Efficacy of preoperative single dose antibiotic in patients undergoing mesh repair for inguinal hernia.

BACKGROUND: Inguinal hernia is the commonest type of external hernias. Lichtenstein mesh repair is the most favoured technique of inguinal hernia repair nowadays. It is tension free repair of weakened inguinal wall using polypropylene mesh. The present study was conducted to determine the efficacy of single dose antibiotic with placebo on patients undergoing inguinal hernia mesh repair. METHODS: This randomised controlled trial was carried out in the Department of General Surgery, Ayub Teaching Hospital, Abbottabad from January to December 2011. The study population included male patients presenting with primary unilateral inguinal hernia, above 18 years of age. Mesh repair was performed in all patients. The patients were randomly divided into two groups. Patients in group A were given a single dose of antibiotic before inguinal hernia mesh repair and patients in group B were given placebo before inguinal hernia mesh repair. Efficacy of antibiotic and placebo was accessed in terms of surgical site infections (SSIs). RESULTS: A total of 166 cases of inguinal hernia mesh repair patients were recorded during the study period. A total of 83 patients were recruited in each group. Surgical site infection was found in 6 (7.2%) in Group B it was 15 (18.1%). The difference being statistically significant (p = 0.036). CONCLUSION: Antibiotic prophylaxis is a preferred option for mesh plasty.

Pre-hospital management of spinal injuries in a natural disaster.

BACKGROUND: Spinal injuries are one of the most devastating and crippling conditions known to mankind. Natural calamities follow no rules, and all have the potential of devastating medical and public health resources, earthquakes being the deadliest. The incidence of spinal injuries increases by leaps and bounds in such calamities. Improper pre-hospital management and inadvertent manipulation of the spine during rescue and transfer can aggravate the damage. This study was conducted in order to access the level of pre-hospital care that had been provided to the patients with spinal injuries reaching Ayub Teaching Hospital, Abbottabad after the October 2005 earthquake. METHODS: This study was conducted in the department of Neurosurgery, Ayub Medical College after the earthquake of October 2005. All patients sustaining spinal injuries were included in the study. Demographic data like age, gender and time of arrival at hospital were recorded. The important aspects of pre-hospital care like spinal immobilisation, intravenous access, fluid resuscitation, catheterisation, pain killers and intravenous steroids administration were also recorded. RESULTS: Out of the 83 patients with spinal injuries, 55 (66.26%) were females and 28 (33.7%) were males. Age ranged from 12-68 years (mean 26.6 +/- 13.2 years). At the time of presentation 70 (84.3%) patients had complete spinal injury whereas 13 (15.6%) had incomplete spinal injury. Sixty-one (73.5%) patients were paraplegic and 22 (26.5%) cases were quadriplegic. Only 8 (9.6%) patients were brought to the hospital after proper spinal immobilisation on the spinal boards. Intravenous line was maintained in 24 (28.9%) patients and only 18 (21.7%) received some sort of fluid resuscitation. Thirty-eight (45.7%) were catheterised. 18 (21.6%) received some sort of parenteral analgesics and 4 (4.8%) received steroids at the time of patients. Only 10(12%) were brought in properly equipped ambulances. CONCLUSION: Poor pre-hospital management of spinal injured patients depicts the lack of emergency preparedness as well as the lack of basic knowledge rescue teams and health care providers about the common trauma management measures. There is a dire need of educating rescue workers and volunteers about spinal injury in order to save lives minimise the secondary damage to already affected spine.

Incidence and risk factors for cholangiocarcinoma in primary sclerosing cholangitis.

Cholangiocarcinoma (CCA) is a dreaded complication of primary sclerosing cholangitis (PSC); however, marked variability in the incidence of CCA in PSC is reported. Furthermore, limited information exists on risk factors for the development of CCA in PSC. The aim of this study was to determine the incidence of CCA in patients with PSC and to evaluate baseline risk factors for the later development of CCA. From a previous study of the natural history of PSC, we identified 161 patients with PSC who did not have CCA at study entry. Patients were followed until a diagnosis of CCA was established, liver transplantation was performed, or death occurred. Patients were followed for a median of 11.5 yr (interquartile range 4.0-16.1 yr). Fifty-nine patients (36.6%) died, 50 patients (31.1%) underwent liver transplantation, and 11 patients (6.8%) developed CCA. The rate of CCA developing was approximately 0.6% per year. Compared to the incidence rates of CCA in the general population, the relative risk of CCA in PSC was significantly increased (RR = 1,560; 95%CI = 780, 2,793; p < 0.0001). On univariate analysis, a history of variceal bleeding (p < 0.001), proctocolectomy (p= 0.01), and lack of symptoms (p= 0.02) were significant risk factors for CCA with the Mayo Risk Score being marginally significant (p= 0.051). Multivariate analysis determined only variceal bleeding to be a significant risk factor for CCA (RR 24.2; 95%CI: 3.3-67.1). No association was found between the duration of PSC and the incidence of CCA. In conclusion, approximately 7% of PSC patients later developed CCA over a mean follow-up of 11.5 yr, which is dramatically higher than the rates in the general population. Variceal bleeding is a major risk factor for the later development of CCA.

Subclinical reactivation of hepatitis B virus in liver transplant recipients with past exposure.

Transmission of hepatitis B infection has been reported in liver transplant recipients whose donor livers were negative for hepatitis B surface antigen (HBsAg) and positive for antibody to hepatitis B core antigen (anti-HBc). These infections usually have a mild clinical course and no adverse effects on survival. However, the outcome of liver transplant recipients with serologic evidence of past infection to hepatitis B virus (HBV) is unknown. The prevalence of HBV DNA positivity by polymerase chain reaction (PCR) pretransplantation in HBsAg-negative, anti-HBc-positive people is reported to be 0% to 32%. To assess the prevalence of HBV DNA in pretransplantation serum and liver tissue and to determine the clinical outcome of HBsAg-negative, anti-HBc-positive recipients, we retrospectively reviewed the first 693 orthotopic liver transplantations performed at Mayo Clinic between March 19, 1985, and May 25, 1996. Pretransplantation specimens of frozen serum and liver tissue were available for HBV DNA by PCR for 35 of 56 HBsAg-negative, anti-HBc-positive recipients. Twenty-two recipients had positive serologic findings for anti-HBc alone, and 13 were positive for anti-HBc and antibody to HBsAg (anti-HBs). Pretransplantation prevalence of HBV DNA in HBsAg-negative, anti-HBc-positive recipients was 6% (serum) to 29% (liver). Of those recipients whose liver was HBV DNA-positive pretransplantation, 40% also had evidence of HBV DNA in posttransplantation liver biopsy specimens, and this finding was more common in patients co-infected with hepatitis C. None of the recipients became antigenemic (HBsAg-positive) or developed clinical hepatitis B posttransplantation. Thus, prophylactic intervention (eg, antiviral or antinucleoside analog therapy) is not warranted after liver transplantation in HBsAg-negative, anti-HBc-positive recipients. In our experience, infected donor livers are the most common source of de novo posttransplantation hepatitis B infection in transplant recipients.