Endoscopic Transnasal Repair of Cerebrospinal Fluid Leakage: Experience in BSMMU.

Endoscopic transnasal repair of CSF rhinorrhoea is gaining popularity around the world because of its tremendous success rate but it depends on defect site, size, technique of repair, experiences of surgeon and also patient's profile. Aim of this study was to analysis of surgical outcome of endoscopic transnasal repair of CSF rhinorrhoea. A retrospective study carried out in the department of ENT and Head neck surgery at Bangabandhu Sheikh Mujib Medical University (BSMMU) from January 2018 to December 2019. Of the total of 24 patients 16(66.0%) were female and 8(33.0%) males. The commonest site of the leak was in the cribriform plate in 18(75.3%) followed by 5(20.8%) in the fovea ethmoidalis, and 1(4.0%) in the sphenoid sinus, the overall success rate of this series with first surgical procedure was 95.83% and 100.0% with a second procedure. Meticulous pre-operative evaluation, proper identification of leakage site, choice of graft materials and surgical technique are keys to attaining excellent results.

A Modified Technique in Submandubular Salivary Gland Excision: Preservation of Facial Artery.

Cutting and ligation of facial artery is the conventional practice for excision of submandibular gland. Facial artery is the main arterial supply to the lower face. Its preservation results in preservation of large proportion of vascularity to the lower face, preserves vascularity of platysma myocutaneous flap, allows repair of lower lip using Bernard's technique; facial artery is one of the most important recipient artery for microvascular free flap in modern reconstructive surgery in head and neck oncology. This prospective study was carried out in Department of Otolaryngology, Bangabandhu Sheikh Mujib Medical University Hospital (BSMMU), Dhaka, Bangladesh from October 2005 to October 2012 on 31 cases. Chronic submandibular sialoadenitis, benign submandibular gland tumours and cases of neck dissection where level I cervical lymph nodes were not involved by metastasis were included in this study. The facial artery was identified proximal to the gland and was dissected free from the gland by ligating or cauterizing its glandular branches to mobilize the gland. Appropriate anatomical aspects were noted and the time required for separation of the artery from the gland was recorded. Thirty-one consecutive cases were studied. The indications were chronic sialoadenitis (67.7%), pleomorphic adenoma (12.9%) and as a part of neck dissection for oncologic clearance of neck (19.4%). The mean duration of time for separation of the artery from the gland was 10.26 minutes. In two cases the facial artery could not be safely separated due to excessive adhesion from chronic inflammation. No significant complications were noted. Preservation of facial artery in submandibular gland excision is a simple procedure. So it should not be routinely sacrificed during this surgery.

Major postoperative complications after pancreatic resection for P-NETS are not associated to earlier recurrence.

BACKGROUND: The oncological impact of surgical complications has been studied in visceral and pancreatic cancer. AIM: To investigate the impact of complications on tumour recurrence after resections for pancreatic neuroendocrine tumours. METHODS: We have retrospectively analysed 105 consecutive resections performed at the Royal Free London Hospital from 1998 to 2014, and studied the long-term outcome of nil-minor (<3) versus major (≥3) Clavien-Dindo complications (CD) on disease-free (DFS) and overall survival (OS). RESULTS: The series accounted for 41 (39%) pancreaticoduodenectomies, two (1.9%) central, 48 (45.7%) distal pancreatectomies, eight (7.6%) enucleations, four (3.8%) total pancreatectomies. Sixteen (15.2%) were extended to adjacent organs, 13 (12.3%) to minor liver resections. Postoperative complications presented in 43 (40.1%) patients; CD grade 1 or 2 in 23 (21.9%), grades ≥3 in 20 (19%). Among 25 (23.8%) pancreatic fistulas, 14 (13.3%) were grades B or C. Thirty-four (32.4%) patients developed exocrine, and 31 (29.5%) endocrine insufficiency. Seven patients died during a median 27 (0-175) months follow up. Thirty-day mortality was 0.9%. OS was 94.1% at 5 years. Thirty tumours recurred within 11.7 (0.8-141.5) months. DFS was 44% at 5 years. At univariate analysis, high-grade complications were not associated with shorter DFS (p = 0.744). At multivariate analysis, no parameter was independent predictor for DFS or OS. The comparison of nil-minor versus major complications showed no DFS difference (p = 0.253). CONCLUSION: From our series, major complications after P-NETs resection are not associated to different disease recurrence; hence do not require different follow up or adjuvant regimens.

