Omental Torsion in a Child – a Case Report

Omental torsion, a very rare cause of acute abdominal pain, mimicking acute appendicitis .A boy of 11 years, presented to us with the symptoms and signs suggestive of acute appendicitis clinically, was admitted through OPD of Apollo Hospitals. His laboratory reports were also in favor of clinical diagnosis. Laparoscopic appendicectomy was planned. But on laparoscopic intra-abdominal inspection it was found to be a case of Omental torsion, distal part was closely adherent to the ascending colon and blackish in color. So, procedure was converted into laparotomy and resection of the tensioned and gangrenous part of the omentum including appendicectomy was done. His post operative period was uneventful. Although torsion of the omentum is a rare clinical entity, but accurate pre-operative clinical assessment and relevant study including imaging and CT abdomen may reduce the diagnostic dilemma between omental torsion and acute appendicitis. DOI: http://dx.doi.org/10.3329/pulse.v6i1-2.20360 Pulse Vol.6 January-December 2013 p.75-77

Plasma Renin in ipsilateral renal vein in patients with chronic unilateral pelvic ureteric junction obstruction

Acute experimental hydronephrosis induces increased output of renin from ipsilateral kidney. In most clinical presentation of unilateral hydronephrosis the patients are however, normotensive with normal circulating plasma renin activity. In consideration of this argument we undertook this prospective study of ipsilateral renal vein renin activity in children with congenital Pelvic Ureteric Junction Obstruction (PUJO) and compared with other wise normal children. In this prospective cross-sectional study, started from July 99 to June 2001, twenty patients, age upto 12 years, with unilateral hydronephrosis and in control group ten patients without hydronephrosis were taken. 2ml blood was taken from the renal vein in study group and from infrarenal portion of inferior vena cava during exploratory laparotomy from the control group. All the patients had advanced grade of hydronephrosis and two patients (13%) had mild hypertension. In this study the mean plasma renin activity (PRA) was 45.58 ng/ml/hr (range: 11.69-67.56 ng/ml/hr) in study group. The mean PRA in control group was 5.9ng/ml/hr. The result of study group was significantly higher than normal (P value 0.0003). In Bangladesh we are doing more conservative kidney preserving surgery for PUJO, but need long term follow up of the patients undergoing surgery for PUJO in childhood for potential of developing renin-angiotensin induced hypertension in later life.

Vacuum-assisted closure (VAC) therapy in the management of wound infection following renal transplantation

OBJECTIVES

Wound infection in the setting of immunosuppressed state such as renal transplantation (RT) causes significant morbidity from sepsis, prolongs hospital stay and is expensive. Vacuum-assisted closure (VAC) therapy is a new technique of management of wound based on the principle of application of controlled negative pressure. The aim of this study was to assess the efficacy of VAC therapy in the management of wound infection following RT.

MATERIALS AND METHODS

This is a prospective study of a cohort of 180 consecutive RTs performed over a period of 4 years, where the data were retrieved from a prospectively maintained computerised database and case-notes.

RESULTS

9 of 180 (5%) patients developed wound infection following RT which led to cavitations and dehiscence with copious discharge, and refused to heal with conventional treatment. All 9 cases were treated with VAC therapy. The VAC system was removed after a median of 9 (range 3-30) days when discharge from the wound ceased. Four patients were discharged home with portable VAC device and managed on an outpatient basis, where the system was removed after a median 5.5 (range 3-7) days. The median hospital stay after initiation of VAC therapy was significantly shorter (5, range 2-12 days) than on conventional treatment prior to VAC therapy (11, range, 5-20 days) (p=0.003). Complete healing was achieved in all cases.

CONCLUSIONS

The use of VAC therapy is an effective and safe adjunct to conventional and established treatment modalities for the management of wound infection and dehiscence following RT. Key words: Renal transplantation, wound infection, vacuum-assisted closure therapy.

