Effect of intra-abdominal pressure on post-laparoscopic cholecystectomy shoulder tip pain: A randomized control trial.

OBJECTIVE: To compare the effect of intra-abdominal pressure on postoperative shoulder-tip pain in laparoscopic cholecystectomy. METHODS: This was a randomized control study, conducted at Lady Reading Hospital Peshawar from January to August 2013 on160 patients, randomized to two groups i.e. the low pressure (LPLC) and the standard pressure group (SPLC) where the intra abdominal pressures were kept 10mmHg and above 10mmHg during surgery respectively. The age, gender, weight, duration of surgery, postoperative pain and frequency of analgesic administration in first 24 hours recorded and analyzed using Statistical Package for Social Sciences v20.0. Frequency and percentages were calculated for categorical while mean ± SD was calculated for continuous variables. P-value of <0.05 was considered significant. RESULTS: The mean operative times in group A and B were 27.84±6.078 vs. 28.51±7.45 minutes (p-value=0.625) respectively. Overall, the shoulder tip pain was reported in 25 (15%) patients. The frequencies in group A and B were 6 (7.5%) vs. 19 (23.8%) respectively (p-value = 0.005). The mean intensity of pain on VAS was 0.28±0.90 vs. 1.31±2.38 in the two groups respectively (p-value of 0.001). The mean number of analgesic administration in the first 24 hours was 2.24±0.48 in Group A vs.2.41±0.52 in Group B (p-value = 0.02) respectively. CONCLUSIONS: Our study shows that low intra-abdominal pressure results in reduced frequency of post-operative shoulder tip pain without any prolongation of duration of surgery.

Aberrant Promoter Methylation at CpG Cytosines Induce the Upregulation of the E2F5 Gene in Breast Cancer.

PURPOSE: The promoter methylation status of cell cycle regulatory genes plays a crucial role in the regulation of the eukaryotic cell cycle. CpG cytosines are actively subjected to methylation during tumorigenesis, resulting in gain/loss of function. E2F5 gene has growth repressive activities; various studies suggest its involvement in tumorigenesis. This study aims to investigate the epigenetic regulation of E2F5 in breast cancer to better understand tumor biology. METHODS: The promoter methylation status of 50 breast tumor tissues and adjacent normal control tissues was analyzed. mRNA expression was determined using SYBR® green quantitative polymerase chain reaction (PCR), and methylation-specific PCR was performed for bisulfite-modified genomic DNA using E2F5-specific primers to assess promoter methylation. Data was statistically analyzed. RESULTS: Significant (p<0.001) upregulation was observed in E2F5 expression among tumor tissues, relative to the control group. These samples were hypo-methylated at the E2F5 promoter region in the tumor tissues, compared to the control. Change in the methylation status (Δmeth) was significantly lower (p=0.022) in the tumor samples, indicating possible involvement in tumorigenesis. Patients at the postmenopausal stage showed higher methylation (75%) than those at the premenopausal stage (23.1%). Interestingly, methylation levels gradually increased from the early to the advanced stages of the disease (p<0.001), which suggests a putative role of E2F5 methylation in disease progression that can significantly modulate tumor biology at more advanced stage and at postmenopausal age (Pearson's r=0.99 and 0.86, respectively). Among tissues with different histological status, methylation frequency was higher in invasive lobular carcinoma (80.0%), followed by invasive ductal carcinoma (46.7%) and ductal carcinoma in situ (20.0%). CONCLUSION: Methylation is an important epigenetic factor that might be involved in the upregulation of E2F5 gene in tumor tissues, which can be used as a prognostic marker for breast cancer.

Routine preoperative chest x-ray and its impact on decision making in patients undergoing elective surgical procedures.

