Open Partial Nephrectomy With Zero IschemiaTechnique Using Thulium Laser: Our Experience of4 Cases

With the advent of newer technologies, the management of small renal masses has shown a paradigm shift.This has resulted in preferring partial nephrectomy over radical nephrectomy, emphasizing the concept of nephronsparing surgery. Various lasers have been used in few cases. We prospectively evaluated the use of thuliumlaser in open partial nephrectomy over last 1 year. The aim is to study thulium laser as an energy source forpartial nephrectomy for peripheral tumor. The role of partial nephrectomy and zero ischemia time in renalpreservation is already proven. Outcomes of total of 4 patients who underwent open partial nephrectomy wereanalyzed prospectively. We used Quanta Cyber TM laser at setting of 30 W both for cutting and coagulation.Preoperative characteristics and outcomes were analyzed. Four patients underwent open partial nephrectomy withzero ischemia. The mean tumor size was 5.26 cm, mean RENAL nephrometry score was 4.5, mean operativetime was 67.5 minutes, active laser time was 2 minutes, mean blood loss related to partial nephrectomy perse was 65 mL. Mean preoperative hemoglobin was 11.12 g% and mean postoperative hemoglobin was 10.05g%. Mean duration of stay was 6 days. Histologically all lesions were renal cell carcinoma pT1/T2, with marginsnegative for tumor and no deterioration in renal function during follow-up. The thulium laser at 2013 nm wavelengthdemonstrates excellent hemostasis and precise cutting capabilities of the renal cortex during open partialnephrectomy for peripheral tumors without requiring renal artery clamping.

Clinical spectrum and outcome of cerebral venous sinus thrombosis in children

Objective: To determine clinical spectrum, neuroimaging finding and outcome of cerebral venous sinus thrombosis [CVST] in children. Study Design: Descriptive and cross-sectional study. Place and Duration of Study: Department of Paediatric Neurology, Children's Hospital and Institute of Child Health, Lahore, from 2015 to 2016

Methodology: Data was collected in a predesigned proforma by non-probability purposive sampling technique from all enrolled 32 patients fulfilling the inclusion criteria. We analysed descriptively the clinical presentation, neuroimaging findings, associated risk factors and outcome. Chi-square test was used to check the association between demographic variables and findings at five percent level of significance

Results: Out of 32 patients enrolled, 75% [24] patients were male; median age was 2.5 years. Fever was found the most common presentation followed by headache and lethargy. Neuroimaging showed superior sagital sinus thrombosis in all [100%], while 25% [8] have additional thrombosis of internal cerebral veins. Ischemic infarction was found in 11 [35%], while hemorrhagic infarction was found in 9 [29%] patients. Death occurred in 6.25% of children

Conclusion: Infections were the common cause of CVST in children followed by anemia and dehydration. Mortality trend was low with earlier diagnosis and aggressive treatment. Anticoagulant treatment along with adequate hydration, antibiotics and correction of anemia can lead to a better outcome. A large local and regional prospective multicenter studies for pediatric cerebral venous sinus thrombosis is suggested to evaluate the risk factors and plan guidelines for managing this condition in children

Positive CT brain during early postoperative period in head injury patients: impact on clinical course and outcome

Objectives: To assess the impact of positive postoperative CT head during the initial 72 hours on overall clinical course and outcome

Methodology: 157 patients of head trauma who underwent cranial surgery were prospectively included. All patients underwent a repeat head CT during the initial 72 hours or as was indicated by neurological status of the patient. Data was collected about patient demographics, initial CT diagnosis, repeat CT findings, re-operation if performed, GCS at discharge, mortality and outcome in terms of GOS. Data was analysed for impact of positive finding in postoperative CT head and its impact on clinical course and outcome

Results: The overall mean age was 34.25 +/-11.59 years with a mean arrival GCS of 9.2 +/-2.32. The mean time to first postoperative CT was 21.45 +/-9.83 hours. The postoperative CT scan was positive in 29 [18.5%] patients in which 16 [10.2%] cases required re-intervention. Overall mortality was 19 [12.1%], of which 9 [44.1%] had a positive post-operative CT scan and 4 [21.1%] of them underwent a repeat intervention. 2.3% of patients with negative CT were re-operated while 44.8% were re-operated in the positive CT [p <0.0001]. Similarly, mortality was 7.8% in the negative CT group while it was 31.0% in the positive CT group [p <0.0001]

