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June 1995, Volume 45, Issue 6

Case Reports

Abstracts From the Journals of the East

Fatema Jawad  ( 7/6, Rimpa Plaza, M. A. Jinnah Road, Karachi. )

Urinary Tract Calculi in Childhood. Abbasi, M.Z. Spe­cialist, Pak.J.Med.Sci., 1994;11 :25-30.
A retrospective analysis of 95 cases of urolithiasis presenting at Children’s Hospital, PIMS, Islarnabad in 1990, is reported. Data was extracted from the case records. Forty-six randomly selected stones were analysed by infrared spectroscopy in Tokyo Laboratories. Urolithiasis was de­tected in one out of 73,8 admissions; the male to female ratio was 3.75:1 and the mean age at presentation was 7. 11 years. The weight record revealed 55% of the children to be below the fifth percentile.
The hygienic status was poor in 63% patients, mean haernoglobin being 9.7G/dl and a history of gastroenteritis was present in two third of the population. Kidney function was slightly impaired in only 3 cases with blood urea more than 3Omg% and a serum creatinine greaterthan 1 .6mg%. The presenting symptoms were dysuria in 26%, lumbar pain in 23% and haematuna in 19% cases. All the patients were subjected to an intravenous urogram whereas ultrasound was performed in 27% cases only. There was no growth of organisms in 85% of the unne specimens.
The study reveals a larger population of children at an earlier age to be inflicted by stone disease in Pakistan compared to the U.S.A. The etiological factors thus seem to be many. Malnutrition coupled with inadequate hygiene which again leads to gastroenteritis and dehydration fonns a viscous circle. Renal stones were predominant (51.6%) with bladder stone being next infrequency. Half the stones were oxalate and phosphate. Analysis ofdnnking water revealed a high calcium level and it was also noted that 92% of the families did not boil theirwater. This is an important factorfor causing an increased calcium level in the blood and predisposing to urolithiasis.
Thyroid Surgery: Shaikh Zayed Hospital Experience. Khalid, K., Khawaja, S., Durrani, KM., Tufail, M., Ah­med , M. Pak.J.Surg., 1994;10:39-44.
The results of a prospective study on 126 patients with thyroid disorders requiring surgery inthe years 1991 and 1992 at the Shaikh Zayed Hospital, Lahore are reported. There were 32 males and 94 females with a mean age of 34.5 years. Besides the routine examination, specific work up included ECG, indirect laryngoscopy, thyroid profile, radio-iodine uptake studies and scintiscan. Fine needle aspiration cytology (FNAC) was carried out in selective cases with solitary nodules. Thoracic inlet X- rays were done in large goitres. Patients with toxic goitres first received anti-thyroid drugs and beta blocker and were operated after being clinically evalu­ated. Pressure symptoms were present in 19 cases whose gland on resection weighed 200Gm. Functionally hyperthy­roidism was found in 20 patients of these 3 had Graves disease and 17 were secondaiy thyrotoxicosis in multi-nodular goitre (MNG). Besides an enlarged thyroid gland other complaints were palpitations, heat in tolerance and weight loss in these cases. Exophthalmos was observed in 2 cases with primary thyrotoxicosis. A true solitary nodule seen peroperatively was determined in 35 patients. j131 uptake gave an accurate diagnosis in all the 20 cases of thyrotoxicosis. Fine needle aspiration cytology done on35 cases gave conclusive findings in 31 subjects only.
Subtotal thyroidectomy was performed in 59 patients forMNG,lobectomy and isthmectomy was done in 50 patients who had had aFNAC, near total thyroidectomy in 10 cases and total thyroidectomy in 7 patients for malignancies. The histopathology revealed simple MNG with colloid degeneration in49 cases, follicular adenoma in 30 patients and 3 had Graves disease. The incidence of malignancy was 15% as differentiated thyroid cancer, In the post-operative period, 7 patients developed chest infection, haematoma under the flap was encountered in 3 cases and required drainage, 3 had transient hypocalcaemia, 2 had wound infection and recurrent laryngeal nerve damage occurred in 2 cases of which one recovered fully. Only one patient died due to chest infection and ventilatory failure.
The follow-up rate declined with only 36% being available after 2 years. No late complications secondary to surgety were noted. It was concluded that a good pre-operative assessment and FNAC where necessary, is a great help to select the operative modality and that thyroid surgeiy is a safe procedure in the hands of an experienced general surgeon.
