Survival and Decision-Making in Patients Turned Down for Abdominal Aortic Aneurysm Repair: A Retrospective Study with Focus on COVID-19 Impact.

OBJECTIVES: To investigate and analyse various aspects related to patients who have been placed on a "turn-down list" for elective or emergency repair of abdominal aortic aneurysms (AAA). METHODS: This retrospective study analysed data from the Black Country Vascular Network (BCVN). Multidisciplinary team (MDT) meetings assessed AAA patients referred through National Abdominal Aortic Aneurysm Screening Programme (NAAASP)or directly to vascular surgery. Patients considered unfit for intervention were added to a prospectively kept turndown list. Survival and cause of death data were collected, along with cardiopulmonary exercise testing (CPET) results and British Aneurysm Repair (BAR) scores for some patients. The study covered a period from January 2015 to May 2023. RESULTS: After exclusions 247 (16%) patients were placed on the turndown list with a median age of 85 years (IQR 8 years). The mortality of turndown cases on medical grounds was 74.1%. Survival was significantly higher for patients who completed CPET before being turned down (p = 0.004). Gender analysis revealed a higher proportion of females being turned down compared to males (p = 0.044). COVID-19 led to a notable reduction in the number of discussed cases and interventions, while the turndown rates remained consistent. Survival at one year in turndown patients was 66%, at three it was 29%, at four years it was18% and at 7 years it was 5%. Most patients whose cause of death was known died of respiratory complications (30%) or malignancy (19%). BAR scores and aneurysm size were not significant predictors of mortality. CONCLUSION: Patients on the turndown list have a substantial mortality rate. A significant proportion of female patients were being turned down compared to men and the reasons for this are not clear. Patients who completed CPET before being turned down had a longer survival time. While COVID-19 impacted healthcare services reducing the number of interventions, it did not influence turndown decisions. The study showed that the cause of death for a significant number of patients was respiratory complications or malignancy.

Evaluation Of Interdepartmental Calls Generated In 8 Tertiary Care Hospitals Of Northern Pakistan.

Objectives: To assess the quality of medical call writing in multiple tertiary care hospitals based on a variety of parameters. METHODS: The cross-sectional study was conducted in 8 tertiary care hospitals across Pakistan from May 27 to June 27, 2021, and comprised residents and consultants aged 25-60 years regardless of gender and specialty. Data was collected using questionnaires related to demographic and professional characteristics, quality of calls received, quality of calls sent, and opinion regarding improvements to the existing system. Data ws analysed using SPSS 22. RESULTS: Of the105 participants, 65(62%) were residents and 40(38%) were consultants. General surgery team received referrals most frequently 26(24.7%). History of the patient along with relevant examination findings were mentioned in 4(3%) and 6(5%), respectively (p=0.6 vs p=0.5). The timeline was mentioned by 10(9.5%), (p=0.09), and it was inconsistent with the clinical relevancy in 13(12.3%) cases (p=0.5). The working diagnosis for which the patient was admitted in a particular service was mentioned in 35(33.3%) of the generated calls (p=0.01). CONCLUSIONS: The call referral system deserved more attention in order to improve communication among the physicians. Analysis of the quality of referral letters should be part of initial and continuing medical education.

Vagal Paraganglioma: A Rare Finding in a 31-Year-Old Male.

Vagal paraganglioma is a rare finding that develops from paraganglionic tissue found around the vagus nerve; it has a prevalence of 0.012% of all tumors. It is the third most common paraganglioma of the head and neck but still accounts for less than 5% of these tumors, and it has a well-established female prevalence. It is a difficult tumor to identify early based on its symptoms alone and only a thorough investigation can help solidify its diagnosis. In this report, we discuss a presentation of this phenomenon that is not only unique in its manifestation but also a very difficult diagnosis due to its deceptive presentation and multiple extensions. These masses need a good surgical regime to be removed properly and postoperative complications are very frequent in most of these cases.

Acute Limb Ischemia in a Patient With COVID-19 Pneumonia.

