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April 1992, Volume 42, Issue 4

Case Reports


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

A review of seven patients with simple vesico­vaginal fistulae, treated with partial thickness skin graft through vaginal approach, at P.I.M.S. is presented. The average age of the patients was 35 years and the fistula was acquired secondary to obstetric injury. Routine laboratory investigation, ECG, x-ray chest and I.V.U. was done in all cases. The flstula was assessed by swab test, urography and cystoscopy. Surgery was performed under general anaesthesia in the lithotomy position. Foleys catheter was retained in the bladder. Medial aspect of the thigh was prepared as the donor site. The surrounding area of the flstula was infiltrated with adrenaline 1:500,000. The edges of the fistula were cut and the edges of the bladder rent were freshened and closed with 2/0 vicryl with interrupted sutures in two layers. The split skin graft removed from the thigh and rinsed in isotonic saline, was placed on the suture line and held by four quadrant angular stitches. The vaginal mucosa was then stitched over it in two layers with 4/0 vicryl. The vagina was packed with roll gauze soaked in diluted antiseptic lotion. Antibiotics parenterally were used for prophylaxis of infection. The catheter was retained for one week following complete healing. Vaginal pack was changed after 48 hours thrice and then daily for 2 weeks. The average hospital stay was 15 to 20 days. The patient was discharged on a long term urinary antiseptic. Follow-up for 1 to 2 years has shown good results except in one where postoperative care was not adequate. Vesico-vaginal fistula is a common complication of obstetric injury in the third world countries. It is a very distressing condition for the patient and usually medical advice is sought late. Repair techniques have been described in literature since 1845 each having its own merits and demerits. Reinforcement of the tissues with graft has also been in use for large flstulae. The presented technique gave satisfactory results, was simple and avoids cystostomy. The postoperative period was comfortable and short. It could be recommended for small and uncomplicated flstulae.
One hundred consecutive admissions of heroin addicts to the Government Mental Hospital Peshawar, for detoxification were studied. Each patient was kept in hospital for 10 days. Data was obtained by semi-struc­tured interviews. Detoxification was carried out by reducing doses of clonidine, chlordiazepoxide and ibuprofen which were stopped on the eighth day. Methadone was not used due to nonavailability. All the addicts in the study were males with ages ranging between 13 and 54 years. 51 individuals were married and 64 were illiterate. 72 of the cases were employed mostly as temporary manual workers. 56 of the addicts were pushed into the habit by friends. Drug pedlars played a minor role. Majority of the families encouraged the addict to give up heroin and 83 patients were regularly visited by the relatives. 31 addicts had been convicted earlier by various drug related offences. 29 had been involved in criminal activities. 36 had been detained in prisons. The study confirmed that heroin addiction in the NWFP is exclusively limited to males, from poor social backgrounds and the drug is inhaled. Standard of education is low and the average age and married individuals in the addicts is greater than that reported in other studies in Pakistan. The average daily expenditure on procuring heroin was found to be Rupees thirty and the average duration of addiction was 8 years. This donflrms the devastating economic effect of heroin abuse. No categorical relation­ship between heroin abuse and criminality could be construed and it has been accepted that a delinquent life style usually precedes drug abuse. The average hospital stay was 7.7 days which was shortened due to the patient wanting to leave early after the acute phase being over and lack of recreational facilities, a sub-standard diet, asecurity oriented environ­ment and the stigma of admission to a mental hospital.
PROFILE OF DIABETIC PATIENTS WITH MICROAL­BUMINURIA. Shah, T., Ahinad, N., Bano, K.A., Ghafoor, F. Pak.J. Med. Res., 1991; 30:29-32.
Microalbuminuria, a good predictor of early diabetic nephropathy eventually leading to end stage renal failure, is defined as urinary albumin excretion between 20 microgram and 200 microgram/mm. 341 diabetic patients were screened for microalbuminuria over a period of one year at the Diabetic Clinic of Pakistan Research Council, Ganga Ram Hospital Lahore. 36 cases were found to be positive and 14 volunteered for further evaluation. Thete were 10 females and 4 males with 7 of them between 5.5 and 65 years age. Two cases had a borderline diastolic hypertension only. 13 patients had noninsulin dependant diabetes and only one female was a type I diabetic. 5 patients had a duration of diabetes of more than 15 years, 4 were diabetics for less than 4 years and the remaining 5 had the disease between 5 and 14 years. Nephropathy is one of the long term complications of diabetes mellitus leading to morbidity and mortality. Microalbuminuria is an early sign of overt nephropathy and its detection and prompt therapeutic intervention can halt the progress of the complication. Patient education and creating an awareness in the general practitioners with appropriate screening for microalbuminuria can considerably reduce morbidity and mortality and medical expenses. Due to the close association between nephropathy and retinopathy, oph­thalmoscopic examinations should be performed regularly. A good metabolic control should be main­tained and ACE inhibitors considered even in the normotensive cases as they reduce glomerular hyperten­sion.
MOYA MOYA DISEASE - A RARE CEREBROVAS­CUIAR MALFORMATION. Iqbal, F., Francis,J.L. Pak. J. Med. Res., 1991; 30:59-61.
The case of a patient diagnosed as moya moya disease is presented. This disease is a rare abnormality of the cerebral circulation of obscure etiology, described first by Takeuchi in Japan in 1961. The patient was a 36 year old male admitted after one episode of convulsions involving the right side of the body. There was no unconsciousness, tongue bite or incontinence. Intermittent frontal headaches were reported in the last 6 months. Examination revealed a right facial nerve palsy, grade 0 power in right arm, grade II to Ill power in right leg, exaggerated tendon reflexes and an extensor plantar on the right side. The patient was aphasic. The remaining physical examination and the routine laboratory investigations were normal. The CT scan of the brain showed a large haematoma in the left temporoparietal region and a carotid angiogram revealed stenosis of the supra-clinoid part of bOth internal carotid arteries with abnormal collaterals. Most of the left hemisphere was supplied through the vertebral arteries. Surgery was not suggested as it would not improve the situation. Speech therapy was started which showed no improvement with time. Physiotherapy lead to mobility.A ceretec brain scan 9 months later showed a major perfusion defect in the left frontoparietal region. Moya moya disease affects females and young children predominantly with the presenting features being of cerebral ischaemia in the former and subarach­noid haemorrhage in the latter. The etiology remains uncertain. Neck trauma, phakomatoses and congenital vascular anamolies have been suggested. Genetic factors play a role and racial predisposition is noted. Cerebral angiography and CT scan elicit the diag­nosis. Ceretec scan now available, is a useful mean to determine regional cerebral blood flow. The treatment is symptomatic and supportive.

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