Early and late complications of thyroidectomy: A descriptive cohort study in Rawalpindi.

OBJECTIVE: To assess the epidemiology of thyroid disorders and early and late complications following thyroidectomy.. METHODS: The descriptive cohort study was conducted at the Benazir Bhutto Hospital, Rawalpindi, Pakistan, from April 2017 to Janurary 2020, and comprised of patients undergoing total and near-total thyroidectomy. Post-operative complications were noted, and patients were followed up after 6 months to assess long-term complications. Data was analysed using SPSS 22. RESULTS: Of the 75 patients, 70(93.3%) were females and 43(58.1%) were aged <40 years. The most common symptom was neck swelling with hyperthyroidism 20(41.7%) and pressure symptom 20(41.7%). Post-operative complications developed in 26(35.6%) patients, with symptomatic hypocalcaemia being the most common 10(13.7%), followed by hoarseness 6(8.2%). Biopsy results were available for 50(66.6%) patients. Benign pathology was present in 44(88%) patients and 6(12.0%) had malignancy. Follow-up data was available for 62(82.7%) patients among whom symptomatic hypocalcaemia was the leading complication in 33(53.2%), followed by permanent hoarseness in 6(9.7%). CONCLUSIONS: Symptomatic hypocalcaemia and hoarseness were found to be the most common post-operative and long-term complications of thyroidectomy.

A Foreign Body in the Cephalic Vein: Broken Piece of Intravenous Cannula.

Peripheral intravenous cannulation is a routine in the medical field with the rarity of complications in expert hands. However, at times, complications arise including the fracture of the cannula inside the vein, which is a rare but potentially serious complication with the possibility of pulmonary embolism. We have reported a case of a broken piece of a cannula in the cephalic vein removed with the help of a Fogarty catheter with the emphasis on preoperative imaging studies to localize it and use of a tourniquet to avoid distal migration during retrieval. There are varied reports about the conservative vs operative approaches for foreign bodies in vasculature. It should be removed in the first place where expertise allow so that the rare but potentially serious complications can be avoided.

Early Oral Feeding Compared With Traditional Postoperative Care in Patients Undergoing Emergency Abdominal Surgery for Perforated Duodenal Ulcer.

Introduction Enhanced recovery after surgery (ERAS) protocols have been widely studied in elective abdominal surgeries with promising outcomes. However, the use of these protocols in emergency abdominal surgeries has not been widely investigated. This study aimed to evaluate ERAS application outcomes via early oral feeding compared to regular postoperative care in patients undergoing perforated duodenal ulcer repairs in emergency abdominal surgeries. Materials and methods We conducted a randomized controlled trial at the Surgical Unit 1 Benazir Bhutto Hospital from August 2018 to December 2019. A total of 42 patients presenting to the emergency department with peritonitis secondary to suspected perforated duodenal ulcer were included in the study. Patients were randomly assigned into two groups. Group A patients followed an ERAS protocol for early oral feeding, and Group B received regular postoperative care (i.e., delayed oral feeding). Our primary outcomes were the length of hospital stay, duodenal repair site leak, the severity of pain (via the visual analog scale), and postoperative ileus duration. Results were analyzed via IBM Statistical Product and Service Solutions (SPSS) Statistics for Windows, Version 20.0 (Armonk, NY: IBM Corp.). and chi-square and independent t-tests were applied. Results Patients who received early oral feeding (Group A) showed a shorter length of hospital stay, lower pain scores, and shorter postoperative ileus duration than patients in the traditional postoperative care group. Also, we noted no duodenal repair site leak in the early oral feeding group. The differences between the two groups were statistically significant (P<0.05). Conclusions Based on our results, ERAS protocols that promote early oral feeding can be applied in patients undergoing emergency abdominal surgery for perforated duodenal repair. Early oral feeding in emergency surgery patients can reduce the patient burden on hospitals. In addition, early oral feeding can promote better outcomes and reduced economic burden for patients. Keywords: Perforated duodenal ulcer, ERAS protocol, randomized controlled trial, duodenal repair site leak, length of hospital stay, VAS score, postoperative ileus.

Association Between Psoriasis and Depression: A Traditional Review.

Psoriasis is a chronic inflammatory disease of the skin with multiple comorbidities, depression being one of them. Psoriasis affects the personal, social, and sexual lives of the patients resulting in psychological strain.  Psoriasis and depression amplify each other. Supporting evidence has proven multiple common mechanisms between the two diseases: inflammatory overlap, genetic evidence, low vitamin D3, and melatonin levels are common in both psoriasis and depression. Fear of social rejection and self-stigmatization act as a fuel to fire inflaming depression in psoriatic patients. The study explains the link between psoriasis and depression and their effects on quality of life. There is a need to highlight the importance of addressing the psychological effects of psoriasis along with its physical aspects for better treatment outcomes.

