Association Between Levels of Pre-operative Glycosylated Hemoglobin and Post-operative Surgical Site Infections After Elective Surgery in a Low-Income Country.

INTRODUCTION: Diabetic patients undergoing surgery are more susceptible to hospital-acquired infection, particularly surgical site infection (SSI). Good glycemic control in preoperative patients significantly decreases the risk of SSI. There is a scarcity of data from low-income countries studying the relation between perioperative glycated hemoglobin (HbA1c) levels and postoperative SSI. We aim to establish statistical relation between HbA1c and SSI which will help decrease post-operative infections and morbidity. METHODS: This study was conducted in the surgical unit of Jinnah Sindh Medical University, Karachi, Pakistan, from August 2020 to April 2022. Patients who underwent elective surgical procedures (n= 1024) were included in the study and divided into two groups based on their HbA1c levels. Patients with HbA1c levels higher than 6.5% were classified as group A and those with HbA1c less than 6.5% belonged to group B. For statistical analysis, IBM SPSS Statistics for Windows, Version 24.0 (Released 2016; IBM Corp., Armonk, New York, United States) was used. RESULTS: Group A comprised 579 (56.5%) patients. The presence of SSI in participants with HbA1c >6.5% was statistically significant (p-value: 0.011). Genderwise comparison with the presence of SSI was found to be insignificant (p-value: 0.28). Smoking was positively correlated with the absence of SSI. No significance in terms of presence or absence of SSI was found in the comparison of the type of wounds (p-value: 0.25). CONCLUSION:  There is a positive relationship between raised HbA1c levels and the development of SSI. Our study emphasizes the importance of the use of HbA1c levels as a more accurate predictor of glycemic control in pre-operative patients rather than blood glucose levels. It is imperative that surgeons must check HbA1c levels before selecting patients for elective surgeries, especially in low-income countries where the healthcare burden is already huge.

Electrocardiographic Abnormalities in Patients With Spinal Cord Injury With Deranged Lipid Profile.

Introduction Spinal cord injury (SCI) can lead to severe disability and neurogenic shock, arrhythmias, autonomic dysfunction, pressure ulcers, etc., of the autonomic nervous system. Therefore, in these patients, cardiovascular problems should be investigated frequently. This study was conducted to evaluate the electrocardiographic (ECG) abnormalities in patients with spinal cord injury having inappropriate lipid profiles and their relationship with each other. Materials and methods This cross-sectional study was held in the Internal Medicine Department of Mayo Hospital, Lahore, for a one-year duration from May 2020 to May 2021. It included 58 patients with spinal cord injury, 35 of whom had paraplegia, and 23 had tetraplegia. Fasting blood samples were taken for lipid profile analysis. Twelve-lead ECGs three times a day for one month were taken and analyzed in the context of previously available ECGs. Results Out of 58, the lipid profiles were found abnormal in 47 patients, 18 of whom had a normal ECG. The lipid profile was normal in 12, of which only one patient had ECG abnormalities. Cholesterol levels were found normal in 39 patients and deranged in 19 patients; low-density lipoproteins in nine patients, triglycerides in 18 patients, and high-density lipoprotein values in one patient were abnormal. Conclusions Sinus bradycardia was the most common ECG abnormality found in SCI patients with deranged lipid profiles. Further studies are needed in the future to validate the findings of this study.

Validity of Sequential Organ Failure Assessment and Quick Sequential Organ Failure Assessment in Assessing Mortality Rate in the Intensive Care Unit With or Without Sepsis.

Introduction Sepsis and septic shock (sepsis-induced hypotension not improved by adequate fluid resuscitation) are among the most common reasons for admission to an intensive care unit (ICU) and display high mortality rates. Different scoring systems are used to diagnose and predict the mortality of patients having sepsis. This study aims to validate the prognostic accuracy of Sequential Organ Failure Assessment (SOFA) and Quick Sequential Organ Failure Assessment (qSOFA) in determining the mortality of both septic and non-septic patients. Materials and methods This retrospective cohort study was conducted in May 2018 in the Surgical Intensive Care Unit (SICU) of a tertiary care hospital in Karachi, Pakistan. Past 200 patient records, from January 2018 to April 2018, were examined, and 20 records were discarded due to insufficient data. Sufficient observational data were collected, which was used to assess the validity of the SOFA and qSOFA in determining the mortality rate of sepsis. A comparison of the two modalities was made. Results Out of the 200 patients, 180 were enrolled. Data from their entire ICU stay were used to calculate their initial, highest, and mean SOFA and qSOFA. Mean SOFA score up to nine correlated with a mortality rate of up to <79%, while scores 10 and above predicted a 100% mortality rate. A mean qSOFA score of three predicted a 67% mortality rate. Univariate logistic analysis performed with odds ratio showed that the mean qSOFA score was in comparison more closely able to predict mortality, followed by mean SOFA score (p values < 0.01). Conclusions This study concluded that both SOFA and qSOFA scores are good predictors of mortality. However, qSOFA is more closely accurate in predicting mortality than SOFA. But further analysis with larger sample size for a longer duration as well as the application of these scores in the emergency departments and general wards can prove the precision of this study.

Functional Outcomes of Cementless Total Hip Arthroplasty in Avascular Necrosis of the Hip: A Prospective Study.