Parathyroid failure following thyroid surgery.

This cross-sectional study was done to see the association of post thyroidectomy parathyroid failure with thyroid disease and type of surgery. It was carried out in the Department of Otolaryngology-Head and Neck Surgery, Bangabandhu Sheikh Mujib Medical University, Dhaka during the period of July 2008 to June 2010. Total 50 cases of thyroid malignancy and multinodular goiter who had undergone total or near total thyroidectomy with or without neck dissection were studied. In this study highest number of cases were found in 3rd decade of age (28%) and there was female predominance (M:F=1:3.54). Overall frequency of post operative hypocalcaemia was 30% (26% was temporary hypocalcaemia and 4% was permanent). Hypocalcaemia revealed clinically in 20% cases and remained subclinical in 10% cases. Hypocalcaemia developed in 42.30% cases of malignant thyroid disease and 16.66% cases of benign thyroid disease (p<0.05). It was found in 54.54% cases with neck dissection and 23.07% cases without neck dissection (p<0.05). Hypocalcaemia developed in 62.5% cases where parathyroid gland were not identified and 23.8% cases where parathyroid gland was identified. Hypocalcaemia developed most commonly on the 2nd post operative day (73.33%). There is a significance difference with development of parathyroid failure after thyroid surgery between benign and malignant thyroid disease and also between thyroid surgery with or without neck dissection.

The analgesic requirement after thyroid surgery under general anaesthesia with bilateral superficial cervical plexus block.

In this study we evaluated the analgesic efficacy of bilateral superficial cervical plexus block after thyroid surgery. Sixty patients were assigned to two groups. General anesthesia was induced with 2mg/kg propofol, 0.1mg/kg vecuronium and 1.5µg fentanyl IV for both group. After endotracheal intubation, bilateral superficial cervical plexus block with 0.25% bupivacaine 15ml in each side was performed in Group I. In Group II (control) no regional block was administered. Intravenous on demand analgesic was used to evaluate postoperative analgesic requirement. Neither visual analog scale scores nor intravenous analgesics doses were different between the groups. The first analgesic requirement time in Group I was significantly longer than for the control group. The incidence of nausea and vomiting was significantly lower in Group I than Group II. We concluded that bilateral superficial cervical plexus block with 0.25% bupivacaine did not decrease analgesic requirement after thyroid surgery.

Phase II study of magnesium sulfate in acute organophosphate pesticide poisoning.

BACKGROUND: Acute organophosphorus (OP) poisoning is relatively common and a major cause of death from poisoning in developing countries. Magnesium has been shown to be of benefit in animal models. METHODS: We conducted a phase II study of bolus doses of (MgSO4) in 50 patients with acute organophosphate poisoning. Patients eligible for inclusion had ingested OP and had cholinergic symptoms consistent with moderate or severe poisoning. All patients received standard care of atropinization titrated to control muscarinic symptoms and pralidoxime. The trial was run in 4 sequential groups of patients. Participants in each group received a different total dose of MgSO4 (20%) administered as intermittent bolus doses infused over 10-15 min or placebo. There was one control patient for every 4 patients who received MgSO4. Group A (16 patients) received a total of 4 gm MgSO4 as a single bolus, group B (8 patients) received 8 gm (in two 4 gm doses q4H), group C (8 patients) received 12 gm (in three 4 gm doses q4H) group D (8 patients) received 16 gm (in four 4 gm doses q4H) and control (10 patients) received placebo). Patients were closely monitored for any adverse reaction like significant clinical neuromuscular disturbance and respiratory depression. RESULTS: No adverse reactions to magnesium were observed. The 24 hour urinary magnesium concentration were statistically different between 16 gm (234.74 ± 74.18 mg/dl) and control (118.06 ± 30.76 mg/dl) (p = 0.019), while it was much lower than the 80% of the intravenous magnesium load. Six patients died in control group compared to 3 in 4 gm, 2 in 8 gm and 1 in 12 gm group. There was no mortality in 16 gm group. CONCLUSION: Magnesium was well tolerated in this study. Larger studies are required to examine for efficacy.