COVID-19, which is caused by the novel severe acute respiratory syndrome coronavirus (SARS-CoV-2), is known to cause a myriad of complications along with the typical lower respiratory tract involvement. One of the emerging complications is a hypercoagulable state leading to venous or arterial thromboembolism. These complications are more common in those presenting with a severe disease with significantly elevated inflammatory markers. Although co-morbid illnesses play a role in worsening such complications, yet they are not the main determinants as these complications also occur in those without any co-morbid illness. Here, we report a case of a 64-year-old male with severe COVID-19 pneumonia presenting with acute limb ischemia with a non-salvageable limb who required subsequent amputation of the affected limb.

A Rare Case of Homocysteinemia Presenting With Multiple Aneurysms in an Adolescent Boy.

Thoracoabdominal aortic aneurysm (TAAA) is primarily a disorder of the elderly; the condition, however, is rare in children, for whom the misdiagnosis is not uncommon. It is one of the leading causes of death in the older age group worldwide, with a 4:1 male to female ratio. There are no real data about the incidence of aortic aneurysms in childhood. Although rare, an aortic aneurysm can be an important cause of mortality in children and adolescents. We present a case of an adolescent boy with a left coronary artery aneurysm, left axillary artery aneurysm, and TAAA type-IV caused by the metabolic disease homocysteinemia. He was referred to our facility when the complicated picture of the disease was discovered.

A Rare Presentation of Type-III Takayasu's Arteritis in a 20-Year-Old Female.

Takayasu's arteritis is a rare chronic granulomatous vasculitis that predominantly affects the aorta and its branches. It is estimated to affect 2.6/million/annum, predominantly women in the second or third decade of their lives. This case report describes the case of a 21-year-old female, who initially only had low-grade fever and acrodynia, which over a few months, progressed to arm and leg claudication, weight loss, nausea, headache, and dizziness. A year later, the patient experienced impalpable radial pulses bilaterally, and her CT angiogram revealed multi-level arterial stenosis. A diagnosis of Takayasu's arteritis was made and the patient was started on steroids and methotrexate. A consult was made with vascular surgery but no intervention was deemed necessary and the patient responded well to the medical treatment given. Though Takayasu's arteritis is a very rare disease, a detailed history, clinical examination, and investigations can help with early diagnosis.

Effect of Buffered Local Anesthesia on Perioperative Pain During Arteriovenous Fistula Surgery: A Randomized Control Trial.

OBJECTIVE: This prospective, pilot randomized double-blind study aimed to compare the effects of buffered and non-buffered xylocaine solutions on injection pain and anesthesia effectiveness in patients undergoing arteriovenous fistula surgery. MATERIAL AND METHODS: A total of 100 adult patients meeting inclusion criteria undergoing arteriovenous fistula surgery were included in the study. They were split into two groups at random. The control group received 1% xylocaine dissolved in 5 ml distilled water, while the intervention group received sodium bicarbonate mixed with 1% xylocaine solution as a local anesthetic. The patients were asked to rate the pain of first and subsequent injections on a visual analog scale (VAS). Besides, the need for extra analgesia was investigated. The mean and standard deviation of the data was determined. RESULTS: During both the first and subsequent injections, the alkalinized local anesthetic group showed substantially lower VAS scores. In the alkalinized local anesthetic group, anesthesia satisfaction was also more than three times higher. Furthermore, the non-alkalinized group's mean analgesic requirement was higher than the intervention group. CONCLUSION: Our findings support the effectiveness of the alkalinized local anesthetic solution in minimizing injection pain and increasing anesthesia duration and overall patient's surgical experience in terms of anesthesia satisfaction score.

Physician Gender Preference Amongst Females Attending Obstetrics/Gynecology Clinics.

