Ghost ileostomy release down: our initial experience

Background: Many publications describe the advantages of the creation of ghost ileostomy (GI) to prevent the need for formal covering ileostomy in more than 80% of carcinoma rectum patients. However, none of the papers describes exactly how to ultimately remove the GI in these 80% of patients in whom it doesn't need formal maturation. Aim: To describe and evaluate the ghost ileostomy release down (GIRD) technique in terms of feasibility, complications, hospital stay, procedure time etc. in patients with low anterior resection/ultra-low anterior resection (LAR/uLAR) with GI for carcinoma rectum. Method: The present was a prospective cohort study of patients with restorative colorectal resections with GI for carcinoma rectum, Postoperatively the patients were studied with respect to ease and feasibility of the release down of GI and its complications. The data was collected, analyzed and inference drawn. Results: A total of 26 patients needed the GIRD and were included in the final statistical analysis of the study. The procedure was done between 7th to 16th postoperative days (POD) and was successful in all patients without the need of any additional surgical procedure. None of the patients required any local anesthetic injection or any extra analgesics. The average time taken for procedure was 5-minutes and none of the patients had any significant difficulty in GI release. There were no immediate postprocedure complications. Conclusion: The GIRD technique is a simple, safe, and quick procedure done around the 10th POD that can easily be performed by the bedside of patient without the need of any anesthesia or additional analgesics. (AU)

Predictors of pathological complete response following neoadjuvant chemoradiotherapy for rectal cancer.

Background: Neoadjuvant chemoradiotherapy (NACRT) is an established treatment option for locally advanced rectal cancer (LARC). Patients achieving pathological complete response (pCR) following NACRT have better oncological outcomes and may be subjected to wait and watch policy as well. The aim of this study was to identify predictors of pCR in LARC following NACRT. Materials and Methods: A retrospective analysis of a prospectively maintained colorectal cancer database from January 2018 to December 2019 was undertaken. A total of 129 patients of LARC who were subjected to conventional long course NACRT, followed by surgery were included in the study. Pathological response to NACRT was assessed using Mandard grading system and response was categorized as pCR or not-pCR. Correlation between various clinico pathological parameters and pCR was determined using univariate and multivariate logistic regression analysis. Results: Mean age of patients was 53.79 ± 1.303 years. Complete pathological response (Mandard Gr 1) was achieved in 24/129 (18.6%) patients. Age of patients more than 60 years (P = 0.011; odds ratio [OR] 3.194, 95% confidence interval [CI] 1.274-8.011), interval between last dose of NACRT and surgery >8 weeks (P = 0.004; OR 4.833, 95% CI 1.874-12.467), well-differentiated tumors (P < 0.0001; OR 32.00, 95% CI 10.14-100.97) and node-negative disease (P = 0.003; OR 111.0, 95% CI 2.51-48.03) proved to be strong predictors of pCR. Conclusion: Older age, longer interval between NACRT and surgery, node-negative disease and favorable tumor grade help in achieving better pCR rates. Awareness of these variables can be valuable in counseling patients regarding prognosis and treatment options.

Association Of Adiponectin With Total Leukocyte Count In Patients Of Coronary Artery Disease.

