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This study was conducted at the Department of Vascular Surgery at Combined Military Hospital Lahore from December 2019to June 2020. The mortality of patients on the waiting list for vascular access in our institution three months afterimplementing strict policies for elective surgeries (30th March 2020 to 29th June 2020) was compared with the preceding threemonths. The mortality of patients in the pre-COVID-19 periods on the waiting list for HD was 11 (7.9%) in the pre-COVID-19 period, while this increased to 5 (12.5%) in the post-COVID-19 period. COVID-19 related suspension of vascular access services negatively influences CKD patients waiting for permanent vascular access.

Objective: To highlight the presentation and outcomes of Aortofemoral bypass surgery at a tertiary care hospital. Study Design: Prospective observational study. Place and Duration of Study: Vascular Surgery department, Combined Military Hospital Lahore, from Jan 2015to Dec 2019. Methodology: A total of 23 patients between 50-80 years of age presenting with critical limb ischemia due toAortoiliac occlusive arterial disease type C or D of Trans-Atlantic inter Society Consensus (TASC) II classificationconfirmed on CT Angiogram, were included in the study. The clinical presentation, co-morbid illnesses, historyof smoking, obesity, post operative patency of graft, wound infection, amputation rates, and mortality weredocumented on a structured proforma. All patients were followed up at 1, 6, 12 and 24 months of surgery.Outcomes were assessed in terms of graft patency, wound infection, limb survival, amputations and mortality.Data was analyzed by SPSS version 23.0. Results: The mean age of patients was 71.04 ± 7.29 years. Most patients presented with rest pain (56.5%). Thefrequency of smokers was 78.3% while 34.8% patients had both diabetes mellitus and ischemic heart disease.Hyperlipidemia was present in 30.4% patients. Two patients (8.7%) developed superficial surgical site infection.The limb salvage rate was 95.7% and the mortality rate was 4.3%. Conclusion: Aortofemoral bypass surgery is a safe and highly effective treatment modality for the management of aortoiliac occlusive arterial disease in experienced hands. Limb salvage can be successfully achieved in more than 95% cases.Keywords: ,, ,, .

Communication is supposed to be important to convey the message to the audience. The communication skills of teachers occupied a major role in effective students’ learning. If a teacher is anxious about speaking, his instructions may not be effective and also may affect the students’ learning. The researchers were intended to measure the language anxiety of the teachers who teach in 10th class while utilizing the survey method. The sample for the study included the teachers from Federal Government Educational Institutions (cants/ Garrisons) – FGEI’s (C/G). The data regarding the teachers’ language anxiety was collected by Teachers’ Language Anxiety Scale adapted by the researcher from (Horwitz, Horwitz, & Cope, 1986). The scale consists of 30 items with a Likert’s Rating scale ranging from strongly agree to strongly disagree. In order to measure the teachers’ performance, the cumulative GPA of their English subject that they have taught in recent anum was taken. This GPA was the outcome of their English teaching taken from Federal Board Intermediate & Secondary Education annual exam. The results showed that there exists a negative, moderate as well as significant correlation between teachers’ anxiety and their performance. It is recommended that the FDCI’s should organize workshops on a regular basis for the teachers that focus on the practice of English speaking proficiency. There should be seminars propagating about the strategies to cope with language anxiety.

Traditional training system of TVET sector is focusing on traditional procedures of learning and is based on the numbering system. Such old fashioned procedures and the numbering system are producing certificate holders who do not have proper skills to complete the tasks independently in a professional manner as per the requirements of the industry. Traditional training is not paying focus on the competency oriented workforce in Pakistan. To meet rapid technological changes and need of modern era, the approach of the TVET sector is now shifting from traditional training to Competency Based Training (CBT). The purpose of this study is to make an innovative effort in the Pakistani context, identify the perceptions of employers and graduates about traditional training and CBT programs. This study falls in the interpretivism paradigm. Phenomenological research design was utilized to conduct this study. 10 TVET trainers, 10 TVET graduates of traditional training, 10 TVET graduates of CBT and 10 employers selected through convenient sampling. Semi structured interviews were conducted from employers, trainers and both types of graduates. Thematic analysis was used for to draw the results. Results showed that graduates of competency based training programs are more competent than that of traditional training program and the employers are comparatively more satisfied with graduates of the CBT program. TVET sector should develop the curriculum according to the current demand of the industry and implement the curriculum effectively by updating the labs for the TVET graduates for better job opportunities in the industry. It is also proposed that TVET sector should shift its educational institutes from traditional training to CBT approach to meet the needs of the labour market for employers’ satisfaction. Furthermore, research should be conducted to explore the challenges and their solutions of training provided in TVET sector and its assessment to meet the level of competency satisfaction to meet labour market needs.

