Role of intraoperative flexible Choledochoscopy in calculous biliary tract disease

Ninety six percent of patients with overlooked bile duct stones required surgery within 5 years of cholecystectomy, every effort should be made to keep the incidence of retained stones minimum. The facilities of pre-operative ERCP are not always available. Examination of the bile ducts under direct vision with a choledochoscope seems a certain method of ensuring that there are no residual stone. A total of 26 patients were evaluated between the periods of 2004 to 2005. Age of the patients ranged from 20 to 70 years. The mean age is about 45.88 years approximately. Six (23.07%) cases had previous history of cholecystectomy. Peroperatively 14(53.84%) cases had only choledocholithiasis, 6(23.07%) cases had cholelithiasis with choledocholithiasis, 4(15.38%) cases had choledocholithiasis with hepatolithiasis and 2(7.69%) cases had Mirrizi's type II with choledocholithiasis. After Choledochoscopy, 22(84.61%) cases had complete blind clearance, 4(15.38%) cases had incomplete blind clearance. Twenty two (84.61%) cases did not require any Choledochoscopy guided stone extraction. Four (15.38%) cases required Choledochoscopy guided Dormia basket extraction. Twenty two (84.61%) cases have undergone T tube drainage, 4(15.38%) cases undergone Roux-en-Y hepaticojejunostomy who had associated hepatolithiasis. In this series percentage of stone overlooked by instrumental exploration was 15.38 & percentage of residual stone in this study was 0%.

Acute abdomen 10 years after surgery for duodenal ulcer disease

A 55 years old male was admitted in the surgical unit of Dhaka Medical College & Hospital with the complaints of pain and discomfort in the upper abdomen for 1 day and hiccough and vomiting for several episodes for same duration. He had history of abdominal operation 10 years back for his peptic ulcer disease probably due to pyloric stenosis. On examination a linear scar mark was present along the upper midline region & visible peristalsis was seen on the left hypochondriac region. A palpable diffuse lump was present in the left hypochondriac region which was intraperitoneal seemed to be distended gut and the peristaltic wave moved from left to right. Endoscopy of upper GIT Showed loops of small intestine (evidenced by valvulae conneventes) protruded through a stoma suggestive of jejunogastric intussusception. Laparotomy revealed a portion of adherent small gut already become gangrenous so the whole portion of the intussuscepted gut was resected. After that revision and take-down of the anastomosis was done with vicryl stitches. The post operative period was uneventful. The patient underwent regular follow up.

Co-morbidity: exploring the clinical overlap between pneumonia and diarrhoea in a hospital in Dhaka, Bangladesh

BACKGROUND

There is limited information on risk factors for pneumonia and pneumonia-related deaths in children who also have diarrhoea.

AIM

To identify risk factors for the above in order to improve strategies for case management and to develop appropriate public health messages.

METHODS

All children under 5 years of age admitted to the Special Care Ward, Dhaka Hospital of the International Centre for Diarrhoeal Disease Research (ICDDR,B) from 1 September to 31 December 2007 were considered for enrollment if they also had diarrhoea. Of the 258 children with diarrhoea enrolled, those with (n=198) or without (n=60) WHO-defined pneumonia constituted the pneumonia and comparison groups, respectively. Among the 198 children with pneumonia, children who survived (n=174) were compared with those who died in hospital (n=24).

RESULTS

After adjusting for socio-demographic factors, including low levels of literacy of either parent, low household income, not having a window or exhaust fan in the kitchen, household smoking and over-crowding, children with pneumonia were more likely to sleep on a bare wooden-slatted or bamboo bed (OR 2·7, 95% CI 1·40-5·21, p = 0·003) than on other bedding, and were also more likely to have a parent/care-giver with poor knowledge of pneumonia (OR 1·94, 95% CI 1·02-3·70, p=0·043). Independent risk factors for death include severe underweight (OR 5·2, 95% CI 1·2-22·0, p=0·03), hypoxaemia (OR 17·5, 95% CI I 1·9-160·0, p=0·01), severe sepsis (OR 8·7, 95% CI I 1·8-41·5, p=0·007) and lobar consolidation (OR 11·9, 95% CI 2·3-61·6, p=0·003).

CONCLUSIONS

Increased public awareness of signs of pneumonia and severe sepsis in children under 5 is important to mitigate the risks of pneumonia and pneumonia-related deaths, and the importance of appropriate bedding for young children in reducing the risk of pneumonia needs to be addressed.

