Molecular Characterisation of Foot‐and‐Mouth Disease Viruses from Pakistan, 2005–2008

Foot‐and‐mouth disease (FMD), an economically important disease of cloven‐hoofed animals, is endemic in Pakistan where three virus serotypes are present (O, A and Asia 1). Fifty‐eight clinical samples collected between 2005 and 2008 from animals with suspected FMD in various locations in Pakistan were subjected to virus isolation on primary cell culture, antigen ELISA and real‐time RT‐PCR (rRT‐PCR). Viruses were isolated from 32 of these samples and identified as FMDV type O (n = 31) or type A (n = 1). Foot‐and‐mouth disease virus (FMDV) genome was detected in a further 11 samples by real‐time RT‐PCR. Phylogenetic analyses of the VP1 nucleotide sequences showed that all of the type O viruses belonged to the MIDDLE EAST–SOUTH ASIA topotype with the majority belonging to the PanAsia‐2 lineage; a single example of the older PanAsia lineage was identified. The single FMDV type A virus belonged to the ASIA topotype, but did not cluster with known strains that are currently circulating (such as Iran‐05) and was not closely related to other type A viruses from the region. These findings demonstrate the widespread distribution of O‐PanAsia‐2 in Pakistan and the presence of undisclosed novel type A lineages in the region.     

A rare complication of forgotten ureteral stent

A 35 years old lady presented with history of something coming out of the genitalia for the last 5 days. She also had history of pain in the left lumbar region which was initially investigated but the patient did not follow-up. About 15 years ago she also underwent left ureteric reimplantation. On examination, a stick like tube was protruding out of the urethral meatus which was fixed to the underlying vesical calculus. The calculus was evident radiologically and on ultrasound. The projecting portion of the stick like tube was cut and the vesical calculus with the inner portion of the tube was removed by open procedure. On evaluation of the specimen, it was found that the vesical calculus was fixed to the plastic tube which had concretions around it. This plastic tube had been placed after the ureteric reimplantation done 15 years ago and the patient was not aware of it.     

Revision of Failed Bariatric Procedures to Roux-en-Y Gastric Bypass (RYGB)

Bariatric surgery for morbid obesity has been established as an effective treatment method and has been shown to be associated with resolution of co-morbidities. Despite its success, some patients may require revision because of weight regain or mechanical complications. From September 2005 to December 2009, 42 patients underwent revisional Roux-en-Y gastric bypass (RYGB). All procedures were performed by one surgeon. Demographics, indications for revision, complications, and weight loss were reviewed. Thirty-seven patients were treated with laparoscopic (n = 36) or open (n = 1) RYGB after failed laparoscopic adjustable gastric banding. Four patient were treated with laparoscopic (n = 3) or open (n-1) RYGB after failed vertical banded gastroplasty, and one patient underwent open redo RYGB due to large gastric pouch. Conversion rate from laparoscopy to open surgery was 2.5% (one patient). Mean operative time was 145.83 ± 35.19 min, and hospital stay was 3.36 ± 1.20 days. There was no mortality. Early and late complications occurred in six patients (14.2%). The mean follow-up was 15.83 ± 13.43 months. Mean preoperative body mass index was 45.15 ± 7.95 that decreased to 35.23 ± 6.7, and mean percentage excess weight loss was 41.19 ± 20.22 after RYGB within our follow-up period. RYGB as a revisional bariatric procedure is effective to treat complications of restrictive procedures and to further reduce weight in morbidly obese patients.     

An observational study of 256 cases of vascular trauma in the north western province of Pakistan.

