Role of N-Acetylcysteine in Clearance of Secretions in Mechanical Ventilated Patients

Objective: To determine the role of nebulized N-acetylcysteine in mechanical ventilation in clearing the airway of these patients Study Design: A Randomized Control Trial. Place and Duration of Study: Department of Anaesthesia and Intensive Care Unit Nishtar Medical University Hospital and Jinnah Hosptal, Lahore. From January 2017 to July 2018. Material and Methods: In this project total 50 patients were enrolled by consecutive sampling who remained on mechanical ventilation for more than 24 hours and were between ages 15 to 80 years old. Written consent of this project was taken from relative of each patient. These patients were divided into two groups by lottery method into case and control. The case group received 2 ml of NAC 20% with 8 ml normal saline 3 times a day for 1 day. The control group only received 10 ml normal saline via their nebulizers 3 times a day at 8 AM, 2 PM, and 9 PM. Data was collected and was analyzed. SPSS 22 was used for this purpose. All numerical variables of this research such as mean FiO2, mean peak and plateau pressure of airway, mean blood pressure, mean age and importantly mean density of secretions were calculated. In these values t test was applied and p value was calculated. If it was less than .005, then it was considered significant. Similarly, qualitative data such as type of disease were calculated in percentage and chi square test was used to check the significance. Results: The mean O2 saturation of baseline, 12 hours and 24 hours of the controls was 93.84±2.28, 94.27±2.33 and 94.08±1.81 respectively. The mean peak airway pressure of baseline, 12 hours and 24 hours of the controls was 23.16±3.49, 25.38±8.86 and 24.01±4.91 respectively. The mean plateau airway pressure of baseline, 12 hours and 24 hours of the controls was 19.04±7.79, 21.37±4.86 and 21.85±8.93 respectively. The mean secretion density of baseline, 12 hours and 24 hours of the controls was 1.04±0.024, 1.05±0.03 and 1.03±0.002 respectively. While, the mean O2 saturation of baseline, 12 hours and 24 hours of the cases was 93.08±2.37, 94.61±2.56 and 94.11±2.34 respectively. The mean peak airway pressure of baseline, 12 hours and 24 hours of the cases was 26.58±5.81, 23.81±8.28 and 24.34±6.15 respectively. The mean plateau airway pressure of baseline, 12 hours and 24 hours of the cases was 21.88±78.01, 24.88±6.67 and 23.51±7.55 respectively. The mean secretion density of baseline, 12 hours and 24 hours of the cases was 1.01±0.021, 1.08±0.022 and 1.008±0.0195 respectively. The differences were statistically insignificant. P-value ≤ 0.05 is considered as significant. Conclusion: It is concluded from our observations that use of N-acetylcysteine in patients on mechanical ventilation is very effective in clearance of secretion and to maintain airway clear. Key words: N-acetylcysteine, mechanical ventilation, airway clearance, normal saline DOI: 10.7176/JMPB/54-07 Publication date: April 30th 201

Relationship of platelet-lymphocyte ratio with severity of obstructive sleep apnea syndrome.

Objective: Objective of study was to assess the inflammation in obstructive sleep apnea syndrome patients by using platelet lymphocyte ratio and relationship between platelet lymphocyte ratio and severity of obstructive sleep apnea. Study Design: Cross sectional study Place and Duration: Pulmonology department of Nishtar Hospital Multan and Jinnah Hospital, Lahore  from June 2018 to March 2019. Methods: This cross sectional study was conducted in Pulmonology department of Nishtar Hospital Multan from June 2016 to March 2017.Total 280 patients were selected by non-probability consecutive sampling. All patients underwent whole night polysomnography. Patients were divided into control group (AHI <5), mild OSAS group (AHI 5-15), moderate OSAS group (AHI 15-30) and sever OSAS group (AHI >30) according to their AHI score. Numerical variables like age, body mass index, white cell count, platelets, hemoglobin (Hb) and platelet lymphocyte ratio were statistically analyzed by mean and standard deviation and t-test applied to assess their significance. Qualitative variables like gender and smoking status were statistically analyzed by frequency and percentage. Chi square test was applied to check the significance. P value <0.05 was regarded as significant. Results: Platelet lymphocyte ratio was significantly raised in patients with obstructive sleep apnea syndrome. There was significant correlation between platelet lymphocyte ratio and AHI (p<0.05). So study showed that there was significant association between obstructive sleep apnea syndrome severity (represented by AHI) and systemic inflammation (represented by PLR). Significant differences were found between age (p =0.000), ESR (p =0.000), CRP (p =0.003), Cholesterol (p =0.000), Platelets (p =0.048), Hb (p =0.000), PLR (p =0.000) and white blood cells (p =0.000), in groups. Association was found between gender (p =0.000) and smoking status (p =0.030) in groups. So, gender and smoking were the effect modifiers. Conclusion: the observations of our study suggest that Platelet lymphocyte ratio was significantly raised in patients with obstructive sleep apnea syndrome. There was significant correlation between platelet lymphocyte ratio and AHI (p<0.05). So study showed that there was significant association between obstructive sleep apnea syndrome severity (represented by AHI) and systemic inflammation (represented by PLR). Key words: Obstructive sleep apnea syndrome, Platelet lymphocyte ratio, polysomnography DOI: 10.7176/JMPB/54-08 Publication date: April 30th 201