Community acquired pneumonia in diabetic and non-diabetic hospitalized patients: presentation, causative pathogens and outcome.

Both community acquired pneumonia (CAP) and diabetes mellitus are common in Bangladesh. Though hospitalization of diabetic patients with CAP is increasing, data regarding their clinical presentation, microbial characteristics, antimicrobial susceptibility and outcome are lacking. This study was aimed at finding any difference in clinical presentation, bacterial causes, antimicrobial susceptibility pattern of isolated bacteria and outcome in diabetic and non-diabetic hospitalized patients with CAP. In this study total 47 diabetic and 43 non-diabetic adult hospitalized patients with CAP were enrolled. Clinical presentation of CAP differed in diabetics and non-diabetics. Frequency of atypical presentation and CURB-65 score were significantly higher in diabetics. Pleural effusion with multilobar infiltration was also common feature for CAP in diabetic patients. Klebsiella pneumoniae was the most frequent causative pathogen for CAP in diabetic patients, whereas Streptococcus pneumoniae was the most frequent causative agent for non-diabetic patients. Bacteria isolated from sputum sample of diabetic patients with CAP were resistant to almost all recommended antibiotics used for CAP but 100% of isolates were sensitive to Carbapenems. Pulmonary complications were relatively more in diabetics than in non-diabetics. Hospitalized diabetics with CAP required referral to intensive care unit more than that of non-diabetics. So, diabetic patients with CAP need extra attention.

Endoscopic dacryocystorhinostomy.

Dacryocystorhinostomy (DCR) is the treatment of distal nasolacrimal duct blockage. It has got many advantages of over external DCR with higher patient's acceptance. Twenty one consecutive cases of endoscopic DCR were studied during the period of two and a half years with a mean follow up period of 13.12 months (SD=7.05). The mean age of cases was 42.95 years (SD=14.49). In most of the cases the cause was either idiopathic (71.43%) or inflammatory (23.81%). The techniques used for making bony window were chisel-hammer (19.50%), powered drill (23.81%), Kerrison punch forceps (14.29%) or combination of powered drill and Kerrison punch forceps (42.86%). Silicon stent was used in 71.43% cases. There was no significant peroperative complication; premature extrusion of stent (4.76%), synaechia (9.52%), excessive granulation tissue formation (9.52%) and stomal stenosis with recurrence of symptoms (9.52%) were the complications noticed here. Anatomical success with patent stoma was observed in 90.48% cases but symptomatic improvement with dry comfortable eyes were seen in 86% cases. There was no statistically significant difference of outcome between this study and that of recently published studies (p>0.05). Some comparative studies showed both higher and lower success rates of endoscopic DCR than external procedure but there was no significant difference (p>0.05).

Single-incision laparoscopic trans-abdominal pre-peritoneal mesh hernia repair: a feasible approach.

BACKGROUND: Single-incision laparoscopic surgery (SILS) is aimed at improving the cosmetic outcome following surgery. If the incision is made through the umbilicus, the surgery is almost 'scarless.' This is increasingly being used for laparoscopic cholecystectomy with good cosmetic results without compromising the safety of the operation. The challenge of this surgery lies in manipulating instruments within the limitations of the closely inserted ports. METHODS: We describe the first case of SILS hernia repair via the trans-abdominal pre-peritoneal approach (TAPP) in a 39-year-old male as a day-case procedure. RESULTS: The patient was discharged without any complications. CONCLUSIONS: This novel surgical technique is feasible and improves cosmetic outcome without additional risk. The advantage of such an approach above and beyond cosmesis remains to be evaluated.

[A critical view of Arabic curriculum as a requirement for medical schools, Gezira University].

We compared the present Arabic syllabus used in Gezira University Medical School with previous ones. We also surveyed students and Arabic professors in medical sciences on their views on the content and teaching/evaluation procedures and how these contributed to students' understanding of the medical science syllabus. The current syllabus was designed to provide students with Arabic language skills with particular reference to scientific language. The students' opinions differed regarding their understanding of clinical medicine and their interaction with patients and also the benefits to them of research procedures and reporting. The professors considered the syllabus was adequate to achieve its aims but emphasized the importance of varying teaching methods and evaluation.

Kikuchi-Fujimoto disease.

