Efficacy and safety of N-acetylcysteine for the treatment of non-acetaminophen-induced acute liver failure: an updated systematic review and meta-analysis.

AIM OF THE STUDY: N-acetylcysteine (NAC) is the treatment of choice for acetaminophen-induced liver injury. However, recent years have witnessed growing interest in its role in the treatment of acute liver failure (ALF) due to other aetiologies. This study aims to determine both its safety and efficacy by pooling data from multiple studies. MATERIAL AND METHODS: A search was conducted for all controlled randomized/non-randomized studies that measured the efficacy and safety of NAC in adult patients with non-acetaminophen-induced acute liver failure (NAI-ALF). Transplant-free survival (TFS) was considered the primary endpoint, while secondary endpoints such as length of hospital stay, and incidence of adverse events during treatment, were included in our analysis. Data were pooled via a random-effects model, I 2 was used as a measure of heterogeneity, and publication bias was assessed via a funnel plot. RESULTS: A total of 3 studies [2 randomized controlled trials (RCTs) and 1 non-randomized cohort] were pooled in this meta-analysis. TFS was significantly higher in patients given NAC, when compared to the placebo/control (PBO) group (RR = 1.54, CI = 1.19-1.98, p = 0.01, I 2 = 0.0%). No secondary endpoint was observed to have improved significantly in patients prescribed NAC: length of hospital stay (SMD = -0.405, CI = -1.44-0.63, p = 0.445, I 2 = 91.1%), renal failure (RR = 1.01, CI = 0.65-1.57, p = 0.967, I 2 = 21.3%), infections (RR = 1.18, CI = 0.91-1.52, p = 0.208, I 2 = 2.3%), pulmonary failure (RR = 1.19, CI = 0.57-2.49, p = 0.649, I 2 = 84.6%). Minimal side effects were reported in around 10-14% of the patients prescribed NAC. CONCLUSIONS: NAC was shown to significantly improve TFS in adult patients with NAI-ALF, while no significant benefit was observed concerning the secondary endpoints of length of hospital stay and incidence of adverse effects.

A rare case of gangrenous foot in juvenile systemic lupus erythematosus.

This report describes a rare case of Juvenile Systemic Lupus Erythematosus (JSLE). A young 13-year-old girl presented to the Civil Hospital Karachi on February 15, 2019 with gangrene as the only manifestation of this autoimmune disease. JSLE has several clinical manifestations such as butterfly rash, fever, joint pain, cardiac problems like pericardial infusion and neuropsychiatric disorders. However, in this case gangrene was the only presenting symptom; only laboratory investigations - anti-SSA and anti-ribosomal P protein - were suggestive of JSLE, while anti dsDNA, considered to be the most sensitive and reliable diagnostic tool for Systemic Lupus Erythematosus (SLE), was negative. Raynaud's phenomenon and gangrene have been described as rare symptoms, with gangrene occurring in only a small percentage of SLE patients. Moreover, the patient had received a blood transfusion a few months ago in Hyderabad which was suspected to be the cause of the transmission of infection which lead to polyclonal activation of lymphocytes.

Awareness Regarding Causes of Infertility Among Out-patients at a Tertiary Care Hospital in Karachi, Pakistan.

INTRODUCTION:  Infertility is the inability of a couple to achieve pregnancy within 12 months of sexual intercourse without the use of contraceptives. The Pakistani population, belonging to a low-middle income country, has a high prevalence of infertility due to a low knowledge and awareness regarding its causes, and lack of healthcare-seeking behavior for this medical issue. The prevalence of infertility in Pakistan is reported as 22%, with primary infertility accounting for 4% of the total cases. This leads to psychological trauma among women as societal norms equate infertility with failure on a personal, emotional, and social level. In this study, we aimed to assess among this population the general awareness regarding infertility and its causes; and identify any key knowledge gaps pertaining to the subject. METHODS:  A cross-sectional study was carried out between June 2019 and November 2019, at a public hospital (Civil Hospital Karachi) in Karachi, Pakistan. Convenience sampling technique was used to collect data from adult participants (older than 18 years) via an interview-administered questionnaire. The questionnaire was based on the Cardiff Fertility Knowledge Scale (CFKS) and assessed the knowledge regarding causes of infertility such as smoking, healthy lifestyle, contraceptives, genital tract infections among others. We also determined the association between socio-demographic variables with mean knowledge scores. Data were analyzed using Statistical Package for Social Sciences (SPSS), version 20.0. RESULTS:  The majority of the participants were married (n=342, 68.8%) and more than half were unemployed (n=259, 52.1%). Approximately, two-quarters (n=250, 50.3%) did not believe that equal proportions of males and females contribute to infertility. The mean knowledge score of our study population was 12.95 ± 2.48 points. An overwhelming proportion of the participants (n=326, 65.6%) falsely believed that the usage of the intra-uterine device contributes to infertility. Additionally, more than half of the responders (n=278, 55.9%) incorrectly believed that a male achieving erection is an indication of fertility. Education (p=0.019), vehicle ownership (p=0.018), and marital status (p=0.031) were the only demographic factors that showed significant differences with mean knowledge scores. CONCLUSION:  Awareness regarding the causes of infertility among the general population was found to be inadequate. Emphasis on targeted fertility education, in association with general public awareness programs regarding its causes and risk factors may help mitigate this problem by potentially reducing the prevalence of this condition, and increasing the number of affected individuals who seek medical care in a timely fashion.

Post-treatment Hematological Variations and the Role of Hemoglobin as a Predictor of Disease-free Survival in Stage 2 Breast Cancer Patients.

Objectives The primary objective of this study was to determine post-treatment variations in the hematological profile of stage 2 breast cancer patients and investigate the influence of disease stage and treatment pattern on these changes. The secondary objective was to evaluate the role of post-treatment hemoglobin as a predictor of disease-free survival. Methods This prospective, observational study included 177 stage 2, female, breast cancer patients. Treatment included surgery, chemotherapy, radiotherapy, and hormonal (anti-estrogen) therapy. Patients were divided into treatment groups based on their histopathological features. Laboratory investigations, including hemoglobin and complete blood count, were carried out twice, first, at the initial cancer diagnosis and, second, eight weeks after completion of radiotherapy. The patients were followed for a period of four years and their disease-free survival was calculated. Results A significant post-treatment decrease in hemoglobin levels and red blood cell (RBC) count was observed in all patients except hormone receptor-positive disease stage 2A patients treated without chemotherapy. Total leukocyte counts were significantly decreased in all hormone receptor-negative patients, and significant neutropenia was observed in all stage 2 patients who received chemotherapy. The severity of anemia was observed to be significantly lower in stage 2A patients (without lymph node metastasis) as compared to stage 2B patients (with lymph node metastasis). Furthermore, no anemia was observed in hormone receptor-positive patients treated without chemotherapy, while moderate anemia was observed in hormone receptor-negative patients who received both pre and post-surgical chemotherapy. The post-treatment hemoglobin levels were found to be a significant predictor of disease-free survival in hormone receptor-positive patients (HR = 0.140, p= 0.000) and in patients of all disease stages except stage 2B (T3 N1 M0). Conclusion  The incidence and severity of post-treatment anemia are low in patients treated with hormonal therapy and high in patients with lymph node metastasis. Higher post-treatment hemoglobin levels predict a longer duration of disease-free survival in hormone receptor-positive patients of disease stages 2A and 2B (T2).