Public health surveillance at a mass gathering: urs of Baba Farid, Pakpattan district, Punjab, Pakistan, December 2010.

The objective of this study was to identify health related problems encountered during an annual mass gathering in Pakpattan, Pakistan, the anniversary of the death (urs) of Baba Farid, and to make recommendations for planning and prevention activities. A surveillance system was established to capture health related data for the event. A list of reportable diseases was developed. Data were collected pre-, during, and post-event by health care workers trained for the purpose. A total of 5918 people reported to the 15 health care facilities providing services during the event; 58% of consultations were because of communicable diseases, 21% of which were respiratory tract infections and 26% gastrointestinal illness. Injuries accounted for 31% of cases and noncommunicable diseases for 11%. Prevalence of reportable disease during the event showed sizeable increases. No major disease outbreak was observed.

Nonoperative management of contained retrohepatic caval injury.

Traumatic inferior vena cava (IVC) injuries are associated with high mortality rates, despite all improvements in the technical skills and prehospital and hospital care. Selective conservative management of the penetrating abdominal injuries involving IVC has not been widely discussed before. Here, we report a case of a young female with a single gunshot wound to her abdomen, who presented to our level 1 trauma center 10 minutes after injury and was hemodynamically stable. A computed tomographic scan revealed a large liver laceration with a trajectory through the liver and the IVC. The IVC was surrounded by a moderate amount of fluid, consistent with a contained retroperitoneal hematoma. We discuss the outcome of nonoperative management of this patient along with a review of the literature.

Reoperations after surgery for lumbar spinal stenosis.

OBJECTIVE: To study the indication for reoperations after lumbar decompression, the factors predisposing to redo operations, and the effect of prior instrumentation on developing adjacent level stenosis requiring reoperation. METHODS: Kaplan-Meier analysis was used to compare the median interval to first reoperation. Cox regression was used for multivariate analysis of time to first reoperation. RESULTS: Of 335 patients who underwent surgery for lumbar spinal stenosis, 63 (18%) underwent instrumentation in addition to decompression. There were 50 reoperations performed in 44 patients (13%). Of these 50 reoperations, 26 were at the same level, 14 were at the same level plus an adjacent level, and 10 were at an adjacent level. In 21 reoperations, the indication was adjacent level spinal stenosis; in 16, adjacent level spinal stenosis plus instability; in 9, instability alone; and in 4, disc problem. The risk of reoperation was higher among male patients (hazard ratio [HR] 1.2, 95% confidence interval [CI] 0.586-2.635) and in patients with prior instrumentation (HR 1.7, 95% CI 0.684-4.640). There was no statistical association between prior instrumentation and subsequent risk of reoperation (P = 0.12). There was no association between prior instrumentation and development of adjacent level stenosis requiring reoperation (P = 0.473). CONCLUSIONS: Many patients with spinal stenosis undergo instrumentation because of instability. Most patients in this study underwent reoperation at the same level, and the most common pathology was spinal stenosis. The risk of reoperation was lower in older patients (≥65 years old). Although there was a trend that the risk of reoperation was higher among patients with prior instrumentation, it did not reach statistical significance. In this study, there was no association between prior instrumentation and adjacent level stenosis requiring reoperation. These findings need to be evaluated further in randomized trials.

Simultaneous arterial and venous ultrasound-assisted thrombolysis for phlegmasia cerulea dolens.

Phlegmasia cerulea dolens is a rare condition in which an extensive deep venous thrombus can partially or completely occlude venous outflow from the affected extremity. Clinical presentation is typically characterized by extremity edema, cyanosis, and pain. This condition is associated with a high rate of extremity amputation and mortality. Although numerous therapies have been described, there is no generalized treatment consensus and less invasive forms of therapy continue to evolve. We report a case of phlegmasia cerulea dolens in a patient who presented with concomitant arterial and venous thrombosis of the affected extremity. The patient's condition was successfully treated using combined ultrasound-assisted intra-arterial and intravenous catheter-directed thrombolysis.

Giant pararenal abdominal aortic aneurysm.

Inflammatory aortic aneurysms are unusual vascular lesions and most commonly involve the infrarenal segment of the abdominal aorta. These complex aneurysms represent a challenge to the vascular surgeon and become even more difficult as the extent of the aneurysm and size of the inflammatory mass increase. Although well described, few cases of giant inflammatory aneurysms are reported. In this case, we review the clinical presentation and surgical management of a patient with a giant pararenal abdominal aortic aneurysm and highlight an uncommon morphologic pattern of aortic disease and provide a review of relevant literature.

Tuberculous peritonitis: a surgical dilemma.

This is a case report of tuberculous peritonitis (TB), an entity which is difficult to diagnose. When TB is found in extrapulmonary organs it is usually associated with an immunocompromised state, such as that caused by the human immunodeficiency virus (HIV). Medical therapy continues to be the treatment of choice and, if the correct diagnosis is made early, surgery is rarely required.

Femororenal arteriovenous graft: a viable option for hemodialysis access.

There has been a significant increase in the number of patients with end-stage renal disease. The limited number of kidney transplants necessitates that most patients become dependent upon chronic dialysis. Due to the numerous complications associated with temporary access catheters, permanent arteriovenous access is more beneficial for long-term vascular access. However, with the restricted availability of sites for permanent vascular access, it is important to have a variety of possibilities. In this case report, we present an alternative choice for an arteriovenous graft, left common femoral artery to left renal vein, in a patient with limited vascular access options.

Monofilament nylon filters for preventing dracunculiasis: Durability and copepod retention after long term field use in Pakistan.

Filtration of drinking water to remove the cyclopoid copepod intermediate hosts of guinea worm. Dracunculus medinensis, is one of the primary intervention strategies for preventing dracunculiasis. In early 1987, monofilament nylon filters with 200 microns pore size were distributed to households in selected guinea worm-infected villages in Pakistan. The filters proved popular with the villagers, although reports of "loss of filters" could diminish the community-wide effectiveness of this control measure. After 12 to 15 months of usage a sample of these filters was collected and examined for damage or impairment which would decrease their use or their capacity to retain potentially infective copepods. Although all naupliar stages and early copepodids (Stages CI-II) passed through these used filters, the larger copepodids including adults (Stages CIII-VI) were retained despite small tears in the fabric. This field trial showed that after 12 to 15 months of regular use, monofilament nylon filters of 200 microns pore size remained effective in removing copepodid stages capable of supporting development of D. medinensis larvae. Considering the ease of use, popularity and effective filtration of potentially infective copepods following prolonged field use, we recommend that monofilament filters be considered in any program of guinea worm elimination.