Pancreatic Duct Stones.

pancreatitis appears to exist in the presence of such calculi upon radiology. Having said that, pancreatic ductal stone due to biliary causes (origin), in face of acute pancreatitis, is rare. To the best of our knowledge this was the first case of its kind presented to our hospital in recent past. A 25-year-old female presented to the emergency department of our hospital with an acute episode of pancreatitis. Computerized tomography (CT) scan, endoscopic retrograde cholangiopancreatography (ERCP) & magnetic resonance cholangiopancreatography (MRCP) concluded acute pancreatitis (AP) with dilated main pancreatic duct left side branches and intra ductal calculi. The findings were not suggestive of any chronic pancreatitis. Conservative treatment was given for the episodic attack of AP. After the episode resolved, an exploration and extraction of the pancreatic ductal calculus was performed successfully. The pancreatic duct stones were removed by lateral pancreaticojejunostomy (partington-rochelle procedure). The patient made a remarkable recovery after the procedure and was perfectly healthy and well-oriented in time and space at 4-months follow up. Acute pancreatitis is an inflammatory condition of pancreas, when, associated with pancreatic duct stones a lateral pancreaticojejunostomy is done, which, results in better outcomes decreasing the mortality and morbidity. Acute pancreatitis due to ductal calculi is rare for which extraction is safe after resolution of the episode of AP. Studies need to be carried out to look for the outcome and the effectiveness of the procedure, when, specifically and specially done for this condition.

Pleomorphic Adenoma Of Minor Salivary Glands.

Pleomorphic adenoma is the most common benign tumour of salivary glands which is Known for its wide pleomorphic architecture. It accounts for 45-75% of all salivary gland neoplasm. It can involve major as well as minor salivary glands. Among minor salivary glands (5-10% of cases) the palate lip, nasal cavity, pharynx, larynx and trachea are the most common sites. Diagnosis is made with biopsy along with histopathology. Wide excision with biopsy and removal of underlying extension of tumour is the treatment of choice. Sixty years old farmer presented with painless swelling in the upper lip for the last 8 years. History revealed recurrent mass in the midline of upper lip with no other complaints. He was operated 3 times for this complaint in the past. Belonging to poor socioeconomic status no biopsy records were found. On examination 3×4 cm hard and mobile mass was found. Lymph nodes of head and neck and parotid gland revealed no enlargement. Surgery by wide excision was planned. After baseline investigation surgery was done and the mass sent for histopathology. Biopsy reports showed pleomorphic adenoma on unusual site. Dissection of salivary gland tumour is important as they have propensity to metastasize. Wide local excision along with biopsy is the method of choice. Proper surgical techniques are required to avoid recurrence.

Eales Disease.

Eales disease is an eponym after a British ophthalmologist Henry Eales. The aetiology behind Eales disease is ill-understood and stands controversial. Various systemic diseases associated with peripheral retinal revascularization and Retinal vasculitis could imitate the proliferative and inflammatory phases of Eales' disease, respectively. We present a case of a 30 years old female patient with Eales disease and discuss the clinical features, treatment plan and its outcome in our patient. Tuberculosis appears to be the cause of Eales disease but the relation is yet to be established and clinically proven. Steroid therapy is usually the main stay of treatment with tapering doses of systemic corticosteroids. Other interventions are vitrectomy, photocogulation or cryotherapy.

Comparison of caudal bupivacaine and bupivacaine-tramadol for postoperative analgesia in children undergoing hypospadias surgery.

OBJECTIVE: To compare the effectiveness of caudal bupivacaine and bupivacaine-tramadol for postoperative analgesia in children undergoing hypospadias surgery. STUDY DESIGN: Quasi experimental study. PLACE AND DURATION OF STUDY: The Postgraduate Medical Institute, Hayatabad Medical Complex, Peshawar, from February 2006 to August 2007. METHODOLOGY: The study was conducted on 60 male children undergoing elective hypospadias surgery at the study centre. Patients were divided into two groups of 30 each. Patients in group 'B' (bupivacaine) were given 0.5 ml/kg of 0.25% plain bupivacaine, while patients in group 'BT' (bupivacaine and tramadol) were given 0.5 ml/kg of 0.25% bupivacaine in combination with 1 mg/kg of tramadol in caudal epidural space just after induction of anaesthesia. ASA status, duration of anaesthesia,duration of surgery, type of anaesthesia and maintenance of anaesthesia were similar for both groups. In the recovery room, patients were compared for pain scores, sedation score, need for rescue analgesia and any unwanted side effects for 24 hours postoperatively. All patients were assessed haemodynamically at regular intervals intraoperatively in both groups. A t-test was used to compare the mean values of the group with significance at p < 0.05. RESULTS: Mean age of the children was 4.2+/-2.35 and 5.5+/-1.51 years in group B and BT respectively. Their weight ranged from 10-30 kg. A lower pain score was observed in the bupivacaine-tramadol group during the first 24 hours in the recovery room, as well as in the postoperative ward. The mean duration of analgesia was significantly prolonged and the requirement for rescue analgesics were significantly less in the bupivacaine-tramadol group (p < 0.0001) postoperatively. Demographic data, haemodynamic variables, sedation score, and minor complications were not significantly different in the two groups. CONCLUSION: Caudal tramadol with bupivacaine provides prolonged and good quality postoperative analgesia compared to plain bupivacaine in children undergoing hypospadias surgery.

