A comprehensive review on ziconotide.

Managing severe chronic pain is a challenging task, given the limited effectiveness of available pharmacological and non-pharmacological treatments. This issue continues to be a significant public health concern, requiring a substantial therapeutic response. Ziconotide, a synthetic peptide initially isolated from Conus magus in 1982 and approved by the US Food and Drug Administration and the European Medicines Agency in 2004, is the first-line intrathecal method for individuals experiencing severe chronic pain refractory to other therapeutic measures. Ziconotide produces powerful analgesia by blocking N-type calcium channels in the spinal cord, which inhibits the release of pain-relevant neurotransmitters from the central terminals of primary afferent neurons. However, despite possessing many favorable qualities, including the absence of tolerance development, respiratory depression, and withdrawal symptoms (largely due to the absence of a G-protein mediation mechanism), ziconotide's application is limited due to factors such as intrathecal administration and a narrow therapeutic window resulting from significant dose-related undesired effects of the central nervous system. This review aims to provide a comprehensive and clinically relevant summary of the literatures concerning the pharmacokinetics and metabolism of intrathecal ziconotide. It will also describe strategies intended to enhance clinical efficacy while reducing the incidence of side effects. Additionally, the review will explore the current efforts to refine the structure of ziconotide for better clinical outcomes. Lastly, it will prospect potential developments in the new class of selective N-type voltage-sensitive calcium-channel blockers.

Comparison of Laparoscopic Intraperitoneal Onlay Mesh (IPOM) Hernioplasty With Laparoscopic IPOM-Plus: Our Initial Experience in Pakistan.

Objectives Laparoscopic intraperitoneal onlay mesh hernioplasty (IPOM) for ventral hernias has been used for a long time. However, there have been some issues associated with it, thereby leading to the introduction of a new technique that involves laparoscopic closure of the fascial defect with suture followed by intraperitoneal onlay mesh placement (IPOM-Plus). We carried out this study to compare the outcome of laparoscopic IPOM with fascial defect closure versus without defect closure in midline ventral hernia repair in terms of recurrence. Methodology This comparative study was carried out in the Department of Surgery, Services Hospital, Lahore, from October 16, 2020, to April 15, 2022. A total of 84 patients of both genders, aged between 18 and 70 years, presenting with midline ventral hernia were included in the study. Patients with recurrent hernia, unstable cardiopulmonary conditions, neurological or psychiatric diseases, chronic renal disease, congestive cardiac failure, and chronic obstructive pulmonary disease (COPD) were excluded from the study. Patients were assigned to two groups. Group 1 underwent IPOM with the closure of the defect, and Group 2 underwent IPOM without the closure of the defect. Patients were observed for immediate postoperative complications. Patients were monitored for one year to assess recurrence through clinical evaluation and ultrasonography. Results In this study, seroma formation was found in 3 (7.14%) patients for laparoscopic IPOM with fascial defect closure and 10 (23.81%) in those undergoing laparoscopic IPOM without defect closure (P-value = 0.035). Recurrence was identified in 2 (4.76%) patients undergoing laparoscopic IPOM with fascial defect closure and 9 (21.43%) in those undergoing laparoscopic IPOM without defect closure (P-value = 0.024). Conclusions This study concluded that the frequency of recurrence is less after laparoscopic IPOM with fascial defect closure in midline ventral hernia repair than after laparoscopic IPOM without fascial defect closure.

Present Status, Limitations, and Prospects of Using Streptomyces Bacteria as a Potential Probiotic Agent in Aquaculture.

