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author:("afar, Hasnain")
1.  Predictors of Sepsis in Moderately Severely Injured Patients: An Analysis of the National Trauma Data Bank 
Surgical Infections  2013;14(1):62-68.
Abstract
Background
Post-traumatic sepsis is a significant cause of in-hospital death. However, socio-demographic and clinical characteristics that may predict sepsis in injured patients are not well known. The objective of this study was to identify risk factors that may be associated with post-traumatic sepsis.
Methods
Retrospective analysis of patients in the National Trauma Data Bank for 2007–2008. Patients older than 16 years of age with an Injury Severity Score (ISS) ≥9 points were included. Multivariable logistic regression was used to determine association of sepsis with patient (age, gender, ethnicity, and insurance status), injury (mechanism, ISS, injury type, hypotension), and clinical (major surgical procedure, intensive care unit admission) characteristics.
Results
Of a total of 1.3 million patients, 373,370 met the study criteria, and 1.4% developed sepsis, with an associated mortality rate of approximately 20%. Age, male gender, African-American race, hypotension on emergency department presentation, and motor vehicle crash as the injury mechanism were independently associated with post-traumatic sepsis.
Conclusions
Socio-demographic and injury factors, such as age, race, hypotension on admission, and severity and mechanism of injury predict post-traumatic sepsis significantly. Further exploration to explain why these patient groups are at increased risk is warranted in order to understand better and potentially prevent this life-threatening complication.
doi:10.1089/sur.2012.009
PMCID: PMC3601717  PMID: 23461696
2.  Predictors of Positive Head CT Scan and Neurosurgical Procedures After Minor Head Trauma 
The Journal of surgical research  2011;173(1):31-37.
Background
There continues to be an ongoing debate regarding the utility of Head CT scans in patients with a normal Glasgow Coma Scale (GCS) after minor head injury. The objective of this study is to determine patient and injury characteristics that predict a positive head CT scan or need for a Neurosurgical Procedure (NSP) among patients with blunt head injury and a normal GCS.
Materials and Methods
Retrospective analysis of adult patients in the National Trauma Data Bank who presented to the ED with a history of blunt head injury and a normal GCS of 15. The primary outcomes were a positive head CT scan or a NSP. Multivariate logistic regression controlling for patient and injury characteristics was used to determine predictors of each outcome.
Results
Out of a total of 83,566 patients, 24,414 (29.2%) had a positive head CT scan and 3,476 (4.2%) underwent a NSP. Older patients and patients with a history of fall (as compared to a motor vehicle crash) were more likely to have a positive finding on a head CT scan. Male patients, African-Americans (as compared to Caucasians) and those who presented with a fall were more likely to have a NSP.
Conclusions
Older age, male gender, ethnicity and mechanism of injury are significant predictors of a positive finding on head CT scans and the need for neurosurgical procedures. This study highlights patient and injury specific characteristics that may help in identifying patients with supposedly minor head injury who will benefit from a head CT scan.
doi:10.1016/j.jss.2011.04.059
PMCID: PMC3684145  PMID: 21872271
Head Injury; Outcomes; Ethnicity; Gender; Age; Disparities; Multivariate Regression; Blunt Trauma
3.  Localised fungal infection in a prosthetic mesh treated conservatively 
BMJ Case Reports  2011;2011:bcr0720103177.
Infection remains one of the most challenging complications of mesh hernioplasty. The authors report a case of a 28-year-old male with no known comorbidities who underwent reversal of ileostomy and prolene mesh hernioplasty. His wound was left open for delayed primary closure, although daily dressing started from second postoperative day. He developed fungal infection of prolene mesh on fifth postoperative day which was successfully treated with irrigation and daily wound dressing with amphotericin B avoiding the complications associated with mesh excision. He made an uneventful recovery and on last follow-up his wound was granulating well with no signs of infection.
doi:10.1136/bcr.07.2010.3177
PMCID: PMC3062274  PMID: 22714603
4.  Emergency incisional hernia repair: a difficult problem waiting for a solution 
Background
Emergency repair of incarcerated incisional hernia with associated bowel obstruction in potentially or contaminated field is technically challenging due to edematous, inflamed and friable tissues with occasional need for concurrent bowel resection and carries high rates of post-operative infectious complications. The aim of this study was to retrospectively assess the wound related morbidity of use of permanent prosthetic mesh in emergency repair of incarcerated incisional hernia with associated bowel obstruction. We also describe a new technique of leaving the mesh exposed to heal by secondary intention with granulation tissue.
Methods
Between 2000 and 2010 a total of 60 patients underwent emergency surgery for incarcerated incisional hernia with associated bowel obstruction with placement of permanent prosthetic mesh. The wound was closed after hernia repair in 55 patients while it was left open to granulate in 5 patients.
Results
In the group of patients with primary wound closure, 11 patients developed superficial surgical site infection, 5 developed deep wound infection and one patient had cellulitis. These patients were treated with wound debridement and antibiotics. Mesh removal was required in one patient. There were no infections in the group of patients who had their surgical wounds left open. One patient in this group died on the fifth postoperative day from septicemia.
Conclusion
Use of permanent prosthetic mesh in emergency repair of incarcerated incisional hernia with associated bowel obstruction. in contaminated field is associated with high risk of wound infection.
doi:10.1186/1750-1164-6-1
PMCID: PMC3261089  PMID: 22216761
Obstructed hernia; Incisional hernia; Emergency hernia repair
5.  Risk factors of gallbladder cancer in Karachi-a case-control study 
Background
Gallbladder carcinoma (GC) is a relatively rare malignancy worldwide but is the second commonest gastrointestinal cancer in Pakistani women. Gallstones have a positive association with GC but other factors also influence in causation.
