Role Of Symptomatic Treatment In Comparison To Antibiotics In Uncomplicated Urinary Tract Infections.

BACKGROUND: Uncomplicated urinary tract infections (UTIs) are the most common bacterial infections among women presenting to primary care causing rapidly increasing strains of resistant bacteria to the growing antibiotic industry. Restricting antibiotics to necessary indications is the only solution. The objectives of the study were to compare the efficacy of symptomatic treatment vs antibiotic in patients with uncomplicated UTI, in terms of individual symptom score, i.e., frequency, urgency, dysuria, supra pubic pain scores and total symptoms scores. METHODS: A randomized control trial (RCT) in 100 women (15-50 years) with symptoms of urinary frequency, urgency, dysuria and pain supra pubic region, associated with uncomplicated UTI, at Urology department, AMI, Abbottabad. Two treatment strategies were compared in uncomplicated UTI patient). Patients were randomized to antibiotic or symptomatic treatment groups on consecutive non-probability basis (50 in each group) given for 05 days. Efficacy of medications was assessed by comparing pre and post treatment symptom scores along with the post treatment scores of both groups compared to see statistical significance of difference by independent samples t-test. RESULTS: There was a statistically significant difference in symptoms improvement in both treatment arms of all scores, i.e., p-value=0.000. Whereas only dysuria score was able to show a statistically significance of difference in post Rx scores comparison of both groups, p-value=0.004. CONCLUSIONS: Symptomatic treatment is not inferior to antibiotic treatment when proper patient selection is undertaken, resulting in decreased need for unnecessary antibiotics use.

Efficacy Of Local Anaesthesia In Repair Of Inguinal Hernia.

BACKGROUND: Local anaesthesia has been identified as the most favourable anaesthesia for elective inguinal hernia repair with respect to complication rate, cost effectiveness and overall patients' satisfaction. This study was conducted to determine the efficacy of local anaesthesia in inguinal hernia in terms of pain relief, wound infection and hospital stay. METHODS: In this randomized controlled trial (RCT), 60 patients with inguinal hernia were included at the General Surgical 'B' Unit, Ayub Teaching Hospital Abbottabad. RESULTS: The day-case rates were significantly higher when patients underwent surgery under LA compared to GA (82.6% versus 42.6%). The incidence of urinary retention was higher in the GA group (p<0.05). There were 17 (2.9%) re-admissions overall. The reasons for readmission included haematoma (n=6), severe pain (n=4), infection (n=3), fainting (n=2) and urinary retention (n=2). CONCLUSIONS: This study demonstrates that local anaesthesia for inguinal hernia repair has better efficacy as compared to general anaesthesia.

Aesthetic analysis in rhinoplasty: surgeon vs. patient perspectives: a prospective, blinded study.

OBJECTIVE: To determine how patients seeking cosmetic rhinoplasty analyze themselves compared to their surgeon's analysis. Simply stated, "Does your surgeon view your nose the same as you?" STUDY DESIGN: Prospective, blinded study. METHODS: All primary rhinoplasty consultations completed a nasal analysis questionnaire. The patients' facial plastic surgeons completed an identical questionnaire. The results were compared and analyzed. RESULTS: Data underwent statistical analysis and subsequent factor analysis was performed. 132 patients participated in the study. Questions were grouped together based on factors: overall appearance, skin quality, tip dimensions, straightness, nostril show, and width. The only factor with reasonable surgeon/patient correlation was factor 1, overall appearance, with correlation 0.6473, p<0.001. CONCLUSIONS: Surgeons and patients are in agreement with the overall appearance of the nose, but differ in their analysis regarding the details. This information can be used to guide future discussions during consultations and most importantly help to better gauge and manage patient expectations.

Endoscopic forehead lift in patients with male pattern baldness.