Conclusions: Positive follow-up CT scan during early post-operative period can affect significantly the clinical course and neurological outcome of patients

Diagnosis of urinary tract infection: medical imaging or laboratory based

Urinary tract infection [UTI] affects women more than males mainly due to smaller urethra and feminine genital anatomy. Symptoms of UTI includes painful micturaition, flank pain, fever etc while its signs are pyuria, bacteriuria and tenderness in flank. In order to rule out UTI, laboratory tests are primarily performed, most important are urine routine examination, urine culture and sensitivity test. Radiological evaluation of urinary system is also done to determine the underlying causes of infection and the extent of damage caused to the renal system by the infection

Effects of two functionally important SLCO1B1 gene polymorphisms on pharmacokinetics of atorvastatin

Organic anion transporter polypeptide 1B1 [OATP1B1] encoded by [SLCO1B1] gene, an uptake transporter involved in the transport of drugs and endogenous compounds and located in hepatocyte sinusoidal membrane. Objective of study was to investigate the effects of two functionally significant SNPs [388A>G and 521T>C] and their respective genotypes of SLCO1B1 gene encoding OATP1B1 on the pharmiacokinetics of atorvastatin. A total of 100 subjects divided into 6 groups as per their genotype profile were recruited. A single dose of 80mg atorvastatin was orally administered and plasma concentration measured up to 48 hours. The 388A>G and 521T>C genotypes were significantly associated with each other when compared for AUC and C[MAX] but exhibited no significant variations in T[MAX] and ti/[2]. 521 SNP is rather more strongly associated with altered pharmacokinetics of atorvastatin when compared with the 388 SNP, though the homozygous bi-allelic variant of 388 SNP also exhibited a fairly significant variation along with homozygous bi-allelic variant of 521 SNP. The inter-individual variation in pharmacokinetics can be explained by SLCO1B1 polymorphism

Polydioxanone vs prolene closure for midline abdominal incisions: to compare postoperative wound dehiscence

The objective of this study was the comparison of Polydioxanone and Prolene for midline abdominal closure in terms of postoperative wound dehiscence. Randomized control trial. This study was conducted at Department of Surgery, Sheikh Khalifa Bin Zaid AlNahyan Hospital Rawlakot Azad Kashmir from 20-12-2012 to 25-12-2014. We studied 106 patients for midline closure of abdominal surgery. We made two groups [Group A consisted patients in whom abdominal closure was done with Polydioxanone no. 1 and Group Bcontained patients who underwent closure with Prolene no. 1. The outcome variablewas wound dehiscence. The average of age for 106 patients was 36.88 +/- 13.28 years. In group A, the wound dehiscence was seen in 4 [3.8%] patients while in group B it was seen in 12 [11.3%] patients. Wound dehiscence was considerably high in group B as compared to groups A, [p-value < 0.05]. Polydioxanone is a synthetic absorbable suture which retains its strength for longer than other absorbable materials. According to our experience Polydioxanone causes less wound dehiscence as compared to Prolene in midline abdominal wound closure

Frequency of recurrent laryngeal nerve palsy after thyroidectomy at sheikh khalifa bin zaid hospital rawlakot Azad Kashmir

The objective of the study was to determine the frequency of post thyroidectomy RLN palsy and to adopt measures to reduce the frequency of RLN palsy after thyroidectomy. Descriptive study. This study was carried out at General Surgery Department, Sheikh Khalifa Bin ZaidHospital Rawlakot Azad Kashmir from 16.11.2012 to 16.11.2014. Total of 80 patients of goiter undergoing thyroidectomy were admitted through outpatient department. All patients underwent thorough clinical examination and investigations. They were informed of th ebenefits and risks associated with surgery and written informed consent was obtained. All information was recorded on performa. Vocal cord status was assessed pre and postoperatively by indirect laryngoscopy. Size of thyroid gland was measured before operation in all the patients and weight of thyroid tissue removed during operation was also assessed. 03 patients were excluded from the study as they were already having hoarseness of voice. 29 were subjected to subtotal thyroidectomy, 30 to total thyroidectomy, and 21 to hemi-thyroidectomy randomly. All were followed up for RLN palsy for 03 months. According to our objective, no test of significance was applicable. However, descriptive statistics including mean, standard deviation was used by using Microsoft statistical package for social sciences [SPSS Version 10.]. The age range of the patients undergoing thyroidectomy was 20-68 years with an average age of 44. Total mortality rate was 0%. Transient hoarseness of voice was present in 01[1.2%] which improved spontaneously with time and permanent hoarseness in 0% patients. No patient was lost at any point. Frequency of RLN palsy can be reduced by careful identification of recurrent laryngeal nerve by various methods per-operatively