Aspiration Cytology of Breast Lumps. Kumara Singhe, M.P., Sheriffdeen, A.H. Ceylon Med.J., 1993;38: 117-119.
The results of 287 aspirations performed on palpable breast lumps over a period of 20 months are presented. The classical fine needle aspiration technique using a 22-23 gauge, 32 mm long disposable needle without local anaesthesia was used. One, two or rarely three aspirations were performed according to the tissue obtained. A smear was made and fixed in 95% alcohol and stained with haematoxylin and eosin or papanicolaou stains. Interpretation was made as malignant, benign, atypical or suspicious. The cytological criteria used were according to Orell and Takahashi. Smears were consid­ered inadequate when epithelial cells were absent. All malignant, suspicious and atypical lesions were excised and assessed histologically. They were correlated with the cyto­logical diagnosis. Most of the benign lesions were also excised. Only 215 smears were adequate for analysis whereas histological follow-up was available in 162 cases. The results showed that positive predictive value and specificity of malignant smears was 100 percent. Two lesions considered benign on cytology were found to be malignant on histology. Three of the eight lesions diagnosed as cytologically atypical were malignant. One smear showed atypia due to lactational changes. Four of the 6 lumps with suspicious smears were diagnosed malignant. Thirty-one patients with inadequate smears were re-aspirated and five samples showed malig­nancy. Thirteen cases were subjected to an excision biopsy without re-aspiration and of these S had malignant disease. Cytological diagnosis of breast disease through a fine needle aspiration biopsy technique can provide accurate results. This requires an experienced hand for aspiration, preparation of the material and cytological analysis. Triple diagnosis of breast disease by clinical assessment, mammog­raphy and. FNA can give accuracy rates reaching 99 to 100 percent.
Elective Caesarean Section for Macrosomia? Yan, J.S., Chang, Y.K., Yin, C.S. Chin.Med.J. (Taipei), 1994;53:141-145.
A retrospective study was carried out at the Tn-Service General Hospital, Taipei, to determine the frequency of dystocia and birth trauma in women with a macrosomic fetus. The period extended from 1990 to 1992 when 6230 women were delivered. Pregnancies with an outcome of a 4000Gm infant were specially analysed. The labour course, route of delivery, outcome, birth weight and indication for caesarian section, was reviewed. The comparison group comprised of women delivering a normal birth weight (2500-3999Gm) infant. Macrosomia was defined as a birth weight of atleast 4000Gm. Dystocia was diagnosed when the arrest of cervical dilatation was present for 2 hours or more. Women undergoing caesarian section for other indications without trial of labour were excluded. Foetal weight was estimated sonographically and birth trauma was defined as nerve injury or fracture of the clavicle or humerus in the new born. During the study period, 207 women delivered a single infant weighing atleast
4000Gm. Of these 104 had a vaginal delivery and 103 were subjected to a caesarian section. The indications for surgery were dystocia in 25 women, estimated macrosornia in 30 and other causes in 48 subjects. Of the 104 vaginal deliveries, 13 infants sustained clavicle fracture and 2 had brachial plexus injury. These occurred in infants weighing more than 4500Gm. Of the 45 cases undergoing caesarian section for estimated macrosomia only 30 were actually macrosomic. A trend of increased dystocia asbirth weight increased was noted in the study group. Birth trauma in the fonn of clavicle fracture was observed in 69 cases with normal birth weights whereas 15 infants in the macroscomic group attained injuries during delivery. This again showed an increased frequency of birth injuries with increased birth weight. Results of other similar studies alongwith the presented one suggest that about 80 percent of macroscomic infants weighing between 4000-4499Gm can be delivered vaginally. Elective cacsarian section in pregnancies with infant weight of 4500Gm or more is appropriate. Predicting weight accurately before birth of the infant is difficult despite the modem ultrasound technology. It is generally accepted that sonog­raphic estimation of foetal weight has a mean absolute error of 10 percent.

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