PURPOSE: The presence of male pattern baldness poses a significant challenge when attempting to optimize treatment of the upper third of the face. The purpose of this study is to demonstrate and discuss results of the endoscopic forehead lift in patients with male pattern baldness. MATERIALS AND METHODS: This was a retrospective case series done in an academic medical center. Eleven patients with male pattern baldness (Norwood class IV-VII) underwent endoscopic forehead lift for forehead creases and brow ptosis. RESULTS: All patients achieved smoothing of the forehead and elevation of the brow with no scalp anesthesia at 1 month postoperatively. All patients were pleased with the healing of their incisions in midline, paramedian, and temporal regions. Alloplastic fixation devices used were visible postoperatively in 2 patients initially. CONCLUSIONS: The endoscopic forehead lift is a suitable approach for treating the upper third of the face in the presence of male pattern baldness. The use of alloplastic fixation devices may be used in this patient population, but other fixation methods should be considered.

Outcome Of The Choice Of Wound Closure Technique In Emergency Laparotomy.

BACKGROUND: Abdominal surgeries are the most common surgeries performed around the world. Closure of abdominal wound is important and a number wound closing techniques are in practice. This study was conducted to determine the outcome of the choice of wound closure technique in emergency laparotomy. METHODS: It was a retrospective study from March-September 2019, conducted at the Surgical A unit, Ayub Teaching Hospital, Abbottabad. Ninety-five patients aged 22-60 years, who underwent emergency laparotomies via midline and para-median incisions were included in the study. RESULTS: There were 74 (77.89%) males and 21 (22.11%) females. Anatomical closure technique was used in 67 (70.53%) of study participants while mass closure technique was used in 28 (29.47%) of study participants. 50 (52.63%) patients had anaemia, 27 (28.42%) had hypo-proteinemia, and 14 (14.74%) developed peritonitis. Post-operative wound infection was noticed in 15 (15.79%) patients. Out of 95 patients, 19 (20%) developed burst abdomen. Overall, 5 (5.26%) patients died in the hospital. All cases of burst abdomen occurred within first two weeks of hospital stay (p= 0.004), had an association with peritonitis (p=0.0001) and post-operative wound infection (p= 0.005). Wound closure technique was not associated with development of post-operative complications including burst abdomen (p >0.05). CONCLUSIONS: Postoperative complications occur independently of wound-closure technique and surgeons should have a low threshold for prevention of post-operative complications where possible.

Frequency of external hernias in Ayub Teaching Hospital Abbottabad.

BACKGROUND: Hernia is a protrusion of a viscous or a part of a viscous through an abnormal opening in wall of its containing cavity. Different external hernias present differently and ultimate treatment is surgical, which is most commonly performed elective operation in the world. The objectives were to know the age and gender wise frequency of external hernias in Ayub Teaching Hospital, Abbottabad. This retrospective study was conducted at the surgical units of Ayub Teaching Hospital from June 2004 to June 2005. METHODS: Records of all cases of hernias operated in Ayub Teaching Hospital during June 2004 to June 2005 were retrieved from the operation registers of the entire three surgical units available at the operation theatres. The data was collected on a proforma and was analysed by SPSS-16. RESULTS: Of the 1063 cases, 982 (92.38%) were male and 81 (7.62%) were female. Right Inguinal Hernia (RIH) was the most frequent as expected, i.e., 44.12%, followed by Left Inguinal Hernias (LIH) 18.72%. Least common hernias were femoral hernias with a frequency of 0.85%. CONCLUSION: It is concluded that 85% hernias occur in the groin, with 12% incisional and only 3% hernias occur elsewhere. To reduce the rate of complications, health education is the most important intervention. For future health planning maintenance of disease register can not be over emphasised.

Long-term outcome of acellular dermal matrix when used for large traumatic open abdomen.

BACKGROUND: The purpose of this study is to prospectively examine the use of Human Acellular Dermal Matrix (HADM) in trauma patients with large open abdominal wounds and assess the long-term outcome. Previous studies have not examined the long-term outcomes in trauma patients with abdominal wall reconstructions. METHODS: An institutional review board approved prospective case series of consecutive patients admitted to a level I university trauma center, who were unable to have their abdomen closed primarily after trauma laparotomy. These patients had HADM placed to attain closure of the abdomen with skin advancement flaps to cover the HADM when possible. Our primary outcome measure was hernia formation and our secondary outcomes were laxity, fistulae, and infections associated with HADM. RESULTS: Ten patients were enrolled during a 1-year period. Mean time to HADM placement was 17.2 days +/- 3.6 days. Mean initial defect size was 425.1 cm2 +/- 75.9 cm2 with the largest 770 cm2. Thirty day follow-up showed no recurrence in 100% patients. Six patients remained for long-term follow-up. Follow-up at 60 days demonstrated significant laxity or recurrent hernia or both in 67% of patients, and this increased to 100% by the end of 1 year follow-up. There were no bowel fistulae in these patients closed with HADM but 20% with infection. CONCLUSIONS: HADM is an alternative available to reconstruct the unclosable open abdomen with no fistulae formation, however, it is associated with a high rate of laxity in large abdominal wounds.