Clinical Profile and Outcome of Patients with Dengue Syndrome in Hospital Care

Dengue is a viral febrile illness, which has become a major international public health concern including Bangladesh, spectrum of illness ranging from dengue fever (DF) to life threatening dengue haemorrhagic fever (DHF), dengue shock syndrome (DSS) and ultimately death. The clinical profiling and outcome during epidemic dengue outbreak was observed in Dhaka Medical College Hospital in 2000 to 2001. One hundred and fifty patients were systematically observed. Male female ratio was 5:1 with severity of illness in younger patients. Hundred percent patients had fever with 83% having generalized weakness. The severe cases(DHF) were having sudden sustained temperature of 103 degree farenheight. Majority have abdominal symptoms(>80%) while 10% had respiratory only. Sixty percent have hepatomegaly while 40 % spleenomealy while 80% of DHF had ascites. Above 75% cases of Dengue haemorhagic fever had positive tourniquet test while melaena was the commonest mucosal bleeds. No fatality was observed in this study although variability of discharge was seen in different groups. Keyword: Clinical, Profile, Outcome, Dengue, Hospital DOI: http://dx.doi.org/10.3329/jom.v12i2.6733 JOM 2011; 12(2): 131-138

Regression of plaque burden after primary percutaneous coronary intervention (PCI) in a patient with TVD: 4 years follow-up

Coronary Artery disease (CAD) is an important cause of mortality and morbidity in the developed world as well as in Bangladesh. Treatment of Acute Myocardial Infarction (AMI) patient either by Streptokinase (STK) or Primary Percutaneous Coronary Intervention (pPCI) has increased the survival outcome and reduced the mortality. Several studies have documented the significant beneficial role pPCI in terms of in-hospital survival outcome over thrombolysis.  Our patient, who had Anterior MI in 2004 and his CAG revealed TVD.  pPCI of the culprit mid LAD lesion with Bare Metal Stent (BMS) was done immediately after hospitalization. He was later referred for CABG, but decision postponed because of asymptomatic status. His re-look CAG on 20-02-2008 (i.e., 4 yrs after the original procedure), revealed patent LAD stent with the regression of atherosclerotic plaque in Ostio-Proximal LAD and proximal LCX. Our findings indicated that pPCI with rigid control of CAD risk factors and modification of lifestyle plays a key role in the regression of atherosclerotic plaque and maintenance of stent patency.DOI: http://dx.doi.org/10.3329/pulse.v4i1.6959Pulse Vol.4 January 2010 p.22-25

Evaluation of a probiotics, Bifidobacterium breve BBG-01, for enhancement of immunogenicity of an oral inactivated cholera vaccine and safety: a randomized, double-blind, placebo-controlled trial in Bangladeshi children under 5 years of age

To evaluate the probiotic, Bifidobacterium breve strain Yakult (BBG-01), for safety and enhancement of immunogenicity in an oral inactivated cholera vaccine, a randomized double-blind placebo-controlled study was performed. Bangladeshi children under 5-year-old received BBG-01 or placebo for 4 weeks with two doses of oral cholera vaccine. Serum/fecal antibodies and fecal bacterial flora in the study participants were monitored. All adverse events were mild and transient and had no significant difference between the two groups. Immunological responses were similar comparing the two groups. A negative correlation between Bifidobacterium and Enterobacteriaceae in the probiotic group suggests a possible involvement of BBG-01 in alteration of the enteric bacterial flora. In conclusion, BBG-01 is well tolerated by Bangladeshi children although the post vaccinal immunostimulatory effect of BBG-01 was not evident.

A 30 year old female with lower abdominal lump

A female of 30 years of age, hailing from Narayangonj, Dhaka got admitted herself into Dhaka medical College & Hospital on 25.10.08 with the complaints of a lump in the lower abdomen for 1 year and pain in the lower abdomen for the same duration. Local examination reveals a lump in the lower abdomen which is intra abdominal, 10cm × 12cm in size. CT scan of Abdomen reveals a solid mass measuring (12 × 9 × 8.5) cm is seen in left side of abdominal cavity extending up to pelvic cavity. FNAC of abdominal lump shows sheets of mesothelial cells and few small clusters of regular epithelial like cells. Laparotomy was done on 27.11.08 under G/A & reveals a solid mass measuring about 10 × 8cm size & was well encapsulated, adherent with omentum found in the lower abdomen. Few mesenteric lymph nodes were enlarged. The mass was gently separated from the omentum ensuring adequate haemostasis. Post-operative period was uneventful. Histopathology report shows neoplasm composed of plump of fibroblasts arranged in broad sweeping fascicles and infiltrate into adjacent tissue consistent with fibromatosis. The patient was discharged with advice on 10th post operative day.

