Postmenopausal virilization secondary to a large ovarian cystadenoma with stromal hyperthecosis.

Ovarian cystadenomas may present in a functional manner. Biochemical workup of seemingly benign ovarian lesions should be considered in the appropriate clinical context.

Laparoscopic-assisted percutaneous endoscopic gastrostomy tube insertion in the immediate post-partum period for head and neck cancer.

Percutaneous endoscopic gastrostomy (PEG) tube placement serves as a well-tolerated and efficacious technique for long-term enteral access in patients with medical conditions precluding oral food intake. The nutritional optimisation of patients with oral cancer is mostly achieved via PEG tube placement. However, certain special situations, such as pregnancy and the immediate post-partum period, may render the placement of PEG tubes to be a challenge. A 28-year-old pregnant female patient presented to us with the diagnosis of squamous cell carcinoma of the tongue during her third trimester. Definitive surgical resection was planned post-delivery along with simultaneous PEG tube placement. Immediately following delivery via an elective Caesarean section, she successfully underwent laparoscopic-assisted PEG tube placement. A gravid uterus or an immediately post-partum distended uterus poses significant difficulties whilst attempting PEG insertion. However, laparoscopic-assisted PEG insertion in a controlled setting may make the process safer to perform.

Near complete aortic transection and its successful repair using a novel cardiopulmonary bypass technique.

The case of a 38-year old female, victim of a road traffic accident who presented with a near complete aortic transection is presented. An emergent repair employing cardiopulmonary bypass was attempted in the operating room. Anticipating a high-risk of compromise to cerebral perfusion from air micro-emboli, the bypass was attempted with an innovative approach involving the successful cannulation of the pulmonary artery and descending aorta. The patient survived and was found to be doing well on subsequent post-operative visits.

Angiographic embolization for major trauma in a low-middle income healthcare setting--A retrospective review.

INTRODUCTION: Interventional radiology (IR) provides a range of adjunctive techniques to assist with hemorrhage control after trauma that can be employed pre- or post-operatively. The role of IR in lower-middle income countries (LMICs) remains unexplored. This study describes the use of adjunctive angioembolization (AE) in severely injured patients following its recent implementation at an urban trauma center in a LMIC. METHODS: Adult patients (≥ 16 years) requiring AE from 2011 to 2013 at a single trauma-care facility were included. Data was collected on demographic parameters, transfer status, injury severity score (ISS), emergency resuscitation characteristics, AE and operative characteristics, complications, and in-hospital mortality. Descriptive analyses were performed. RESULTS: Thirty six patients underwent AE for trauma-related hemorrhagic complications and were included in the study. Average age was 31.5 (± 11.3) years with a male preponderance (91.7%). Penetrating trauma (61.1%) was the most common type of injury. The primary mechanism of injury was gunshot (58.3%). The median ISS was 24 (IQR: 20-29). Pre-operative AE was performed in 23 (63.9%) patients and these patients had a lower median ISS (22) than those who underwent post-operative AE (p = 0.015). Hepatic (55.6%) and pelvic (33.3%) trauma more commonly required radiological intervention. Bleeding from the right hepatic (n = 14), and the right internal iliac (n = 6) arteries and/or their branches, were more often embolized. Microcoils were the preferred AE agents (61.1%). Median length of hospital stay was 7.5 (IQR: 3-14) days. Eight (22.2%) patients did not survive. CONCLUSION: With the availability of multi-detector computed tomography and a dedicated interventional radiology suite, implementation of AE for the care of trauma patients in LMIC settings is possible.

Abdominal gunshot wounds-a comparative assessment of severity measures.