Methods
This is a retrospective case control study over a period of 19 years. The cases (Group A) were patients with histopathological proven carcinoma gallbladder (N = 60) and controls were patients with cholelithiasis but no carcinoma gallbladder on histopathology (N = 120). Multivariate regression analysis was done to calculate the odds ratio, 95% confidence interval and P-Value. A positive relationship was found between size of stone > 1 cm, solitary stone, age > 55 years and multi-parity in women.
Results
There were 60 patients in Group A and 120 patients in Group B. mean age of diagnosis in Group A patients was 57 ± 2.4 years while mean age of diagnosis in Group B patients was 48 ± 1.35 years. Sixty seven percent of cancer group patients were female as compared to 78% females in non-cancer group. In Group A, 69% of female patients were multiparous (parity of more than 5) while 43% of group B patients were multiparous. For body mass index (BMI), both groups were not very different in our study population i.e. around 78% patients in each group has BMI of more than 23 Kg/m2. In Group A, 37% (n = 22) have solitary stones as compared to 15% (n = 18) in group B. similarly Group A patients has larger stone size as compared to Group B i.e.59% (n = 36) patients in Group A have stones of more than 1 cm when compared to 35% (n = 41) patients in Group B. After using multivariate regression analysis, age more than 55 years (OR - 7.27, p value- < 0.001), solitary stone (OR - 3.33, p value - 0.002) and stone of more than 1 cm (OR - 2.73, p value - 0.004) were found to be independent risk factors for development of gallbladder cancer.
Conclusion
Most of the patients (78%) with GC were female, and the statistically significant risk factors were older age, solitary stones and stones size more than one centimeter. A case can be made for prophylactic cholecystectomy in such a high risk group. However a population based study is required to calculate the true incidence of GC in Karachi and a prospective multi center study is needed to produce strong evidence for screening and prophylactic cholecystectomy.
Trial Registration
As this was a retrospective review of medical records, as per institution policy, its gives waiver from any registration (ethical/trial).
doi:10.1186/1477-7819-9-164
PMCID: PMC3256117  PMID: 22151791
Gall bladder cancer; Prophylactic cholecystectomy; Risk factors for gallbladder cancer
6.  Isolated adult hypoganglionosis presenting as sigmoid volvulus: a case report 
Introduction
Isolated hypoganglionosis is a rare cause of intestinal innervation defects. It is characterized by sparse and small myenteric ganglia, absent or low acetylcholinesterase activity in the lamina propria and hypertrophy of the muscularis mucosae, principally in the region of the colon and rectum. It accounts for 5% of all intestinal neuronal malformations. To the best of our knowledge, only 92 cases of isolated hypoganglionosis were reported from 1978 to 2009. Isolated hypoganglionosis usually manifests as enterocolitis or poor bowel function, and is diagnosed in infancy or childhood. We report the first case of isolated hypoganglionosis presenting with sigmoid volvulus in a 34-year-old woman.
Case presentation
A 34-year-old Asian woman had progressively increasing abdominal pain and had not passed stool or flatus for two days. A physical examination revealed a distended abdomen with sluggish gut sounds. A computerized tomography (CT) scan demonstrated gross dilatation of the sigmoid colon (maximal diameter 14.3 cm) suggestive of sigmoid volvulus. During emergency laparotomy, sigmoidectomy with a side-to-side colorectal anastomosis was performed. Histopathology of the resected specimen showed occasional ganglion cells and hypertrophied nerve bundles in the muscle layers, suggesting hypoganglionosis. Colonoscopy was performed, and multiple full-thickness biopsies were taken that showed hypoganglionosis of the entire large bowel. Our patient underwent total colectomy with an ileorectal anastomosis. Subsequently our patient reported a dramatic improvement in her bowel function.
Conclusions
Isolated hypoganglionosis is a rare cause of intestinal dysganglionosis and cannot be differentiated from Hirschsprung's disease based on clinical presentation. This case report describes an atypical presentation of the disease. A definitive diagnosis requires histopathological analysis of full-thickness intestinal biopsies. Treatment should be tailored to the extent of hypoganglionosis.
doi:10.1186/1752-1947-5-445
PMCID: PMC3179760  PMID: 21902826
7.  Treatment of Complex Fistula in Ano with Cable-Tie Seton: A Prospective Case Series 
ISRN Surgery  2011;2011:636952.
Objective. To determine the fecal incontinence and recurrence rate in patients with complex fistula in ano managed with cable tie seton at a tertiary care teaching hospital. Methods. This is a prospective case series of patients with complex anal fistula i.e. recurrent fistula or encircling >30% of external anal sphincter, managed with cable tie seton from March 2003 to March 2009. Patients were seen in the clinic after 72 hours of seton insertion under anesthesia and then every other week. Each time the cable-tie was tightened if found loose without anesthesia and incontinence was inquired according to wexner's score. Results. Seventy nine patients were treated during the study period with the age (mean ± standard deviation) of 41 ± 10.6 years and. The seton was tightened with a median of six times (3–15 times range). Complete healing was achieved in 11.2 ± 5.7 weeks. All the patients were followed for a minimum period of one year and none of the patients had any incontinence. Recurrence was found in 4 (5%) patients. Conclusion. The cable tie seton is safe, cost effective and low morbidity option for the treatment of complex fistulae-in-ano. It can, therefore, be recommended as the standard of treatment for complex fistulae-in-ano requiring the placement of a seton.
doi:10.5402/2011/636952
PMCID: PMC3200136  PMID: 22084768

Results 1-7 (7)