Background: Hypoadiponectinemia and raised total leukocyte count have been associated with coronary artery disease. The aim of this study was to investigate association of serum adiponectin levels with total leukocyte count in patients of coronary artery disease belonging to Khyber Pakhtunkhwa. Method: This cross-sectional/analytical study consisted of two groups. Group A contained 100 patients of coronary artery disease while group B contained 100 healthy controls. Consent of the study subjects was obtained, their history was recorded and fasting blood samples were analyzed for serum adiponectin level, total leukocyte count (TLC), serum lipid profile which included serum total cholesterol (T-C), triglyceride level (TG), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C). Adiponectin level was determined with ELIZA method, TLC was estimated on automated haematology analyzer and lipid profile was determined using enzymatic colorimetric method. SPSS version 21 was used to analyze the data. Results: Subjects with coronary artery disease when compared to healthy subjects showed significantly high level of total leukocyte count (9.26±1.488 vs. 6.37±4.052) and low level of serum adiponectin (4.3±0.80 vs. 9.6±3.69). Moreover, serum lipid profile showed low HDL-C (30.04±9.1 vs. 43.64±7.3) and rose triglyceride (220.1±67.7 vs. 181.86±41.4), total cholesterol (229.3±37.01 vs. 189.4±32.7), and LDL-C (153.78±38.53 vs. 109.16±33.91) levels. Significant negative association of adiponectin with TLC (r -0.826 with p<0.01) was observed in the study subjects. Conclusion: We observed elevated level of total leukocyte count and reduced level of adiponectin in subjects with coronary artery disease. Moreover, hypoadiponectinemia correlated negatively with TLC levels.

Association Of C-Reactive Protein With Hyperlipidemia In Patients With Polycystic Ovarian Syndrome In Khyber Pakhtunkhwa.

BACKGROUND: It has been unknown whether there exist any relations of C-Reactive Protein (CRP) level with hyperlipidaemia in polycystic ovarian syndromes patients. To determine Association of CRP with Hyperlipidaemia in patients with polycystic ovarian syndrome. METHODS: This was a cross sectional descriptive study conducted among 50 each polycystic ovarian syndrome and normal women. After taking a written consent from participants predesigned questionnaire was filled including information regarding demography and medical history. A 3 to 5 ml blood was taken from patients and controls and transferred to laboratory for determination of CRP level and lipid profile. The test results were collected, compiled, entered and analyzed using SPSS Version 20 for determination of any kind of association of CRP with Hyperlipidaemia in patients with polycystic ovarian syndrome. RESULTS: The mean age of study participants was 29.72±4.00 for cases and 29.04±3.99 for control. The cases and control were with the same age range, however there was a significant difference p=0.00 in BMI of the cases and control. There was no significant association observed between CRP and lipid profile parameters among polycystic ovarian syndrome patients. CONCLUSIONS: There exist no association between increasing CRP level and hyperlipidaemia in polycystic ovarian syndrome patients however CRP and lipid profile parameters showed high values among these patients.

Role of covering Ileostomy in causation of anastomotic strictures in low anterior resections for rectum carcinoma / O papel da ileostomia de proteção como causa das estenoses anastomóticas nas ressecções anteriores de reto

Abstract Background Colorectal resection anastomosis is the commonest cause of rectal strictures. Anastomotic site ischemia, incomplete doughnuts from stapled anastomosis and pelvic infection, are some of the risk factors that play a role in the development of postoperative rectal strictures. However, the role of diverting stoma in the development of rectal strictures has not been studied extensively. Objectives To study the difference in the occurrence of anastomotic strictures (AS) in patients submitted to low anterior resection (LAR) with covering ileostomy (CI), and to LAR without CI for carcinoma rectum. Methods This was a prospective, comparative case control study carried out at a tertiary care referral center. Low anterior resection with covering ileostomy was performed in patients with rectum carcinoma in the study group, while LAR without covering ileostomy was performed in the control group. The study group had 29 patients, while the control group had 33 patients with rectum carcinoma. Results During themean follow-up period of 9.1months, 8 (28%) patients in the study group and 2 (6%) patients in the control group developed AS (p =0.019). Out of these 8 patients with AS in the study group, 50% had Grade-I AS, 25% had Grade-II AS, while 25% of the patients had Grade-III (severe) AS. However, both patients who developed AS in the control group had a mild type (Grade I) of AS. Conclusion Covering ileostomy increases the chances of AS formation after LAR for rectum carcinoma. Also, the SKIMS Clinical Grading of Rectal Strictures is a simple and