BACKGROUND: Penetrating abdominal trauma is a common feature of trauma treated in low- and middle-income countries (LMICs). The penetrating abdominal trauma index (PATI) and the injury severity score (ISS) are severity-measures most often used to gauge injury severity. It remains unclear which measure better accounts for the severity of sustained injuries. This study compares the predictive ability of both injury severity measures in patients presenting to an LMIC in South Asia. METHODS: All isolated gunshot wounds to the abdomen presenting to a university hospital between 2011 and 2012 were included. ISS and PATI were calculated for each case. Primary outcome measures included all-cause mortality and complications. Multivariable analysis adjusting for age, sex, referral status, hypotension, tachycardia, and injury severity measures was performed. The area under the receiver operating characteristic (AUROC) curve were further calculated to compare the respective abilities of ISS and PATI at predicting death and complications. RESULTS: A total of 70 patients were included. The average age on presentation was 34.5 y (±11.4) within a predominantly male (n = 68, 97.1%) cohort. Most gunshot wounds were intentionally inflicted (n = 67, 95.7%). The crude rates of death and complications were 34.3% and 15.7%, respectively. The median ISS was 14 (interquartile range: 11-21), and the median PATI was 16 (interquartile range: 9-26). AUROC analysis revealed that ISS was comparable with PATI at predicting mortality (AUROC [95% confidence interval]: 0.952 [0.902-1.00] versus 0.934 [0.860-1.00]) and complications (AUROC [95% confidence interval]: 0.868 [0.778-0.959] versus 0.895 [0.815-0.975]). CONCLUSIONS: The predictive ability of ISS and PATI severity measures was found to be comparable. The results suggest that both measures can be used to risk-stratify patients with isolated abdominal gunshot wounds in an LMIC.

National estimates of predictors of outcomes for emergency general surgery.

BACKGROUND: Identifying predictors of mortality and surgical complications has led to outcome improvements for a variety of surgical conditions. However, similar work has yet to be done for factors affecting outcomes of emergency general surgery (EGS). The objective of this study was to determine the predictors of in-hospital complications and mortality among EGS patients. METHODS: The Nationwide Inpatient Sample (2003-2011) was queried for patients with conditions encompassing EGS as determined by the American Association for Surgery of Trauma, categorizing them into predefined EGS groups using DRG International Classification of Diseases-9th Rev.-Clinical Modification codes. Primary outcomes considered included incidence of a major complication (pneumonia, pulmonary emboli, urinary tract infections, myocardial infarctions, sepsis, or septic shock) and in-hospital mortality. Separate multivariate logistic regression analyses for complications and mortality were performed to identify risk factors of either outcome from the following domains: patient demographics (age, sex, insurance type, race, and income quartile), comorbidities, and hospital characteristics (location, teaching status, and bed size). RESULTS: This study included 6,712,151 discharge records, weighted to represent 32,910,446 visits for EGS conditions. Mean age was 58.50 (19.74) years; slightly more than half (54.66%) were female. Uninsured patients were more likely to die (odds ratio,1.25; 95% confidence interval, 1.20-1.30), whereas patients in the highest income quartile had the least likelihood of mortality (odds ratio, 0.86; 95% confidence interval, 0.84-0.87). Old age was an independent predictor of mortality for all EGS subdiagnoses. The overall mortality rate was 1.76%; the overall complication rate was 10.03%. Of the patients who died, 62% experienced at least one major complication. Patients requiring resuscitation had the highest likelihood of mortality followed by patients with vascular disease and hepatic disease. CONCLUSION: Death patterns of EGS patients were discerned using an administrative data set. Understanding patterns of mortality and complications derived from studies such as this could improve hospital benchmarking for EGS, akin to trauma surgery's previous success. LEVEL OF EVIDENCE: Prognostic and epidemiologic study, level III.

Impact of a predefined hospital mass casualty response plan in a limited resource setting with no pre-hospital care system.

