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   Table of Contents - Current issue
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July-September 2018
Volume 8 | Issue 3
Page Nos. 95-151

Online since Friday, September 27, 2019

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ORIGINAL ARTICLES  

Time-related outcome in patients with traumatic brain injury admitted to neurosurgical care in a tertiary centre p. 95
David O Udoh, Oduwa O Aghahowa, Emmanuel C Obeta
DOI:10.4103/ais.ais_14_19  
Background: The decreased mortality and improved outcomes associated with constantly metamorphosing trauma systems is particularly relevant in traumatic brain injuries (TBI) in which the duration from injury to neurosurgical intervention is an important determinant of outcome. With defective organization of trauma systems comes reduced access to quick and effective neurosurgical care which impact inexorably on outcomes. Using a time honoured scale, we took a critical look at TBI outcomes on the background of time of arrival to specialist neurosurgical care. We sought the association of various demographic factors with outcomes of traumatic brain injury in patients who arrived at our neurosurgical facility at various time intervals following injury. Patients and Method: A retrospective study of 385 of 483 patients with TBI admitted to neurosurgical care from 2009 to 2011 at our teaching hospital. Data was obtained from a computerized log of all TBI patients, case files and intensive care unit records, and analyzed using STATA software version 12. Results: Seventy percent (70%) of the patients arrived within 24 hours, especially between 12 to 24 hours i.e. 27.01%. However, only 5.71%, comprising those with mean age 22.59(±12.31) years arrived within the first hour Young patients arrived significantly earlier to specialized care than those ≥40 years. Regardless of injury duration, most patients had severe TBI (p value 0.012). Most, 77.69%, outcomes were favourable (Glasgow outcome scores, GOS, 4 and 5); 16.54% died (GOS 1). The middle strata of GOS 2 and 3 were almost absent. Injury duration did not influence duration of intensive care or overall hospital stay. Mortality was highest after 24hours. Conclusion: There is a dearth, in this region, of any auditing of the relationship between time of arrival of patients with TBI to specialized care, recovery characteristics (post-neurosurgical care) and eventual outcome using the Glasgow outcome scale.
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Early experience with penetrating keratoplasty in South-South Nigeria: Initial audit of indications and outcome p. 101
Ukeme I E Umana, Ernest I Ezeh, Dennis G Nkanga, Utam A Utam, Affiong A Ibanga, Bassey A Etim, Elizabeth D Nkanga, Sylvia I Akpan
DOI:10.4103/ais.ais_44_18  
Background: Corneal diseases are major causes of severe visual impairment and blindness in developing countries, unfortunately. Keratoplasty, which is a major treatment modality, is either nonexistent or at its infancy in these climes. Indications for penetrating keratoplasty (PKP) and the short-term success and survival rates vary in different geographical locations. We sought to evaluate the indications and short-term success rates of penetrating keratoplasty (PKP) in a Nigerian Private Practice Setting in South South Nigeria. Patients and Methods: It was a retrospective audit of 12 patients that had undertaken PKP in the hospital by December 2017. Data obtained from medical records included demographic information like age and sex. Others included preoperative diagnosis, indications for surgery, and pre- and postoperative best corrected visual acuity (BCVA) of subjects. Other information included intraocular pressure pre- and postoperatively, levels of corneal clarity, presence of other ocular comorbidities, and documentation of preoperative graft failure risk assessments. All patients in the series had optical penetrating keratoplasty, performed by a single experienced surgeon for purpose of vision restoration. Results: The mean age of the patients was 50.1 years, with a standard deviation of ± 15.5 years. The indications for PKP were bullous keratopathy seven (58.3%) and five corneal scars (41.7%). The etiological distribution was six patients with pseudophakic bullous keratopathy, one patient was postuveitic bullous keratopathy, three patients were postinfectious corneal scar, and two patients were postmeasles adherent leucomatous corneal scar. Pre-PKP 10 patients (83.4%) were corneal blind on the affected eye and the corneal clarity grades were 2 patients (16.7%) in grade 0, 7 patients (58.3%) in grade 1, and 3 patients (25.0%) in grade 2. At 6 months post-PKP, three patients (25.0%) remain blind in the affected eye, two patients (16.7%) in pre-PKP blind category moved to SVI, one patient (8.3%) with SVI and five patients (41.7%) with blindness at pre-PKP had respectively moved to MVI, and one patient (8.3%) with MVI at pre-PKP had regained normal vision. At 6 months post-PKP, corneal clarity improved from grades 0–2 to grades 3 and 4, in 25% and 75% of the patients, respectively, compared to the pre-PKP grades 0, 1, and 2, in 16.7%, 58.3%, and 25.0% of patients, respectively. Conclusion: In this study, bullous keratopathy and corneal scar were the main indications for penetrating keratoplasty. The short-term (6 months) success and survival of corneal grafts were reasonably good.