A 14 year-old Bangladeshi girl presented with high fever, painful swellings in the neck, anorexia, weight loss and night sweating. On examination she had multiple enlarged and tender cervical lymph nodes. Other systems were normal. Laboratory investigations for sepsis and autoimmune diseases were negative. Initial fine needle aspiration and cytology of affected lymph node was suggestive of tubercular lymphdenitis. But she did not respond to anti-tubercular treatment. Kikuchi-Fujimoto disease was diagnosed from the histopathological appearance of excised lymph node. She completely recovered with symptomatic treatment. Kikuchi-Fujimoto disease, also called Kikuchi's disease or histiocytic necrotizing lymphadenitis is a rare, benign but enigmatic disease of unknown aetiology. The disease is self-limited and has an excellent prognosis. Its recognition is crucial because it can be mistaken for systemic lupus erythematosus, malignant lymphoma, tubercular lymphadenitis or even, for metastatic adenocarcinoma. Clinicians' and pathologists' awareness of this disease may help prevent misdiagnosis and inappropriate treatment.

Serum C-reactive protein concentration and the prognosis of ductal adenocarcinoma of the head of pancreas.

BACKGROUND: The prognostic role of serum C-reactive protein in pancreatic cancer has received increasing attention; however the confounding effects of biliary obstruction have not been addressed in previous studies. We sought to determine the prognostic importance of serum CRP prior to biliary intervention in the prognosis of pancreatic adenocarcinoma. METHODS: A retrospective case note review of patients diagnosed with pancreatic cancer between 2001 and 2006. Clinical, radiological and biochemical criteria were correlated with overall survival. Patients were divided into: Group 1 who underwent potentially curative resection, and Group 2 with advanced unresectable disease managed non-surgically. RESULTS: In total, 199 patients were included (58 resected). The proportion of patients with biliary obstruction was equal in both groups. Serum CRP and serum bilirubin concentration at presentation were significantly higher among patients in Group 2 compared to Group 1 (P values). On multivariate analysis, advancing age (P=0.012) and raised serum CRP concentration were independently associated with overall survival only in Group 2 patients (P=0.027, 95% CI 0.31-0.93). This association was independent of biliary tract obstruction. CONCLUSION: Raised serum C-reactive protein concentration at the time of presentation of advanced pancreatic cancer carries a poor prognosis independent of biliary tract obstruction.

Fixed drug eruptions due to cotrimoxazole.

This prospective study on Fixed Drug Eruption (FDE) was carried out between January 2003 to December 2006 in Dermatology department of Mymensingh Medical College Hospital & private chambers. This study was carried out with an objective to see the specific site of involvement and other clinical parameters in FDE due to cotrimoxazole. In each case, a detailed history was taken and a thorough physical examination was done by at least one dermatologist. Patients with suspected FDE, who had consented, were included in the study. Oral re-challenge test was done in each case after written or verbal consent of the patient or legal guardian. For oral re-challenge, usually half of the usual therapeutic dose of the suspected drug (s) was given first and reactions were observed and if no reaction, then full therapeutic dose was given and then again reactions were observed. In case of no reaction to one drug, the next drug was tested after 2 to 7 days. Age & sex distribution, number of attacks of FDE, number of lesions, distribution of sites of involvement were determined in each case of FDE. All informations were recorded in pre-tested data sheet. Among 93 patients of suspected FDE, 61 patients were confirmed as FDE with identified causes, of which 36 cases were due to cotrimoxazole (59.02%). Age range of patients was from 5 years to 65 years with mean of 24.92 years. Male was predominantly affected (M:F=6.2:1). In 50% cases presenting attack was the 2nd attack. Rest 50% had 3 to more than 10 attacks. Number of lesions was: 2-5 lesions in 50%, solitary lesion in 16.67%, 6-10 lesions in 13.89% and more than 10 lesions in 19.44% cases. Sites of involvement in cases of FDE due to cotrimoxazole (n=36) were as follows: lips 58.33%, genitalia 33.33%, oral 13.89%, trunk 38.89%, limbs 55.56%, hands 16.67%, feet 19.44%, face 19.44% and conjunctiva 2.78%.

Predictors of malignant potential of cystic lesions of the pancreas.