Resumo Introdução A anastomose de ressecção colorretal é a causa mais comum de estenoses retais. A isquemia do local da anastomose, donuts (anéis) incompletos de anastomose grampeada e infecção pélvica são alguns dos fatores de risco que desempenham um papel no desenvolvimento de estenoses retais pós-operatórias. No entanto, o papel do estoma de desvio no desenvolvimento de estenoses retais não foi estudado extensivamente. Objetivos Estudar a diferença na ocorrência de estenoses anastomóticas (EA) em pacientes submetidos à ressecção anterior baixa (LAR) com ileostomia de proteção e a LAR sem ileostomia de proteção para carcinoma de reto. Métodos Este foi um estudo prospectivo e comparativo de caso-controle realizado em um centro de referência de atenção terciária. A ressecção anterior baixa com ileostomia de proteção foi realizada em pacientes com carcinoma de reto no grupo de estudo, enquanto LAR sem ileostomia de proteção foi realizada no grupo controle. O grupo de estudo tinha 29 pacientes, enquanto o grupo controle tinha 33 pacientes com carcinoma de reto. Resultados Durante o período de acompanhamento médio de 9, 1 meses, 8 (28%) pacientes no grupo de estudo e 2 (6%) pacientes no grupo controle desenvolveram EA (p=0,019). Destes 8 pacientes com EA no grupo de estudo, 50% tinham EA de Grau I, 25% tinhamEA de Grau II, enquanto 25% dos pacientes tinham EA de Grau III (grave). No entanto, ambos os pacientes que desenvolveram EA no grupo de controle tinham um tipo leve (Grau I) de EA. Conclusão A ileostomia de proteção aumenta as chances de formação de AS após LAR para carcinoma de reto. Além disso, o SKIMS Clinical Grading of Rectal Strictures é uma ferramenta simples e útil disponível para cada cirurgião para graduar, classificar e monitorar as estenoses retais pós-operatórias.

"PNR-Bleed" classification and Hemorrhoid Severity Score-a novel attempt at classifying the hemorrhoids / Classificação "PNR-Bleed" e escore de gravidade das hemorróidas - uma nova tentativa de classificação de hemorróidas

ABSTRACT Hemorrhoids are the most common anorectal disorders with a prevalence of 39% in general population. Hemorrhoids are generally classified on the basis of their location and degree of prolapse. Goligher's classification does not describe the number of hemorrhoidal columns involved and does not give much consideration to the amount of blood loss. To describe the hemorrhoidal disease more vividly, we devised the "PNR-Bleed" (or PNR-Booking) classification system. We tried to classify the hemorrhoids based on the four main characteristics of the hemorrhoidal disease i.e. the degree of hemorrhoidal Prolapse (P), Number (N) of the primary hemorrhoidal columns involved, Relation (R) of the hemorrhoidal tissue to dentate line and the amount of Bleeding (B) from it. All the four components in this classification system are graded into five grades ranging from 1 to 5. The peculiarity of this new classification system is that it allows more detailed documentation of the hemorrhoids in a particular patient and conveys more explicit meaning and information about the hemorrhoids for future references. Based on this 'PNR-Bleed' classification, we are introducing another concept of scoring the severity of hemorrhoids and referred it as the Hemorrhoid Severity Score (HSS). Hemorrhoid Severity Score (HSS) is the total score obtained by the sum of the numerical grades of all four characteristics of hemorrhoids in "PNR-Bleed" classification. This new "PNR-Bleed" system of classifying the hemorrhoids and calculation of HSS seems to be more comprehensive, detailed, more objective and easily reproducible.