INTRODUCTION: Pre-hospital triage is an intricate part of any mass casualty response system. However, in settings where no such system exists, it is not known if hospital-based disaster response efforts are beneficial. This study describes in-hospital disaster response management and patient outcomes following a mass casualty event (MCE) involving 200 victims in a lower-middle income country in South Asia. METHODS: We performed a single-center, retrospective review of bombing victims presenting to a trauma center in the spring of 2013, after a high energy car bomb leveled a residential building. Descriptive analysis was utilized to present demographic variables and physical injuries. RESULTS: A disaster plan was devised based on the canons of North-American trauma care; some adaptations to the local environment were incorporated. Relevant medical and surgical specialties were mobilized to the ED awaiting a massive influx of patients. ED waiting room served as the triage area. Operating rooms, ICU and blood bank were alerted. Seventy patients presented to the ED. Most victims (88%) were brought directly without prehospital triage or resuscitation. Four were pronounced dead on arrival. The mean age of victims was 27 (±14) years with a male preponderance (78%). Penetrating shrapnel injury was the most common mechanism of injury (71%). Most had a systolic blood pressure (SBP) >90 with a mean of 120.3 (±14.8). Mean pulse was 90.2 (±21.6) and most patients had full GCS. Extremities were the most common body region involved (64%) with orthopedics service being consulted most frequently. Surgery was performed on 36 patients, including 4 damage control surgeries. All patients survived. CONCLUSION: This overwhelming single mass-casualty incident was met with a swift multidisciplinary response. In countries with no prehospital triage system, implementing a pre-existing disaster plan with pre-defined interdisciplinary responsibilities can streamline in-hospital management of casualties.

Do delays in surgery affect outcomes in patients with inter-trochanteric fractures?

OBJECTIVE: To study the differences in outcomes of early versus delayed surgery in patients with intertrochanteric fractures. METHODS: The retrospective chart review was conducted at Aga Khan University Hospital, Karachi, and comprised data of patients who underwent surgery for intertrochanteric hip fractures from 2005 to 2010. A gap of >48hours between the event and the surgery was considered a delayed procedure and its impact on outcome was assessed. RESULTS: Of the 190 patients, 138(72.6%) were in the early group and 52(27.3%) in the delayed group. The most common cause for delay of surgery was electrolyte imbalance in 14(27%) patients. Patients with delayed surgery had more comorbidites and higher ASA grades compared to those that underwent early surgery (p<0.05). Inpatient mortality was significantly higher in the delayed group (p=0.006). Multivariate analysis showed that higher mortality was associated with delay in surgery. CONCLUSIONS: In patients with multiple comorbid conditions, expedited optimisation for surgery may be warranted to reduce mortality.

Dynamic hip screw fixation for inter-trochanteric fractures: determinants of outcomes.

OBJECTIVE: To evaluate factors associated with revision of dynamic hip screw implant in patients undergoing the procedure for the fixation of intertrochanteric fractures. METHODS: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised records of patients who had undergone dynamic hip screw fixation surgery between 2008 and 2012. Medical records and data for all patients were obtained from the medical records office. For all patients, the record files were systematically reviewed using a structured, pre-defined data extraction sheet. SPSS 20 was used statistical analysis. RESULTS: Out of 317 patients who had undergone the procedure, 8(2.5%) were excluded due to missing records. The study sample as such stood at 309(97.5%). Of them, 6(1.9%) required revision of the dynamic hip screw placed initially. High tip apex distance was found to be associated with the revision (p<0.0001).Demographic parameters and co-morbid conditions were not associated with a need for revision surgery (p>0.05). CONCLUSIONS: Patients requiring dynamic hip screw implant revision had higher tip apex distance than the rest. A lower value is advisable during placement of the screw to reduce the need for subsequent revision.

Hip fracture surgery: does type of anesthesia matter?