BACKGROUND: Cystic lesions of the pancreas (CLP) are a diagnostic dilemma, the correct characterisation of which determines surgical management. METHODS: From 1995 to 2005, radiology and pathology records were reviewed for the presence of CLP. CLP were divided into three groups; Group 1: Benign, Group 2: Pre-malignant, and Group 3: Malignant. RESULTS: Seventy-nine of 121 patients were included [Group 1: n=46, Group 2: n=10, Group 3: n=23], with a median age at diagnosis of 68 (31-92) years. The median follow-up period was 24 (14-84) months. On univariate analysis, female gender (p=0.04), jaundice (p<0.01), raised serum ALT concentration (p=0.03), cyst size (> or = 2.5 cm) (p<0.01), and biliary duct dilatation (p<0.01) were associated with malignant potential. Benign cysts were more likely to present incidentally (p<0.01). On multi-variate analysis, cyst size (> or =2.5 cm) was an independent predictor of malignant potential. Sub-group analysis revealed that cysts <2.5 cm in the head of the pancreas with evidence of biliary obstruction (either abnormal liver function; raised ALT [p=0.01], ALP [p=0.01], total bilirubin [p=0.02], and/or biliary duct dilatation [p<0.01]) were associated with malignant potential. CONCLUSION: Cyst size > or =2.5 cm on computer tomography imaging was an independent predictor of pre-malignant and malignant pancreatic cysts. Cyst size and the presence of biliary obstruction predict potentially malignant cysts of the head of the pancreas, which require surgical management.

Outcome of management of differentiated thyroid carcinoma.

A prospective study was done on 93 cases of differentiated thyroid carcinoma to find out the outcome of management according to the protocol followed in the Department of ENT-Head and Neck Surgery of Bangabandhu Sheikh Mujib Medical University Hospital. Here Papillary carcinoma is more common (76.35%) than follicular carcinoma. Papillary carcinoma affected in the younger patients more commonly than the follicular carcinoma with a mean age of 34.37years (SD=12.81) for papillary carcinoma and 44.93 years (SD=16.01) for follicular carcinoma; but age as a risk factor showed no significant difference between two histological types (p>0.05). Female was the predominant sex with a ratio of 3.04:1. In this series majority of patients were categorized as high risk group (75.27%). There is strong association between histological type & risk group (P<0.05). High risk group is more common in follicular carcinoma (95.45% Vs 69.01%). There was a significant differences between the two histological types for extrathyroidal extention and distant metastasis as risk factors (p<0.01 and p<0.001); but tumour size and lymphatic metastasis showed no significant difference (p>0.05). All low risk patients were treated by hemithyriodectomy followed by life long thyroxine. All high risk cases were treated with total thyroidectomy with (35.71%) or without (62.86%) different types of neck dissection (according to the degree of lymph node involvement) followed by radioiodine ablasion and lifelong thyroxine therapy routinely. Overall rate of complication of thyroid surgery was 23.08%. The commoner complications were vocal cord palsy (5.5%), hypoparathyroidism (5.5%) and haemorrhage (4.4%). Less common complications were laryngeal oedema (2.2%), wound infection (2.2%), tracheal injury (1.1%) and death (2.2%). Many cases lost to follow up. Sixty seven cases (73.64%) responded well for follow-up. Mean duration of follow up was 3.40 years (SD=1.41). There was recurrence in thyroid remnant in 9.09% of hemithyroidectomy cases and were treated by completion thyroidectomy followed by radioiodine ablasion. Regional lymphatic metastasis was seen in six cases and was treated by different types of neck dissection. Recurrence at distal site was seen in 4 cases (18.18% of follicular carcinoma). These were treated by radioiodine ablation; two of them died during the period of follow-up.

Optimization studies on acid hydrolysis of oil palm empty fruit bunch fiber for production of xylose.

Oil palm empty fruit bunch fiber is a lignocellulosic waste from palm oil mills. It is a potential source of xylose which can be used as a raw material for production of xylitol, a high value product. The increasing interest on use of lignocellulosic waste for bioconversion to fuels and chemicals is justifiable as these materials are low cost, renewable and widespread sources of sugars. The objective of the present study was to determine the effect of H(2)SO(4) concentration, reaction temperature and reaction time for production of xylose. Batch reactions were carried out under various reaction temperature, reaction time and acid concentrations and Response Surface Methodology (RSM) was followed to optimize the hydrolysis process in order to obtain high xylose yield. The optimum reaction temperature, reaction time and acid concentration found were 119 degrees C, 60 min and 2%, respectively. Under these conditions xylose yield and selectivity were found to be 91.27% and 17.97 g/g, respectively.