Infection in orthopedic implant surgery, its risk factors and outcome.

BACKGROUND: Infection in orthopedic surgery is a disaster both for the patient and surgeon. Although its incidence has been reduced due to modern theatre facilities and aseptic measures but in developing countries its prevalence is still high. It is better to prevent infection rather than to treat it. The objective of this study is to know the frequency of infection in orthopedic implant surgery in a public hospital and to evaluate the risk factors, causative organism, complications and treatment. METHODS: This prospective study was conducted in orthopedic unit-B Ayub Teaching Hospital, Abbottabad, from 1st April 2007 to 30th October 2007. Close fracture cases admitted for internal fixation devices were included. The exclusion criteria were soft tissue surgery, wounds and open fractures needing external fixation devices. The follow up was done for six months. RESULTS: Infection developed in 6 patients (5.76%), out of which superficial and deep infections were 2 (1.92%) and 4 (3.84%) respectively. There were 2 infection cases in each stage of the infection i.e. early, delayed and late. The staphylococcus aureus was the commonest organism, i.e., 3 (50%) out of 6. The age of the patients was more than 60 years in 3 (2.88%) patients, 30 to 60 years in 2 (1.92%) patients and below 30 year in 1 (0.96%) patient. The smoking history was in 2 (1.92%) patients. CONCLUSION: Infection rate in our study was quite high and needs proper measures to control it because it had great financial burden on patient and on hospital resources and could lead to morbidity and mortality in patients. We could not find significant risk factors in our small sample size study although the infection was relatively more common in patients with advanced age, prolonged surgery time, smoking and skin abrasion at fracture site. Commonest organism was Staphylococcus aureus.

Patient Self Delay Among Women With Breast Cancer.

BACKGROUND: Delay in the diagnosis of carcinoma breast has important prognostic, clinical and medico-legal implications. This study assesses the frequency and causes of patient delay in women with breast cancer presenting to a breast clinic run by a specialist surgical unit in a tertiary care hospital. METHODS: For this study all women, aged between 16-90 years, who presented with primary breast carcinoma of any histological type, diagnosed between June 2016 to September 2017 were eligible. Structured interviews were administered during the first visit with a confirmed diagnosis or the first hospitalization due to carcinoma breast, and the frequencies of the factors for delay analysed.. RESULTS: 84% of the patients presenting with primary carcinoma breast present with a significant patient delay, of which older patients who are illiterate, poor, coming from rural areas and unaware of carcinoma breast as a disease, among other factors, have a higher tendency to delay consultation. CONCLUSIONS: Healthcare advice-seeking behaviour in women suffering from breast cancer in Pakistan is alarming with a vast majority of patients presenting late leading to delayed treatment and probable worse outcomes and survival.

Objective Outcomes of Minimally Invasive Temporalis Tendon Transfer for Prolonged Complete Facial Paralysis.