Colitis in a renal transplant patient with human herpesvirus-6 infection

A male patient developed colitis and a thrombotic microangiopathy 3 weeks after renal transplantation. Immunosuppression at the time of presentation was with sirolimus, mycophenolate mofetil, and prednisolone, but without a calcineurin inhibitor. Cytomegalovirus infection was excluded. However, human herpesvirus-6 DNA was detected at high copy number in both blood and colonic epithelium. The patient recovered after reduction in immunosuppression, with nutritional support and ganciclovir therapy.

A study of histopathological pattern of neuromuscular disorders with clinico-pathologic correlation

Neuromuscular disorders are frequently seen in our clinical practice, though no certain data are available in this regard. This prospective, observational study which was done as a partial fulfillment of M.Phil (Pathology) degree in BSMMU. The study was undertaken at the Department of Pathology of Bangabandhu Shiekh Mujib Medical University from August 1999 to December 2000 to study the histomorphological pattern of neuromuscular disorders in a selected group of patients attending the neuromedicine, paediatrics and medicine departments of BSMMU. Another purpose of this study was to evaluate the diagnostic utility of muscle biopsy and clinico-pathologic correlation in the diagnosis of neuromuscular disorders. In this study, 55 cases of clinically diagnosed neuromuscular disorders of different kinds were included. Detail clinical history was obtained in all the cases. Clinical diagnosis were made on the basis of history, physical examination, reports of routine and special laboratory tests whenever available. Muscle biopsy was performed in all the cases and histological changes could be identified in 42 cases. In the remaining thirteen undiagnosed cases; eight cases revealed 'essentially normal muscle tissue' and five cases were inadequate for histological evaluation. So, the later two categories were not included for further analysis. Among the histologically diagnosed 42 cases of neuromuscular disorders, basically two different classes of diseases were identified; 1) Dystrophic type of muscular diseases 64.28% and 2) Non dystrophic (acquired) type of neuromuscular diseases such as Inflammatory myopathy 21.82% and Neurogenic muscular atrophy 7.14%. Within the dystrophic group the maximum number of diseases were diagnosed as Duchenne muscular dystrophy 21.49%, Primary myopathy-unclassified 19.04%, Baker muscular dystrophy 4.76% and Limb girdle muscular dystrophy 4.76% etc. Properly executed muscle biopsy is usually the most useful and effective technique for diagnosis of neuromuscular diseases in cases where immunohistochemical, genetic and electron microscopic examination is not possible.

In hydronephrosis less than 10 % kidney function is not an indication for nephrectomy in children

PURPOSE

To reduce the incidence of nephrectomy or hydronephrosis in children.

MATERIALS AND METHODS

From September 1998 to October 2000, we treated 58 patients with hydronephrosis; their ages ranged from 35 days to 11 years (mean age 4 years 7 months). All patients were subjected to a DTPA renogram with split function. In 12 patients (study group), kidney function was less than 10 % (range 0 - 10 %). Initially, nephrostomy was carried out in all 12 patients followed by Anderson-Hyne's pyeloplasty after 4 - 6 weeks. Postoperatively renal USG, urine r/m/e & c/s (routine and microscopic examination and culture and sensitivity test), blood urea, serum creatinine were assessed and DMSA scan and DTPA renogram with split functions were carried out in all patients.

RESULTS

In the study group, all 12 patients showed improvement of renal function (more than 10 %) after nephrostomy and in all of them pyeloplasty was subsequently carried out within 4 - 6 weeks. There were no significant pre-, peri- or postoperative complications.

CONCLUSIONS

Contrary to common practice we do not recommend nephrectomy for hydronephrotic kidneys which show < 10 % of renal function on renogram. The renal functional status improves significantly after a preliminary nephrostomy, thus avoiding the need for a straightforward nephrectomy in children along with all the possible long-term effects of a single kidney.