Perceived effects of undergraduate medical study on social life: a descriptive study at poonch Medical College in Rawlakot Azad Kashmir

This study explored how second year medical students of Poonch Medical College related studying in medical college with their social activities. Cross-sectional study. This study was conducted with the first batch of students at PMC in Rawlakot AJ and K from January 2013 to July 2014. This study obtained data in a purposive sample from the entire second year class using a structured self-administered questionnaire, with 88% response rate. Of total 88 respondents, 63 girls [72%] and 25 boys [28%] with a mean age of 19 participated. More than 80% respondents had many friends, 81% girls and 36% boys didn't have time to meet them [[p<.000]. Around 89% girls and 68% boys didn't have time to play [[p.029], 49% girls and 44% couldn't see their families [p<.197], 40% hostelite and non-hostelite could play [p<.991], and 76% boys and 65% girls perceived burdensome medical study which deprived them from regularly meeting with their family and friends. Findings of this study have broader implications for furnishing academic environment in medical institutions of Pakistan more conducive, supportive and effective. Medical instititionsshould review their curriculum and teachinglleaming schedules and try to redesign their educational programs keeping a balance between study load and the social life of a medical student. Students should also be encouraged to set their educational and social priorities and try to ensure this balance

Experience with endoscopic third ventriculostomy in the management of hydrocephalus secondary to posterior fossa tumor

To analyze the outcome of endoscopic 3[rd] ventriculotomy in the management of hydrocephalussecondary to posterior fossa tumor. Sixty five cases of hydrocephalus secondary to posterior fossa tumor underwent endoscopic3[rd] ventriculostomy in the Department of Neurosurgery, Lady Reading Hospital, Peshawar Pakistan from January, 2011 to June, 2012 [18 months]. This was an observational study and the sampling was by simple random method. The study included 65 patients, 37 males, 28 females; M/F ratio, 1.32; with the age range 1-45 years. Fifty one percent [33 cases] of posterior fossa tumors occurred in children less than five years, 23% [15cases] in the 6-10 year age group, 16% [11 cases] occurred in 11-14 years and 10% [06 cases] in age group >14 yrs. Endoscopic third ventriculostomy was performed in 54 [83.07%] patients with successful outcome. Ventriculoperitoneal shunt was required in 5 [7.69%] patients for the suspicion of inadequate ventriculostomy. Ventricular drainage device [EVD] was inserted in 2 [3.07%] cases for hemorrhagic CSF. In 4 [6.15%] patients no drainage procedure was done [4th ventricle floor not involved / Aqueduct opening visible]. Preoperative endoscopic third ventriculostomy [ETV] control the intracranial pressure [ICP], avoid the necessity of an emergency procedure, allow appropriate scheduling of the operation for tumor removal, and eliminate the risks related to the presence of an external drainage. The most common age group involved was under 5 years. The success rate of ETV was 83% and Medulloblastoma was the most common Histopathological findings

Anatomy resource centre

It has been seen that just delivering the lectures of anatomy followed by dissection may fail to produce a long lasting understanding of the subject. The students are also unable to appreciate the importance of clinical anatomy integrated within various medical disciplines. A medical college or university may look at restructuring the medical curriculum with an anatomy resource centre which can have a pivotal influence on self-directed learning. [1] To prepare an innovative resource centre for teachers. [2]. To rain student to achieve sufficient knowledge, skill and attitude when given a problem-solving exercise. The resource centre is equipped with routine cadaveric dissection. Such gross structural relationships are made more meaningful by the use of living anatomy such as conventional radiographs, CT, MRI, ultrasound, laparoscopic, videos and surface anatomy. Simultaneous presence of microscopic anatomy [histology] can help to understand cell biology and molecular medicine in great detail. It is also necessary to use plastic models to overcome the complexity of the structures such as perineum and joints. Web-based computer sites can supplement the effort and to achieve what is called 'self-directed assessment skill'. Once the students are aware of the normal structures, they can be challenged with abnormal structures or tissues. An anatomy resource centre thus, can be integrated with various disciplines. However, it is felt that an efficient clinical anatomy curriculum can only lead to the success in developing an innovative anatomy resource centre for teachers and students

