Cerebellar tuberculoma mimicking posterior cranial fossa tumour

A young girl presented with history of prolonged fever, vomiting and headache. CT scan of brain revealed a space occupying lesion in posterior cranial fossa with moderate hydrocephalus. Surgery was performed and histopathology report confirmed the lesion as tuberculous. Patient showed smooth postoperative recovery and complete remission of complaints on antituberculous treatment for one year and regular follow-up.     

Frequency of dual tuberculosis/human immunodeficiency virus infection in patients presenting at tertiary care centers at karachi

Objective: To determine the frequency of dual infection of Tuberculosis and Human Immunodeficiency Virus (HIV) and document the sexual practices of infected patients. Design: Cross-sectional study. Place and Duration of Study: Medical Unit-IV of Civil Hospital, Karachi, Pakistan, in collaboration with Sindh AIDS Control Program at Services Hospital, Karachi, from January 2003 to December 2004. Patients and Methods: Patients were recruited in the study at both centers and tested for both HIV and TB if any one disease was identified. Diagnosis of TB was based on positive sputum AFB smear / caseous granulomatous lesion on histopathology. Diagnosis of HIV was based on positive anti-HIV serology by LISA technique. A questionnaire was also administered to all the study participants regarding demographics, sexual practices, blood transfusion and intravenous drug abuse. Results: A total of 196 patients of HIV and TB were screened for the presence of dual infection (TB/HIV). Dual infection was present in 38 (19.39%) of patients. Out of 126 patients of HIV, evidence of TB was detected in 38 (30.16%). During the same duration, 70 patients of tuberculosis were screened for HIV and none was tested positive for HIV. History of illicit sexual relationship was found in 121 (96.03%) patients and 5 of these were homosexuals. Conclusion: Dual infection was present in patients of HIV with TB but vice versa was not documented in this study.     

Burnout and self‐employment: a cross‐cultural empirical study

This study examined the differences between full‐time self‐employed and organizationally employed individuals in Canada (n = 248) and Pakistan (n = 306) in terms of overall burnout and its three dimensions (emotional exhaustion, depersonalization and lack of accomplishment), turnover intentions and non‐work satisfaction. Data were collected by means of a structured questionnaire from Canadian employees in Montreal and Pakistani employees in Lahore. One‐way analysis of variance and multivariate analysis of variance were used to analyse the data. The self‐employed reported significantly higher overall burnout, emotional exhaustion, lack of accomplishment, non‐work satisfaction and turnover intention than the organizationally employed in both countries. No significant differences were found between self‐employed and organizationally employed in terms of depersonalization in both countries. Results are discussed in light of previous empirical evidence on self‐employment and the quality of work and non‐work life from cross‐cultural perspectives. Copyright © 2007 John Wiley & Sons, Ltd.     

Should rituximab be the rescue therapy for refractory mixed cryoglobulinemia associated with hepatitis C?

BACKGROUND: Mixed cryoglobulinemia (CG) is a systemic immune complex-mediated disease that involves small-to-medium vessel vasculitis, provoked by the CG containing immune complexes that precipitate in cold. It is associated with hepatitis C virus (HCV) infection in 80% of patients. Mixed CG-mediated vasculitis can affect vital organs such as kidney, liver and heart. Laboratory parameters show presence of cryoglobulin, and in most cases of mixed CG, rheumatoid factor IgM kappa. The current treatment strategy of HCV-associated CG includes targeting the viral trigger HCV with a combination of antiviral medication, interferon-alpha (IFN-alpha) and ribavirin, or the downstream pathogenic events by means of plasmapheresis, steroids or immunosuppression. With multiorgan involvement, the antiviral therapy may be limited due to severity of renal disease, treatment failure, side effects or contraindications. On the other hand, immunosuppressive therapy may be poorly tolerated or ineffective. Therefore, new treatment options such as rituximab (RIT), a chimeric monoclonal anti-CD20 antibody, have been proposed as a rescue therapy. METHODS: We reviewed the literature to evaluate the current evidence in treating HCV-related refractory mixed CG. RESULTS: The use of RIT in treatment of HCV-related CG was first described by Zaja et al. Since then there have been numerous published case series and case reports. So far there has been no randomized controlled trial. In the literature, there have been 60 patients with CG treated with RIT. The male to female ratio was 14:46. Fifty-three patients were HCV-positive. Forty-six patients had mixed type II CG, 7 had type III CG and for 7 the type was not specified. Twenty-five patients had renal involvement ranging from proteinuria, to nephrotic syndrome, to nephritic syndrome to chronic kidney disease. Eight patients had had a renal transplant and were on immunosuppression. Most patients responded to RIT, with only 17 of 60 patients relapsing, and 8 of 17 of those were rechallenged with RIT with a good response. Total follow-up period varied between 3 and 31 months. CONCLUSION: RIT is a suitable rescue therapy in recalcitrant CG associated with HCV. There is evidence supporting the use of RIT as first-line therapy, as opposed to the proposals of others who would strongly recommend antiviral therapy. However, a prospective randomized controlled trial is required to evaluate the efficacy and safety of RIT compared with current standard therapy, which includes antiviral therapy, immunosuppression and plasmapheresis.     

Outcomes of Laparoscopic Sleeve Gastrectomy in Patients Older than 60 Years

Background

Morbidity and mortality following laparoscopic sleeve gastrectomy (LSG) occur at acceptable rates, but its safety and efficacy in the elderly are unknown.