Streptomyces is a Gram-positive bacterium, belonging to the family Streptomycetaceae and order Streptomycetales. Several strains from different species of Streptomyces can be used to promote the health and growth of artificially cultured fish and shellfish by producing secondary metabolites including antibiotics, anticancer agents, antiparasitic agents, antifungal agents, and enzymes (protease and amylase). Some Streptomyces strains also exhibit antagonistic and antimicrobial activity against aquaculture-based pathogens by producing inhibitory compounds such as bacteriocins, siderophores, hydrogen peroxide, and organic acids to compete for nutrients and attachment sites in the host. The administration of Streptomyces in aquaculture could also induce an immune response, disease resistance, quorum sensing/antibiofilm activity, antiviral activity, competitive exclusion, modification in gastrointestinal microflora, growth enhancement, and water quality amelioration via nitrogen fixation and degradation of organic residues from the culture system. This review provides the current status and prospects of Streptomyces as potential probiotics in aquaculture, their selection criteria, administrative methods, and mechanisms of action. The limitations of Streptomyces as probiotics in aquaculture are highlighted and the solutions to these limitations are also discussed.

Post-esophagectomy Anastomosis Leak: A 10-Year Experience at a Specialized Center for Cancer Surgeries in Pakistan.

Esophageal cancer has been reported to be the seventh most common cancer and the sixth most common cause of mortality. Use of advanced diagnostic techniques has increased the detection of preoperative metastases and resulted in better patient selection for further management by curative surgery. We carried out a study to evaluate the outcome of esophagectomy at our institute in terms of acute leak, mortality and hospital stay. We also looked at various preoperative, intraoperative and postoperative risk factors contributing to leak after esophagectomy. We evaluated 589 patients during the period from January 2009 to December 2019. All these patients underwent elective esophagectomy for esophageal cancer at our hospital. Out of these, leak was seen in 30 patients (5.1%). We found no statistically significant difference when evaluating patient and tumour characteristics of patients who developed leak against those who did not. We also didn't find any significant difference in intraoperative or postoperative factors between the two groups. Proper preoperative evaluation and optimization are necessary to overcome various patient co-morbidities. On the basis of our study we conclude that when performed in high-volume centers with an adequately trained multi-disciplinary team approach, esophagectomy for carcinoma has a good outcome.

Laparoscopic Gastro-jejunostomy: An Ideal Solution to the Problem of Gastric Outlet Obstruction Post-corrosive Intake.

OBJECTIVE: To evaluate the outcome of Laparoscopic Gastro-jejunostomy in patients presenting with Gastric Outlet obstruction secondary to Corrosive intake at the Services Hospital. STUDY DESIGN: Case series. PLACE AND DURATION OF STUDY: Department of Surgery, Services Hospital, Lahore, Pakistan, from June 2013 to June 2021. METHODOLOGY: Data was gathered from the patients who presented with gastric outlet obstruction with a pre-hospitalised history of corrosive intake. Consenting patients subsequently underwent laparoscopic gastro-jejunostomy and were followed up post-operatively at a 1-week time-point and 4-week time-point to monitor progress. Studied variables included duration of surgery, duration of hospital stay, complications, and mortality at the 1st and 4th weeks. RESULTS: A total of 30 patients participated in the study including 27 (90%) females and 3 (10%) males. The mean age was 27.2 ± 4.07 years. The mean duration of hospital stay was 9.3 ± 3.2 days. Complications were seen in 3 patients (10%) with 1 death (3.33%). CONCLUSION: Laparoscopic gastro-jejunostomy appears to be safe and effective in corrosive intake patients presenting with gastric outlet obstruction. KEY WORDS: Corrosive Intake, Gastric outlet obstruction, Laparoscopic, Gastrojejunostomy.

Outcome of Laparoscopic Repair for Perforated Peptic Ulcers in a Resource-Limited Setting.

Background Perforation of peptic ulcers is a common cause of emergency surgery and has significant morbidity and mortality. The use and range of laparoscopic surgery have greatly increased over the past three decades. Laparoscopic approach is an option for perforated peptic ulcers because of the simple nature of the intervention. The aim of this study was to evaluate the outcome of laparoscopic approach for peptic ulcer repair in emergency setting by means of operative time, post-operative pain, mean hospital stay, and post-operative complications. Methods In this study, we enrolled patients presenting with perforated peptic ulcers in the emergency department of a tertiary care hospital in Lahore, Pakistan. Approval from the hospital ethical committee and informed consent were taken from all patients. After resuscitation, the patient underwent laparoscopic repair of perforation. Post-operative course of patients was monitored. Duration of surgery, post-operative pain, length of hospital stay, and post-operative complications were noted for all patients. Results Between December 2018 and December 2021, 31 patients with perforated peptic ulcers underwent laparoscopic repair at our hospital. Mean age of patients was 37.25 ± 7.80 years. Most of the patients were male (70.76%). The mean operation time was 109.35 ± 17.02 minutes for laparoscopic repair. Mean duration of hospital stay was 5.10 ± 0.87 days. Mean post-operative pain was 3.55 ± 0.85 assessed using the Visual Analogue Scale. There were no mortalities during the 30-day post-operative window. Conclusion With proper patient selection, laparoscopic surgery offers better results as compared to open surgery in patients undergoing emergency surgery for perforated peptic ulcers.