Histomorphological features of placentae in pregnancies complicated with intrauterine growth restriction

Fetal growth retardation is most commonly caused by placental letdown to meet the increasing demand for oxygen and nutrients of the developing fetus. Intrauterine growth restriction [IUGR] is common happening in Pakistani setup especially in rural areas. Current literature suggests that placental causes are more common than the maternal causes in intrauterine growth restriction. Macroscopic and microscopic examination of placenta can help us to identify the patho-physiology of placental involvement. This is reasonable especially in those cases of intrauterine growth retardation which are not perplexed by maternal causes. To identify macroscopic and microscopic features of placenta in pregnancy complicated with IUGR. Descriptive study. This study was conducted at Sheikh Zayed Medical College/Hospital, Rahim Yar Khan in collaboration with Department of Pathology Quaid-e-Azam Medical College, Bahawalpur and Anatomy Department, Nishtar Medical College, Multan. Study duration was two years from July, 2010 to June, 2012. One hundred and fifty placentae, 85 from cases of intrauterine growth retardation and 65 from normal [control] were enrolled for the study. Fetal and placental weights and placental diameter and thickness were measured. Tissue for histological examination was obtained from: i] Umbilical cord ii] membranes and iii] three placental zones. The tissues were processed and stained with Haematoxlyin, Eosin and Mallory's Trichrome. The prepared tissues were studied microscopically for villous and intervillous lesions utilizing various criteria. Macroscopically there was significant decrease in placental weight, fetal weight, and placental diameter and thickness. Microscopic findings were increased fibrinoid necrosis [46.7%], increased perivillous fibrinoid deposition [16.7%], increased syncytial knots [60%] and increased placental infarction [1.8%]. These findings document comparatively higher frequency of fibrinoid necrosis and perivillous fibrinoid deposition. This draws ours attention to the predominant role of placental causes in cases of idiopathic intrauterine growth retardation

Childhood primary angiitis of the central nervous system

To analyze the clinical course and magnetic resonance angiographic [MRA] abnormalities in children with primary angiitis of the central nervous system [cPACNS]. Cohort study. Neurosciences and Neuroradiology Department of the Children's Hospital, Lahore, from January 2009 to December 2010. The cohort comprised consecutive patients diagnosed as having cPACNS based on clinical findings and identification of arterial stenosis on magnetic resonance angiography [MRA] in the absence of an underlying condition that could cause these findings. The treatment protocol for ischaemic infarcts consisted of induction therapy with intravenous steroids pulses and intravenous immunoglobulin followed by maintenance therapy with azathioprine and low dose aspirin. When indicated, they were treated with anticoagulants at least for 4 weeks along with induction therapy. Patients were followed at a single centre and systemically assessed for clinical presentation, classification of disease as progressive or non-progressive, adverse effects of anticoagulants, aspirin, azathioprine and their hospital course. Sixty-eight children with medium-large vessel cPACNS [62% boys, 38% girls] with mean age of 8.5 +/- 3.5 years were enrolled in this study. Motor deficit [70%]; headache [64%] and fever [20%] were the commonest symptoms; whereas hemiparesis [60%]; seizures 55% [focal 35%, generalized 20%] and decreased conscious level [30%], were the commonest neurological findings. Neuroradiological findings were ischaemic strokes in 50 [73.5%], haemorrhagic strokes in 10 [14.7%] and ischaemic haemorrhagic lesions in 8 cases [11.8%]. Angiographically 51 [51/68, 75%] of the cohort had non-progressive [obliterative] and 17 [17/68, 25%] had evidence of progressive arteriopathy at the time of admission. No secondary haemorrhagic lesions were documented among infarcts strokes, which were treated with heparin and oral anticoagulants. Outcome was survival in 56 cases [81.5%] and death in 12 cases [18.5%]. All survivors were discharged on long-term oral aspirin; 15 of them were also commenced on azathioprine. Neurological findings among the 56 survivors were; normal 20%, minor disabilities in 25%, moderate disabilities in 20% and severe disabilities in 35%. The spectrum of cPACNS includes both progressive and non-progressive forms with significant morbidity and mortality. This treatment protocol of immunosuppressive therapy may improve long-term neurological outcome in children with medium-large vessel childhood primary angiitis of the CNS