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Reasons for contraceptive discontinuation at Ahmadu Bello University Teaching Hospital Zaria, Northern Nigeria p. 108
Hauwa Shuaib Umar, Hajaratu Umar
DOI:10.4103/ais.ais_47_18  
Background: Despite the low uptake of contraceptive methods in Nigeria and the associated obstetric and medical complications of high birth rate, some of the clients still find reason to discontinue the methods. To determine the reasons for discontinuation of contraceptive methods among clients at the Ahmadu Bello University Teaching Hospital, Shika-Zaria. Patients and Methods: A descriptive cross-sectional study of clients attending the reproductive health clinic of Ahmadu Bello University Teaching Hospital, Zaria, from January to June 2013. Structured questionnaires were administered to consented clients. Information obtained included the following: sociodemographic data, gynecological history, history of contraception, and reasons for discontinuing a contraceptive method. Data were analyzed using Minitab version 15. Results: Majority of the respondents were multiparous, within the age group of 20–29 years, with tertiary education and civil servants. Most of the respondents, 161 (53.3%), had used a contraceptive method before, mostly injectables 64 (40%). In total, 100 clients (62.5%) were still on their methods of choice, whereas 61 (37.8%) had discontinued, giving a discontinuation rate of 37.9%. Majority, 26 (42.6%) discontinued due to reduced need for the method (mostly to conceive), whereas 22 (36.1%) discontinued due to method problems (mostly menstrual problems). Others had no known reason 6 (9.8%), not interested 6 (9.8), and 1 (1.6%) had failure of the method. Clients aged 30–34 years and only Quranic education were more likely to have unmet need for contraceptive use. Conclusion: There is need for effective counseling, education on side effects, and health concerns regarding modern contraceptive methods.
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Cephalic vein cut down technique for chemoport implantantion and ease of chemoport access - A cohort study p. 113
Jency Mathews, Seethal Abraham, Rani Philip
DOI:10.4103/ais.ais_11_19  
Background: Multiple techniques have been established for the insertion of totally implantable chemotherapy ports. Cephalic vein cut down technique is considered a safe technique with reasonable success. The surgical team implanting the chemoports and the nursing team handling them have a learning curve. This prospective observational cohort study aimed to document the techniques used for the implantation, the success and failure of cephalic vein cut down technique, the intraoperative and delayed complications of chemoport implantation, and the ease and difficulties of the nursing personnel in subsequent handling of the chemoports. Patients and Methods: All consecutive patients undergoing surgical implantation of chemoports between September 2015 and December 2017 were included in this study. Chemoport implantation was first attempted in the cephalic vein by cut down technique followed by closed Seldinger method in the subclavian or internal jugular vein. Surgical details were recorded and further access of the chemoport by the nursing personnel was monitored. Any difficulty in access or use of the chemoports was noted and help sought. All data were collected prospectively and analysed. Results: Thirty chemoport implantations and 280 chemoport cannulations were performed during the study period. Cephalic vein cut down technique was performed in 28 (96%) patients. Cephalic vein implantation of chemoport was successful in 14 (50%) patients. Obliterated vein, small luminal diameter and adverse anatomy were reasons for failure. Patients who had not previously received chemotherapy had a cephalic vein success rate higher than those who had, with an odds ratio of 2.4. Chemoport access by nursing personnel was easy in 92% patients. No blood return was seen in 7%. Conclusion: Cephalic vein cut down technique was successful in 50% patients. It was less successful in patients who have previously been treated with chemotherapy. No blood return on access was the commonest cause for concern while handling chemoports. An algorithm for the preference of veins to be used and an institutional protocol for chemoport access and use increase safety and efficiency.