Comparison of Epidural Steroid Injections with conservative management in patients with lumbar radiculopathy.

OBJECTIVE: To determine the difference in short- and long-term pain improvement between lumbar Epidural Steroid Injections (ESIs) and conservative management in patients with lumbar radiculopathy. STUDY DESIGN: Quasi-experimental study. PLACE AND DURATION OF STUDY: The Postgraduate Medical Institute of Hayatabad Medical Complex, Peshawar, from April 2005 to March 2007. METHODOLOGY: Fifty elective patients fulfilling the inclusion criteria were randomly divided into two groups. Patients in the steroid group were treated with 80 mg of methylprednisolone injected in combination with 3 ml of 2% plain xylocaine and 3 ml of normal saline in the lumbar epidural space, while patients in the conservative group were treated with bed rest, non-steroidal anti-inflammatory agents, muscle relaxants, and opioids. All the 50 patients in the two groups were regularly assessed at 2 weeks, 1 month, 3 months and 6 months of periods for pain score by the Visual Analogue Scale (VAS), patients satisfaction score and any unwanted side effects. RESULTS: A marked improvement of the pain score and patients satisfaction score were noticed in the steroid group. Less significant improvement was seen in the conservative group during the initial period i.e 2 weeks and 1 month (p < 0.05). The difference in Visual Analogue Scale (VAS) and patients satisfaction score was non-significant in chronic stages of treatment in both groups (p > 0.05). CONCLUSION: Epidural steroid injections in acute symptoms of sciatica are considered to be a better option compared to conservative treatment.

Risk factors of preseptal and orbital cellulitis.

OBJECTIVE: To estimate the frequency and major risk factors of preseptal and orbital cellulitis. STUDY DESIGN: A cross-sectional analytical study. PLACE AND DURATION OF STUDY: The Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar from July 2003 to December 2006. METHODOLOGY: All consecutive patients between ages 6 and 40 years, admitted to the institute with the diagnosis of preseptal and orbital cellulitis were included in the study. The patients were divided into two groups. Group I included patients with ages 6-16 years and group II with ages 17-40 years. The clinical features, diagnosis and risk factors were entered on a specially-designed proforma. The risk factors included were trauma, insect bite, localized or systemic infection and postsurgical. Odd ratio and p-values were calculated for potential risk factors. RESULTS: The frequency of orbital cellulitis was 0.1% of total admission. Out of 26 patients, 42.30% patients were in group I and 57 in group II. In group I, insect bite was the most common risk factor identified in 40% of patients with preseptal cellulitis and trauma as a common cause in 50% with orbital cellulitis. In group II, trauma was the leading cause in 50% of patients with preseptal cellulitis and sinusitis as a common cause in 18.1% with those of orbital cellulitis. In both groups the p-values were found insignificant (p>0.5). Complications included cicatricial ectropion in 44.4% and orbital abscess in 41.1%. CONCLUSION: For preseptal cellulitis, insect bite was the most common cause in group I and trauma was the leading cause in group II. For orbital cellulitis, trauma was important cause in group I and sinusitis in group II.

Midazolam with bupivacaine for improving analgesia quality in brachial plexus block for upper limb surgeries.

OBJECTIVE: To compare the onset, duration and postoperative pain scores of supraclavicular block with bupivacaine alone and bupivacaine-midazolam combination. STUDY DESIGN: Randomized controlled clinical trial. PLACE AND DURATION OF STUDY: The Postgraduate Medical Institute, Hayatabad Medical Complex, Peshawar, from April 2005 to June 2007. METHODOLOGY: A randomized controlled clinical trial was conducted on 50 ASA-I or II adult patients undergoing upper limb surgeries under supraclavicular brachial plexus block. Patients were randomly allocated into two groups of 25 each. Patients in group A were administered 30 ml of 0.5% bupivacaine and those in group B were given 30 ml of 0.5% bupivacaine with midazolam 50 microg x kg-1. Hemodynamic variables (heart rate, noninvasive blood pressure, oxygen saturation), pain scores, rescue analgesic requirements and sedation score were recorded for 24 hours postoperatively, and compared using ANOVA with significance at p <0.05. RESULTS: The onset and duration of sensory and motor block was significantly faster and longer in group B compared to group A (p < 0.001). Pain scores were significantly lower in group B for 24 hours postoperatively (p < 0.001). Demand for rescue analgesic were significantly less in group B. Hemodynamics and sedation scores did not differ between the groups in the studied period. CONCLUSION: Bupivacaine (0.5%) in combination with Midazolam (50 microg x kg-1) quickened the onset as well as prolonged the duration of sensory and motor blockade of the brachial plexus for upper limb surgery. It improved postoperative analgesia without producing any adverse events compared to plain bupivacaine (0.5%) in equal volume.

Frequency and causes of bilateral occular trauma.

