Normal and Abnormal Development of Left Vertebral Artery and Its Implications in Cervical Region Surgery

Aortic arch (AA) anomalies occur in approximately 3-5% of cadavers, but these atypical branches remain a point of discussion in cervical region surgery. This case report describes a 73-year-old Caucasian female who died of renal failure following a complicated urinary tract infection whose left vertebral artery (LVA) originated from the AA between the left common carotid and subclavian arteries. The preforaminal part of the LVA was 5 mm in diameter and entered the C6 transverse foramen while the right vertebral artery (RVA) arose from the right subclavian was 6.5 mm in diameter and entered the C5. Embryologically, VAs are formed during weeks four through eight by development of longitudinal anastomoses linking the cervical intersegmental arteries (ISA). The ISA regress except the seventh, which becomes the proximal subclavian artery, the point of origin of the adult VA. Persons with LVA that arises from the AA may be asymptomatic; however, secondary dilatation of the RVA may be implicated in the development of cerebrovascular disorders and atherosclerotic changes due to increased blood flow. Additionally, the anatomical positioning of a left vertebral artery is important when considering an anterior approach for cervical spine surgery and other head-neck procedures when soft structures arteries, veins and muscles are retracted to reach the cervical spine.

Retardo na transferência do pronto-socorro para a unidade de terapia intensiva: impacto nos desfechos do paciente. Um estudo retrospectivo / Delayed intensive care unit admission from the emergency department: impact on patient outcomes. A retrospective study

RESUMO Objetivo: Estudar o impacto do retardo na admissão à unidade de terapia intensiva em mais do que 4 horas nos desfechos de pacientes críticos. Métodos: Este foi um estudo observacional retrospectivo, no qual pacientes adultos admitidos diretamente do pronto-socorro para a unidade de terapia intensiva foram divididos em dois grupos: Tempo Adequado, se admitidos dentro de 4 horas, e Admissão Retardada, nos casos em que a admissão demorou mais do que 4 horas para ocorrer. Compararam-se, entre os grupos, o tempo de permanência na unidade de terapia intensiva e a taxa de mortalidade na unidade de terapia intensiva e no hospital. Foi realizado pareamento por escore de propensão para correção de desequilíbrios. Utilizou-se uma análise de regressão logística para explorar retardo da admissão como fator independente de risco para mortalidade na unidade de terapia intensiva. Resultados: Durante o período do estudo, 1.887 pacientes foram admitidos diretamente do pronto-socorro para a unidade de terapia intensiva, sendo que 42% dessas admissões foram retardadas. Os pacientes com retardo tiveram permanências na unidade de terapia intensiva significantemente mais longas e maior mortalidade na unidade de terapia intensiva e no hospital. Esses resultados persistiram após pareamento dos grupos por escore de propensão. O retardo da admissão foi fator independente de risco para mortalidade na unidade de terapia intensiva (RC = 2,6; IC95% 1,9 - 3,5; p < 0,001). A associação de retardo e mortalidade na unidade de terapia intensiva surgiu após período de retardo de 2 horas e foi mais alta após período de retardo de 4 horas. Conclusão: O retardo da admissão do pronto-socorro para a unidade de terapia intensiva é fator de risco independente para mortalidade na unidade de terapia intensiva, sendo a associação mais forte após retardo de 4 horas.

Abstract Objective: To study the impact of delayed admission by more than 4 hours on the outcomes of critically ill patients. Methods: This was a retrospective observational study in which adult patients admitted directly from the emergency department to the intensive care unit were divided into two groups: Timely Admission if they were admitted within 4 hours and Delayed Admission if admission was delayed for more than 4 hours. Intensive care unit length of stay and hospital/intensive care unit mortality were compared between the groups. Propensity score matching was performed to correct for imbalances. Logistic regression analysis was used to explore delayed admission as an independent risk factor for intensive care unit mortality. Results: During the study period, 1,887 patients were admitted directly from the emergency department to the intensive care unit, with 42% being delayed admissions. Delayed patients had significantly longer intensive care unit lengths of stay and higher intensive care unit and hospital mortality. These results were persistent after propensity score matching of the groups. Delayed admission was an independent risk factor for intensive care unit mortality (OR = 2.6; 95%CI 1.9 - 3.5; p < 0.001). The association of delay and intensive care unit mortality emerged after a delay of 2 hours and was highest after a delay of 4 hours. Conclusion: Delayed admission to the intensive care unit from the emergency department is an independent risk factor for intensive care unit mortality, with the strongest association being after a delay of 4 hours.