RESUMO As hemorróidas são os distúrbios anorretais mais comuns, com uma prevalência de 39% na população em geral. As hemorróidas são geralmente classificadas com base em sua localização e grau de prolapso. A classificação de Goligher não descreve o número de colunas hemorroidais envolvidas e não dá muita importância à quantidade da perda de sangue. Para descrever a doença hemorroidária de maneira mais precisa, criamos o sistema de classificação "PNR-Bleed" (ou PNR-Booking). Tentamos classificar as hemorróidas com base nas quatro principais características da doença hemorroidária, isto é, o grau de prolapso da hemorroida (P), número (N) das colunas hemorroidais primárias envolvidas, a relação (R) do tecido hemorroidário para a linha denteada e a quantidade de sangramento (B) originando-se dele. Todos os quatro componentes deste sistema de classificação são classificados em cinco graus, variando de 1 a 5. A peculiaridade desse novo sistema de classificação é que ele permite uma documentação mais detalhada das hemorróidas em um paciente em particular e transmite o significado e informações mais explícitos sobre as hemorróidas. para referências futuras. Com base nessa classificação "PNR-Bleed", estamos introduzindo outro conceito para o escore da gravidade das hemorróidas e denominado HSS, de "Hemorrhoid Severity Score". O escore de gravidade da hemorroida (HSS) é o escore total obtido pela soma dos graus numéricos de todas as quatro características das hemorróidas na classificação "PNR-Bleed". Esse novo sistema "PNR-Bleed" de classificação de hemorróidas e cálculo do HSS parece ser mais abrangente, detalhado, mais objetivo e facilmente reproduzível.

Asymmetrical dimethyl arginine in type 2 diabetic patients with coronary artery disease.

OBJECTIVE: To compare clinical and biochemical parameters for type 2 diabetic patients having coronary artery disease with controls. METHODS: The analytical, cross-sectional study was conducted at Khyber Medical College, Peshawar, Pakistan, for a period of one year between 2010 and 2011, and comprised two groups; Group A had normal controls, while Group B had type 2 diabetic patients with coronary artery disease. Clinical parameters were blood pressure and body mass index. Blood was centrifuged for blood sugar, glycosylated haemoglobin, total cholesterol, high-density lipoprotein, low-density lipoprotein, triglyceride and asymmetrical dimethylarginine. SPSS 15 was used to analyse data. RESULTS: Of the 150 subjects, there were 75(50%) each in Group A and Group B, which had the mean age of 50.8±80 years and 53.4±52 years, respectively. Both systolic and diastolic blood pressure and body mass index were raised and an elevated level of serum asymmetric dimethylarginine, fasting blood sugar, total cholesterol, triglycerides, glycosylated haemoglobin was noted among Group B patients (p<0.05). . CONCLUSIONS: All clinical and biochemical parameters were found raised among diabetic patients with coronary artery disease.

RELATIONSHIP OF ADIPONECTIN LEVEL WITH LIPID PROFILE IN TYPE-2 DIABETIC MEN WITH CORONARY HEART DISEASE.

BACKGROUND: Cerebro-vascular disease is a commonest long term complication of type-2 diabetes mellitus. The study was done to determine concentration of serum adiponectin and lipid profile in type-2 diabetic men with coronary heart disease (CHD) in the region of Khyber Pakhtunkhwa (KPK), and to find possible relationship between them. METHODS: This was a cross-sectional study comprising of randomly selected thirty six healthy adult males and thirty six type-2 diabetic males with coronary heart disease. Their fasting blood samples were analysed for serum adiponectin, fasting blood glucose, glycosylated haemoglobin and lipid profile which included total cholesterol (T-C), triglycerides (TG), high-density lipoprotein cholesterol (HDL-C) and low-density lipoprotein cholesterol (LDL-C). The relationship of adiponectin with other variables in type-2 diabetic men with coronary heart disease was determined with Pearson correlations coefficient (r). RESULTS: Type-2 diabetic males with coronary heart disease when compared to healthy males showed significantly low levels of serum adiponectin (p=<0.001) and HDL-C (p=<0.001) and significantly high level of FBG (p=<0.001), HbAlc (p=<0.001), TC (p=<0.05), TG (p=<0.05) and LDL-C (p=<0.05). Serum adiponectin level showed a significant negative correlation with FBG (r = -0.332; p= 0.04), HbAlc (r = -0.818; p=<0.01) and TG (r = -0.640; p=<0.01) in type-2 diabetic men with coronary heart disease. Adiponectin showed a significant positive association with HDL-C in controls (r = 0.948; p=<0.01) and patients of type-2 diabetes with CHD (r = 0.650; p=<0.01). CONCLUSION: Serum adiponectin concentration is markedly decreased in patients of type-2 diabetes with coronary heart disease. Hypoadiponectinemia is related with deranged lipid profile, i.e., high TG and low HDL-C levels in type-2 diabetic men with CHD. Moreover, adiponectin is associated positively with HDL-C and negatively with HbAlc and TG levels in the studied population.