Mirizzi's syndrome--results from a large western experience.

BACKGROUND: This paper reports a series of patients with Mirizzi's syndrome (MS) who were managed at our institution over an 11-year (1994-2005) period. METHODS: Retrospective case note study of patients with a definitive or possible diagnosis of MS stated in radiology reports were identified using the hospital's radiology computer coding system. RESULTS: 33 patients were identified with a median age of diagnosis of 70 (35-90) years and male to female ratio of 15:18. Liver function tests were deranged in all patients. Pre-operative radiological diagnosis was achieved in 28 patients: ultrasound scan (n = 4), computer tomography (n = 3), magnetic resonance cholangiopancreatography (n = 10) and endoscopic retrograde cholangiopancreatography (n = 11). Five patients were diagnosed intra-operatively. Type I MS was reported in 27 patients. Laparoscopic cholecystectomy was attempted in 18 patients with 6 being converted to open cholecystectomy. Six patients had biliary stent insertion only and 3 were conservatively managed. Six patients had type II MS, 4 were treated with open cholecystectomy and Roux-en-Y hepaticojejunostomy, 1 underwent an open subtotal cholecystectomy with fistula closure and 1 had percutaneous biliary stent insertion only. The median follow-up period was 2 (1-7) months (n = 18). 10 patients are currently under follow-up. Overall morbidity was 27% (n = 8) and mortality was 7% (n = 2). CONCLUSION: Pre-operative diagnosis of MS can be achieved using MRCP. Laparoscopic cholecystectomy for type I MS is a safe option and type II MS can be treated with Roux-en-Y hepaticojejunostomy or subtotal cholecystectomy with fistula closure.

[Evaluating the impact of Arabization on medical students' acquisition, Gezira University, Sudan].

This study aimed to assess the teaching of medicine in Arabic at the Faculty of Medicine, University of Gezira, and its impact on the academic attainments of graduates in terms of their final grade point average (GPA). Of a total of 20 graduation classes, 16 classes were selected, 8 of which (classes 5 to 12) studied in English whereas the other 8 (classes 13 to 20) studied in Arabic. The last 8 classes include all graduates (until January 2004) since the Arabic teaching system was first introduced. The proportion of graduates with excellent grade (GPA 3.5 to 4.0), very good and good grade (GPA 2.50 to 3.49), overall pass grade (2.00 and above) of both groups were calculated and compared, as were the failure rates (GPA below 2.00). The overall performance of the classes that studied in Arabic was better (P < 0.05).

Cyclooxygenase-2 expression associated with severity of PanIN lesions: a possible link between chronic pancreatitis and pancreatic cancer.

BACKGROUND: Cyclooxygenase-2 (COX-2) is a key modulatory molecule in inflammation and neoplasia. Increasing evidence suggests a role for COX-2 in pancreatic cancer (PAC). However, expression of COX-2 in pancreatic intraepithelial neoplasia (PanIN), the precursor lesion of PAC which is often present in chronic pancreatitis (CP), has received little attention. METHOD: COX-2 immunostaining was performed on sections of PAC (n = 26), CP (n = 34), PanIN (n = 68) and normal pancreas (n = 11). Sections were also stained for macrophages (CD68), activated pancreatic stellate cells (alphaSMA), and collagen (Sirius Red) as markers of fibrosis. Semiquantitative scoring was based on the extent and intensity of immunostaining. RESULTS: COX-2 expression was increased in PAC compared to normal (p = 0.02) with 89% of cases exceeding COX-2 immunostaining in normal ducts. In PanIN lesions, COX-2 expression increased with escalating severity of the PanIN change (p < or = 0.01). COX-2 expression was increased in PanIN-2/3 compared to normal pancreas and CP (p < or = 0.001). In ducts of CP, COX-2 expression did not differ from that in normal tissue. There was no association between COX-2 expression and clinicopathological variables. CONCLUSION: The high level of COX-2 expression in PanIN lesions suggests that this enzyme could be a therapeutic target at a non-invasive stage of pancreatic carcinogenesis and feasible for chemoprevention in CP.