Efficacy of Cross-Linked Hyaluronic Acid Gel for the Reduction of Post-operative Obstructive Symptoms Due to Adhesions.

Background Adhesions occur frequently after surgery. A number of methods are being employed for reducing post-operative adhesions. The purpose of this study was to determine the efficacy of hyaluronic acid gel in the reduction of post-operative bowel obstruction symptoms in patients undergoing emergency laparotomy due to small bowel perforation and presenting with peritonitis. Methods In this experimental study, 78 patients were evaluated. All had presented to the emergency department with peritonitis secondary to small bowel perforation. Exploratory laparotomy was performed and after thorough lavage, a loop stoma was formed on the right side of the abdomen with an injection of hyaluronic acid gel injected into the abdominal cavity before the closure of the abdomen. Postoperative obstructive symptoms at one, three, and six months were evaluated. All patients underwent stoma reversal at three months. Results Obstructive bowel symptoms were seen in 18 patients (23.07%) patients. The cumulative incidence of obstructive symptoms at three months was only 8.97% but after the second intervention without protective gel, it increased to 23.07% at six months. Conclusions Cross-linked hyaluronic acid gel was effective in the reduction of post-operative bowel obstructive symptoms due to adhesions in patients who had presented with peritonitis due to small bowel perforation and had undergone exploratory laparotomy with stoma formation.

Early migration of biliary stent leading to free intra-peritoneal duodenal perforation - A case report.

Intestinal perforation from a plastic biliary stent is a known but rare complication of endoscopic biliary stent placement. Intra-peritoneal perforation is less common but carries more morbidity and mortality. Only a few cases of early stent migration and perforation have been reported. We present the case of a duodenal perforation caused by early migration of plastic biliary stent that resulted in intra-peritoneal biliary peritonitis.

Laparoscopic cholecystectomy in a type Va Mirizzi syndrome patient.

Mirizzi syndrome is a rare syndrome, caused by the compression of gall stones which may result in CBD obstruction or fistula formation. It may sometimes present without any prior symptoms. It has been classified into five types by Csendes. Usually open surgical approach is recommended for the condition, especially for Types III-V. We present the case of a patient who presented with right hypochondrial pain and was intra-operatively discovered to have type Va Mirrizi syndrome and was managed successfully laparoscopically.

Correlation Of Global Longitudinal Systolic Strain With Severity Of Coronary Artery Disease In Non-Stelevation Acute Coronary Syndrome Having Normal Ejection Fraction.