Assessment of male reproductive health by conventional method of semen analysis.

BACKGROUND: Data available over the past twenty years reveal that in approximately 30% of cases of infertility, pathology is found in man alone, and in another 20% both man and woman are abnormal. Therefore, the male factor is at least partly responsible in about 50% of infertile couples. The longer a couple remains sub fertile, the worse is their chance for an effective cure. This study was planned to analyse the complete semen picture of infertile men for assigning the specific cause to male infertility related to concentration, motility and morphology and to know the distribution and pattern of male infertility in the various subclasses in Pakistani population. METHODS: It was a prospective descriptive analytical study conducted at Department of Reproductive Physiology/Health, Public Health Divisions, National Institute of Health (NIH), Islamabad. One thousand five hundred twenty-one (1,521) infertile male patients, and 97 proven fathers, taken as a control. Conventional semen analysis was performed on all samples. RESULTS: Out of 1,521 infertile men, 13.3% were azoospermic, 23.2% oligozoospermic, 0.9% polyzoospermic, 14.5% normozoospermic, 35.2% asthenozoospermic 10.5% oligoasthenozoospermic and 2.4% teratozoospermic. Sperm concentration and active motility of proven fathers, was significantly higher (p<0.05) than the normal concentration group. Least liquefaction time was recorded in case of polyzoospermic subjects, and highest for azoospermic cases. Although, the liquefaction time of azoospermic and oligozoospermic subjects varied non-significantly (p>0.05) with the proven fathers. Normal forms were significantly higher (p<0.05) among the proven fathers and polyzoospermic cases, in comparison with the other groups. Head defects were more in teratozoospermic group, followed by oligoasthenozoospermic and oligozoospermic patients. Neck defects were more profound in oligoasthenozoospermic and oligozoospermic patients, while, tail defect showed significant increase in teratozoospermic and asthenozoospermic cases only. Head and neck defect varied significantly (p<0.05) with proven fathers in all groups, while tail defect varied significantly (p<0.05) in oligozoospermic, asthenozoospermic and teratozoospermic groups only when compared with proven fathers. CONCLUSIONS: Complete semen analysis which provides important information about the quality and quantity of the sperm, should be performed before reaching a final conclusion.

Effect of race, gender and age on thyroid and thyroid stimulating hormone levels in North West Frontier Province, Pakistan.

BACKGROUND: Thyroid is one of the ductless endocrine gland, which is located immediately below the larynx on either side of and anterior to the trachea. The principal hormones of thyroid gland are thyroxine (T4) and triiodothyronine (T3). The current study was carried out to investigate the impact of race, gender and area on the levels of Thyroxine (T4), Triiodothyronine (T3) and Thyroid Stimulating Hormone (TSH) in normal healthy individuals. METHODS: Serum levels of T4, T3 and TSH in 498 normal healthy individuals belonging to different districts of North West Frontier Province, Pakistan, were examined. Serum T4 and T3 were analysed by Radio Immuno Assay (RIA) method whereas TSH was estimated by Immunoradiometric assay (IRMA) method. RESULTS: Levels of T4, T3 and TSH ranged from 53 to 167 etamol/L, 0.6 to 3.1 etamol/L and 0.3-4.8 microIU/L respectively. The levels of these hormones show significant change from the reference values that are used in clinical laboratories as well as in Institute of Radiotherapy and Nuclear Medicine (IRNUM), Peshawar, Pakistan. CONCLUSION: It is concluded that the age, gender, race and area, all have an appreciable effect on the levels T4, T3 and TSH.