Flow cytometric analysis of peripheral blood lymphocyte subset light scatter characteristics as a means of monitoring the development of rat small bowel allograft rejection

This investigation used flow cytometry to monitor peripheral blood lymphocyte morphology after rat small bowel transplantation. Preliminary studies demonstrated that in vitro activated peripheral blood lymphocytes exhibited increased cell size and granularity as measured by flow cytometric analysis of forward (FSc) and side (SSc) light scatter characteristics. The formation of distinct 'activated' light scatter regions by such lymphoblastoid transformation occurred concomitantly with up-regulated p55IL-2R expression. Heterotopic small bowel transplantation was performed between PVG donor and DA recipient rats without immunosuppression. Animals receiving isografts served as controls. Peripheral blood lymphocyte subsets were identified using appropriate MoAbs, and the light scatter characteristics of each cell subset were determined by backgating strategies. Increased proportions of activated alpha/beta T cell receptor (TCR)-positive cells could be detected in allografted animals as early as day 2 post-transplantation. B cells showed peak activation by day 4, at which time the proportion of activated cells was over two-fold greater than that seen in untransplanted animals--few activated B cells were detected in isografted animals. Resting natural killer (NK) cell light scatter regions only partially overlap with those of resting T and B lymphocytes, but in allografted animals almost the entire NK population fell outside the resting lymphocyte gate by day 2 post-transplantation, an activation state which was maintained until day 4. These findings associate peripheral blood cell subset lymphoblastoid transformation with developing small bowel allograft rejection. Importantly, changes were detected early and prior to the onset of overt rejection. These data suggest that analysis of peripheral blood lymphocyte light scatter properties may provide an insight into in vivo immune status after small bowel transplantation.

A community-based nested case-control study of maternal mortality

OBJECTIVES

Population-based information from Pakistan on maternal mortality is inadequate to define the magnitude of the problem or to contribute information on the distribution of clinical causes and risk factors. A population-based survey was conducted in eight urban squatter settlements of Karachi, Pakistan, to address these key issues.

METHODS

Pre-coded questionnaires were administered to the 10,135 households to ascertain deaths of household members in the 5 years preceding the survey (1984-1989). A verbal autopsy questionnaire was administered to the 121 households where a female death between 15 and 49 years of age was reported.

RESULTS

The maternal mortality ratio was estimated as 281 per 100,000 livebirths with hemorrhage, eclampsia and puerperal sepsis as the major causes of maternal deaths. Important risk factors identified were maternal employment, paternal unemployment, and poor prior pregnancy history. Women did seek health care but the assistance sought was often inappropriate.

CONCLUSION

Intervention programs for improving timely referral and upgrading of hospitals are suggested.

Activation antigen expression on peripheral blood neutrophils following rat small bowel transplantation. NKR-P1 is a novel antigen preferentially expressed during allograft rejection

This study used flow cytometric analyses to monitor activation antigen expression (MHC class II; interleukin-2 receptor, p55IL-2R and 3.2.3/NKR-P1 antigen) on peripheral blood neutrophils following rat small bowel transplantation. The rat 3.2.3 antigen is a member of the NKR-P1 family of natural killer (NK) cell-associated molecules, which are expressed at high levels on NK cells and lymphokine-activated killer cells, and low levels on at least one T cell subset. Peripheral blood neutrophils in normal animals express very low or undetectable levels of NKR-P1. Detectable levels of NKR-P1 were induced as early as day 1 following small bowel transplantation in all allografted animals, whereas expression was only rarely detected in isografted animals. In addition, NKR-P1 density was significantly higher in allografted animals and was maintained as rejection developed. MHC class II and p55IL-2R expression was also induced following transplantation. The mechanisms of induction and functional relevance of NKR-P1 expression on neutrophils remain to be defined. However, the concomitant increased expression of MHC class II and p55IL-2R suggest NKR-P1 to be a neutrophil activation marker and implicate a potential role for NKR-P1+ neutrophils in small bowel allograft rejection. This hypothesis is further supported by the loss of detectable peripheral blood neutrophils only with developing rejection. Flow cytometric analysis of neutrophil activation antigen expression may be useful for monitoring human small bowel transplant recipients.