During the past 10 years Peshawar has dealt with increasing casualties with penetrating trauma inflicted by a wide variety of missiles. The aim of this study was to assess whether delay in arrival and mode of presentation affects the outcome of patients with penetrating vascular trauma. Prospective data were collected on 256 vascular injuries in 248 patients (median age, 29 years; range, 7-60 years) between January 1995 and June 1998. Early presentation (group A, 55 cases, < 12 h) was compared with late presentation (group B, 201 cases, > 12 h). The majority of injuries (93%) were caused by fire-arms. Arterial injuries accounted for 71% of the total, venous injuries accounted for 10% and 19% were mixed. The site of injury was the lower limb (61%), upper limb (32%), abdominal cavity (5%) and neck (2%). Patients presented with absent pulses (56%), haemorrhage (46%), false aneurysms (8%), A-V fistula (5%) and 11% presented with more than one sign. There were significantly more lower limb amputations in group A than group B (23% versus 5%; P < 0.05), with fractures having a positive association with lower limb amputations (odds ratio, 0.32; 95% CI, 0.13-0.94; P < 0.05). Group A had a higher mortality than group B (18% versus 7%; P < 0.05). This study shows that patients with vascular trauma can be managed successfully with clinical assessment alone. Patients with fractures were more likely to suffer eventually from lower limb loss. Due to self-selection, arrival at the hospital less than 12 h after sustaining vascular injury was associated with a higher mortality than those presenting after 12 h.     

Combination cisplatin, 5-fluorouracil and radiation therapy for locally advanced unresectable or medically unfit bladder cancer cases: a Southwest Oncology Group Study

PURPOSE: Patients with locally advanced bladder cancer or who are not medically fit for surgery are a therapeutic dilemma. Radiotherapy with or without single agent cisplatin has been the major therapeutic modality. A phase II Southwest Oncology Group trial investigated the efficacy and feasibility of 5-fluorouracil, cisplatin and radiation in this patient subset. MATERIALS AND METHODS: Eligible patients had muscle invasive bladder cancer (clinical stages T2-T4) with nodal involvement at or below the level of bifurcation of the iliac vessels, were medically or surgically inoperable, or refused cystectomy. Patients underwent pretreatment cystoscopy and detailed tumor mapping, and were treated with 75 mg. /m.2 cisplatin on day 1 and 1 gm./m.2 daily, 5-fluorouracil on days 1 to 4 and definitive radiotherapy. Chemotherapy was repeated every 28 days, twice during and twice after radiation. RESULTS: From October 1993 to April 1998, 60 patients were enrolled in study. Of the 56 eligible patients 34% had unresectable tumors, 21% were not medically fit for surgery and 45% refused cystectomy. Overall, 68% of the patients had clinical T3 tumors or greater and 22% had nodal metastasis. Treatment was completed as planned in 32 of 56 (57%) patients. The most frequent grade 3 or 4 toxicities were neutropenia, stomatitis or mucositis, diarrhea, neuropathy and nausea. There were 53 patients who were evaluable for response, although response was not determined for 18. The overall response rate was 51% (95% confidence interval [CI] 37 to 65) based on intent to treat with a complete response rate of 49% (95% CI 35 to 63). Estimated median survival of the 56 patients was 27 months (95% CI 21 to 40 months) with an overall 5-year survival of 32%. The 5-year survival of the 25 patients who refused surgery was 45%. CONCLUSIONS: Concurrent 5-fluorouracil, cisplatin and radiation therapy is feasible. Despite a promising complete response rate, the overall 5-year survival suggests the need for more effective systemic therapy. The 5-year survival of patients who refused cystectomy suggests that this combined modality may provide another alternative to cystectomy for these patients.     

Venous air embolism during the use of a Nd YAG laser

We report a case of a 47-year-old female who suffered a cardiac arrest during sub-mucosal diathermy of the inferior turbinate using a Nd YAG laser. The possible causes of the cardiac arrest are discussed. Venous air embolism due to Nd YAG laser was thought to be the most likely cause in this case. Although venous air embolism has previously been reported during nasal sinus surgery and choanal atresia when using a Nd YAG laser, the occurrence of this complication during a relatively minor surgical procedure has not previously been reported. It is important, therefore, to raise the awareness of this life threatening complication during use of a Nd YAG laser regardless of the duration of surgery. We recommend the use of appropriate methods and techniques to avoid this life threatening complication during the use of Nd YAG laser even for relatively short procedures.     

Compound palmar ganglion with carpal tunnel syndrome

Compound palmer ganglion is an uncommon condition characterized by a swelling in the distal part of volar aspect of wrist and communicating with another swelling over palm across the flexor retinaculum. It commonly results from tuberculous tenosynovitis. It may lead to carpal tunnel syndrome and need surgical excision with division of flexor retinaculum.