Introduction Avascular necrosis occurs due to impaired blood supply to the bone. It can be caused by fractures, dislocations, chronic steroid use, chronic alcohol use, coagulopathy, congenital source, and many other factors. It mostly affects the femoral head (hip joint). Its management can be conservative or invasive. Total hip arthroplasty is the treatment of choice for third and fourth stage avascular necrosis that can be cemented or uncemented. The purpose of this study is to access the functional outcomes of cementless total hip arthroplasty in patients with avascular necrosis of the hip. Materials and methods This prospective study was conducted at a major metropolitan hospital in Karachi, Pakistan over a period of six months. A total of 30 patients of age <60 years, either gender, and a confirmed diagnosis of avascular necrosis of hip with no other associated hip pathologies were included in this study. Demographic features, comorbidities, level of activity, range of movement before the development of avascular necrosis, Charnley's class, and laterality were noted. Cementless press-fit extensively porous-coated acetabular cup with or without cancellous screws and cementless press-fit extensively hydroxyapatite coated femoral stem were used through modified Gibson's posterior approach. The patients were checked for early and late complications, the position of acetabular and femoral components by radiography, and overall performance by Harris Hip Score (HHS) and modified HHS over a period of 12 months. All statistical analyses were performed using Statistical Package for Social Sciences (SPSS) version 19.0 (IBM Corp, Armonk, NY). Results The mean age was 43.9±6.7 years with 21 (70%) patients ranging from 40 to 60 years of age. There were 22 (73%) male and 8 (27%) female patients. Nine (30%) patients had diabetes mellitus, eight (27%) had hypertension, two (7%) had other comorbidities, and eleven (37%) had no comorbidities. A total of 11 (37%) patients were highly active, 18 (60%) were moderately active, and 1 (3%) was non-active before developing avascular necrosis. There were 4 (13%) patients in Charnley's class I, 15 (50%) in Charnley's class II, and 11 (37%) in Charnley's class III. Fifteen (50%) patients were operated on the left side, seven (23%) on the right side, and eight (27%) bilaterally. No significant early or late complications were noted. Acetabular component was found to be anteverted in 22 (73%), retroverted in zero (0%), neutral in 8 (27%), <35o inclined in 0 (0%), 35o-50o inclined in 23 (77%), and >50o inclined in 7 (23%) patients, while femoral component was found neutral in 28 (93%), valgus in 2 (7%), and varus in zero (0%) patients on radiography at follow-up. On functional assessment, the HHS was 100% in 27 (90%) patients, 96% in 2 (7%) patients, and 83% in 1 (3%) patient with an average of 99.2%, while 29 (97%) patients had excellent and only 1 (3%) patient had a good outcome on modified HHS. Conclusions Cementless total hip arthroplasty, performed in patients <60 years of age and avascular necrosis of the hip with no other associated hip pathologies, has excellent functional outcomes with no pain, limping, physical deformity, difficulty in walking, difficulty in climbing stairs, difficulty using public transport, difficulty in sitting, or difficulty in wearing shoes and socks. They usually attain normal limb length and range of movement.

The Success Level of Hypospadias Repair in Adults.

Introduction Hypospadias is the abnormal opening of the urethra at the undersurface of the penis. Hypospadias repair is performed in such patients to treat the condition. The success level of hypospadias repair in adults still needs to be established on a larger scale. Therefore, we conducted this study to document the success level of hypospadias repair in adults in our setting to add to the literature. Materials and methods This prospective study was conducted at a major metropolitan hospital in Karachi over a period of six months. A total of 75 male patients aged between 20-50 years and diagnosed with hypospadias of any level with or without mild to moderate chordee were included. Demographic features such as age and the duration of hypospadias were noted. Hypospadias repair using a tubularized incised plate (TIP) urethroplasty technique was performed, and the patients were observed for three days in the ward and for three months in the outpatient department for any complications. The procedure was considered a success if there were no complications and no need for a second surgery; we also took into account patient satisfaction with the procedure to determine the success level. The mean and standard deviation were calculated for patient age and the duration of hypospadias. Frequency and percentages were calculated for distribution of patient age, distribution of the duration of hypospadias, and the success of hypospadias repair. The correlation of patient age and the duration of hypospadias with the success of hypospadias repair was also determined by applying the Chi-square test, and a p-value of ≤0.05 was considered to be statistically significant. Results The mean age and the duration of hypospadias for the study population were the same at 31.43 ± 8.47 years. Distribution of patient age and the duration of hypospadias was also the same with 51 (68%) patients of ≤35 years of age and 24 (32%) patients of >35 years of age. Hypospadias repair was successful in 52 (69.33%) patients but unsuccessful in 23 (30.66%). The stratification of patient age and the duration of hypospadias with the success of hypospadias repair showed a significant inverse relationship (p = 0.017). The data relating to patient age and the duration of hypospadias showed the same values as hypospadias is a birth defect. Conclusion Adult patients undergoing primary hypospadias repair generally show good outcomes. However, the chances of favorable outcomes gradually decrease with age. Hence, patients should be encouraged to undergo the procedure as early in their lives as possible. Patients who are middle-to-old aged should especially be counseled about the relatively higher risk of unsuccessful procedures. Further analysis is needed to confirm the validity of these findings.