The Adoption of Management Accounting Practices (Maps) in Small and Medium Enterprises (SME's) of Pakistan

The practices of Management Accounting have not been highly adopted in developing countries. But with increased importance of these practices, firms of developing countries are motivated to adopt MAPs. In this research, MAPs align with increased importance of SMEs have been studied and provide understanding to enhance adoption of MAPs in SMEs. This study outlines the usage of MAPs in Pakistani SMEs; identify the contextual factors that affect the adoption of MAPs by SMEs and lastly explore perceived benefits and problems in adoption of these practices.  A mixed methodology was used to collect data. A questionnaire with five categories of MAPs was used to examine the extent of use of MAPs by 100 SMEs of Multan from textile sector. Eight interviews were conducted to identify the factors, benefits and problems. However, the results shows that majority of respondent firms adopt traditional MAPs and other medium sized firms do more focus on contemporary MAPs. The findings of current study can be helpful and informative for practitioners and policy makers in the development of contemporary MAPs as well as provide deep insight for SMEs to enhance their business by adopting these practices

Eccrine spiradenoma: A rare adnexal tumour with atypical presentation: A case report

First described in 1934, eccrine spiradenoma (ES) is a rare, benign adnexal tumour arising from eccrine sweat glands. It commonly presents as a slow-growing nodule on the upper trunk, and head and neck region, mostly in the age bracket of 15-35 years, with no gender preference. While no established guidelines exist for optimal management of malignant ES, some therapies have been studied. The diagnosis of this entity is extremely important as it can harbour a malignant component with disastrous outcomes which may be missed due to its strong resemblance to benign lesions, such as a papilloma. Here, we present the case of a 35-year-old lady who presented with a papilloma-like growth on the upper medial aspect of the thigh which was diagnosed as eccrine spiradenoma upon excision

Persistent post-surgical pain following breast cancer surgery: An observational study in a tertiary care hospital

Objective: To determine the frequency of persistent pain in patients after breast cancer surgery, and to assess the distribution and characteristics of pain in such patients.Methods: The prospective observational single cohort study was conducted at the Department of Anaesthesiology and in the Breast Clinic of the Department of Surgery, Aga Khan University Hospital, Karachi, from August 2016 to January 2017, and comprised adult female patients with biopsy-proven carcinoma of breast who were scheduled for elective definitive breast cancer surgery. The patients were followed up for up to three months post-surgery and those with persistent pain were followed up for six months post-operation. Data was analysed using SPSS 19.Results: Of the 120 patients, 26(21.7%) developed persistent post-surgical pain for up to three months, while in 17(14.2%) patients, the pain continued for up to six months after the operation. Among those with persistent post-surgical pain, 11(42.3%) had burning pain, 10(38.5%) had throbbing pain, 3(11.5%) had numbness and 2(7.7%)had mixed character of pain. Also, 11(42.3%)patients developed pain at more than one site including axilla, chest wall, upper arm and surgical scar area, and the site of pain in majority patients 15(57.7%) was axilla.Conclusion: The incidence of persistent pain following breast cancer surgery was found to be 21.7%

Giant juvenile fibroadenoma of the breast in a 13-year-old Pakistani girl with excellent cosmetic outcome after subareolar enucleation - A case report

Introduction: Fibroadenoma is the most common benign lesion of breast in young women, characterized by an aberrant proliferation of both epithelial and mesenchymal elements. It is termed giant fibroadenoma when it is larger than 5 cm or weighs more than 500 g with an incidence of 0.5-2% of all fibroadenomas.Presentation of case: In this report, we discuss a case of a 13-year-old Pakistani girl who presented with a giant juvenile fibroadenoma in left breast and was treated by a subareolar lump excision through a periareolar incision with excellent cosmetic outcome. To the best of our literature search, this is the first case of giant juvenile fibroadenoma in an adolescent being reported from Pakistan.Discussion: Surgical management of giant juvenile fibroadenoma in immature breast is challenging as it may either result in asymmetric defect or damage to developing breast tissue resulting in long term poor outcomes. Surgical decision should be carefully undertaken and reported for future reference in such cases.Conclusion: The diagnosis and management of giant juvenile fibroadenoma can be challenging because these tumors clinically and histologically mimic phyllodes tumor due to their rapid growth and large size. Excision through a periareolar approach for fibroadenomas located in subareolar region provides good cosmetic results in these patients with minimal scar visibility