OBJECTIVE: To determine the frequency and causes of bilateral ocular trauma. DESIGN: A descriptive case series. PLACE AND DURATION OF STUDY: Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar from October 1999 to September 2006. PATIENTS AND METHODS: All patients coming to the hospital with bilateral eye trauma and requiring admission were recruited into the study. The details of patients' demographics, risk factors, ocular examination, treatment offered and final visual acuity were noted and described as frequency and percentages. RESULTS: Out of a total of 1551 patients of hospitalized ocular trauma, 46 (2.9%, 92 eyes) had bilateral ocular trauma. The majority (54.3%) were due to landmine blast injuries followed by dynamite blast in 10.8%, coalmine blast and firearm injury in 6.5% each. Pressure cooker explosion and road traffic accident was the cause in 4.3% each. Gas cylinder and automobile battery explosion, alkali and acid burn, assault and incidental trauma occurred in 2.1%. Sixty three percent were between 16 and 40 years of age. Males were affected in 93.4%. Corneal and / or scleral repair was done in 58.6%, conjunctival and or corneal foreign body removal in 26% and extracapular cataract extraction with intraocular lens implantation in 16.3%. The visual acuity was in the range of 6/60 and perception of light in 54.3%, while in 21.7%, there was no perception of light at the time of admission. Due to severity of injury, the final visual acuity was poor and only 28.2% regained vision between 6/18 and 6/60. CONCLUSION: In this series, landmine, dynamite and coalmine blasts were the major causes of bilateral ocular trauma. Victims were usually young males. Due to severity of ocular trauma, majority had poor visual outcome.

Spectrum of ocular surface squamous neoplasia.

OBJECTIVE: To describe the pattern of ocular surface squamous neoplasia (OSSN), clinical presentations, the risk factors and treatment options. DESIGN: An observational case series. PLACE AND DURATION OF STUDY: Khyber Institute of Ophthalmic Medical Sciences, Hayatabad Medical Complex, Peshawar, from April 2003 till August 2006. PATIENTS AND METHODS: The study included 36 eyes of 35 patients with biopsy-proven ocular surface neoplasia. The details of patients regarding age, gender, laterality and risk factors were entered into a specially-designed proforma. Each patient was also assessed biomicroscopically for type and complications of ocular surface neoplasia. RESULTS: The frequency of OSSN was 0.37 among admitted hospital patients. Among 36 cases of OSSN, squamous cell carcinoma of the conjunctiva was the most common type of OSSN seen in 63.9%, followed by carcinoma in situ of conjunctiva in 25% and carcinoma in situ of cornea in 11.1%. Male patients outnumbered female (65.7% vs 34.3%) with 71.42% of patients above 60 years of age. The risk factors identified were: old age, ultraviolet B exposure and xeroderma pigmentosa. Treatment consisted of local resection with or without adjuvant therapy in 61.1%, exenteration in 30.5%, enucleation in 5.5% and chemo/radiotherapy in 2.7%. Intraocular invasion was seen in 5.5% and orbital spread in 30.5%. CONCLUSION: The frequency of OSSN was 0.37% among admitted patients. Identification of exact etiological factors will enable to formulate strategies that are likely to decrease the incidence of this disease and the associated morbidity and mortality.

Dexamethasone as antiemetic during gynaecological laparoscopic surgery.

OBJECTIVE: To evaluate the efficacy of intravenous dexamethasone for preventing postoperative nausea and vomiting in women undergoing gynecological laparoscopic surgery. DESIGN: Double blind trial. PLACE AND DURATION OF STUDY: December 2001 to June 2002 at Hayatabad Medical Complex, Peshawar. PATIENTS AND METHODS: A 100 admitted female patients of ASA-1-II scheduled for diagnostic gynecological laparoscopic surgery were included in this study. Patients with severe systemic or endocrine disease who had predisposing factors for delayed gastric emptying, such as diabetes, chronic cholecystitis or neuromuscular disorders were excluded. In addition patients who suffered from postoperative nausea and vomiting (PONV) or had received an antiemetic agent or narcotic medications within last 24 hours were also excluded. Patients were divided into two equal groups, patients in one group were given dexamethasone while saline was injected to patients in the second group. Nausea and vomiting were assessed immediately after operation, at 1 hour interval for 4 hours in the recovery and from 4-10 hours in the Ward. Result was compared in two groups by chi-square test. RESULTS: During patient s stay in the Postanaesthesia Care Unit (4 hours postoperatively) 26% patients in the dexamethasone group in comparison with 54% of patients in the saline group reported PONV (P < 0.01). Sixteen percent of patients in the dexamethasone group, in comparison with 28% of patients in the saline group needed rescue antiemtic (P 0.05), postoperative nausea vomiting (P < 0.01). During the postoperative observation period of 10 hours, 42% of the patients in the dexamethasone group in comparison with 82% of patients in the saline group reported postoperative nausea and vomiting (P < 0.001). CONCLUSION: Dexamethasone significantly reduced the incidence of postoperative nausea and vomiting in women undergoing laparoscopic surgery. Furthermore, it is freely available, is less costly and has few side-effects. So, it should be more frequently used as prophylactic antiemetic in women undergoing gynaecological laparoscopic surgery.