Traumatic cerebrospinal fluid leakage following septorhinoplasty

Septoplasty/septorhinoplasty is a common ear, nose and throat procedure offered for those patients with deviated septum who are suffering from nasal obstruction and functional or cosmetic problems. Although it is a basic and simple procedure, it could lead to catastrophic complications including major skull base injuries which result in cerebrospinal fluid (CSF) leaks. We describe two different cases of traumatic CSF leaks following septoplasty/septorhinoplasty at two different sites. The first patient suffered a CSF leak following septoplasty and presented to Alexandria University Hospital. The leak was still active at presentation and identified as coming from a defect in the roof of the sphenoid sinus and was repaired surgically. The second patient presented 4 days after her cosmetic septorhinoplasty with a CSF leak and significant pneumocephalus. She was managed conservatively. Understanding the anatomical variations of the paranasal sinuses and implementing proper surgical techniques are crucial in preventing intracranial complications when performing either septoplasty or septorhinoplasty. A good quality computed tomography of the nose and paranasal sinuses is a valuable investigation to avoid major complications especially CSF leaks following either procedure.

effectiveness of vacuum assisted wound closure [VAC] In diabetic foot

Objectives: To determine the mean healing time of vacuum assisted wound closure in diabetic foot ulcer patients

Study Design: An interventional case Series

Place and Duration: Department of General Surgery, The Royal Oldham Hospital, Oldham, U.K from 1[st] September 2012 to 30[th] March 2013

Methodology: All patients with diabetic foot ulcer of any size and duration were included in the study that fulfills inclusion criteria. Patients were subjected to VAC dressing which involved the controlled application of sub-atmospheric pressure to the local wound environment, using a sealed wound dressing connected to a vacuum pump. Patients were followed by disappearance of exudates and appearance of granulation tissue and the time of healing of wound

Results: Among 40 patients studied, 45.0% were between 41 to 50 years of age with male to female ratio was 1.6:1. The mean duration of diabetes in patients was an average of 14 +/- 5.65 years. Duration of diabetic foot was 24 +/- 6.0 and initial average wound area was 50.6 +/- 27.6cm[2]. After VAC therapy, the wound area ranged from 3.4 to 92.35 cm[2], the average area being 41.75 cm[2]. The actual reduction in wound area attained by VAC therapy varied from 3.4 to 38.6 cm[2], with an average reduction of 11.4 +/- 4.55 cm[2]. The percentage reduction in wound area ranged from 10.3% to 62.11%, with an average reduction of 27.9 +/- 13.7%. Wounds were healed after VAC therapy for an average of 21.75 +/- 10.55 [range, 14 to 40] days

Conclusion: VAC therapy is very effective and useful in the treatment of diabetic foot and ulcers and has an effective role in promotion of proliferation of granulation tissue, reduction in the wound size and healing of wound in lesser time

Can spinal anaesthesia be a routine for single level lumbar discectomy?