BACKGROUND: In patients of non-ST-elevation acute coronary syndrome (NSTEACS), the global longitudinal peak systolic strain (GLPS) has been used to detect the presence of coronary artery disease (CAD) before left ventricular ejection fraction (LVEF) is affected. We tried to find out the correlation between the GLPS and severity of CAD in such patients. METHODS: A descriptive correlational study was conducted from March 2018 to January 2020 at Jinnah Hospital Lahore. Two hundred and sixteen patients of NSTEACS with EF of ≥60% were included. Patients were divided according to angiographic results into those having non-significant, one-vessel, two-vessel or three-vessel disease. These four groups were compared regarding left ventricular end-systolic dimension (LVESD), left ventricular end-diastolic dimension (LVEDD), LVEF, global longitudinal peak systolic strains in apical long axis view (GLPS-APLEX), in apical 4-chamber view (GLPS-A4C), in apical 2-chamber view (GLPS-A2C) and average of these (GLPS-AVG). All these parameters were also compared between patients having and those not having left main coronary artery (LMCA) disease. RESULTS: Out of 216 patients, males and females were 124(57.4%) and 92 (42.6%) respectively. There were 28 (13.0%), 83 (38.4%), 62 (28.7%) and 43 (19.9%) patients who had non-significant, one-vessel, two-vessel and three-vessel CAD respectively. With increase in severity of CAD, GLPS-AVG progressively decreased from nonsignificant CAD being 20.6±0.7 to three-vessel CAD being 16.1±0.7. There was a significant negative correlation between severity of CAD and all of the GLPS-APLEX, GLPS-A4C, GLPSA2C and GLPS-AVG (p<0.001 in all). GLPS-AVG was significantly low in patients having LMCA disease (16.5±0.7) than those not having LMCA disease (18.2±1.5) with p-value of <0.001. All other types of GLPSs showed the similar trend. CONCLUSIONS: Global longitudinal peak systolic strain has a significant negative correlation with severity of coronary artery disease in non-ST-elevation acute coronary syndrome having normal ejection fraction.

Cardiopulmonary resuscitation: Knowledge and Attitude of doctors from Lahore.

OBJECTIVE: The objective of study was to assess the knowledge and attitude of doctors from Lahore regarding CPR as per American Heart Association (AHA) guidelines. METHODS: The researchers visited various hospitals and filled e-questionnaires by interviewing respondents.The study was conducted at Jinnah Hospital Lahore, Mayo Hospital Lahore, Punjab Institute of Cardiology Lahore, Sir Ganga Ram Hospital Lahore, Services Hospital Lahore and Mid City Hospital. Data were analyzed using statistical package for social sciences (SPSS) 23 version. Knowledge was assessed based on the scores, with those scoring 10 or more being considered to have good knowledge while those having score less than 10 were considered to have poor knowledge. P values < 0.05 were considered statistically significant. RESULTS: Out of 792 participants, 68 refused to take part in the study. The total respondents were 724 with the response rate of 91%. The knowledge regarding cardiopulmonary resuscitation of 601(83%) respondents was poor with only 123(17%) doctors having good knowledge. The doctors who received formal CPR training had better knowledge (20.17%) than the doctors who didn't get any training regarding CPR (4.69%). Anesthesiologists scored better among all specialties. The overall attitude of the doctors towards CPR was positive with 93.8% of the respondents willing to do CPR. CONCLUSION: The overall knowledge of the doctors regarding CPR is not satisfactory. A practical and functional approach is needed to improve this situation. However, the attitude of the doctors towards CPR is positive.

Overview of the latest developments in the role of probiotics, prebiotics and synbiotics in shrimp aquaculture.

With the growing world population, the demand for food has increased, leading to excessive and intensive breeding and cultivation of fisheries, simultaneously exacerbating the risk of disease. Recently, shrimp producers have faced major losses of stocks due to the prevalence of periodical diseases and inappropriate use of antibiotics for disease prevention and treatment, leading to bacterial resistance in shrimp, along with imposing health hazards on human consumers. Strict regulations have been placed to ban or reduce the use of prophylactic antibiotics to lessen their detrimental effects on aquatic life. Dietary and water supplements have been used as substitutes, among which probiotics, prebiotics, and synbiotics have been the most beneficial for controlling or treating bacterial, viral, and parasitic diseases in shrimp. The present analysis addresses the issues and current progress in the administration of pro-, pre-, and synbiotics as disease controlling agents in the field of shrimp farming. Furthermore, the benefits of pro-, pre-, and synbiotics and their mechanism of action have been identified such as; strengthening of immune responses, growth of antibacterial agents, alteration in gut microflora, competition for nutrients and binding sites, and enzymes related activities. Overall, this study aims to depict the antagonistic action of these supplements against a variety of pathogens and their mode of action to counter diseases and benefit shrimp species.

Role of Chewing Gum in Reducing Postoperative Ileus after Reversal of Ileostomy: A Randomized Controlled Trial.