Level of spinal involvement in patients operated for spinal tuberculosis

To determine the frequency of different levels of spinal involvement in patients operated for spinal tuberculosis. This observational study was conducted in the Department of Neurosurgery Lady Reading Hospital Peshawar from January 2008 to December 2010. In this study medical record of all patients operated for spinal tuberculosis were analyzed. The frequency of different spinal levels involved was determined. Patients were divided into five groups based on the involvement of different vertebral level i.e. cervical, upper dorsal, lower dorsal lumbar and sacral. Data stratified regarding age, sex and locality. Results were analyzed and presented in the form of tables, bar and pie charts by using SPSS software version 11 for analysis. A total of 81 patients with spinal tuberculosis were operated during this period. Their age ranged from 13 to 65 years. Patients presented with male to female ratio of 1.25 to 1. Per-operatively majority of the patients [i.e., 49.38%] had involvement of lower dorsal spine [D7 to D12], while 19.75% had involved cervical vertebrae, 22.22% involved upper dorsal spine that is from D1 to D6 while only 8% had lumbar vertebrae involved. Most of the patients had multilevel involvement, which is 70.37%. This study shows that most of the patients with spinal tuberculosis involve lower dorsal spine while lumbar area in very little and no sacral area involvement. We found that most of the time it was multiple level involvement rather than single vertebrae

Clinical spectrum of infantile spasm at presentation

To determine the clinical and EEG findings in children with infantile spasms at their initial presentation to the Neurophysiology Department, Children's Hospital, Lahore, Pakistan. Observational study. The Neurophysiology Department, Children's Hospital, Lahore, Pakistan, from January 2008 to December 2010. Children aged

unusual cause of traumatic brain injury in Khyber Pakhtunkhwa: a case report

Penetrating head injuries can be the result of numerous intentional or unintentional events, including missile wounds, stab wounds, motor vehicle and occupational accidents [nails, iron rods] or assaults [screw-drivers]. Penetrating head injuries caused by screw-drivers constitute only a small part of the total number of traumatic head injuries seen in casualty. We report a case of neuro-trauma who was operated in our institution. A 25 years gentleman presented in casualty on with a screw-driver penetrating into the skull, as an unusual case of violence

Post extraction bleeding associated with long term maintenance dose of aspirin 75-150mg

The objective of this study was to see post extraction bleeding associated with long term maintenance dose of aspirin 75mg-150mg without discontinuation. This study was conducted at Lady Reading Hospital Peshawar from January 2009 to June 2010. Patients for simple single tooth extraction and on aspirin [75-150 mg] were included. Patients with systemic disease like hematologic, renal, or liver disease, bone marrow disorders, alcoholism, or any concurrent medication affecting hemostasis such as anticogulants or anti-inflammatory drugs and patients who needed extractions of deciduous teeth, surgical extractions, extractions in different quadrants, or multiple extractions [>1 tooth] were excluded. Patients were evaluated for immediate and late post extraction bleeding. A total of 254 patients were studied. Patients were categorized into two groups with equal number of patients in each group i.e. 127 each. Group 1 [study] on maintenance dose of Aspirin 75-150mg while group 2 [control] were not taking aspirin. In aspirin group 05 [03.93%] patients had post extraction prolonged immediate bleeding while 03 [02.36%] were in control group. This difference was not statistically significant [p=0.722]. In aspirin group 02 [01.57%] patients had late bleeding at 12 hour post extraction while one [0.78%] patient suffered in control group [p=1.00]. The bleeding was successfully controlled with pressure on gauze and no patient required suturing or re-hospital visit. There was no bleeding in post extraction period at 24 and at 48 hours. It was concluded that simple tooth extraction in patients on long term maintenance dose of 75-150mg aspirin without discontinuation is safe as far as post extraction bleeding is concerned

Abdominal angina - a rare cause of chronic abdominal pain

We report here a case of chronic postprandial abdominal pain and weight loss of more than one year duration. He was diagnosed to have abdominal angina [chronic mesenteric ischemia] on CT angiography. Open surgical revascularization procedure-right common iliac mesenteric polytetrafluoroethylene [PTFE] bypass graft achieved positive short and long-term outcome with follow-up of twenty two months