A survey of perioperative complications with Clavien-Dindo classification: A cross-sectional study.

OBJECTIVE: To determine the incidence of complications in elective surgeries and to grade them according to the Clavien-Dindo Classification System. METHODS: The cross-sectional study was conducted in the General Surgery Operation Theatre of Holy Family Hospital, Rawalpindi, Pakistan, from February to April 2018, and comprised patients undergoing elective surgeries. Age, gender, region of surgery, type and grade of complications, were recorded using Clavien-Dindo Classification proforma. Data was analysed using SPSS 23. RESULTS: Of the total 212 patients, 36(16.9%) had some complication. There were significantly more complications in people aged 40 years or above compared to those <40 years (p<0.05). Of the total surgeries, 126(59.43%) were in the abdomino-pelvic region. CONCLUSIONS: Peri-operative complications were found to be significantly related with age of the patient and the type of surgery.

Newer Trends in Pancreatic Cancer Treatment: Genetic Alterations and the Role of Immune Therapeutic and Targeted Therapies.

Pancreatic cancer prognosis has remained poor and no significant improvement has been achieved over the past two decades. A number of genetic alterations are found in pancreatic cancer with a complex genome and proteome that needs further research investigation and discovery. There is an urgent need for innovative research findings that would increase the 5-year survival rate in patients with pancreatic ductal carcinoma, which in fact has seen only small increments over the past two decades. Targeting the tumor and modifying the stroma could help improve therapy responses. Genomic medicine is useful in a fraction of patients currently; however, the newer proteomic approaches are potentially more likely to help the majority of patients in the future. Future treatments of pancreatic cancer will likely be based on the development of novel therapies per genomic and proteomic identifications of cellular/immunological processes and molecular pathways as therapeutic targets. Herein, we systematically review the newer trends in pancreatic cancer treatment with emphasis on the genetic alterations and role of immune therapeutics and targeted therapies.

Familial Pancreatic Cancer: A Critical Review.

Up to 20% of patients with pancreatic cancer have a family history of the disease. Familial pancreatic cancer is defined as at least two first-degree relatives with pancreatic cancer that occurs without being part of a cancer syndrome. Although this does not follow a specific Mendelian pattern of inheritance, research is underway to better understand this cohort of patients. Recent expert opinion/recommendations encourage physicians treating patients with pancreatic cancer to ask them to consider having germline testing. Herein, we summarize the current peer-reviewed literature on the most common syndromes associated with pancreatic cancer, associated genetic mutations, and recommendations from various consortia regarding screening strategies. Lastly, we describe the economic impact of pancreatic cancer and the impact of screening tools in high-risk populations.

Amyand's hernia in an eighteen month old boy: A case report.

Amyand's hernia is a rare type of hernia in which vermiform appendix is found in the hernial sac. We describe the case of an 18 month old boy in which a non-inflamed appendix was found incidentally in the hernial sac of right sided inguinal hernia while doing herniotomy by Mitchell- Banks' technique. We also discuss the different types of Amyand's hernia and how they can be managed by reviewing the literature.

Signet Cell in the Brain: A Case Report of Leptomeningeal Carcinomatosis as the Presenting Feature of Gastric Signet Cell Cancer.

Malignant infiltration of pia and arachnoid mater, referred to as leptomeningeal carcinomatosis (LMC), is a rare complication of gastric carcinoma. The most common underlying malignancy in patients with LMC are leukemia, breast cancer, lymphoma, and lung cancer. We report a case of gastric adenocarcinoma that presented with LMC in the absence of overt gastrointestinal signs or symptoms. A 56-year-old Hispanic woman presented to the hospital with a three-week history of intermittent headaches and visual blurring. An initial brain imaging showed infarction in the distribution of right posterior inferior cerebellar artery (PICA) along with communicating hydrocephalus. She underwent ventriculoperitoneal (VP) shunt placement with improvement in her symptoms. Two months later she presented again with deterioration in her mental status. Imaging studies and cerebrospinal fluid (CSF) analysis confirmed the diagnosis of LMC. Further studies determined the primary tumor to be signet ring cell gastric adenocarcinoma. However, she did not have any preceding gastrointestinal symptoms. In light of the poor prognosis, the patient's family proceeded with comfort care measures. Our case portrays a rare presentation of gastric adenocarcinoma with LMC without other distant organ metastatic involvement. It also illustrates the occult nature of gastric carcinoma and signifies the importance of neurologic assessment of patients, with or at risk of gastric carcinoma. â€‹It also raises a theoretical concern for VP shunt as a potential conduit of malignant cells from the abdomen to the central nervous system, which may serve as an important susbtrate for future research.

A Mexican Honeymoon Marred by Gastrointestinal Upset: A Case of Dientamoeba fragilis Causing Post-infectious Irritable Bowel Syndrome.