BACKGROUND: Postoperative ileus is one of the most prevalent and troublesome problems after any elective or emergency laparotomy. Gum chewing has emerged as a new and simple modality for decreasing postoperative ileus. The aim of this study was to determine the effectiveness of chewing gum in reducing postoperative ileus in terms of passage of flatus and total length of hospital stay. PATIENTS AND METHODS: This single-blinded, randomized clinical trial was conducted in department of surgery, Services Hospital Lahore, between November 2013 and November 2015. The patients were divided into two groups: chewing gum (Group A) and no chewing gum (Group B). Starting 6 h after the operation, Group A patients were asked to chew gum for 30 min every 8 h; bowel sounds, passage of flatus and total length of hospital stay were noted. Outcome measures such as passage of flatus and total length of hospital stay in patients undergoing reversal of ileostomy were compared using t-test. RESULTS: Mean age of the patients in Group A was 26.12 (± 7.1) years and in Group B was 28.80 (± 10.5) years. There were 25 males (50%) and 25 females (50%) in Group A. In Group B, there were 29 males (58%) and 21 females (42%). Mean BMI in Group A was 23.5 (± 5.3), and in Group B was 21.4 (± 4.6). The mean time to pass flatus was noted to be significantly shorter, 18.36 (± 8.43) hours, in the chewing group (Group A), whereas in the no chewing gum group (Group B), it was 41.16 (± 6.14) hours (p value < 0.001). The mean length of hospital stay was significantly shorter 84 (± 8.3) hours in the chewing gum group (Group A) as compared to 107.04 (± 6.4) hours in the no chewing gum group (Group B) (p value 0.000). CONCLUSION: It is concluded that postoperative chewing of gum after the reversal of ileostomy is accompanied with a significantly shorter time to passage of flatus and shorter length of hospital stay.

Effect of COVID-19 on the Working of a Tertiary Care Hospital.

OBJECTIVE:  To evaluate the effect of COVID-19 on the working of a tertiary care hospital. STUDY DESIGN: Audit study. PLACE AND DURATION OF STUDY:  Services Hospital, Lahore from 1st March to 30th June 2020. METHODOLOGY:  We calculated and compared various parameters of hospital working. Two time periods were selected. The study period was defined as the time after first confirmed case of COVID-19 in Pakistan. The control period was defined as one year prior to the first case being reported, taken from 1st March 2019 to 29th February, 2020. The parameters we studied included were number of number of hospital admissions, emergency patients, OPD patients, major surgeries, total surgeries, radiological investigations done, laboratory investigations done, births and mortalities. All parameters were calculated by taking monthly average during each time period and then compared. RESULTS:   A decrease in almost all parameters was seen when the cases of the two time periods were compared. There was a decrease in the average hospital admission by 51%, while the patients seen in OPD fell by almost 60%. A slight decrease of 25% was seen in the cases presenting to the emergency. The most marked decrease was in the elective surgeries, which was 66% closely followed by average monthly mortality which decreased by 64%. Average monthly minor surgeries and births were decreased by 33% and 35%, respectively. CONCLUSION:  There had been a decrease in the number of patients presenting to the hospital across the board with the most marked increase being in elective surgeries. Key Words: COVID-19, Hospital working, Patient load, Elective surgery.

Setting up a COVID-19 care facility at a prison: An experience from Pakistan.

Since its emergence from Wuhan at the end of last year, the novel coronavirus has spread to almost every country of the earth posing a significant challenge to healthcare systems everywhere. This article presents a practical model adopted in light of the WHO guidelines which was used by our team to set up the facility and care for the 69 COVID-19 prisoners within the prison itself. In addition to the challenges posed by the COVID-19 the healthcare team also had to overcome the challenge of the unique nature of the setup. The purpose of this article is to describe our response to help providers tasked with caring for prisoners especially in lower socio-economic countries.

Systolic Strain Rate In Left Ventricular Dysfunction Caused By Rheumatic Chronic Severe Mitral Regurgitation.