English language, as it is employed as a common medium used for communication with people, whom native language is not understandable. In this regard, Governments of developing countries paying attention to promoting English. That require upgradation in the curriculum, as well as, the shift of teaching methodology from teacher to student centered, are the basic requisites for making the change in the educational system possible. That provides opportunities for cooperative learning. Therefore the current experimental study was carried out to find the role of cooperative learning in promoting language proficiency and achievement with regards to English among 8th grade students, who are supposed to study in the private schools of Lahore. The 8th grade students enrolled in private schools of Lahore district implied the population of the study. Whereas, the two girls sections of the 8th class of The Educators School, Jinnah Campus, Lahore, were chosen as the sample and nominated as experimental and control groups. Before and after the intervention, English language proficiency tests (EPT) to measure the students' proficiency in English and English achievement test (EAT) to identify students’ achievement in English developed by the researchers were utilized. Findings highlighted that cooperative learning is an effective teaching methodology that proves beneficial in the improvement of 8th grade students' proficiency and achievement in English. It is recommended that our teachers may use such innovative teaching methodologies in their classroom that not only promote students' involvement for discussion on the relevant topic

Objective: To compare the frequency of wound infection with and without subhepatic drain in patient’s undergoing laparoscopic cholecystectomy. Study Design: Randomized controlled trial. Place and Duration of Study: Study was carried out at department of Surgery, Combined Military Hospital (CMH) Lahore, from Nov 2014 to Apr 2015 over a period of six months. Material and Methods: This study included a total of 140 patients (70 in each group). In group A, a drain was placed in subhepatic space after laparoscopic cholecystectomy and no drain was placed in group Bafter laparoscopic cholecystectomy. Results: In our study, out of 140 patients (70 in each group), patients in the age range of 20-50 years were 61.43% (n=43) in group-A and 57.14% (n=40) in group-B while those in the age range of 51-70 years were 38.57% (n=27) in group-A and 42.86% (n=30) in group-B. Mean ± SD was found to be 46.34 ± 7.54 and 46.23 ± 10.34 years respectively. About 28.57% (n=20) in group-A and 22.86% (n=16) in group-B were male while 71.43% (n=50) in group-A and 77.14% (n=54) in group-B were females. Wound infection was compared in both groups which showed that 18.57% (n=13) in group-A and 7.14% (n=5) in group-B had wound infection. A p-value was calculated as 0.04 which was significant. Conclusion: We concluded that the frequency of wound infection with subhepatic drain in patients undergoing laparoscopic cholecystectomy was found significantly higher when it was compared to cases without drain.

Interlocking nails are the gold standard treatment of fractures of shaft of long bones of lower limbs. It is also frequently performedfor most of the humerus fractures. The procedure is commonly performed using an image intensifier and orthotable. These are expensive andare not readily available in peripheral/field hospitals especially in resource – poor countries. Design: Retrospective study. Setting: FieldHospital Muzaffarabad and Combined Hospital Kharian. Period: Sep 2007 to July 2011. Patients & Methods: 138 consecutive cases offractures of femur, tibia and humerus shafts fixed with I/M I/L Nails in a field hospital. Reduction was achieved by open method in 87 (96.66%)cases of femur, 24 (60%) case of tibia and 5(62.5%) of humerus. Results: There were 34 females and 100 males’ ratio 1:2.94. All the cases wereadults with mean age 38.2 years and range was 16-78 years. Bones fixed were femur (90) 65.21%, tibia (40) 28.21%, and humerus (8) 5.70%.Fracture line was transverse in 104 (75.3%) and communited 10 (7.2%). Fractures were closed 112 (81.2%) and 26 (18.8%) of case. Recentfractures were 122 (88.4%) and old non united 16 (11.6%). Mean follow up period was 06 months - range 3 months to 1 ½ years. Complicationswere failure to achieve distal interlocking 6 cases, infection 3 cases. Union time averaged 3.5 months. Conclusions: It is therefore concludedthat I/M I/L nailing can be done without image and traction table.