INTRODUCTION: The objective of our study was to explore the views and perceptions of female patients attending the obstetrics and gynecology (OB/GYN) outpatient department towards the gender of their healthcare provider, to look for any preference that might exist in this regard, and to highlight any discrimination towards male obstetricians/gynecologists. MATERIAL AND METHODS: A cross-sectional study was conducted from November 2020 to March 2021 at Combined Military Hospital, Lahore. A total of 280 female patients were included in the study and interviewed consecutively. A self-designed questionnaire was administered. Data were analyzed using Statistical Package for Social Sciences (SPSS) version 22 (IBM Corp., Armonk, NY). Chi-square test was used to determine for any statistical significance and p≤0.05 was considered significant. Numerical data were represented as percentages. RESULTS: Over 280 female patients participated in our study, out of which 132 were married and 148 were single. Thirteen of these patients were uneducated, 40 had completed high school and 227 patients had obtained a bachelor's level of education; 120 patients were aged 15-25 years, 95 patients were aged 26-35 years, 30 patients were aged 36-45 years, and 35 patients were aged >46. Women with less education preferred to be seen by a female obstetrician/gynecologist, whereas those with higher education were less biased (p=0.0001). Married patients preferred to be seen by female obstetrician/gynecologists as compared to single patients (p=0.0004). A significant proportion of females were impartial in terms of physician competence but those who did have a preference preferred female obstetrician/gynecologist based on three significant variables: competence, rapport building and empathy, and personal comfort. CONCLUSION: A female gender preference exists in obstetrics and gynecology clinic attendees. This is significant in those who are married and those with no formal education. Overall, a significant proportion of women feel a higher comfort level with female doctors and find it easier to discuss their medical issues and develop rapport.

Takayasu's Arteritis in a 33-Year-Old Male.

Takayasu's arteritis (TA), commonly referred to as "pulseless" disease, is a large-vessel inflammatory vasculitis most commonly affecting the aorta and its major branches. Due to its irregular nature, it has the propensity to involve any organ system thus leading to a wide spectrum of clinical features. Most patients affected by TA are females in their second or third decades of lives. Our case is of a 33-year-old male who presented with sudden onset of hypertension for which he was prescribed antihypertensives. Over the next few weeks, he had multiple visits to the emergency department for a variety of different symptoms including fever, myalgias, left arm numbness, and persistence of hypertension. His CT aortogram showed multi-vessel narrowing including that of the celiac axis, superior mesenteric, renal, and internal iliac arteries with right atrophic kidney. At this time, a diagnosis of TA was made and he was started on oral corticosteroid and immunosuppressant therapy and continued to be treated as an outpatient. Nearly five years after his initial symptoms, he presented to the Emergency for acute abdomen, severe vomiting, and constipation, at which time an emergency laparotomy was done and peritonitis was found. A CT angiogram of the abdomen done after this procedure showed tight stenosis of the inferior mesenteric artery (IMA) and proximal stenosis of the left renal artery. He is currently planned for left renal artery and IMA stenting. Our case highlights the important characteristics of TA in male patients and how they differ from females. It also focuses on the importance of early initial workup and diagnosis and the need for a multi-disciplinary team when handling any patient with TA.

Accuracy of BISAP score in prediction of severe acute pancreatitis.

OBJECTIVE: To determine the accuracy of BISAP score in comparison with Ranson's score in detection of severe acute pancreatitis. METHODS: This cross sectional study was performed in Emergency department and Surgery department of Dow university hospital from January 2015 to December 2015. A total of 206 patients were included. Those diagnosed with acute pancreatitis on the basis of epigastric pain, serum amylase levels more than 300 (more than 3 times normal) and meeting the inclusion criteria were subjected to investigations for Ranson's and BISAP scoring. BISAP score was calculated at 24 hours and Ranson's score both at 24 and 48 hours. A score of > 3 was used to label severe acute pancreatitis according to both scoring systems. RESULTS: In our study accuracy to predict SAP by BISAP score was 76.2 % and Ranson's score was 82.2%. On the basis of sensitivity, Ranson's scores predicted SAP more accurately than BISAP scores (97.4% vs. 69.2%). Regarding specificity, both scores predicted SAP almost equally (78.4% vs. 77.8%). CONCLUSION: BISAP score is a valuable tool in predicting severe Acute Pancreatitis in early hours.