Methods

A retrospective review was performed of all patients aged >60 years who underwent LSG from 2008 to 2012. These patients were 1:2 matched, by gender and body mass index (BMI) to young patients, 18?<?age?<?50. Data analyzed included demographics, preoperative and postoperative BMI, postoperative complications, and improvement or resolution of obesity-related comorbidities.

Results

Fifty-two morbid obese patients older than 60 years underwent LSG (mean age, 62.9?±?0.3 years). These were matched to 104 young patients, age 18–50 years (mean age, 35.7?±?0.8 years). Groups did not differ in male gender (44 vs. 43 %, p?=?0.9), preoperative BMI (42.6?±?0.7 vs. 42.6?±?0.6, p?=?0.97), and length of follow-up (17?±?2 vs. 22?±?1.4 months, p?=?0.06). Obesity-related comorbidities were significantly higher in the older group (96 vs. 65 %, p?<?0.001). Excess weight loss (EWL) was higher in the younger group (75?±?2.4 vs. 62?±?3 %, p?=?0.001). Older patients had a significantly higher rate of a concurrent hiatal hernia repair (23 vs. 1.9 %, p?<?0.001). Overall postoperative minor complication rate was higher in the older group (25 vs. 4.8 %, p?<?0.001). This included atrial fibrillation (9.5 %), urinary tract infection (7 %), trocar site hernia (4 %), dysphagia, surgical site infection, bleeding, bowel obstruction, colitis, and nutritional deficiency (2 %, each). No perioperative mortality occurred. Comorbidity resolution or improvement was comparable between groups (88 vs. 80 %, p?=?0.13).

Conclusions

LSG is safe and very efficient in patients aged >60, despite higher rates of perioperative comorbidities.     

Gynaecomastia correction: A review of our experience

Introduction:

Gynaecomastia is a common problem in the male population with a reported prevalence of up to 36%. Various treatment techniques have been described but none have gained universal acceptance. We reviewed all gynaecomastia patients operated on by one consultant over a 7-year period to assess the morbidity and complication rates associated with the procedure.

Materials and Methods:

Clinical notes and outpatient records of all patients who underwent gynaecomastia correction at University Hospital North Staffordshire between 01/10/2001 to 01/10/2009 were retrospectively reviewed. A modified version of the Breast Evaluation Questionnaire was used to assess patients satisfaction with the procedure.

Results:

Twenty-nine patients and a total of 53 breasts were operated on during the study period. Patients underwent either liposuction alone (6 breasts - 11.3%), excision alone (37 breasts - 69.8%) or both excision and liposuction (10 breasts - 18.9%). Twelve operated breasts (22.6%) experienced some form of complication. Minor complications included seroma (2 patients), superficial wound dehiscence (2 patients) and minor bleeding not requiring theatre (3 patients). Two patients developed haematomas requiring evacuation in theatre. No cases of wound infection, major wound dehiscence or revision surgery were encountered. Twenty-six patients (89.7%) returned the patient satisfaction questionnaire. Patients scored an average 4.12 with regards comfort of their chest in different settings, 3.98 with regards chest appearance in different settings, and 4.22 with regards satisfaction levels for themselves and their partner/family. Overall complication rate was 22.6%. Grade III patients experienced the highest complication rate (35.7%), followed by grade II (22.7%) and grade I (17.6%). Overall complication rates among the excision only group was the highest (29.8%) followed by the liposuction only group (16.7%) and the liposuction and excision group (10.0%). There were high satisfaction rates amongst both patients and surgeon. Eleven patients (37.9%) had their outcome classified as ‘excellent’ by the operating surgeon, 16 patients (55.2%) as ‘good’, 1 (3.4%) as ‘satisfactory’ and 1(3.4%) as ‘poor’.

Conclusion:

Gynaecomastia is a complex condition which poses a significant challenge to the plastic surgeon. Despite the possible complications our case series demonstrates that outcomes of operative correction can be favourable and yield high levels of satisfaction from both patient and surgeon.KEY WORDS: Plastic Surgery, University Hospital North Staffordshire, Correction, gynaecomastia, surgery     

Safety and effectiveness of single- versus double-anastomosis duodenal switch at a single institution

Background

Biliopancreatic diversion with duodenal switch (DS) is known to be superior in weight loss to other bariatric procedures, but with the disadvantage of increased complication rates. Single-anastomosis duodenal-ileal bypass (SADI-S) is reported to have similar weight loss with lower complication rates compared with traditional DS.

Is surgical PD catheter insertion safe for urgent‐start peritoneal dialysis?

Urgent‐start peritoneal dialysis (USPD) is increasingly seen as a viable alternative to hemodialysis through a central venous catheter for late‐presenting end‐stage renal disease patients. However, concerns remain about starting dialysis early following the surgical implantation of the peritoneal dialysis (PD) catheter; urgent PD is often thought to be a safe option only after minimally invasive percutaneous catheter insertions. Analysis of the cumulative data from published literature presented in this review appears to negate this general perception and shows that compared to the percutaneous catheter insertions, starting PD urgently following surgically placed catheter is not associated with more catheter leaks, dysfunctions, or other complications. The outcome of USPD is independent of the mode of catheter insertion. Instead, measures to minimize intra‐peritoneal pressure including using the low initial dwell volume based on patient's weight and body habitus and keeping patients in strict supine posture during exchanges in the first 2 weeks of treatment are the two most important factors ensuring a minimization of the risk of catheter‐related complications.     

Re-redo cervical mediastinoscopy for a recurrent lung cancer

Indian Journal of Thoracic and Cardiovascular Surgery -