Varicose veins are among the most common ailments of the affluent nations. Primarily it is considered to be caused by valvular dysfunctions, but it may be secondary to other pathologies. This study was conducted to evaluate the unusual secondary causes of varicose veins.This case-series was conducted at department of vascular surgery Combined Military Hospital Rawalpindi from January 2009 to January 2012 over a period of two years. All cases of varicose veins reporting to vascular surgical department CMH Rawalpindi were studied over a period of 02 years. Detailed history and thorough physical examination was performed in all cases. Cases secondary to deep vein thrombosis (DVT) of limb up to common femoral vein (CFV) and pelvic malignancy were excluded. Duplex Ultrasonography (USG) was performed in all cases while CT angiography/Venography was conducted in those suspected of having secondary cause.A total of 288 cases were found eligible and included in the study. Ten patients (3.47%) were having unusual secondary cause most common being traumatic arterio-venous fistula (AVF) (60% cases) followed by iliac vein thrombosis (20%). One patient had Klippel Trenaunay syndrome (KTS) and another suffered arterio-venous malformations (AVM).An unusual secondary varicose vein is important but rare clinical entity. Diagnosis is often delayed/overlooked and patients are mismanaged for extended period of time. Exact delineation of aetiology, prompt recognition and appropriate operative technique significantly alters outcome.

To assess the presentation, diagnostic evaluation, various techniques of vascular repair and their outcomes.The prospective descriptive study was conducted at the Combined Military Hospital, Rawalpindi, from October 2008 to December 2010. It involved 54 patients with vascular injuries in the extremities who underwent various vascular surgical interventions.Those who presented with irreversible ischaemia or had primary amputation and presented late with missed vascular injuries were excluded. The cases were evaluated for mechanism of injury, site and type of injury, associated injuries, type of repair performed and its outcome. Mean with standard deviation and frequency and percentage was calculated wherever relevant.The mean age of 54 patients was 26.8 +/- 9.2 years (range: 9-67 years), and the male-to-female ratio was 17:1. Penetrating trauma was the most common cause (n=34; 62.9%). Lower extremities were affected more commonly (n=33; 61.1%) and superficial femoral artery was the most frequently involved vessel (n=14; 25.9%). Besides, 16 (29.6%) patients had associated fractures, while concomitant venous injuries were present in 12 (22.2%). Interposition autogenous saphenous vein graft was the most common type of repair performed (n=42; 77.7%). Prosthetic graft was used only in 3 (5.5%) patients. Wound infection was the common complication (n=6; 11.1%). Three (5.5%) patients had secondary amputation and 2 (3.7%) died due to associated injuries. Vascular reconstruction was successful in 49 (90.7%) cases.Early recognition and re-vascularisation by a vascular surgeon hold the key to saving more than 90% limbs with vascular injuries.

To describe the different presentation, diagnostic evaluation, management and outcome of complications of missed vascular injuries.A case series.Combined Military Hospital, Rawalpindi and Combined Military Hospital, Kharian Cantt, from June 2009 to June 2012.All the patients with vascular injuries missed at the time of causative trauma who reported during this study period were included. Patients presented with acute vascular injuries and iatrogenic aneurysm at the vascular anastomosis site were excluded. All cases were evaluated with either CT or conventional angiography and managed with various open vascular surgical techniques and their results were assessed.Twenty eight patients with missed vascular injury underwent various vascular repairs. Age of patients ranged from 16 to 78 years (mean = 33.7 ± 15.4 years). Male to female ratio was 6:1. Twelve (42.8%) patients presented with pseudoaneurysm alone, 10 (35.7%) with traumatic arteriovenous fistulae, 4 (14.3%) with post-traumatic thrombosis and occlusion and 2 (7.1%) with pseudoaneurysm and hemorrhage. Penetrating injuries were the commonest cause in 19 (67.8%). The time interval between injury and presentation in hospital ranged from 2 to 1300 weeks (mean 228 weeks). Lower limb vessels were affected in 20 (71.4%), the upper limb in 5 (17.8%) and neck vessels in 3 (10.7%). Superficial femoral artery was the most frequently involved artery in 9 (32.1%) cases. Interposition reverse autogenous saphenous vein graft was most common type of repair in all types of missed vascular injuries. One (3.5%) patient had amputation after secondary hemorrhage.Low velocity penetrating trauma was the common cause of missed vascular injury. Pseudoaneurysm was the most common presentation.