Oxidative stress and level of-iron indices in coronary heart disease patients.

OBJECTIVE: Oxidative stress is characterized by an increased concentration of oxygen free radicals which can cause a critical, or even an irreversible, cell injury. The study was designed to determine and compare the levels of oxidative stress and iron indices in Coronary Heart Disease and healthy individuals. MATERIAL AND METHODS: Blood malondialdehyde, iron, total iron-binding capacity, transferrin saturation and ferretin levels were determined in 140 Coronary Heart Disease and 100 healthy subjects. RESULTS: Values of blood malondialdehyde, iron, transferrin saturation and ferretin were observed to be significantly increased with exception of total iron-binding capacity, which was significantly decreased (p < 0.005) in Coronary Heart Disease patients when compared with normal healthy controls. CONCLUSION: Elevated serum malondialdehyde, iron concentration and body iron stores in patients reveal a possible role of iron indices in the development of coronary atherosclerosis. Therefore, it is suggested by this study that levels of malondialdehyde and biochemical markers of body iron stores can be used as an early investigative tool for assessing the oxidative stress in coronary heart disease.

Effect of folic acid supplementation on homocysteine level in postmenopausal women.

BACKGROUND: Hyperhomocysteinemia is an independent risk factor for atherosclerotic diseases including Ischaemic heart disease, stroke and peripheral vascular disease. Homocysteine (Hcy) is an intermediate formed during the catabolism of essential sulphur containing amino acid methionine, increased Hcy is associated with endothelial dysfunctions in healthy human. Plasma Hcy is significantly lower in premenopausal women than young men but after menopause basal homocysteinemia increases significantly in women approaching those in men. Several studies showed that hyperhomocysteinemia to be stronger risk factor for CHD (Coronary Heart Disease) in women than men. It seems likely that altered hormonal status and age related low folate intake are responsible for this. The present study was designed to evaluate the effect of folic acid supplements for six months, on Hcy level in postmenopausal women. METHODS: Hcy was estimated by Flourescence Polarization Immunoassay (FPIA). RESULTS: There was a significant (P < 0.001) decrease in Hcy level after six months of folic acid supplements. CONCLUSION: Hcy is an independent risk factor for atherosclerotic disease, this study favours the view that after menopause Hcy level increases significantly and a simple non Toxic and relatively inexpensive vitamin (folic acid) intervention might be useful in primary cardiovascular prevention in this high risk group because Hcy is a stronger risk factor for CHD in postmenopausal women than men.

Naturally occurring antioxidant vitamin levels in patients with type-II diabetes mellitus.

BACKGROUND: Type II diabetes mellitus is characterized by an inability of peripheral tissues to respond to insulin and the dysfunction of the endocrine pancreas to compensate for this resistance. Diabetes mellitus is associated with increased lipid peroxidation. Increased levels of lipid peroxides have been implicated in the pathogenesis of diabetic complications. To control and reduce the deleterious effects of lipid peroxides exist several antioxidant protective mechanisms. They comprise of enzymatic defenses and naturally occurring vitamins. The study was designed to determine and compare the antioxidant vitamin levels in Type II diabetic individuals and control healthy subjects. METHODS: Blood glucose, triglycerides, total cholesterol, HDL-c, LDL-c, VLDL-c and antioxidant vitamins (beta-Carotene, A, E, and C) levels were determined in 36 Type II diabetic patients and 30 healthy subjects. RESULTS: Values of blood glucose and lipid parameters were observed to be significantly increased (P < 0.001) with the exception of HDL-c, which was significantly decreased (P < 0.001) in Type II diabetes mellitus patients. The levels of antioxidant vitamins (beta-Carotene, E, and C) were found to be significantly low in Type II diabetes mellitus group whereas the concentration of vitamin A showed a non-significant change when both Type II and control healthy groups were compared. CONCLUSIONS: Low levels of antioxidant vitamins observed in the study suggest, that Type II diabetes mellitus patients have significant defects of antioxidant protection.