To compare the efficacy of spinal anaesthesia with general anaesthesia for lumbar discectomy in terms of theatre time and post-operative effects. Randomized controlled trial. Neurosurgery department Combined Military Hospital Rawalpindi, from November 2013 to April 2014. A total 60 consecutive patients with herniated lumbar discs were enrolled in this study to undergo randomly into assigned spinal anaesthesia group SA [n=30, group A] or General anaesthesia GA [n=30, group B].Variables included age, gender, level of lumbar disc prolapse, type of anaesthesia, operative time, and combined total theatre time, post-operative pain using visual analogue scale [VAS] and hospital stay in days. Mean theatre time in group A was 62.70 and for group B it was 90.73 [p<0.001]. The mean hospital stay after surgery in group A was 2.0 days and in group B was 2.27 days [p< 0.002]. Peak post- operative pain scores according to visual analogue scale and resultant analgesic requirements in group A was 5.10 while for group B it was 6.87 p< 0.001. Spinal anaesthesia is safe and can be routine anaesthesia for most of the patients undergoing lumbar discectomy

Outcome of decompressive craniectomy [DC] for severe traumatic brain injury [STBI] in adults

To evaluate the outcomes of decompressive craniectomy [DC] in adults with severe traumatic brain injury [STBI]. Observational cross-sectional. Neurosurgical unit CMH Rawalpindi from July, 2011 to June 2014. Total of 39 patients who underwent DC for STBI were included in the study. Patients of both sexes and of age range 20 - 48 [32.03 +/- 8.01] years were included in the study. The DC was performed within 24 and after 24 hours. Parameters recorded were mortality, neurological outcome / complications like brain herniation, wound dehiscence, cerebrospinal fluid [CSF] leak, contusion expansion, sinking flap syndrome, subdural hygromas and hydrocephalus. Data was analyzed by using SPSS version 17 and descriptive statistics, frequency, rate and percentage was computed for presentation of qualitative outcomes. Favourable neurological outcome was seen in 21 patients [53.85%] where as 6 patients [15.38%] had moderate to severe disability and 3 patients [7.69%] were vegetative respectively. Patients operated within 24 hours and with Glasgow coma scale [GCS] range 6-8 had better outcome. . Overall 9 patients [23.08%] did not survive the injury and procedure. As high mortality is associated with STBI, DC is an effective option to lower down the refractory intracranial hypertension with an acceptable surgical outcome

Ondansetron versus combined dexamethasone and metoclopramide in prevention of nausea and vomiting after laparoscopic cholecystectomy

To compare the efficacy of combined metoclopramide and dexamethasone with ondansetron in preventing nausea and vomiting after laparoscopic cholecystectomy. Randomized controlled trial. Surgical Unit I Combined Military Hospital Rawalpindi, from 1[st] June 2010 to 3[rd] January 2011. A total of 120 patients were observed for 24 hours after elective laparoscopic cholecystectomy for nausea and vomiting and divided into two groups of 60 patients each. Nausea and vomiting was rated by the patients according to a three point scale [O=no nausea and vomiting, 1= nausea, 2= retching or vomiting]. Early postoperative nausea and vomiting was not present in 31[51.7%] patients of group 1 and 40[66.7%] of group 2 [score = 0]. In 11[18.3%] patients of group 1 and 12 [20.0%] of group 2 only nausea was present [score = 1], while 18[30.0%] patients in group 1 and [13.3%] in group 2 scored 2.The late postoperative nausea and vomiting was not present in 21[35.0%] patients in group 1 and 37[61.7%] in group II [score = 0]. In 28 [46.7%] patients in group 1 and 22[36.7%] in group 2 nausea was present [score = 1] while 11[18.3%] patients of group 1 and 1[1.7%] in group 2 scored 2. Ondansetron was effective as compared to combined metoclopramide and dexamethasone in prevention of post-laparoscopic cholecystectomy nausea and vomiting