To compare polypropylene suture and skin staples for securing mesh in Lichtenstein inguinal hernioplasty in terms of mean operating time and postoperative pain.Randomized clinical trial.Surgical Ward, Combined Military Hospital, Kharian, from August 2011 to February 2012.All individuals fulfilling inclusion criteria underwent elective Lichtenstein inguinal hernioplasty as admitted patients, under spinal anaesthesia and with aseptic measures. In group 1, during the operation, mesh fixation was done with 2/0 polypropylene suture and skin was closed with subcuticular 2/0 polypropylene suture whereas in group 2, the anchorage of mesh was done with skin staples and skin was closed with staples from the same stapler. Mean operative time and postoperative pain, assessed on a visual analog score, were compared between the groups.The overall postoperative pain was lower (p = 0.026) when staples were used to anchor mesh. Moreover, operative time was also lower (37.42 ± 2.69 minutes) in staple group versus (42.44 ± 2.55 minutes in polypropylene group).Mean operating time and postoperative pain is less in securing mesh with skin staples as compared to polypropylene suture in Lichtenstein inguinal hernioplasty.

Coarctation of abdominal aorta, Middle aortic syndrome (MAS) is a rare disease with only 200 reported cases. MAS may present clinically as uncontrolled hypertension, abdominal claudication or lower limb claudication. Surgical treatment is effective in controlling symptoms and improves life expectancy. We present another case of this rare entity, diagnosed and treated at Armed Forced Institute of Cardiology and Combined Military Hospital, Rawalpindi. This is the second reported case of MAS diagnosed and treated in Pakistan.

A case of post-traumatic arteriovenous fistula in the left thigh is reported 25 years after injury with haematuria. The patient had sustained bullet injury in his left thigh in 1986. Clinically, he had thrill and bruit in his left thigh and groin. Ultrasound abdomen and pelvis revealed a vascular mass in the left side of urinary bladder. CT angiography showed communication between left superficial femoral artery and vein and gross dilatation of thigh and pelvic veins with mass effect on the urinary bladder. He was managed by excision of fistula and repair of both artery and vein with interposition of a prosthetic graft.

We report a case of renal hydatid cyst in a 25-year-old male who presented with hydatiduria. Intravenous pyelography revealed presence of a space-occupying lesion in the lower pole of right kidney with curvilinear calcifications. Ultrasound, computed tomography and MRI were suggestive of hydatid cyst in the right kidney. Patient underwent right-sided nephrectomy. Passage of hydatid cysts in urine is an exceedingly rare occurrence. Urinary tract involvement develops in 2-4% of all cases of hydatid cyst. Hydatiduria is an extremely rare manifestation of renal hydatid cyst. We report such a case with emphasis on IVU, sonographic, CT and MRI findings.

A young soldier was crushed between two vehicles sustaining severe injury to right side of chest leading to multiple rib fractures, tension pneumothorax, bronchopleural fistula, and later on gross surgical emphysema. Rigid bronchoscopy confirmed injury to right upper bronchus. Surgical repair and postoperative care of such a major, although rare, injury was successfully achieved in this small hospital by a team augmented by a specialist from thoracic surgery centre. The risks of transport of a major thoracic injury should be assessed against a possible definitive treatment locally. Fibreoptic or rigid bronchoscopy should be employed as early as possible in all suspected cases of major airways injury. An outreach service by a thoracic surgery centre can be life-saving.

A case of transverse testicular ectopia of the left testis is hereby reported. A 5-year-old boy presented in surgical outpatient department with right inguinal hernia and impalpable testis in left scrotum and inguinal canal. Right herniotomy was performed. Left testis was found in right superficial inguinal pouch and brought to the left scrotum through transceptal window.