyslipidemia, Sedentary life style, and Obesity was looked for in these patients. A total of 104 patients were studied during this period. Majority [97.11%] of patients had at least one major modifiable risk factor for IHD. Sedentary life style [53.84%] was the most common risk factor present in these patients followed by hypertension and dyslipidemia [47.11% each], smoking [43.27%], diabetes [35.57%], and obesity [9.61%]. Multiple risk factors [two or more] were found in 78 [75.0%] of patients. Most of the patients with coronary artery disease, severe enough to warrant coronary artery bypass grafting, have at least one of the major modifiable risk factors for IHD. Modification of these factors may well reduce the disease burden of CAD and reduce the cardiovascular mortality.

Shouldice versus lichtenstein repair

To compare the results of tissue based Shouldice repair with the Lichtenstein tension free repair of inguinal hernia. A prospective randomized controlled trial. From Jan 2004 to Dec 2006. Surgical Unit-II, Allama lqbal Medical College /Jinnah Hospital Lahore, Pakistan. A total of 156 patients were included in this study were equally divided into two groups. The mean age was 45 years. After a follow up of upto 2 years there was significant difference in the recurrence rate. It was 5% in the Shouldice group and 1.28% in the Lichtenstein group. Similarly chronic pain was also much higher i.e. 5% in the Shouldice group compared to 1.28% in Lichtenstein Group. The rate of hematoma and seroma formation was the same [1.28%] in both groups, however infection was seen slightly more in Lichtenstein repair [3.84%] as compared to Shouldice repair [2.56%]. Tension free Lichtenstein technique was found to be superior to the tissue based Shouldice repair with respect to post operative complications and recurrence

Enterocutaneous high output fistulae; octreotide an effective tool in management

Enterocutaneous fistula is an abnormal communication between epithelial lined lumen of Gl tract and epithelium of an adjacent viscous or skin. To find out role of octreotide in the management of high enterocutaneous fistula. Case study. Department of Surgery unit-ll Punjab Medical College and A and E Department of Jinnah Hospital /AIMC Lahore. From Jan 2007 to Dec 2008. 479 laparotomies were carried out due to trauma. Out of these 21 i.e. 4.38% developed high out put enterocutaneous fistula. All patients were put on similar conservative management including, TPN, antibiotics, fluid electrolyte replacement and stoma care. Patients were split into two groups alternatively. There were no statistical difference between the study groups with regard to the age [p-value=0.515]. Group I contains 11 patients [octreotide] received additionally 100mg octreotide S/C 8 hourly, showed decrease of volume from 680 to 150ml within 10 days. Spontaneous closure was observed in 8 [72.72%] patient and surgery was required in 2 [18.18%] patients. Death was 1 [9.09%]. In Group II remaining 10 patients[without octreotide], fistula discharge volume decreased form 650mg to 150ml in 20 days. Spontaneous closure was noted in 5 [50%] cases. Surgery was required in 3 [30%], while death rate was 2 [20%]. It is concluded that Octreotide, an analogue of somatostatin with longer half life is effective in treatment of high output fistula

Laparoscopic cholecystectomy; outcome in patients with co-morbidity

To determine the frequency of bleeding, surgical site infection and common bile duct injury after laparoscopic Cholecystectomy in patients with co-morbidity. Descriptive Study. [Case series]. Department of Allied and D.H.Q hospital Faisalabad. July 2006 to December 2007. It comprised of 30 consecutive patients of cholelithiasis with co-morbidity presenting in surgical department. Patients having uncontrolled hypertension, chronic obstructive airway disease and malignancy were excluded. Detailed history and physical examination was carried out as per protocol. It was followed up by relevant investigations. All the cases underwent laparoscopic cholecstectomy. The age of the patients ranged from 23-68 y, with mean age of 40-56 y. Among these 14 cases were having D.M [46.66%], 06 patients were cirrhotic [20%], 06 patients had acute cholecystitis [20%], 02 patients were having H.T.N [6.6%] and 02 patients were > 70 years [6.6%]. All the patients were females. Out of diabetic patients undergoing laparoscopic cholecystectomy, SSI was noted in 02 [6.66%] patients. While mild postoperative bleeding was noted in 01 [16.6%] of cirrhotic patients after laparoscopic cholecystectomy.No untoward event was noted in patients with H.T.N ac, Cholecystitis and advanced age. In high risk patients undergoing laparoscopic cholecystectomy, very few complications were noted. Postoperatively, Morbidity following above procedure was quite low as compared to conventional one. Laparoscopic cholecystectomy should be the preferred option in high risk patients for better outcome

Agricultural machines injuries; incidence

[1] To determine the extent of agricultural injuries in term of their site severity, management and type of agriculture machine. [2] To determine the techniques that can decrease the morbidity and mortality caused by agricultural injuries. Descriptive study. This study was conducted in surgical department of Allied and DHQ hospital Faisalabad. January 2007 to December 2007. This descriptive study was performed in 40 consecutive patients in surgical department DHQ/Allied hospital Faisalabad during Jan. 2007 to Dec. 2007. All people who got agricultural injuries were included. People who got traumatic injuries other than agricultural machines were excluded. All injuries were noted with respect to the age and sex of the patient, site, size, and severity of injury, and type of agricultural machine. Management was done accordingly. Out of 40 cases 34 [85%] were male and 06 [15%] were female. In 25 cases [67.5%] fodder cutter were involved In 10 cases [25%] pinching machines [gears, belt, chain machines] were involved. 03 cases [75%] run over by machine 02 cases [05%] by harvesting machines. In 30 cases [75%] upper limb was involved. In 05 [12.5%] cases scalp injuries were noted. In 02 cases [05%] genitalia were avulsed. In 03 cases [7 5%] lower limb was involved Injuries range from simple lacerations, degloving injuries tendons and vessels injuries and finally amputations. Mostly young male population is involved in agricultural machine injuries. Morbidity of agricultural machine injuries can be reduced, by modifying design of agriculture machines by training farm workers and by their proper treatment