BACKGROUND: Hip fracture surgery is a common procedure, and the geriatric population with its multiple comorbid conditions is at most at risk of developing anesthesia-related complications. Data on the impact of type anesthesia on postoperative morbidity and mortality is limited. The effects of regional and general anesthesia on postoperative outcomes need to be clearly elucidated. METHODS: In this study, all patients who underwent dynamic hip screw (DHS) fixation for intertrochanteric fractures, between January 2005 and December 2010, at the Aga Khan University Hospital, were included. Patients were divided into two groups; group A included those patients who received general anesthesia, and group B consisted of patients who had received regional anesthesia. The two groups were compared for differences in morbidity, mortality, and intraoperative complications based on the type of anesthesia administered. RESULTS: During this period, 194 patients underwent DHS fixation. One hundred and seven patients received general anesthesia whereas eighty-seven patients received regional anesthesia. The mean operative time was significantly lower in the group receiving regional anesthesia (1.25 ± 0.39 hrs) as compared to those who received general anesthesia (1.54 ± 0.6 hrs) (P < 0.05). There were no statistically significant differences in the rates of wound infections, length of hospital stay, postoperative ambulation status, intraoperative blood loss, postoperative complications, and mortality between the regional and general anesthesia groups. CONCLUSION: Even though administration of regional anesthesia was positively correlated with shorter operative duration, the type of anesthesia was not found to affect surgical outcomes in the two study groups. Based on these results, we recommend that anesthesia should be tailored to individual patient requirements.

Obesity and the need for bariatric surgery in Pakistan.

After establishing a foothold in the West, the pandemic of obesity now threatens to spin out of control in the developing nations of Asia and the Indian subcontinent. Like many of its neighbors, Pakistan has witnessed an unprecedented growth in the number of overweight and obese individuals in its population, and obesity is proving to be an issue of considerable public health concern. Conventional medical therapies for obesity and related complications have proven to be less than effective, especially in the population of the southeast, which appears to be inherently predisposed to developing obesity-related complications. Bariatric surgery is fast emerging as a definitive therapeutic alternative for obesity and has proven to be highly successful and cost-effective at producing remission of complications of the same. In this article, we expound the need for introducing and incorporating bariatric surgery as part of the therapeutic protocols for obese individuals of South Asian descent suffering from the chronic and debilitating complications of obesity.

A randomized, double-blind, placebo-controlled trial of oral montelukast in acute asthma exacerbation.

BACKGROUND: Leukotriene receptor antagonists (LTRAs) are well established in the management of outpatient asthma. However, there is very little information as to their role in acute asthma exacerbations. We hypothesized that LTRAs may accelerate lung function recovery when given in an acute exacerbation. METHODS: A randomized, double blind, placebo-controlled trial was conducted at the Aga Khan University Hospital to assess the efficacy of oral montelukast on patients of 16 years of age and above who were hospitalized with acute asthma exacerbation. The patients were given either montelukast or placebo along with standard therapy throughout the hospital stay for acute asthma. Improvements in lung function and duration of hospital stay were monitored. RESULTS: 100 patients were randomized; their mean age was 52 years (SD +/- 18.50). The majority were females (79%) and non-smokers (89%). The mean hospital stay was 3.70 ± 1.93 days with 80% of patients discharged in 3 days. There was no significant difference in clinical symptoms, PEF over the course of hospital stay (p = 0.20 at day 2 and p = 0.47 at day 3) and discharge (p = 0.15), FEV1 at discharge (p = 0.29) or length of hospital stay (p = 0.90) between the two groups. No serious adverse effects were noted during the course of the study. CONCLUSION: Our study suggests that there is no benefit of addition of oral montelukast over conventional treatment in the management of acute asthma attack. TRIAL REGISTRATION NUMBER: 375-Med/ERC-04.

Pulmonary talcosis 10 years after brief teenage exposure to cosmetic talcum powder.

Pulmonary talcosis is a rare but debilitating variant of pneumoconiosis often presenting with isolated non-specific symptoms of progressive exertional dyspnoea or cough. Occupational exposure to talc dust and intravenous drug abuse are well-recognised aetiological factors with only a few cases related to cosmetic talc exposure being reported to date. The authors report a case of a young woman in whom a mere 4 month ritual of inhaling cosmetic talcum powder led to full-blown pulmonary talcosis being diagnosed 10 years later. The importance of a taking a pertinent history relating to environmental exposures in all patients presenting with respiratory symptoms is re-established here.