Association Between Systemic Lupus Erythematosus and Myasthenia Gravis: Coincidence or Sequelae?

Systemic lupus erythematosus (SLE) is a systemic autoimmune disease and myasthenia gravis (MG) is an organ-specific autoimmune disease, both may exhibit positive anti-nuclear antibodies and a female preponderance. They may have similar features and can coexist in a patient or precede one another. This review article is based on electronic searches using PubMed as the primary database. Most of the articles used for this review were published in the last ten years with the exception of seven articles which were from 1995-2009. No guidelines have been followed. A total of 55 research articles were found related to the topic of this review article, and further scanning was done to eliminate some articles that did not meet the criteria. The coexistence of autoimmune diseases has been reported in many cases. The prevalence of a second autoimmune disease is higher among patients with a primary diagnosis of autoimmune disease than the general population. The prevalence of SLE in MG patients or vice-versa is greater than the general population. The association has been hypothesized to many mechanisms: thymectomy resulting in loss of central tolerance and generation of autoantibodies, regulatory T cell dysfunction, the dysregulated function of Fas receptor (CD95), anti-malarial drugs directly affecting the neuromuscular junction, the role of chemokine CXCL13 and GM-CSF in the pathogenesis. The association is rare, and the presence of one should be closely followed for further progression into other diseases. More research work needs to be done for a clear conclusion.

The Utility of Therapeutic Anticoagulation in the Perioperative Period in Patients Presenting in Emergency Surgical Department With Extremity Vascular Injuries.

Extremity vascular trauma is a challenging surgical emergency in both civilian population and combat environment. It requires vigilant diagnosis and prompt treatment to minimize limb loss and mortality. A multidisciplinary team approach is required to deal with shock states, concomitant abdominal injuries, head injuries, and fractures with significant tissue loss and psychological stress. Anticoagulation is frequently used during traumatic vascular repair to avoid repair site thrombosis, postoperative deep venous thrombosis, and pulmonary embolism (PE). In this review article, we are going to search about how frequent is the use of anticoagulation in terms of limb salvage rates, and mortality rates or side effects of anticoagulation in terms of risk of bleeding episodes, and the need for future prospective studies. Extremity vascular trauma is managed by a variety of methods including open repairs, endovascular repairs, and nonoperative management. Most of the literature demonstrates the use of systemic or regional anticoagulation in the management of vascular injuries with the improvement in limb salvage rates and reduced morbidities but confounding factors lead to variable results. Some studies show an increased risk of bleeding in trauma patients with the use of anticoagulants in trauma settings without any significant effect on repair site thrombosis. More comprehensive studies and randomized controlled trials are needed to confirm the importance of perioperative anticoagulation while avoiding the confounding factors in terms of injury severity scores, ischemia time, demographics of patients, modes of injury, comorbidities, grades of shock, concomitant injuries that need anticoagulation like venous injuries or intracranial injuries that are contraindications to the use of anticoagulation, type of anticoagulation and expertise available as well as the experience level of the operating surgeon. Literature also reveals the use of new oral anticoagulants (e.g., dabigatran) to be associated with lesser bleeding episodes when compared to warfarin, so in future, we can check the feasibility of these agents to reduce the bleeding episodes and at the same time improve the limb salvage rates.

Comparative genomics using teleost fish helps to systematically identify target gene bodies of functionally defined human enhancers.

BACKGROUND: Human genome is enriched with thousands of conserved non-coding elements (CNEs). Recently, a medium throughput strategy was employed to analyze the ability of human CNEs to drive tissue specific expression during mouse embryogenesis. These data led to the establishment of publicly available genome wide catalog of functionally defined human enhancers. Scattering of enhancers over larger regions in vertebrate genomes seriously impede attempts to pinpoint their precise target genes. Such associations are prerequisite to explore the significance of this in vivo characterized catalog of human enhancers in development, disease and evolution. RESULTS: This study is an attempt to systematically identify the target gene-bodies for functionally defined human CNE-enhancers. For the purpose we adopted the orthology/paralogy mapping approach and compared the CNE induced reporter expression with reported endogenous expression pattern of neighboring genes. This procedure pinpointed specific target gene-bodies for the total of 192 human CNE-enhancers. This enables us to gauge the maximum genomic search space for enhancer hunting: 4 Mb of genomic sequence around the gene of interest (2 Mb on either side). Furthermore, we used human-rodent comparison for a set of 159 orthologous enhancer pairs to infer that the central nervous system (CNS) specific gene expression is closely associated with the cooperative interaction among at least eight distinct transcription factors: SOX5, HFH, SOX17, HNF3ß, c-FOS, Tal1beta-E47S, MEF and FREAC. CONCLUSIONS: In conclusion, the systematic wiring of cis-acting sites and their target gene bodies is an important step to unravel the role of in vivo characterized catalog of human enhancers in development, physiology and medicine.