Comparison of serum lipids, lipoproteins and apolipoproteins in patients undergoing CABG with healthy adults

Objective: to assess the pattern of plasma lipoproteins in CAD patients including comparison between diabetic and non-diabetic subgroups

Methods: this case control study was conducted at National Institute of Cardiovascular Diseases [NICVD] Karachi on patients admitted for CABG from June, 2000 to June, 2001. A total of 100 patients and 100 healthy subjects were enrolled during the study. 38 patients [38%] were diabetic with mean age of 46.16 years and 62 patients [62%] were non-diabetic with mean age of 45.26 years. Serum lipids, apolipoproteins A, apolipoproteins B and Lp [a] of each subject were analyzed. One way ANOVA and 95% confidence interval for mean were applied to find the association of CAD with age, BMI, glucose, cholesterol, triacylglycerol's, HDL-c, LDL-c, and Lp [a]

Result: CABG patients had significantly higher blood TAG levels than controls. Similar results were observed for HDL-c, which was significantly lower when compared with control subjects. Apo-B and Lp [a] in controls were significantly lower than both diabetic and non-diabetic CAD patients. The level of Apo-B in diabetic CAD was significantly higher when compared with control subjects

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

Open prostatectomy

To study the morbidity of open prostatectomy. To assess the frequency of complications after open prostatectomy. Descriptive cross sectional. Surgical Unit-IV, DHQ Hospital, Faisalabad. 01-01-2003 to 31-12-2003 [One Year]. Patients of bladder outlet obstruction due to benign prostatic hyperplasia [PBH] were operated by open surgery [Transvesical or retropubic prostatectomy]. Open prostatectomy was performed in 54 cases. In 38 cases, suprapubic transvesical prostatectomy was performed, while in 6 cases, retropubic prostatectomy was done. Our youngest patient was 42 years old and oldest 90 years. Mean age was 62 years. In our study, the most common complications were wound associated seen in 7[12.96%] cases. They included cellulites in 3[5.56%] cases, stitch abscess in 1[1.85%] cases, seroma in 1[1.85%] cases, and abscess in 2[3.70%] cases. Other complications were bleeding in the form of reactionary haemorrhage/clot retention in 2[3.70%] cases and secondary haemorrhage in 3[5.56%] cases. Urinary fistula was seen in 5[9.26%] cases while retrograde ejaculation in 6[11.11%] cases, stricture urethra in 3[5.56%] cases, urinary incontinence in 4[7.41%] cases and urinary tract infection in 5[9.26%] cases. Epididimo-orchitis, deep vein thrombosis and osteitis pubis were not seen in our study. The average duration of hospital stay was 6 days. Most cases were discharged within five days of operation, while stitches were removed on the eighth postoperative day. The morbidity of open prostatectomy is higher than transurethral resection [TURF], as TURP is better procedure due to lower complication rate, short hospital stay, cost effectiveness and better tolerated by old and unfit patients, presenting with small fibrotic prostate. Open prostatectomy is still a good option for BPH where TURP facilities are not available

Atrial fibrillation following coronary artery bypass graft surgery

To know the frequency of atrial fibrillation [AF] after coronary artery bypass graft surgery and the risk factors which predispose these patients to develop post-operative AF. This prospective, observational, analytic study was carried out at National Institute of Cardlovascular Diseases Karachi, from January 2001 to January 2002. It included 200 patients undergoing elective or emergency coronary artery bypass graft [CABG] surgery without concurrent valvular heart disease, prior history of AF, ventricular arrhythmias or redo CABG surgery. All patients underwent CABG and were followed for three weeks for incidence of AR Patients who developed AF [group A] were compared with patients without AF [group B] for different variables. Univariate analysis was done using Student's t-test for continuous variables and Chi-square test for categoric variables. The mean age was 52.78 +/- 8.32 years. The average bypass time and cross clamp time were 83.20 [SD +/- 18.73] minutes and 29.73 [SD +/- 7.25] minutes respectively. The mean ejection fraction was 49.34%. The median number of grafts was three. The frequency of AF was 12 [6%]. Univariate analysis revealed that advanced age, male sex, right coronary artery lesion, prolonged bypass time and low ejection fraction were statistically significant risk factors [p<0.005]. AF is a common, but potentially preventable, complication following CABG surgery. The Advanced age, low ejection fraction, prolonged cross clamp and bypass time are the important risk factors which may predispose these patients to develop postoperative atrial fibrillation

Surgical revascularization: hospital outcomes

Coronary Artery Bypass surgery was first started in Pakistan in NICVD Karachi. The purpose of this retrospective study is to document the total number of CABG done during the last 25 years at NICVD as regards their mortality and morbidity+ Files of all patients undergoing CABG between January 1977 to December 2001 were reviewed for details of surgery as well as outcome and complications during the hospital stay. A total of 4711 patients including 4437 males and only 273 females [5.7 percent] underwent CABG. All patients had angina pectoris and 942 patients [19.9] also had symptoms of heart failure. A total of 382 patients died [8.1 percent] and 24 percent patients had other complications. In the recent years mortality has been reduced to 3.9 percent. CABG sugery is now a well-established treatment for multi-vessel occlusive coronary artery disease. Short-term morbidity and mortality have declined over the years