Journal of Ayub Medical College, Abbottabad : JAMC最新文献

A multi-organ granulomatous disease with characteristic lung manifestations, sarcoidosis generally responds well to glucocorticoid therapy but 10% of cases are refractory necessitating immunosuppressive therapy. A 58-year-old lady presented with a dry cough and progressively worsening shortness of breath for the last 12 months. On investigation, her ESR was raised but cultures, malignancy screen and TB quantiferon were negative. HRCT chest demonstrated multiple pulmonary nodules with hilar lymphadenopathy and CT guided biopsy revealed non-caseating granuloma. She was diagnosed with Pulmonary Sarcoidosis and started on oral steroids with minimal improvement. Azathioprine was added but due to gastric intolerance switched to methotrexate. Her disease however continued to worsen and infliximab was started but she developed a severe allergic reaction. She was then started on mycophenolate mofetil but her chest imaging continued to worsen. After failing prednisone, azathioprine, methotrexate, infliximab and mycophenolate mofetil, the patient was started on rituximab.

Background: Endotracheal tube (ETT) is inserted into the trachea to maintain airway patency. Maintaining adequate ETT cuff pressure is important to ensure a proper seal to lower the risk of aspiration and tracheal trauma. This study was designed to assess the frequency of inappropriate ETT cuff pressure at the time of intubation and variation in ETT pressure at the end of a prolonged surgery.

Methods: This study was conducted in the Department of Anaesthesiology, Aga Khan University from October 2019 to March 2020. All adult patients of both genders, undergoing prolonged surgery under general anaesthesia were included. Patients were intubated with an appropriate size ETT, and the cuff was inflated with air. ETT cuff pressure was measured after intubation and, at the end of prolonged surgery to assess any variation.

Results: Fifty-eight patients were included, of which 37 (63.8%) were female. The mean age was 47.36 years. The frequency of inappropriate ETT cuff pressure at the time of intubation was found in thirty-five (60.3%) patients, which was corrected to 25 cm H2O before the start of surgery. At the end of the surgery, forty-one (70.7%) patients showed an increase in ETT cuff pressures with the majority (33%) having a variation of 51-70 (81-100 cm H2O).

Conclusions: The frequency of inappropriate ETT cuff pressure at the time of intubation was found in thirty-five (60.3%) patients. In six (10.3%) patients, ETT cuff pressure was below 20 cm H2O while in twenty-nine (50%) patients, ETT cuff pressure was above 30 cm H2O. In forty-one (70.7%) patients ETT cuff pressure was abnormally high that is >30 cm H2O at the end of prolonged surgical procedures.

Background: Surgical site infection (SSI) is always a matter of utmost concern in cases of spinal instrumentation in low-income countries. This study was conducted to determine the efficacy of local intrawound application of vancomycin powder in reducing postoperative SSI following Thoracolumbar-Sacral spinal instrumentation.

Methods: This randomized controlled trial was done in the Department of Neurosurgery, Ayub Teaching Hospital Abbottabad from 1st July 2019 to 31st December 2021. Seventy-eight patients of either gender with an age range from 15 to 65 years, who were planned for posterior spinal instrumentation surgery (transpedicular screw fixation), were included in the study. Patients were divided into two equal groups, A (Vanco group) and B (control group). In addition to standard systemic prophylaxis, 1 gm of Vancomycin powder was applied over the implant in Group A patients.

Results: The mean age of the patients in Group A was 36±16.6 while the mean age of patients in the group was 33.7±15.9 years. A statistically significant reduction of surgical site infection was observed in those who received a prophylactic intra-wound application of vancomycin powder (Vanco group) (5.2%) compared to the control group (20.5%).

Conclusions: Intrawound vancomycin powder administration significantly decreases SSI following spinal instrumentation surgeries. Patients at high risk of infection are highly recommended as a candidate for this technique.

Williams syndrome (WS), is a multisystem disorder occurring in 1 in 10,000 live births with supravalvular aortic stenosis (SVAS) being the most common cardiovascular manifestation. We present the case of a 2.5 years old male, a known case of WS who presented with cognitive delay, a history of right-sided stroke and left hemiplegia. Echocardiography revealed severe SVAS with a gradient of 105 mmHg. The diameter of the Sino tubular junction was 4 mm. Computerized tomography angiogram showed diffuse stenosis of ascending aorta with intraluminal thrombus. At surgery, the ascending aorta was augmented with autologous pericardial patches and end-to-end anastomosis of the proximal and distal aorta completed the reconstruction. The patient was discharged in a stable condition. He presented 6 weeks post-op with a pulsating pseudoaneurysm through the sternal wound. Emergency surgery with the removal of fungal vegetation and reconstruction of the ascending aorta was performed. He expired due to fungal sepsis a week later.