Risk factors for coronary heart disease in patients below 45 years of age

To examine the traditional risk factors and biochemical profile of patients with established CAD [coronary artery disease], and compare the trends of these in specified age groups of different populations as depicted in various studies. All consecutive patients below 45 years of age, having classical history of Ischemic heart disease and also having definite ECG changes consistent with coronary artery disease were enrolled. These patients were admitted to CCU/Intermediate Coronary Care Unit of Pakistan Ordinance Factories [POF] Hospital Wah Cantonment from April 2007 to December 2011. Patients who had doubtful history as regards CHD and those having ECG changes not classically consistent with CAD were excluded. Information collected through Performa included history including family history and details of risk factors. Clinical examination was carried out and relevant investigations including the serial ECG changes were recorded. Blood samples were collected after an overnight fast of 14 hours and tests were done for total cholesterol and HDL cholesterol by using Pioneer-USA, linear chemical kits by cholesterol oxidase and enzymatic calometric method. A total of 109 cases were included. Cigarette smoking [46%] Family history [43%], Hypertension [37%], Dyslipidemia [33%], Diabetes mellitus [18%] and above normal BMI [63.3%] are the most common risk factors in our patients. Increased abdominal girth has appeared to be an important risk factor and at occasions is documented to be independent of obesity. Casual dietary habits and sedentary life style are the other less important risk factors. The majority of risk factors were equally prevalent in males as well as females except smoking which was less prevalent in females. Our study shows that Family history, Smoking, Hypertension, increased BMI, increased Abdominal girth, Dyslipidemia and Diabetes Mellitus are the main risk factors. Considering the increasing incidence of the coronary heart disease in our society it is essential to assess and evaluate these risk factors at national level

Bilateral inferior thyroid artery ligation and transient hypocalcaemia: a comparison of two surgical techniques

To compare the frequency of hypocalcaemia in thyroid surgery after ligation of inferior thyroid artery trunk and ligation of Inferior thyroid artery branches at gland surface. Quasi experimental comparative study. Department of Surgery, Combined Military Hospital Rawalpindi, from February 2008 to August 2008. The patients were assigned to two equal groups, Group 'A' and Group 'B'. Estimation of serum calcium [Ca] levels was done before surgery in both the groups. In group 'A' patients underwent thyroid surgery with ligation of inferior thyroid artery [ITA] trunk, while in group 'B' terminal branches of ITA were ligated on gland capsule. Following the surgery serum calcium levels was measured 6 hours after surgery. Afterwards levels of serum calcium were checked daily for three days. The two groups were compared for the frequency of transient hypocalcaemia. Four patients in group A [13.3%] developed transient hypocalcaemia [serum corrected Ca < 2.0mmol], while in group B three patients [10%] developed transient hypocalcaemia. Fishers Exact test was applied and this difference was found statistically insignificant at p=1.0. Over all frequency of transient hypocalcaemia in this study was 11.6%. Ligation of ITA trunk does not increase the risk of hypocalcaemia in thyroid surgery.

Cervical lymphadenopathy: a common diagnostic dilemma

To determine the diagnostic accuracy of fine needle aspiration cytology [FNAC] in cervical lymphadenopathy using histopathologic examination of the excised lymph node as gold standard. Cross sectional study. Combined Military Hospital Rawalpindi in collaboration with Armed Forces Institute of Pathology [AFIP] Rawalpindi, from January 2007 to January 2008. A total of 70 patients suffering from cervical lymphadenopathy were selected. After obtaining informed consent FNAC was obtained from the lymph node. Afterwards same lymph node was removed under local anesthesia for histopathology. All specimens were sent to AFIP for histopathology reporting. Sensitivity, specificity, positive and negative predictive values and diagnostic efficacy for both the modalities were calculated. Data was analyzed using SPSS version 10. Mean and standard deviation for age and gender were calculated. Mean age of the patients was 38.14 +/- 16.88 year. FNAC findings showed a sensitivity of 79.5%, specificity 47.61%, positive predictive value 78%, negative predictive value 50% and diagnostic efficacy 70%. FNAC appears well established method of diagnosis, as its results compared favorably in many respects with those obtained from traditional surgical biopsy.