The synergy of permeable pavements and geothermal heat pumps for stormwater treatment and reuse

The use of permeable pavement systems with integrated geothermal heat pumps for the treatment and recycling of urban runoff is novel and timely. This study assesses the efficiency of the combined technology for controlled indoor and uncontrolled outdoor experimental rigs. Water quality parameters such as biochemical oxygen demand, nutrients, total viable heterotrophic bacteria and total coliforms were tested before and after treatment in both rigs. The water borne bacterial community genomic deoxyribonucleic acid (DNA) was analyzed by polymerase chain reaction (PCR) amplification followed by denaturing gradient gel electrophoresis (DGGE) and was further confirmed by DNA sequencing techniques. Despite the relatively high temperatures in the indirectly heated sub-base of the pavement, potentially pathogenic organisms such as Salmonella spp., Escherichia coli, faecal Streptococci and Legionella were not detected. Moreover, mean removal rates of 99% for biochemical oxygen demand, 97% for ammonia-nitrogen and 95% for orthophosphate-phosphates were recorded. This research also supports decision-makers in assessing public health risks based on qualitative molecular microbiological data associated with the recycling of treated urban runoff.

A 40 year old man with acute abdomen

A 40 years old man with the complaints of abdominal pain and per rectal bleeding for 2 days and abdominal distension for 1 day. There was an ill defined, tender intra abdominal solid mass at the left side of the lower abdomen measuring about 3 x 3cm2 on deep palpation. Direct rectal examination could not be done due to excessive pain at the anal region and non co operation of the patient. Plain X-ray of the abdomen A/P view in erect posture including both domes of the diaphragm shows distended large intestinal gas shadow & bottle like radiopaque shadow at the lower mid abdomen. Ultrasonogram (USG) of the abdomen could not be done due to the restlessness of the patient. With all available aseptic precaution the abdomen was opened by a lower midline incision. After exploration of the sigmoid colon two glass bottles (One measuring 10cm x 5 cm, the other 12cm x 7cm) were removed and the colon was closed primarily. There was also a small piece of stone found in the peritoneal cavity measuring 2 cm in diameter which was sent for histopathology. Post operative period was uneventful. The patient was discharged with advice on the 8th POD.

High Dose Chemotherapy with Thiotepa, Mitoxantrone and Carboplatin (TMJ) Followed by Autologous Stem Cell Support in 100 Consecutive Lymphoma Patients in a Single Centre: Analysis of Efficacy, Toxicity and Prognostic Factors

High dose chemotherapy with autologous stem cell transplant is often used in patients with Hodgkin's disease (HD) and non-Hodgkin's lymphoma (NHL) who either do not respond to, or relapse after conventional chemotherapy. There is no consensus on the "ideal" pretransplant conditioning regimen. In this study, we analyzed the results of 100 consecutive patients with HD and NHL who met our eligibility criteria and underwent autologous stem cell transplant at New York Medical College and Zalmen A. Arlin Cancer Institute. All patients received high dose chemotherapy with thiotepa, mitoxantrone and carboplatin (TMJ). One hundred patients, 37 with HD and 63 with NHL underwent autologous stem cell transplant using TMJ as a conditioning regimen. All patients with HD had chemo-sensitive relapse while 50 patients with NHL had chemo-sensitive relapse and 13 patients had first complete remission. The source of stem cells was bone marrow (18 patients), peripheral blood (50 patients) and both bone marrow and peripheral blood (32 patients). With a median follow up of 91 months (range 23-147 months), the median survival of patients with HD and NHL who underwent autologous stem cell transplant is 107 months and the 5 years disease free survival is 43%. Median survival of patients with HD and NHL is 87 and 107 months respectively. There were 4 transplant related deaths. Median survival of patients who had sensitive relapse at the time of transplant is 87 months while median survival has not been reached for patients who had first complete remission at the time of transplant. Multivariate analysis identified age>35 years (P=0.02) as a predictor for poor survival for the whole group as well as for patients with NHL (P=0.04). TMJ is a safe and effective regimen when used as a part of autologous stem cell transplant for patients with HD and NHL.

Upper abdominal mass with diagnostic dilemma

A 32 years old gentleman presented with a lump occupying the epigastric, left hypochondriac and umbilical region for the last 3 months which gradually increased in size & dull aching pain. He also complained of low grade fever and early satiety. On examination, he had a lump on upper abdomen which was irregular, firm, mildly tender, lobulated surface, restricted mobility, dull on percussion. USG examination of HBS revealed hepatomegaly and SOL in liver. CT abdomen revealed soft tissue mass in left upper abdomen. FNA revealed cells of mesenchymal origin. Per operatively a large lobulated, myxomatous highly vascular mass arising from the fundal part of the stomach was found and removed. Histopathology report comments about two differential diagnosis-leiomyosarcoma and gastrointestinal stromal tumour. CD117 immunostaining confirmed it was gastrointestinal stromal tumor (GIST). Post operatively patient was treated by Imatinib and is now under regular follow up.