Background: The growing rate of caesarean section is a major concern for quality of maternal life and public health. Concerns about such increases prompted the WHO to recommend Robson ten group classification system for assessing the Caesarean Section rate. The present study's aim was to assess the caesarean rate using Robson's ten group classification system and highlighted the reliable information system, in turn, helps to construct interventions to reduce avoidable caesareans.

Methods: This cross sectional study was carried out on 5796 women who delivered from 25th November 2021 to 24th November 2022 in Jinnah Post Graduate medical Centre Karachi. Data was collected from the women admitted for delivery using Robson's Pro forma. Relative size and caesarean rate of each group and overall caesarean section rate was calculated.

Results: Of the total 5796 deliveries, 2141 (36.9%) were caesarean deliveries and 3655 (63.1%) had normal deliveries. Out of Robson's ten groups system, Group 10 had a higher contribution of 705 (12.2%) to the overall caesarean rate followed by group 5 had 627 (10.8%). The contributing prevalence of Group 1, 2, 3, 4, 6, 7, 8 and 9 were 122 (2.1%), 317 (5.5%), 50 (0.87%), 167 (2.9%), 42 (0.72%), 35 (0.6%), 49 (0.85%) and 27 (0.46%) respectively.

Conclusions: Our study concluded that Group 10 and 5 were the most responsible for the whole Caesarean Section rate. In all contributing groups, there is a need to identify the indications and to sub classify these groups further so that preventable caesarean sections can be avoided by reducing these factors.

Background: Pregnancy-induced hypertension (PIH) occurs in about 5% of pregnancies and is a major cause of high perinatal and maternal morbidity and mortality. In several international studies, primigravidas were associated with a significantly higher incidence of eclampsia. The local studies so far have a small sample size and mainly focus on preeclampsia in all pregnant women. limited data is available on the frequency of eclampsia in primigravidas in our population. This study aims to determine the frequency of primigravidas in patients with eclampsia after 20 weeks of gestation.

Methods: This descriptive Cross-sectional study was conducted in the Department of Obstetrics and Gynaecology, Ayub Teaching Hospital Abbottabad from 7/10/2020 to 7/4/2021. A total of 134 patients were observed. Diagnosis of eclampsia was based upon obstetrical history, presence of fits or coma, raised blood pressure and presence of proteinuria on urine complete examination. Immediate management included stabilizing the patient and delivery by Induction of labour or Caesarean section. The guardians of the patients explained the purpose and the benefits of the study and informed written consent was taken.

Results: : Our study shows that among 134 patients, 96 (72%) patients were in the age range of 18-27 years while 38 (28%) patients were in the age range of 28-35 years. The mean age was 30 years with SD±10.94. Eighty two (61%) patients had a POG range ≤34 weeks while 52 (39%) patients had a POG range >34 weeks. Forty-eight (36%) patients had BMI <27 Kg/m2 while 86 (64%) patients had BMI >27 Kg/m2. Fifty-six (42%) patients had a positive history of hypertension while 78(58%) patients had a negative history of hypertension. Out of 134 patients, 102(76%) were primigravidas while 32 (24%) were multigravidas.

Conclusions: Our study concludes that the frequency of primigravidas was 76% in patients with eclampsia after 20 weeks of gestation presenting at tertiary care hospital Abbottabad.

Background: The separators are a preliminary step for band insertion, but there is a potential risk of bacteraemia during their placement, particularly in susceptible patients. The objective of the study is to determine the effect of separators on the bacterial count in gingival crevicular fluid (GCF) and to assess the efficacy of chlorhexidine mouth rinse and saline irrigation in the reduction of the bacterial count.

Methods: This randomized controlled trial was conducted on 51 participants who were divided into three equal g roups randomly (brushing only/control, saline irrigation, and 2% chlorhexidine mouthwash rinse). The inclusion criteria were age between 18-25 years, good oral hygiene, gingival and plaque index <1, no previous orthodontic treatment, and healthy individuals. The bacterial count was obtained from GCF samples after two hours, on the third day, and on the seventh day. Kruskal Wallis test was used to compare the bacterial count among the three groups, and post hoc analysis was done using Dunn's test. Friedman test was applied to see the difference at three-time points in each group.

Results: In both saline and chlorhexidine groups the mean bacterial count decreased significantly from baseline to 3rd day and 7th day after separator placement (p<0.001). For the third day, a significant difference was found in control versus saline and control versus chlorhexidine. No significant difference was found between saline and chlorhexidine on the third day. Similar results were found on the 7 thday. For controls, the bacterial count increased with time and for both saline and chlorhexidine groups the bacterial count decreased. The highest decrease in the bacterial count was found for the chlorhexidine group.

Conclusions: After the placement of separators, there was an increase in the bacterial count in GCF. Notably, chlorhexidine was found to be more effective than saline irrigation in reducing the bacterial count.

