Laparoscopy: A Better Approach for Perforated Duodenal Ulcer.

Background Laparoscopic surgery is becoming the gold standard for most abdominal surgeries in recent times. Laparoscopic repair of perforated duodenal ulcer (PDU), however, is still an area of debate. The purpose of this study was to evaluate the safety and efficacy of laparoscopic repair of PDU versus open repair. Methods In this cross-sectional study, patients were consecutively sampled. Out of 101 patients with clinically diagnosed PDU, 36 patients underwent laparoscopic Graham patch repair and 65 underwent open Graham patch repair in a tertiary care academic hospital. Open repair was via upper midline incision, and laparoscopic repair by the three-port technique. The following stages were calculated: operative time, duration of postoperative analgesia, time taken to mobilize, and patient length of stay after the operation. Results The mean operative time was somewhat longer in the laparoscopy group compared to the open repair group (74.01 vs 56.17 minutes, respectively). Mean postoperative analgesia requirement, time taken to mobilize, and hospital stay were significantly shorter after laparoscopy than after open repair (1.21 days, 9.32 hours, and 3.12 days vs 3.83 days, 16.20 hours, and 4.85 days, respectively). Three patients (8%) in the laparoscopy group and 35 (54%) in the open repair group had postoperative complications. Conclusions Laparoscopic repair of PDU is a safe approach and better than open repair in terms of operative time with the right level of expertise only, postoperative analgesia requirement, mobilization, duration of hospital stay, and incidence of postoperative respiratory and wound complications.

Teleoncology: improving patient outcome through coordinated care.

INTRODUCTION: There are few specialized oncology centers in Pakistan. Teleoncology was introduced for weekly tumor case meetings between the surgery departments of Holy Family Hospital and NORI Hospital using videoconferencing. The team of surgeons, radiologists, and histopathologists of Holy Family Hospital and the oncologists from NORI Hospital are now conducting joint regular multidisciplinary meetings weekly for the well-being of patients of the area. The purpose of this study is to describe the infrastructure, consultative process, technical aspects, and initial evaluation of these meetings. MATERIALS AND METHODS: The surgical oncology patients are discussed every Friday morning since November 2009. A standardized format was adopted for case discussion in these multidisciplinary meetings. The postgraduate trainee presents the case from either side followed by management plan discussion. The oncologists may request a discussion to plan an intervention at Holy Family Hospital, or the surgeons at Holy Family Hospital may present a case that would benefit from multidisciplinary skills. RESULTS: In total, 264 patients were discussed. The mean age of the patients was 51±16.2 years. In 43% of the patients, the joint treatment strategy was refined from the initial proposed treatment. Breast and gastrointestinal tract malignancies were the most common cases, followed by endocrine and skin and soft tissue tumors. CONCLUSIONS: Teleoncology services can be extended easily with little addition to existing infrastructure but significantly reduce the stress for families as they deal with this challenging disease. Moreover, they improve the clinical evaluation and management strategies.

The impact of curriculum on a national telehealth program.

Pakistan developed a curriculum for training in telemedicine based upon international experience and regional needs. The curriculum was offered to selected specialists across the spectrum of medicine, policymakers, and engineer experts. The curriculum was experience based and hands-on. Each participant at the end was asked to develop a telemedicine application based upon their area of practice or expertise. Most of the first 30 graduates are currently involved in telemedicine applications in varied and unanticipated areas of contribution. The first graduates also were instrumental in the national and regional response to the earthquake disaster of 2005 in the Rawalpindi region. The curriculum is being expanded under government sponsorship to become a national telemedicine initiative.

Complications in patients with spinal cord injuries sustained in an earthquake in Northern Pakistan.