BACKGROUND: It is the routine of our hospital that all patients undergoing any kind of surgery in any specialty are subjected to routine pre-op chest x-ray (CXR). However there is increasing evidence that this practice does not have much influence on patient management and thus could be limited to a very small number of patients in whom it is justified. We conducted this study to know the significance of routine pre-op x-rays chest in patients admitted in a surgical unit for elective surgery and to what extent such routine x-ray affected our surgical intervention. METHODS: It is a cross sectional study in which 500 consecutive adult patients admitted in surgical 'C' unit of Lady Reading Hospital Peshawar, for elective surgical procedures were included. The age, gender, co-morbidity, delay in operation if any was recorded and CXR were reported upon by a qualified radiologist. The influence on decision making regarding fitness of patients for general anaesthesia/surgery was also determined. Data were analysed using SPSS-20. RESULTS: Out of total of 500 chest x-rays 109 (21.8%) were reported to have some abnormality in the film. Out of these 109, 58 were male 51 were female patients. The percentages of abnormal CXR according to age were 13.6%, 35.8%, and 50% in the 16-39 years, 40-69 years and > or = 70 year age groups respectively. Amongst the patients with abnormal CXR, 30 had their surgery delayed. However in only one patient out of the 30 the delay was on the basis of significant finding on the CXR. CONCLUSION: Good medical history and clinical examination can save many patients from unnecessary CXR. Preoperative CXR may only be dclone in patients who have a clear indication for this investigation.

Trainees' feedback on the prevailing teaching methods in postgraduate medical institute, Lady Reading Hospital, Peshawar, Pakistan.

OBJECTIVE: To determine the feedback of postgraduate (PG) trainees on their current teaching methods and their level of satisfaction with those at a tertiary care hospital in Pakistan. STUDY DESIGN: Cross-sectional study. PLACE AND DURATION OF STUDY: Department of Surgery, Lady Reading Hospital, Peshawar, from January to May 2010. METHODOLOGY: A semi-structured proforma was filled by the trainees regarding teaching methods and preferences. Level of satisfaction was measured by five points Likert scale. Results were processed through SPSS 17.0 for descriptive statistics. RESULTS: The response rate was 260 out of the total 268 trainees. Lecture / tutorials were reported as the major method of teaching by 239 (91.9%), bedside teaching by 229 (88.1%), journal club by 217 (83.5%), e-learning by 157 (60.4%), audit meetings by 152 (58.5%), interactive sessions by 144 (55.4%), radiology meeting by 101 (38.8%) and TOACS by 39 (15%) trainees. Out of 28 units, TOACS were practised as a teaching method in 3 units. It was noted that 47 trainees (18.1%) graded the current training to be unsatisfactory, 127 as fair (48.8%), 77 as good (29.6%), 9 as very good (3.5%) while none considered it to be excellent. TOACS was the most preferred method of teaching, reported by 239 PGs (91.9%). Excessive work load as a cause for the dissatisfaction was reported by 229 trainees (88.1%), inadequate teaching by 157 (60.4%), lack of motivation 124 (47.7%), inappropriate teaching 122 (46.9%) and personal problems by 118 (45.4%). CONCLUSION: Lecture is the most commonly used method of teaching in the Lady Reading Hospital, Peshawar, while TOACS is the most preferred method amongst trainees, but it is the least practiced.

Frequency of hepatitis C infection in diabetic patients.

BACKGROUND: Diabetic patients are at an increased risk of acquiring Hepatitis C virus (HCV) infection owing to the nature of the disease and its inherent complications or frequent parentral exposure. On the other hand HCV infection may itself contribute to the development of Diabetes Mellitus. The epidemiological evidence of this association has not been studied in Pakistan at a population level and its exact biological mechanisms are not obvious. Objective of this study was to study the frequency of HCV infection among adult diabetic patients attending the Hospital. METHODS: The study comprised of 100 Diabetic patients visiting the out patient clinics or admitted in the medical wards of a Teaching Hospital, in Peshawar. Diabetes was confirmed according to the new diagnostic criteria based on 2 fasting or 2 random plasma glucose levels of more than 126 milligram per deciliter (mg/dL) and 200 mg/dL respectively. The presence of HCV infection was confirmed by Enzyme Linked Immuno-Sorbent Assay (ELISA) method. A concise history of the patient, examination and laboratory findings were recorded on a Performa. RESULTS: Out of the hundred diabetics, 36% were found to be anti HCV positive and all of them had type II diabetes. There was no gender difference in the seropositive cases. Serum Glutamic-Pyruvic Transaminase (SGPT) level was raised in 75% of the positive cases as compared to the 25% of the seronegative patients. The seropositive cases had a comparatively higher blood sugar level. CONCLUSION: HCV infection occurs more often in type II diabetics and further investigations should be done in diabetic patients with raised SGPT for the presence of chronic HCV infection.