Background: Full-thickness macular hole is defined as an anatomical defect in the fovea that spans from the internal limiting membrane to the retinal pigment epithelium, assessed by spectral domain optical coherence tomography. The Objectives of the study are to determine the anatomical and visual outcome in patients undergoing pars plana vitrectomy along with inverted internal limiting flap closure in large idiopathic full-thickness macular holes (>400 μm).

Methods: A prospective interventional study was conducted at a tertiary teaching eye hospital in Karachi, where patients of either gender and having macular holes greater than >400 μm were recruited. The study was conducted From January 9 to July 8, 2022, and all patients underwent pre-operative fundus examination and pars plana vitrectomy with inverted ILM flap closure. Data was entered and analyzed using SPSS 23. Follow-ups were conducted at 1 and 3 months.

Results: A total of 94 patients were enrolled with a mean age of 49.17±13.8 years. The mean duration of symptoms was 3.1±1.4 months. The mean pre-operative macular hole diameter was 854.31±08.36 μm and Stage 3 and 4 MH was present in 36.2% and 63.8% of patients, respectively. Anatomical closure was achieved in 93.6% of eyes (n=88/94). Pre-operative mean BCVA was LogMAR 0.90±0.24, which improved to LogMAR mean 0.70±0.27 at the final follow-up. As of the last follow-up, 92.6% of patients showed improved visual outcomes, with a mean three-line improvement in Snellen lines. After data stratification, no statistically significant result was obtained.

Conclusion: The use of the inverted ILM flap technique resulted in improved anatomical and visual outcomes, in cases of large idiopathic macular holes.

Background: Giant penoscrotal lymphedema is a rare condition and is treated by surgical debulking and reconstruction with remaining skin and skin grafts. The described techniques may result in a staged surgery, multiple blood transfusions, orchidectomy and early debulking of the scrotal skin. We present a case series describing our technique to address all the concerns, discuss management to decrease progression and transmission in secondary cases and present a novel questionnaire to assess of quality of life of these patients.

Methods: This descriptive case series was done from July 2016 to October 2019. Patients with Campisi grade 5 disease were included. Clinical assessment and relevant investigations were done to identify the cause and confirm the extent of the disease. Procedural detail, post-op haemoglobin levels (Hb), need for transfusion and weight of excised specimen were recorded. Wound healing, recurrence and body mass index were noted on follow up. A scrotal lymphedema quality questionnaire was developed and was filled on follow-up visit.

Results: Twelve patients were operated on. The mean history was 3.0±0.5 years. 4 tested positive for microfilariae, while 4 out of 8 who tested negative had taken the anthelmintic drug. The mean weight excised was 15.8±2.3 kg, mean pre-operative score on quality-of-life assessment questionnaire was 83.3±2.6 versus 9.3±0.8 post operatively. The mean follow up time was 1.4±0.6 years. 1 patient had a minor recurrence necessitating re excision. Mean Hb was 13.5±0.5 mg/dl preoperatively compared to 11.8±0.5 mg/dl post operatively, with none requiring transfusion.

Conclusions: Single staged excision with split thickness skin grafting is an effective and safe way to treat patients with giant scrotal lymphedema. It's the single best way to address the quality of life of patients.

Background: Doxorubicin is one of the most commonly used anti-cancer drugs that treat a large number of haematological and solid malignancies. Its usage in dose and duration is nevertheless restricted by dose related organ damage, particularly cardiotoxicity. Lovastatin is a commonly prescribed drug for hypercholesterolemia and possesses remarkable antioxidant potential. Our study was aimed at evaluating and comparing its cardioprotective effect in two pre-treatment schedules against doxorubicin-induced cardiac damage.

Methods: In this lab-based randomized controlled experiment, 40 BALB/c mice were randomly grouped into five groups (n=8). Group 1 served as control whereas Group 2 was given doxorubicin intraperitoneally at a dose of 10mg/kg. Group 3 received 10mg/kg of oral lovastatin for five days. Groups 4 and 5 were administered lovastatin for five and ten consecutive days correspondingly and doxorubicin was given on 3rd and 8th experimental days of these groups.

Results: Doxorubicin caused a significant rise in cardiac enzymes; Creatine kinase MB (CK-MB) and Lactate Dehydrogenase (LDH) (p value ≤0.0001) whereas cardiac histological alterations were ranked as moderate. The damage was significantly attenuated by lovastatin in the ten-day study design with a p-value of ≤0.001 for both LDH and CK-MB whereas a slightly less efficient restoration was observed in the five-day design with a p value of ≤0.001 for LDH and 0.012 for CK-MB. Histological preservation in both pre-treatment schedules was in accordance with the biological markers.

Conclusions: In doxorubicin-based regimens, pretreatment for at least seven days with an easily available and safe statin can effectively prevent its potentially life threatening cardiotoxicity.