BACKGROUND: Spinal cord injury (SCI) is a devastating trauma suffered by many of the victims of an earthquake that struck Northern Pakistan on October 8, 2005. It rendered approximately 600 patients paraplegic, which is the highest number ever reported in any disaster. This study was conducted to evaluate the risk of complications. METHODS: The cross-sectional retrospective study covering a 2-month period was conducted on 194 patients admitted to the surgical/neurosurgical wards of Rawalpindi Medical College and allied hospitals (Holy Family Hospital, Rawalpindi General Hospital, and District Headquarter Hospital) and Melody Relief and Rehabilitation Center, Islamabad. RESULTS: The male-to-female ratio was approximately 1:3 (n = 50 [26%] and n = 144 [74%], respectively). The majority (78% [n = 151]) were 16 to 39 years of age; 62% (n = 120) had lumbar-level injuries, 25% (n = 48) had thoracic-level injuries, 9% (n = 18) had thoracolumbar-level injuries, and a few had cervical- or sacral-level injuries. Forty-six percent (n = 90) had American Spinal Injury Association type A injuries; 4% (n = 8) were graded B, 11% (n = 21) were graded C, 9% (n = 18) were graded D, and 14% (n = 27) were graded E. Twenty percent (n = 39) developed pressure ulcers, of which 38% (n = 15) had grade 1, 36% (n = 14) had grade 2, 23% (n = 9) had grade 3, and 3% (n = 1) had grade 4. All patients developed urinary tract infections; 15% (n = 30) had bowel complaints; 2% (n = 3) developed deep-vein thrombosis (1 died of pulmonary embolism); and 0.05% (n = 1) developed wound infection. CONCLUSION: Awareness of potential complications in patients with paraplegia is essential to care planning in the disaster setting. The priorities include skin, bowel, and bladder care and provision of prophylactic heparin. SCI post-disaster care requires comprehensive long-term planning.

Complications in Patients with Spinal Cord Injuries Sustained in an Earthquake in Northern Pakistan

Background: Spinal cord injury (SCI) is devastating trauma suffered by many of the victims of an earthquake that struck Northern Pakistan on October 8, 2005. It rendered approximately 600 patients paraplegic, which is the highest number ever reported in any disaster. This study was conducted to evaluate the risk of complications. Methods: The cross-sectional restrospective study covering a 2-month perido was conducted on 194 patients admitted to the surgical/neurosugical wards of Rawalpindi Medical College and allied hospitals (Holy Family Hospital, Rawalpindi General Hospital, and District Headquarter Hospital) and Melody Relief and Rehabilitation Center, Islamabad. Results: The male-to-male ratio was approximately 1:3 (n=50 [26%] and n=144 [74%], respectivily). The majority (78% [ n=151]) were 16 to 39 years of age; 62% (n=120) had lumbar-injuries, 25% (n=48) had thoracic-level-injuries, 9% (n=18) had thoracolumbar-level injuries, and a few had cervical - or sacral-level-injuries. Forty six percent (n=90) had American Spinal Injury Association type A injuries; 4% (n=8) were graded B, 11% (n=21) were graded C, 95 (n=18) were graded D, and 14% (n=27) were graded E. Twenty percent (n=39) developed pressure ulcers, of which 38% (n=15) had grade, 1, 36% (n=14) had grade 2, 23% (n=29) had grade 3, and 3% (n=1) had grade 4. All patients developed urinary tract infections; 15% (n=30) had bowel complaints; 2% (n=3) developed deep-vein thrombosis (1 died of pulmonary embolism); and 0.05% (n=1) developed wound infection. Conclusion: Awareness of potential complications in patients with paraplegia is essential to care planning in the disaster setting. The priorities include skin, bowel, and bladder care and provision of prophylactic heparin. SCI post-disaster care requires comprehensive long-term planning. (AU)

Comparison of store and forward method of teledermatology with face-to-face consultation.

BACKGROUND: To compare the accuracy of store and forward method of teledermatology with the traditional face-to-face consultation. METHODS: The comparison was done between Institute of Dermatology King Edward Medical College Lahore that served as teledermatology center and Dermatology Department of Pakistan Institute of Medical Sciences Islamabad from where patients were selected. Telmedpak provided the technical support. Thirty three patients were selected from outpatient department of PIMS and images were taken using a digital camera. Images were stored in computer and were sent to Institute of Dermatology via e-mail for Teleconsultation along with a short history and examination findings. Diagnosis of consultant after face-to-face consultation was then compared with the image based diagnosis that is after teleconsultation. RESULTS: In 81% of the cases the diagnosis on face-to-face consultation was same (p < 0.05) while in 18% of the cases the two diagnoses differed. In 9% (n = 3) of the cases, image resolution was not good but out of these three, diagnosis was same in two and differed in one case. CONCLUSION: This study concludes that store and forward method of teledermatology is reliable and can provide a means of increasing access to dermatological care in rural and under-served areas.