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Fibrin glue reinforcement of choledochotomy closure suture line for prevention of bile leak in patients undergoing laparoscopic common bile duct exploration and primary closure p. 119
Anish Gupta, Jagdish Chander, Bhavna Gupta, Rahul Jain
DOI:10.4103/ais.ais_1_19  
Background: Laparoscopic common bile duct (CBD) exploration (LCBDE) allows cholecystectomy and the removal of CBD stones to be performed during the same sitting, thereby decreasing hospital stay. CBD exploration through choledochotomy can be closed primarily with an absorbable suture material but can lead to biliary leakage postoperatively. In this study, we tried to find a solution to further lower the incidence of bile leakage using fibrin glue to reinforce the sutures put on choledochotomy suture line. Patients and Methods: This study was conducted at a tertiary care teaching hospital in New Delhi, India. Twenty patients with CBD stones documented on magnetic resonance cholangiopancreatography with CBD diameter of 9 mm or more were included in this study. Patients were randomized into two groups, namely – Group “A” in which choledochotomy was closed with polyglactin 4-0 suture and suture line reinforced with fibrin glue and Group “B” in which choledochotomy was closed with polyglactin 4-0 suture alone. Both the groups were evaluated and compared on clinical parameters such as operative time, drain content, drain output, number of days drain was required, blood loss and transfusion requirements, length of postoperative hospital stay, and conversion to open surgery. Results: The operative time for Group A ranged from 60 to 210 min (mean: 131.50 min) and Group B ranged from 65 to 300 min (mean: 140 min). In Group A, there was no case of bile leak but there was bile leak in 2 cases in Group B, minimum 0 and maximum 900 ml with a mean of 97 ml and P= 0.147 with no statistically significant difference in bile leak in test and control groups. The minimum and maximum serous drainage in Group A was nil and 80 ml (mean: 11 ml) and in Group B was nil and 270 ml (mean: 72.50 ml).P value came as 0.028 which was statistically significant. Thus, serous leakage in Group A was significantly less than in Group B. The drains in Group A were removed from 2 to 4 days (mean: 3 days) while in Group B from 2 to 9 days (mean: 3.9 days). The patients in Group A stayed in hospital postoperatively from 3 to 8 days (mean: 5.30) while in Group B, it ranged from 3 to 10 days with a mean of 5 days. Conclusion: Fibrin glue application on CBD decreases bile leakage but in statistically insignificant manner. Fibrin glue application on CBD can significantly decrease postoperative serous drainage after LCBDE. Fibrin glue application on CBD is safe and easy technique without any significant adverse effects and can help less experienced surgeons performing LCBDE.
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An overview of male breast cancer in North East India: A hospital-based study p. 128
Jagannath D Sharma, Nizara Baishya, Amal C Kataki, Chandi R Kalita
DOI:10.4103/ais.ais_8_19  
Background: Breast cancer in males is a rare disease and accounts for <1% of all cancers in men. The objective of this study was to analyze the incidence and clinicopathological behavior of male breast cancer (MBC) at a tertiary cancer center of North East India. Patients and Methods: The medical records of 60 histologically confirmed that MBC was retrospectively reviewed for the period from January 2010 to December 2015. Result: MBC accounted for 1.9% of the total breast cancer cases. The median age of presentation was 50 years. Left and right breast were almost equally affected (51.6% vs 48.4%). Central quadrant involvement was found in 19 (31.7%) patients followed by 15 (25%), 11 (18.3%), 8 (13.3%), and 7 (11.7%) in upper outer, lower outer, lower inner, and upper inner quadrants, respectively. Most of the patients presented in advanced stage. About 80% (48) patients had nodal metastasis and 18.3% had distant metastasis at presentation. Hormone receptor and human epidermal growth factor receptor 2 (HER2)/neu was found to be positive in 53.3% and 15%, respectively. Triple negative breast cancer constituted 18.3% of cases. Conclusion: MBC is seen at a relatively younger age in our subset of population. Late presentation with advanced disease is a common feature in our population. Feasibility of clinical trials was limited because of the rarity of the disease. But for better understanding of the clinical spectrum of this rare disease comprehensive, multi-institutional collaborative studies are warranted.