OBJECTIVES: We describe an approach to reanimation of complete, prolonged facial paralysis using minimally invasive temporalis tendon transfer (MIT3) by the melolabial or transoral approach. Objective outcome measures are evaluated based on symmetry, and grading of preoperative/post-operative results and the scar at the melolabial fold. STUDY DESIGN: Retrospective cohort study. METHODS: Twenty-five patients undergoing the MIT3 technique were studied. Photographic analysis was used to determine the percentage of difference between the 2 sides (symmetry). Using the Delphi method to achieve consensus, a panel of experts graded pre/post-operative photos using the Terzis' Facial Grading System and a 1 to 10 Likert-type scale and the melolabial scar using the Beausang Scar Scale. RESULTS: Percentage of difference (symmetry) with smiling improved from 18.6% ± 1.5% (mean ± standard error of the mean [SEM]) preoperatively to 5.0 ± 0.9% (mean ± SEM) post-operatively. Expert grading by the Terzis system showed improvement post-operatively (mean 3.7/5; median 3.6/5) versus preoperatively (mean 1.5/5; median 1.2/5). Perceived improvement was also largely favourable (mean 8.1/10; median 8.0/10). Melolabial scar grading was favourable in terms of colour (mean 1.53/4), surface character (mean 1.05/2), contour (mean 1.60/4), and distortion (mean 1.74/4). CONCLUSIONS: The MIT3 technique offers immediate, predictable, and symmetrical return of smile function. Objective symmetry analysis and favourable expert grading of both pre-/post-operative photographs and the scar at the melolabial fold demonstrate applicability for facial reanimation in patients where other procedures have failed, or when a direct return to function is desired. Both the melolabial approach and transoral approach were found to be acceptable and effective, although applicability varies.

OBJECTIFS: Les auteurs décrivent une approche de la réanimation d'une paralysie faciale complète et prolongée par transfert mini-invasif du tendon temporal (MIT3) par l'abord mélolabial ou transoral. Les mesures objectives de résultats sont évaluées en fonction de la symétrie, du classement des résultats préopératoires et postopératoires et de la cicatrice au pli mélolabial. CONCEPTION: Étude rétrospective de cohorte. MÉTHODOLOGIE: Les chercheurs ont étudié 25 patients qui avaient subi la technique MIT3. L'analyse photographique a déterminé la différence en pourcentage entre les deux côtés (symétrie). À l'aide de la méthode Delphi pour parvenir à un consensus, un groupe d'experts a classé les photos préopératoires et postopératoires à l'aide du système de classement facial de Terzis et de l'échelle de Likert de 1 à 10. Il a aussi classé la cicatrice mélolabiale à l'aide de l'échelle de cicatrices de Beausang. RÉSULTATS: La différence du sourire en pourcentage (symétrie) est passée de 18,6±1,5 % (moyenne±erreur-type) avant l'opération à 5,0±0,9 % (moyenne±erreur-type) après l'opération. Le classement par les experts à l'aide du système de Terzis a démontré une amélioration après l'opération (moyenne 3,7/5; médiane 3,6/5) par rapport à l'aspect préopératoire (moyenne 1,5/5; médiane 1,2/5). De plus, l'amélioration perçue était largement favorable (moyenne 8,1/10; médiane 8,0/10). Le classement de la cicatrice mélolabiale était positif sur le plan de la couleur (moyenne 1,53/4), de l'aspect de la surface (moyenne de 1,05/2), du contour (moyenne de 1,60/4) et de la distorsion (moyenne de 1,74/4). CONCLUSIONS: La technique MIT3 assure un retour immédiat, prévisible et symétrique du sourire. L'analyse de symétrie objective, un classement favorable par des experts d'après des photos avant-après l'opération et la cicatrice au pli mélolabial démontrent la possibilité de réanimation faciale des patients lorsque d'autres interventions ont échoué ou qu'un retour direct à la fonction est souhaité. Tant l'abord mélolabial que transoral étaient acceptables et efficaces, même si leur applicabilité varie.

Measurement of Change in Lower Eyelid Position in Patients Undergoing Transcutaneous Skin-Muscle Flap Lower Eyelid Blepharoplasty.