Causes of reproductive age mortality in low socioeconomic settlements of Karachi

The Maternal and Infant Mortality Survey (MIMS) was conducted in eight squatter settlements of Karachi. The female mortality rate was 151.0 per 100,000 women aged 10-49 years and the maternal mortality ratio was 281 per 100,000 livebirths. The leading causes of deaths among women were complications of pregnancy (28.1%), infectious diseases (24.8%), cardiovascular diseases (20.7%), neoplasia (10.7%) and trauma (10.7%). Hemorrhage (47.1% of all maternal deaths), tuberculosis (40.0% of all infectious disease deaths), oropharyngeal cancer (23.1% of all neoplastic deaths), and burns (61.5% of all trauma deaths) were among the major causes identified. Maternal deaths were associated with young age and nulliparity (p-value < 0.01), and a higher proportion occurred in the hospital or on the way to the hospital as compared to non-maternal deaths.

Disease pattern, health services utilization and cost of treatment in Pakistan

Population based data on disease patterns, health services utilization and cost incurred on treatment in Pakistan were collected through a nation-wide sample survey in 1982-83. The survey for the first time revealed, the burden of disease on the society. The analysis done here suggest, that about one-sixth of the population suffered from an illness during the past one month period. As expected, illness was more prevalent among children, women in reproductive ages and the elderly. Over two-thirds of those who fell ill, suffered from malaria and fever and one-fifth from diarrhoea and dysenteries. There was heavy reliance on private physicians for treatment of those who fell, about two- thirds in the urban and one-third in the rural areas, consulted private physicians. On the other hand, in both the areas, less than one-sixth utilized the government health facilities. The cost of health care on an average, was 4% of the total income in the urban and 5% in the rural areas. In both the areas, this constituted over 7% of the monthly household income of the poorest. Suggestions are made to overcome the high cost of health care through broad based national health policy and implementation of primary health care programme.

The effect of renal ischemia on cyclosporine clearance in rabbits

The renal handling of cyclosporine was studied in ischemically damaged kidneys in New Zealand White rabbits and nonischemic control animals. CsA, 25 mg/kg/day, was administered intravenously for 10 days starting with the day of operation. Blood CsA (B CsA) was higher in the ischemic group compared with the controls (median: 285 micrograms/L, range 95-785 micrograms/L vs. 170 micrograms/L, range 110-185 micrograms/L, P = 0.05) on day 1 after operation. B CsA dropped rapidly to a level equivalent to the controls by day 4 (median: 105 micrograms/L, range 60-280 micrograms/L vs. 195 micrograms/L, range 70-215 micrograms/L, P = NS). Median CsA clearance (C CsA) as a percentage of creatinine clearance (C Cr) was some ten-fold greater in the ischemic animals (6.32%, range 2.93-18.41% vs. 0.55%, range 0.13-0.78%, P less than 0.001) on day 1. The ratio gradually declined, approaching the value in controls by day 10 (0.86%, range 0.24-7.21% vs. 0.23%, range 0.16-0.73%, P = 0.05). The data suggest that renal impairment has an important effect on CsA blood levels. In the clinical situation this may be of particular importance during both oliguria and the recovery from acute tubular necrosis.

Fournier gangrene following urethral necrosis by indwelling catheter

A patient with Fournier gangrene secondary to necrosis of the urethra by a catheter balloon is presented. This is believed to be the first case of scrotal and perineal gangrene resulting from an indwelling catheter. The fact that an inflated catheter balloon can slip down into the urethra and produce necrosis is demonstrated. A short review of the literature is presented.

Migration, urban growth, and development: Pakistan's experience

The authors "focus primarily on voluntary, peacetime migration [in Pakistan], both internal and international, and attempt to analyze some of its possible socioeconomic consequences." The importance of the role of migration in urban population growth is discussed, with attention to implications for social and economic development. The impact of large-scale emigration of workers to the Middle East is also assessed. The analysis is based on data from the 1951, 1961, 1972, and 1981 censuses as well as from secondary sources.