BACKGROUND: In rheumatic severe mitral regurgitation, earlier detection of left ventricular dysfunction is very necessary in order to refer the patients for surgery at appropriate time. This study tried to find a correlation between conventional parameters of left ventricular dysfunction with systolic strain rate. METHODS: A descriptive correlational study conducted from September 2016 to March 2018. One hundred and ninety-two patients of severe rheumatic MR and fifty-eight healthy controls were included. Left ventricular ejection fraction (LVEF), end diastolic dimension (LVEDD) and end systolic dimension (LVESD) were measured. Healthy controls were taken as group-I and patients were divided into group-II (ejection fraction ≥60% and LVESD ≤40 mm), group-III (ejection fraction ≥60% and LVESD ≤41-50 mm), and group-IV (ejection fraction <60%). Systolic strain rate at medial wall (SSR-med), at lateral wall (SSR-lat) and average of both (SSR-avg) were also measured by tissue doppler method for each study subject. RESULTS: Out of 250 study subjects, males were 113 (45.2%) and females were 137 (54.8%). Means of the age, LVEF, LVEDD and LVESD were 30.8±9.1, 60.0±8.3, 58.5±7.8 and 37.4±9.9 respectively. Group I, II, III and IV contained 58, 69, 67 and 56 subjects respectively. Comparing these groups, mean LVEF progressively decreased from 63.9%±2.2 in group-I to 46.2±6.5 in group-IV while means of LVEDD and LVESD progressively increased from 45.9±3.5 and 23.2±2.3 in group-I to 64.3±3.6 and 49.0±2.9 in group-IV respectively. Average systolic strain rate (SSR-avg) decreased progressively from 1.57±0.06 in group-I to 0.83±0.08 in group-IV. All the strain rates, i.e., SSRmed, SSR-lat and SSR-avg showed significant negative correlation with left ventricular dysfunction, i.e., the group number (p<0.001). CONCLUSIONS: Systolic strain rate measured by tissue doppler method have significant negative correlation with left ventricular dysfunction in patients having rheumatic chronic severe mitral regurgitation.

Mortality after inpatient stay for proximal humeral fractures.

BACKGROUND: A proximal humeral fracture is well established as a fracture of fragility in elderly patients. However, this injury does not receive the same emphasis on post-injury management as a femoral neck fracture. The objectives of this study were to establish the influence of sustaining a proximal humeral fracture on mortality and to identify the variables predictive of 5-year mortality. METHODS: Between January 2007 and January 2011, 288 consecutive patients who were admitted after sustaining a proximal humeral fracture were identified from the clinical coding department. Data were retrospectively collected and included patient demographic characteristics, comorbidities, anemia, physical and social independence, length of inpatient stay, management, and mortality. RESULTS: Of the patients, 13 (4.5%) had died at 1 month; 28 (9.7%), at 3 months; 46 (16.0%), at 1 year; and 117 (40.6%), at 5 years. A Cox proportional hazards regression identified male sex, comorbidities, unemployment or retirement, and nonoperative management as independent predictors of 5-year mortality. CONCLUSIONS: Elderly patients who require admission after sustaining a proximal humeral fracture are frail and subject to a greater-than-average risk of mortality for their age. The risk of mortality is greater for those of male sex who have comorbidities and a loss of physical and social independence.

Laparoscopic Cholecystectomy in Situs Inversus Totalis.

Situs inversus is a rare condition. It is characterised by reverse handed positioning of the internal viscera. Laparoscopic cholecystectomy is the standard procedure for cholelithiasis, but it may lead to technical difficulties in case of situs inversus, especially to right-handed surgeons. A 40-year female presented to the department with epigastric pain and bloating usually after fatty meals. Diagnosis of symptomatic gall bladder stone was made. She was a known case of situs inversus. Laparoscopic cholecystectomy was performed by right-handed surgeon with uneventful recovery.

Type 1 gallbladder perforation: A rare cause of acute abdomen.

Gallbladder perforation is rare. Diagnosis is usually made during operative intervention. Delay in recognition is associated with high morbidity and mortality. We report a case of type 1 gall bladder perforation in a male patient with no previous complaints related to gallstones.