Pharmacokinetic evaluation of oblimersen sodium for the treatment of chronic lymphocytic leukemia.

INTRODUCTION: Chronic lymphocytic leukemia (CLL) is the most common form of leukemia in the western hemisphere. Developing new therapies remains a priority as present treatment options do not offer a cure. BCL-2 overexpression in CLL is associated with aggressive disease features and resists chemotherapy. Oblimersen sodium (G3139) is a phosphorothioate oligonucleotide antisense drug targeting the BCL-2 mRNA and is the first antisense to reach advanced clinical testing in oncology. Preclinical evaluation has demonstrated good antineoplastic effect in B-cell cancers; several clinical trials have confirmed its safety and efficacy both alone and in combination with other therapeutics. AREAS COVERED: This review focuses on the chemistry, pharmacodynamics, pharmacokinetics and clinical evaluation of oblimersen in CLL. PubMed and MEDLINE searches assisted in data collection. EXPERT OPINION: Bcl-2 is an important target in CLL. Antisense therapy is a novel approach to target oncoproteins; this can be beneficial in the clinical setting. Oblimersen sodium demonstrates the clinical safety of the antisense therapeutic approach and, with chemotherapy, shows survival advantage in a subset of CLL patients. However, future approval of oblimersen sodium in CLL remains uncertain. Nevertheless, BCL-2 remains a critical target in drug development and is an area of high-priority research.

In cardiac surgery patients does Voluven(R) impair coagulation less than other colloids?

Hydroxyethyl starch (HES) solutions are commonly used for volume replacement in cardiac surgery patients. The degree of impairment of the haemostatic system depends on the molecular weight and substitution degree of HES solutions. It is claimed that as HES 130/0.4 (Voluven(®)) exhibits a lower in vitro molecular weight and a lower degree of hydroxyethyl substitution than HES 200/0.5 (HAES-steril(®)) therefore it has less impact on haemostasis. A best evidence topic in cardiac surgery was written according to a structured protocol to verify this statement. The question addressed was: in cardiac surgery patients does volume replacement with Voluven(®) impair coagulation less than other colloids? Using the reported search 12 papers, three in vitro and nine clinical studies, were found to represent the best evidence to answer the clinical question. The nine clinical studies were all randomised controlled trials. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The in vitro studies suggest that HES 130/0.4 has no significant effect on platelet variables, shows a faster clot formation process and a better clot retraction as compared with the other HES solutions. On the other hand, current best available evidence (level 1b) from clinical studies, limited by heterogeneity predominantly in terms of dosage of HES 130/0.4 administered and the sample size of individual trials, overwhelmingly suggests that HES 130/0.4 compared with HES 200/0.5 or gelatin-based volume replacement fluid affects coagulation to the same extent resulting in similar degree of blood loss. It can be concluded that contrary to in vitro studies HES 130/0.4 in clinical practice has comparable effects on blood loss after cardiac surgery.

Enhanced external counter pulsation (EECP) for refractory angina pectoris (RAP); results from a first case series.

Enhanced External Counterpulsation (EECP) has emerged as a promising non-invasive modality not only for patients with refractory angina pectoris (RAP) but also for patients with heart failure. To our knowledge, no published data exists in Pakistan about the benefits of EECP. We report on a case series of 16 consecutive patients undergoing EECP. All patients were either deemed not to be candidates for revascularization or had failed revascularization with RAP on optimal medical therapy. Data was collected regarding the coronary anatomy, clinical presentation, Pre and Post EECP Canadian Cardiovascular Society (CCS) class, nitrate use and 6-min walk test. Patients with severe peripheral vascular disease and arrhythmias were excluded. The mean age was 56 +/- 11.1 years. Eight patients had 3-vessel disease. 4 post-CABG with occluded grafts and the rest with variable combination of coronary disease. Seven (44%) patients had Unstable Angina and 9 (56%) had Stable Angina. The mean 6 min walk distance before EECP was 295 +/- 148.60 meters and after EECP was 360 +/- 102.12 meters (p = 0.013). The CCS class before and after EECP also showed significant improvement (p = 0.017). Sublingual nitroglycerine use also showed a positive trend after EECP. EECP was noted to be a safe and effective modality for patients with RAP with statistically significant improvement in measures of quality of life.