IMPORTANCE: Transcutaneous lower eyelid blepharoplasty is a commonly performed procedure with a postoperative risk of eyelid malposition. OBJECTIVE: To quantify the change in lower eyelid position after transcutaneous lower eyelid blepharoplasty. DESIGN, SETTING, AND PARTICIPANTS: This retrospective medical record review describes patients who underwent transcutaneous blepharoplasty at a private facial plastic surgery practice. Patients with less than 3 months of follow-up, a history of periocular trauma, and concurrent midface lift were excluded. INTERVENTIONS: Bilateral skin-muscle flap lower eyelid blepharoplasties with possible tarsorrhaphy, canthopexy, or canthoplasty as indicated. MAIN OUTCOMES AND MEASURES: Lower eyelid position determined by measurement of preoperative and postoperative pupil to eyelid and lateral limbus to eyelid distances. RESULTS: Data from 100 consecutive patients (mean age, 56.7 years; 92 female [92.0%]) undergoing bilateral skin-muscle flap lower eyelid blepharoplasty were analyzed. The mean increase in distance was 0.33 mm (95% CI, 0.24-0.42 mm) from the pupil to the lower eyelid margin and 0.32 mm (95% CI, 0.23-0.41 mm) from the lateral limbus to the lower eyelid margin at final follow-up. For both measurements, patients undergoing concurrent canthopexy had a significantly greater change in eyelid position (P < .001). Men had a greater change in the distance of pupil to lower eyelid compared with women (0.76 mm; 95% CI, 0.44-1.08 mm, vs 0.30 mm; 95% CI, 0.20-0.39 mm, respectively; P = .008) at final follow-up. Two patients required revision procedures secondary to eyelid malposition, and 25 patients had new onset of dry eye symptoms. CONCLUSIONS AND RELEVANCE: Transcutaneous skin-muscle lower eyelid blepharoplasty with selective performance of canthoplasty or canthopexy causes a small, predictable eyelid position change in this population with a low rate of revision procedures. LEVEL OF EVIDENCE: 3.

Sinonasal epithelial cells synthesize active vitamin D, augmenting host innate immune function.

BACKGROUND: Vitamin D, long recognized for its role in bone metabolism and calcium homeostasis, has been increasingly shown to augment innate immunity. 1-α-Hydroxylase, the enzyme responsible for the synthesis of active vitamin D, has been shown to have extrarenal expression in multiple cell types, including airway epithelial cells. The purpose of this study is to explore whether sinonasal epithelial cells (SNECs) express 1-α-hydroxylase, allowing for the local production of active vitamin D, thereby augmenting innate immune function. METHODS: Human SNECs were grown in culture and stimulated by inactive vitamin D. Expression of 1-α-hydroxylase was measured by real-time polymerase chain reaction and immunocytochemistry. Active vitamin D production was measured by enzyme-linked immunosorbent assay (ELISA). The expression of cathelicidin, an antimicrobial peptide, was measured by real-time polymerase chain reaction and immunocytochemistry. RESULTS: SNECs constitutively express the enzyme 1-α-hydroxylase resulting in active vitamin D production. SNECs exposed to inactive vitamin D had a significant 8-fold increase in cathelicidin expression when compared to controls. CONCLUSION: SNECs can generate active vitamin D, which significantly increases expression of the antimicrobial peptide cathelicidin. © 2013 ARS-AAOA, LLC.

Custom-made, 3D, intraoperative surgical guides for nasal reconstruction.

This article presents the use of an intraoperative surgical guide created by 3D laser surface scanning and rapid prototyping. The authors present outcomes of 3 patients in whom the nasal surgical guide was used intraoperatively for reconstruction of full-thickness, complex nasal defects. This effort highlights the multidisciplinary approach involving a surgeon and anaplastologist integrated with the latest technology to provide patients with the best possible outcomes.

The role of TNF-α in inflammatory olfactory loss.

BACKGROUND: Despite the significant health impact of olfactory loss in chronic rhinosinusitis (CRS), the underlying pathophysiology is incompletely understood. A transgenic mouse model of olfactory inflammation induced by tumor necrosis factor-alpha (TNF-α) has provided new insights into the cellular and molecular basis of inflammatory olfactory loss. Here, we utilize systemic corticosteroids to suppress downstream cytokine expression, in order to study the direct role of TNF-α in CRS-associated olfactory dysfunction. METHODS: Transgenic mice were induced to express TNF-α in the olfactory epithelium for 6 weeks. In a subset of mice, 1 mg/kg prednisolone was administered concurrently to inhibit downstream inflammatory responses. The olfactory epithelium (OE) was analyzed by histology and electro-olfactogram (EOG) recordings. RESULTS: Treatment with prednisolone successfully prevented inflammatory infiltration over significant regions of the OE. In areas where significant subepithelial inflammation was present, a corresponding loss of olfactory neurons was observed. In contrast, areas without major inflammatory changes had normal olfactory neuron layers, despite chronic local expression of TNF-α. Prednisolone partially reversed the complete loss of olfaction in the mouse model, preserving odorant responses that were significantly diminished compared to controls, but not absent. CONCLUSIONS: The addition of prednisolone to the transgenic model of olfactory inflammation isolates the direct effects of induced TNF-α expression on the OE. The finding that prednisolone treatment prevents neuronal loss in some regions of the OE suggests that TNF-α does not directly cause neuronal apoptosis--rather, that subepithelial inflammation or other downstream mediators may be responsible. At the same time, EOG results imply that TNF-α directly causes physiologic dysfunction of olfactory neurons, independent of the inflammatory state. An understanding of the role of TNF-α and other inflammatory cytokines may suggest novel therapeutic strategies for CRS-associated olfactory loss.