Handwashing Practices in Health Care Professionals of allied Hospitals of Rawalpindi Medical University

Objective: To assess the practice of hand washing in the teaching hospitals of Rawalpindi Medical University. Methodology: A descriptive cross sectional study was conducted by on-site observations of HCP regarding hand-hygiene compliance in allied hospitals of Rawalpindi Medical University. Health care professionals having any sort of allergy or sensitivity problem of hands were excluded. A predesigned checklist was used to collect the data. In all the hospitals included in our study, a proper technique, provided by the World Health Organization (WHO), is displayed in almost all the wards. Results: A total of 218 respondents (74 doctors, 71 medical students and 73 nurses) were observed. Out of these, medical students had best hand-washing practices when compared to that of doctors and nurses. Basic hand-washing facilities were available in all the hospitals but only 36.6% of health-care professionals (10.58% Doctors, 19.58% Medical students, 6.45% nurses) with p value=0.05 practiced hand-washing. Moreover, out of the 36.6%, only 19.22% (p=0.01) followed WHO technique of handwashing, whereas, 86.7% of them used antiseptic solution. Conclusion: Despite the bedside availability of antiseptic solution in all the three hospitals, inadequate compliance was seen in health-care professionals. A multi-disciplinary, multidimensional approach is required to challenge the problems of non-compliance.&nbsp

Clinicopathological features of young versus older patients With breast cancer at a single Pakistani institution and a comparison with a national US database

METHODS: We conducted a retrospective review of patients with symptoms of breast cancer presenting to Aga Khan University Hospital (AKUH), a large tertiary care center in Pakistan, between 2001 and 2010; we compared young (≤ 40 years) versus older (\u3e 40 years) patients in terms of their clinicopathological characteristics. We also compared this Pakistani cohort with the US population using data from the National Cancer Database (NCDB). RESULTS: A total of 1,334 patients with breast cancer presented to our center over the 10-year review period. The median age at diagnosis was 50 years, compared with 60 years for patients in the NCDB. In the AKUH cohort, younger patients were significantly more likely than their older counterparts to present with metastatic disease (13.1% v 10.8%; P \u3c .01). They also were more likely to present with higher-grade tumors (grade 3: 40.1% v 28.3%; P \u3c .001), have triple hormone receptor-negative phenotype (25.4% v 14.1%, P \u3c .001), and have positive axillary lymph node involvement (70.9% v 57.5%; P \u3c .001) compared with older women. Younger and older patients in the AKUH cohort tended to present with higher-stage disease ( P \u3c .001) and were more likely to have triple hormone receptor-negative disease ( P \u3c .001), compared with all patients in the NCDB and with those of Indo-Pakistani origin. CONCLUSION: Young Pakistani women, similar to their Western counterparts, present with more advanced disease and more aggressive tumor biology than their older counterpart

Outcome and cost effectiveness of autobiographically guided surgical clip placement for tumor localization in patients undergoing neo-adjuvant chemotherapy for breast cancer.

Abstract BACKGROUND: To determine the outcome and cost saving by placing ultrasound guided surgical clips for tumor localization in patientsundergoing neo-adjuvant chemotherapy for breast cancer. MATERIALS AND METHODS: This retrospective cross sectional analytical study was conducted at the Department of Diagnostic Radiology, Aga Khan University Hospital, Karachi, Pakistan from January to December 2014. A sample of 25 women fulfilling our selection criteria was taken. All patients came to our department for ultrasound guided core biopsy of suspicious breast lesions and clip placement in the index lesion prior to neo-adjuvant chemotherapy. All the selected patients had biopsy proven breast cancer. RESULTS: The mean age was 45 ± 11.6 years. There were no complications seen after clip placement in terms of clip migration or hemorrhage. The cost of commercially available markers was approximately PKR 9,000 (US$90) and that of the surgical clip was PKR 900 (US$ 9). The cost of surgical clips in 25 patients was PKR 22,500 (US$225), when compared to the commercially available markers which may have incurred a cost of PKR 225,000 (US$ 2,250). The total cost saving for 25 patients was PKR 202,500 (US$2, 025), making it PKR 8100 (US$ 81) per patient. CONCLUSIONS: The results of our study show that ultrasound guided surgical clip placement in index lesions prior to neo-adjuvant therapy is a safe and cost effective method to identify tumor bed and response to treatment for further management