March 1995, Volume 45, Issue 3

Practical Epidemiology and Biostatistics in Research

Abstracts from the Journals of the East

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

Neonatal Tetanus in Pakistan. Hassan, M., Raza, S.H. J.Pak.Instit.Med.Sci., 1993;4:198-201.
A retrospective study was done on 88 cases of neonatal tetanus, admitted in the Children Hospital, PIMS, Islamabad from 1990- 1992. Diagnosis was made on the criteria of signs and symptoms, clinical examination, immunization status of the mother, unsterile conditions at the time of delivery, cutting of the umbilical cord withunstenle tools and use of indigenous application on the severed cord.
Of the total patients treated, 73.8% were male and 26.2% female. Untrained traditional birth attendants had delivered 86.36% women, 9.08% werO handled by midwives and 4.54% were hospital deliveries. Kitchen knives were used for cutting the cord in 53% cases, used blades in 20.45%, scissors in 17.04% and sharp wood in 9.09%. Butter fat was applied to the wound in 40.9%, cow dung in 25% and surma in 2 1.5% cases. All the women belonged to the poor socioeco­nomic class. 93. 1%were non-immunized, 5.6%were partially immunized and 1.13% were fully immunized. It was also observed that neonates presenting with short incubation periods had higher mortality rates. The survival rate in the series was 78.36%.
All the babies were brought into the hospital with a complaint of refusal to feed, 97.1% had stiffness or spasms, 61.3% were irritable and 56.8% had fever.
The treatent protocol was 50.000 units ATS intrave­nously, Benzyl Penicillin, Gentamycin, Diazepam followed by Phenobarbitone and Chiorpromazine. Breast milk through the nasogastric tube was used for feeding. Intubation and ventilation was applied in cases having apnoeic spells.
Neonatal tetanus, caused by the spore forming gram positive, anaerobic organism. clostridium tetani, is a major contributor to the neonatal mortality in the developing countries.
It is encountered mostly in infants of home deliveries, conducted by untrained women under unhygienic conditions. The slum areas house a population belonging to the poor class and having a low literacy rate leading to lack of health awareness. To reduce the mortality and mothidity due to neonatal tetanus, it is recommended to have active immuniza­ tion of all women in the child bearing age with tetanus toxoid, impmve health education and awareness and an easy access to treatment facilities.
Spinal Tuberculosis with Neurological Deficit. All, N., Ahmad, A. Specialist, Pak.J.Med.Sci., 1993;9:339-343.
Twenty patients (12 female, 8 male) diagnosed as spinal tuberculosis and treated with various modalities have been presented. The mean age of the patients was 46.8 years with range being 1.5 to 70 years. They all hada neurological deficit in the form of paraplegia with a duration of 10 days to 9 months. All complained of back pain and weakness of lower extremities. Numbness was present in 20%, weight loss in 20% and a groin mass in 10% cases. Sphincters were involved in 40% patients. All the patients underwent investigations as Mantoux test, chest X-ray, bone X-ray, bone scan, myelogra­phy in 70% and CT scan in 30% cases.
Antitubercular therapy with four drugs was adminis­tered to all patients for 3 months. Ten cases showing a favourable response were continued on chemotherapy. The other ten were subjected to surgery. The procedures used were modified Hong Kong operation in 6 cases, anterolateral decompression 3 cases and costotransversectomy one case. Histological diagnosis was confirmed in seven cases and the mean follow-up period was nine months.
Of the 10 patients on chemotherapy. 7 completed the prescribed period and recovered. Three cases were lost to follow-up. Of the 6 cases who underwent the Hong Kong operation. 4 recovered, one was lost to follow-up and one died. Of the 3 patients who had anterolateral decompression, one recovered and 2 died. Costotransversectomy was performed on one child who recovered fully.
Spinal tuberculosis is still a problem in many parts of the world. Different procedures of surgery have been performed by surgeons internationally. Conservative treatment with chemotherapy shows a good response in lesions inthe cervical and lumbosacral regions due to more space for the spinal cord and nerve roots.
Surgical treatment is implemented in cases not showing the desired response with initial chemotheray and where debridement is necessaiy.The management of spinal tubemu­losis is thus based on individual merits and has to be decided accordingly the lesions in each patient.
Patent Vitello-Intestinal Duct: An Unusual Presenta­tion. Perara,J. Ceylon Med.J., 1993;38:140-142.
The case of a 4 year old girl passing a roundworm through the umbilicus is presented. She was admitted to Lady Ridgeway Hospital, Cok)mbo with an umbilical discharge followed by a worm appearing at the navel. The round worm was removed by a general practitioner. On examination there were no abdominal signs except for a penumbilical skin ulceration and a serous discharge. Stool examination revealed roundworm and hookworm infection for which Mebendazole was prescribed. The skin lesion was treated with local antiseptics. A fistulogram was performed using Gastrograffin and a tract connecting the umbilicus to the distal ileum was demonstrated.
Exploratory laparotomy was undertaken and a patent vitello- intestinal duct identified and excised. End to end anastomosis restored the ileal continuity. The post-operative recovery was uneventful.
The vitello-intestinal duct connects the gut to the yolk sac in the fetus and detaches itself from the midgut by the sixth week of gestation. In some cases the duct remains completely patent or partially patent. This usually remains asymptomatic in life but it can cause a recurrent or persistent umbilical discharge. Prolapse of the ileum can occur leading to intestinal obstruction. Ectopic gastric mucosa in the duct can cause bleeding per rectum. Due to the potential complications it is desirable to excise a patent vitello-intestinal duct whenever detected.
Left Sided Appendicitis - A Case Report. Samdani, G. Bangladesh Med.J., 1992;21:124-125.
A case of left sided appendicitis, successfully dignosed and surgically treated is presented. The patient was a 15 year old girl admitted to the surgical ward of the Cornilla General Hospital. She came in with pain in the left iliac fossa, nausea and vomiting. The pain had originally started in the epigas­trium. Similar episodes had occurred earlier, subsiding with antispasmodics. Her general examination revealed no abnor­malities. The abdomen had localised tenderness and guarding in the left iliac fossa. Blood and urine tests alongwith gynaecological examination were normal. As the history was highly suggestive of left sided appendicitis, situs inversus was looked into. Chest mdiographs and ultrasonography of the abdomen confirmed the suspicion. There was complete transposition of the thoracic and abdominal viscera.
Elective appendecectomy was performed. On opening the abdominal cavity the caecum with the apendix was found in the left iliac fossa and it was chronically inflamed. The appendix was excised in the routine manner and the patient was discharged after 7 days in a satisfactoiy condition.
The appendix normally lies in the right iliac fossa. But when signs and symptoms are highly suggestive of appendici­tis and the pain is in the left iliac fossa then evidence must be searched for transposition of the viscera.

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