Dientamoeba fragilis (D. fragilis) is an anaerobic intestinal protozoan parasite that has been associated with irritable bowel syndrome (IBS)-like symptoms. We report a case of post-infectious IBS caused by D. fragilis treated successfully with metronidazole. A 33-year-old African American male with an unremarkable past medical history was seen in the office with a three-month history of intermittent, generalized, crampy abdominal pain with bloating and flatulence without associated weight loss. He visited Mexico for his honeymoon four months ago. Initial lab work was normal. Dietary changes including fermentable oligosaccharides, disaccharides, monosaccharides, and polyols (FODMAP) diet and loperamide were prescribed with the presumptive diagnosis of IBS; however, his symptoms persisted. Three samples of stool for ova and parasites (O&P) were positive for D. fragilis. The patient was treated with metronidazole for 14 days. Repeat fecal O&P were negative. Upon follow-up, the patient' symptoms substantially improved with a resolution of abdominal pain and flatulence. Infection caused by D. fragilis may be symptomatic or asymptomatic. It is transmitted by the fecal-oral route. Symptoms include abdominal pain, bloating, and alteration of bowel movements, resembling IBS. The diagnosis is made via the detection of D. fragilis trophozoites in appropriately fixed and stained stool samples or by a polymerase chain reaction. Treatment options include tetracyclines, paromomycin, metronidazole, and Iodoquinol. Further epidemiologic studies may help in elucidating the association between D. fragilis and IBS.

Identification of risk factors for hepatitis B and C in Peshawar, Pakistan.

BACKGROUND: Hepatitis B and C need immediate worldwide attention as the infection rates are too high. More than 240 million people have chronic (long-term) liver infections. Every year, about 600,000 people die globally due to the acute or chronic consequences of hepatitis B and more than 350,000 people die from hepatitis C-related liver diseases. METHODS: Our study was designed as a case-control, descriptive study. It was conducted through formal interviews by using structured questionnaires. A total of 100 cases were included, with four controls for each case. RESULTS: This study confirms household contact, history of dental work, history of surgery, sexual contact, and history of transfusion (blood and its components) as the main risk factors which are responsible for the increased prevalence of hepatitis. CONCLUSION: The important risk factors, responsible for the high prevalence of hepatitis B and C in our society are household contact, history of dental work, history of surgery, sexual contact, and history of transfusion (blood and its components). The odds ratio of probability for these risk factors are: 4.2 for household contact history, 4.1 for history of dental work, 3.9 for sexual contact, 2.7 for history of surgery, and 2.1 for history of transfusion. Associations of other predictor variables (diabetes status, education level, profession, contact sports, intravenous drug abuse, residence, immunosuppression, and skin tattoos) were not statistically significant.

Complex sleep apnea syndrome.

Complex sleep apnea is the term used to describe a form of sleep disordered breathing in which repeated central apneas (>5/hour) persist or emerge when obstructive events are extinguished with positive airway pressure (PAP) and for which there is not a clear cause for the central apneas such as narcotics or systolic heart failure. The driving forces in the pathophysiology are felt to be ventilator instability associated oscillation in PaCO2 arterial partial pressure of Carbon Dioxide, continuous cositive airway pressure (CPAP) related increased CO2 carbon dioxide elimination, and activation of airway and pulmonary stretch receptors triggering these central apneas. The prevalence ranges from 0.56% to 18% with no clear predictive characteristics as compared to simple obstructive sleep apnea. Prognosis is similar to obstructive sleep apnea. The central apnea component in most patients on followup using CPAP therap, has resolved. For those with continued central apneas on simple CPAP therapy, other treatment options include bilevel PAP, adaptive servoventilation, permissive flow limitation and/or drugs.

Critical evaluation of the claims made by pharmaceutical companies in drug promotional material in Pakistan.

BACKGROUND: In Pakistan, there is no mechanism to monitor the drug promotional campaign by pharmaceutical industry despite the fact that there is enough evidence that irrational pharmacotherapy is increasingly encountered even in the developed countries due to unethical practices of pharmaceutical promotion. Objectives. To audit the drug promotional claims made by the pharmaceutical companies in Pakistan. METHODS: Drug promotional pamphlets and brochures containing claims for the drugs, which were circulated by the pharmaceutical representatives were collected from 122 general practitioners (GPs) from Karachi and Larkana cities of the Sindh Province. The claims were critically analyzed and audited with the help of currently available evidence in the medical literature. RESULTS: 345 distinct advertisements covering 182 drugs from different manufacturers were critically analyzed for information content. Sixty two out of 345 (18%) of the reviewed advertisements were adjudged to be misleading / unjustifiable, which were again classified as, exaggerated (32%), ambiguous (21%), false (26%), and controversial (21%). The primary source of information (approximately 78%) about the newly launched drugs for the GPs was found to be the pharmaceutical representatives followed by hospital doctors (5%) and colleagues (5%). Furthermore, 110 (90%) GPs were of the view that the drug promotion has definitely an influence on their prescribing pattern. CONCLUSIONS: Since GPs in Pakistan rate pharmaceutical companies as their primary source of information regarding drugs, it can be anticipated that inappropriate advertisement claims would lead to irrational prescribing if physicians had no any other information to follow.