The role of hepatocyte growth factor/c-Met in chronic rhinosinusitis with nasal polyps.

BACKGROUND: Hepatocyte growth factor (HGF) is a growth factor thought to attenuate Th2-driven eosinophilic airway inflammatory responses. Increased expression of HGF and its receptor c-Met in nasal polyps suggests a role in disease pathogenesis. The effect of HGF on human sinonasal epithelial cell (SNEC) responses to Th2 inflammatory cytokines in chronic rhinosinusitis with nasal polyps (CRSwNP) has not been explored. METHODS: SNECs isolated from patients with CRSwNP and control subjects were grown in cell culture at the air-liquid interface. The Th2 cytokine IL-13 was applied for 24 hours in the presence or absence of HGF. Eotaxin-3 and c-Met expression was assessed using real-time PCR, immunohistochemistry, and flow cytometry. RESULTS: SNECs obtained from both CRSwNP and control subjects showed markedly increased expression of eotaxin-3 after exposure to IL-13. HGF significantly blocked IL-13-induced expression of eotaxin-3 in control SNECs, but not in SNECs derived from CRSwNP subjects. CONCLUSION: SNECs are active participants in sinonasal mucosal immunity, expressing inflammatory mediators in response to potential pathogens and endogenous cytokines. Although Th2 cytokines can elicit expression of proeosinophilic mediators by SNECs, HGF appears to have a down-regulating effect on this response. In patients with CRSwNP, SNECs are resistant to this attenuation, showing continued IL-13-induced eotaxin-3 expression despite HGF treatment. Abnormalities in the regulation of epithelial cell responses to endogenous cytokines and growth factors may contribute to the persistent eosinophilic inflammatory state in CRSwNP.

Congenital nasal pyriform aperture stenosis: feeding evaluation and management.

PURPOSE: We identified four patients with congenital nasal pyriform aperture stenosis (CNPAS) with feeding and respiratory difficulties. While feeding difficulties have been described in infants with other causes of nasal obstruction (e.g., choanal atresia), little attention has been focused on feeding in infants with CNPAS. FINDINGS: All four patients were treated with nasal steroids and nasal saline and two underwent surgical repair of the CNPAS at 2 months of age. Except for gastroesophageal reflux in one patient, upper gastrointestinal tract (UGI) contrast studies were normal in all patients. Three patients underwent bedside swallow evaluations, two of whom participated in videoflouroscopic swallow studies (VFSS) because of limited oral intake or respiratory problems during feeding. These three patients presented with intact oral-motor coordination at rest and during non-nutritive sucking, and nasal whistling, nasal congestion, or breathing difficulties/desaturations with oral feeding. On VFSS, one infant had trace aspiration with thin and thick liquids. Three patients required supplemental feeding during the first year of life. All three patients with normal brain MRIs were successful oral feeders by 16 months of age, the fourth is undergoing feeding therapy at 24 months of age. SUMMARY: Feeding problems are common in infants with CNPAS and supplemental feedings may be needed even after management of airway difficulties. Infants with CNPAS should undergo comprehensive feeding/swallowing evaluations which may include bedside swallow evaluations and VFSSs. The prognosis for transitioning to total oral feedings is good and related to the extent of the airway obstruction and presence of other comorbidities.