Comparison between lateral internal anal sphincterotomy and diltiazem in the treatment of chronic anal fissure

To compare lateral internal anal sphincterotomy with 2% diltiazem in the treatment of chronic anal fissure in terms of fissure healing and complications. Randomised controlled trial. Surgical unit Combined Military Hospital Lahore, from August 2008 to February 2009. Sixty patients were randomly assigned into two treatment groups. Group A was assigned to apply 2% diltiazem paste while, in group B lateral internal sphincterotomy [LIS] was done. Response to the treatment was assessed in terms of fissure healing, pain relief and occurrence of complications. Follow up of the patients was carried out at the end of 2[nd]d, 4[th], and 6[th] week of treatment. To compare lateral internal anal sphincterotomy with 2% diltiazem in the treatment of chronic anal fissure in terms of fissure healing and complications. In group A six patients had healing of fissure after 4 weeks and a further 4 at 6[th] week. In group B 14 patients had healing at 2 weeks, 10 at 4 weeks, and 5 at 6 weeks. One patient in group B and 20 in group A had no healing. In this study overall healing rate after 6 weeks with diltiazem was 33.33% and 96.66% with LIS. Lateral internal sphincterotomy is better than 2% diltiazem cream

unique presentation of unexploded ordnance in a patient

Rocket injuries in the war are common,but the retained unexploded rocket injury is quite rare and uncommon. We report an unusual case of unexploded rocket in knee area that required removal with unique safety measures, so as to prevent patient from potentially catastrophic situation

Comparison of tramadol with bupivacaine as local anaesthetic in postoperative pain control

To determine the effectiveness and duration of postoperative pain relief after local infiltration of tramadol in comparison with bupivacaine, in adult hernia surgery. Quasi experimental study. Department of Surgery, Combined Military Hospital Rawalpindi. Study was conducted on 60 patients aged between 20-60 years with elective mesh repair of inguinal hernia. Patients were divided into two groups of 30 patients for 0.25% bupivacaine [group A] and tramadol [group B]. Patients were assessed for pain at 1, 6, 12, 18 and 24 hours following surgery using visual analogue pain score [VAPS]. Patients with score =5 were given rescue analgesia in the form of 75 mg intramuscular diclofenac sodium. Comparison of first analgesia requirement time and the VAPS between the two groups was done using "t" test taking a p-value of <0.05 as significant. Patients in group A had a mean age of 46 +/- 11.03 years whereas in group B the mean age was 46 +/- 11.39 years. Mean visual analogue pain score after 1 and 6 hours of operation was 2.73 and 4.7 respectively in group A while it was 1.43 and 3.43 in group B. VAPS after 24 hours of operation was 3.47 in group A and 2.53 in group B. Mean time when 1st dose of rescue analgesic used was 8.20 hours in group A and 11.60 hours in group B. independent sample t-test for VAPS between the 2 groups revealed a highly significant difference [p-value <0.05] at 1, 6, 12 and 24 hours but no significant difference was seen at 18 hours. Independent sample t-test for time required for rescue analgesia and total number of doses required was also highly significant [p-value <0.05] between the two groups. Locally infiltrated tramadol provided an improved postoperative analgesia in comparison to bupivacaine and decreased the requirement of postoperative analgesics with early patient mobility and discharge

Comparative analysis of alvarado and teicher scores in the diagnosis of acute appendicitis

To compare the efficacy of Alvarado and Teicher scores in the diagnosis of acute appendicitis, using postoperative histopathology as gold standard. Comparative, cross sectional study. Department of surgery, Combined Military Hospital Rawalpindi, from 22nd June 2006 to 26th February 2007. Hundred cases of clinically diagnosed/suspected of acute appendicitis were included in the study by convenience [non-probability] sampling. Selected patients were graded according to Alvarado and Teicher scores, and underwent appendicectomy. All appendicectomy specimens were sent for histopathology reporting. A 2 x 2 table was used to determine sensitivity, specificity, positive and negative predictive values and diagnostic efficacy for both the scoring systems. Using Alvarado and Teicher scores, a sensitivity of 95% and 89.55%, specificity of 69.69% and 66.66%, positive predictive value of 86.48% and 85.71%, negative predictive value of 88.46% and 76.66%, negative appendicectomy rate of 13.5% and 15.49% and diagnostic efficacy of 87% and 83% were found, respectively. Alvarado score has better diagnostic accuracy as compared to Teicher score in the diagnosis of acute appendicitis