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A clinical profile and outcome of patients with acute pancreatitis: A prospective study in North India p. 132
Yamandeep Chauhan, Neha Jindal, Ram Kumar Verma, Praveen Kumar Tyagi, Madhulata Rana, Sukhwinder Singh
DOI:10.4103/ais.ais_3_19  
Background: Acute Pancreatitis (AP) is an inflammatory process. The average mortality rate in severe AP approaches 2%–10%. Gall stones and alcohol abuse account for 70% of cases of acute pancreatitis. Almost all patients have acute upper abdominal pain. Systemic complications and multi organ system failure may develop. Patients and Methods: A prospective study conducted from November 2016 to December 2017 in Shri Guru Ram Rai Institute of Medical and Health Sciences, Dehradun, India, in patients who were diagnosed to have acute pancreatitis. A total of 54 patients were enrolled in the study out of which four patients had left against medical advice. The data collected were evaluated to see the outcome. Results: Majority of patients 22 (44.0%) were in age group ranging from 41 to 60 years. Males were dominant (58%). The most common etiology was alcoholism followed by gall stone. The majority of patients were found with abdominal pain (100.0%). The majority of the patients were having moderate Balthazar CT Severity Index (CTSI) (54.0%). In all, 43 patients were having pancreatic complications and pancreatic necrosis was the commonest; 31 developed extra-pancreatic complications, among which pleural effusion was the commonest. Some patients were having multiple complications. The duration of hospital stay was highest in severe group of Balthazar CTSI. Rise in total leucocyte count, serum amylase level and low calcium levels were significantly associated with increase in pancreatic/extra-pancreatic complications. There was only 1 (2%) patient who died and remaining 49 (98%) patients were discharged. Conclusion: Most common etiology of acute pancreatitis was alcohol consumption (50%) followed by gall stones (32%). Increases in total leucocyte count, serum amylase level and low level of serum calcium were significantly associated with increase in pancreatic/extra-pancreatic complications leading to higher morbidity and hospital stay. Patients with higher Balthazar CTSI were having higher morbidity.
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CASE REPORTS Top

A rare case report of long-standing foreign body in the abdomen; forgotten scalpel blade in a multipara p. 139
Joel A Adze, Matthew C Taingson, Makama G Jerry, Stephen B Bature, Durosinlorun M Amina, Mohammed Caleb, Abubakar Amina, Airede Lydia, Sheyin John
DOI:10.4103/ais.ais_42_18  
The unintended retention of foreign objects (URFOs) after invasive procedures can cause morbidity and in some cases mortality. There may be an extended period between occurrence and detection of an URFO. Retained foreign objects are most commonly detected immediately postprocedure by X-ray, during routine follow-up visits, or from the patient's report of pain or discomfort. This is a case report of a 46-year-old lady Para 3+04 alive who presented to the gynecological clinic following an incidental radiological finding of a size 22 scalpel blade while being evaluated for low back pain. She had an exploratory laparotomy and retrieval of the blade. She did well and was discharged home in good condition on postoperative day 7.
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Rare presentation of patent vitellointestinal duct-Meckel's diverticulum and vitelline cyst-A case report p. 143
Vasudha R Nikam, Amit S Garud, Pratik D Patil
DOI:10.4103/ais.ais_24_18  
Meckel's diverticulum is one of the most common anomalies of the gastrointestinal tract. Many of them remain unexpressed and are discovered accidentally. Vitello-intestinal duct anomalies are rare and occur in 1–2% of the population. These anomalies may present in adult life like appendicitis; hence, proper investigations will reveal the correct diagnosis. Meckel's diverticulum requires surgical correction. Here, we present a rare case report of Meckel's diverticulum with Vitelline cyst in a 21-year-old male patient, which was successfully resected surgically.
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Pemphigoid gestationis in a resource-limited setting p. 147
Fadimatu Bakari, Gabriel Dogbanya, Tahir Turaki Muhammad, Hajara Umaru-Sule, Hajaratu Umar Sulayman, Solomon Avidime, Adebiyi Gbadebo Adesiyun
DOI:10.4103/ais.ais_15_19  
Pemphigoid gestationis is a rare autoimmune vesicobullous dermatosis that is unique to pregnancy. It commonly occurs during the second half of pregnancy, particularly the 3rd trimester. In general, it presents with intense, itchy erythematous papules and plaques that often spares the palms and soles. These lesions culminate to form intense bullae that often become secondarily infected if neglected. Vertical transmission of maternal antibodies in utero can occur and the infants could present with similar lesions for few weeks postdelivery. In resource-rich setting, the diagnosis is often confirmed with the direct immuno-fluorescence study, but in a resource-limited setting, a high index of suspicion is required to make a clinical diagnosis and commence prompt therapy to optimize maternal and fetal outcomes. We report a case of a 32-year-old grand multipara who presented at 34 weeks gestation with a 12-week history of infected skin lesions characteristic of pemphigoid gestationis. She was commenced on steroid therapy and antibiotics based on the clinical diagnosis. She went into preterm spontaneous labor at 36 weeks and delivered a boy baby who manifested with similar lesions at 2 weeks of live.
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