Development and content validation of a financial and functional outcomes tool for diabetes-related foot disease in patients undergoing major lower limb amputation: a prospective observational study from Pakistan.

OBJECTIVE: To develop and content validate a questionnaire to assess the financial and functional impact of major lower limb amputation in patients with diabetes-related foot disease. DESIGN: Prospective observational study. SETTING: This study was conducted at a tertiary care centre in Pakistan. PARTICIPANTS: We conducted a thorough literature review and a group interview with 10 participants, resulting in domain identification and item generation. The group included seven patients with diabetes-related foot disease who underwent major lower limb amputation and three caregivers. Subsequently, a focused group discussion was held to assess overlap and duplication among the items, and two rounds of content validation were carried out by five content and five lay experts in both English and Urdu. Question items with a Content Validity Index (CVI) score of >0.79 were retained, items with a CVI score between 0.70 and 0.79 were revised and items with a CVI score of <0.70 were excluded. RESULTS: The initial literature review and group interview resulted in 61 items in the financial and functional domains. After the focused group discussion, the questionnaire was reduced to 37 items. Following two rounds of content validation, the English questionnaire achieved the Scale-Content Validity Index/Average (S-CVI/Ave) of 0.92 and 0.89 on relevance and clarity, respectively. Similarly, the Urdu questionnaire achieved the S-CVI-Ave of 0.92 and 0.95, respectively. CONCLUSION: A 37-item multidimensional questionnaire was developed and rigorously content-validated to assess the financial and functional impact of major lower limb amputation in patients with diabetes-related foot disease. The questionnaire used in this study has shown robust content validity specifically for our population.

Guar gum-based stimuli responsive hydrogels for sustained release of diclofenac sodium.

In the current study, hydrogels for the controlled release of diclofenac sodium were synthesized from graphene oxide-reinforced guar gum and poly (N-vinyl-2-pyrrolidone) using the Solution Casting Technique. Varying concentrations of 3-Glycidyloxypropyl trimethoxysilane (GLYMO) were employed for the crosslinking of hydrogels. Further, the characterization of hydrogels was carried out using different techniques such as Fourier Transform Infrared Spectroscopy (FTIR), X-ray diffraction, thermal analysis and scanning electron microscope. The FTIR investigations reveals particular functionalities and development of hydrogel interfaces. While thermal analysis prophesied that, improvement in forces among hydrogel components is directly proportional to the GLYMO concentration. In-vitro biodegradation test and cell viability assay against HEK-293 cell lines confirmed their biodegradable and biocompatible nature. GPG-32 demonstrated maximum antibacterial activity against P.aeruginosa and E.coli strains. The maximum swelling 2001 % and 1814 % in distilled water were recorded for GPG (control) and GPG-8 respectively that obeyed Fick's law. Hydrogels displayed high swelling responses at pH 6 in buffer and non-buffer solutions. In 2.5 h, 88.7 % diclofenac sodium was released which was determined by UV visible spectrophotometer. In conclusion, guar gum-based non-toxic, biocompatible and biodegradable hydrogels would be a model platform for targeting inflammation and pains. Furthermore, improved mechanical and viscoelastic behavior of hydrogels could also be explored for making drug loaded dressings for wound healing applications.

Graphene oxide reinforced biopolymeric (chitosan) hydrogels for controlled cephradine release.

In the current study, chitosan, poly (N-vinyl-2-pyrolidone) and polyamidoamine based hydrogels were prepared by Solution Casting Method using different quantity of graphene oxide (GO) for controlled cephradine (CPD) release. The hydrogels were characterized by Fourier transform infrared spectroscopy (FTIR), X-ray diffraction, thermal analysis, scanning electron microscope and atomic force microscopy. FTIR results endorsed the presence of particular functionalities and developed interfaces in hydrogels. The thermal stability was directly proportional to the amount of GO. Antibacterial activity was investigated against gram-negative bacteria resultantly; CAD-2 exhibited maximum bactericidal activity against Escherichia coli and Psuedomonas aeruginosa. In addition, in-vitro biodegradation was examined in phosphate buffer saline solution and proteinase K for 21 and 07 days respectively. The maximum swelling was exhibited by CAD-133777 % in distilled water that was governed by quasi-Fickian diffusion. The swelling volumes were inversely proportional to the amount of GO. In the same way, pH sensitive CPD release was detected by UV visible spectrophotometer that followed zero order and Higuchi models. However, in 4 h, 89.4 % and 83.7 % of CPD was released in PBS and SIF solution correspondingly. Therefore, the chitosan-based biocompatible and biodegradable hydrogel platforms offered substantial potential for the controlled CPD release in medico-biological applications.

Prevalence Of Human Adenovirus In Paediatric Patients Presenting With Acute Respiratory Symptoms At Different Hospitals Of Pakistan.

BACKGROUND: Human Adenovirus (HAdV) is one of the most common causes of infection in children. HAdV commonly affects respiratory system, however can also involve other parts of the body like nervous system, eyes and urinary tract. The virus usually causes a mild infection of the lower and upper respiratory tract. Objective of the study was to find the prevalence of HAdV in paediatric patients presenting with Influenza like symptoms and severe acute respiratory illness across Pakistan. METHODS: This cross-sectional study was conducted at the National Institute of Health, Islamabad. Respiratory swabs were collected from 389 children with age less than five years from 14 hospitals in different regions of Pakistan from October 1, 2017 to September 30, 2018. Patients' demographics, signs and symptoms were recorded through a predesigned proforma while Real-time polymerase chain reaction (RT-PCR) was performed for respiratory samples. RESULTS: Out of all 389 samples, HAdV was found in 25 (6.4%) cases. The proportion of HAdV obtained was greater in females 18 (4.6%) than male 7 (1.8%). The influenza-like illness in children attending outpatient department had a higher prevalence of HAdV 13 (3.3%) compared to admitted children 12 (3.1%). Similarly, patients from one to 6 months of age had higher positive outcome than older children. Majority of positive patients were from Islamabad (2.0%) followed by Gilgit (1.8%), Azad Jammu Kashmir (1.0%), Multan (0.5%), and Karachi (0.5%). The most frequent signs and symptoms were cough, fever, sore throat, nasal congestion and shortness of breath. CONCLUSIONS: The present study concludes that HAdV infection is common in Pakistan especially in female patients aged 1-6 months. It's crucial to improve the diagnosis of HAdV infections in our country to prevent complications associated with the virus. Furthermore, genetic analysis may help find different genotypes of HAdV circulating in Pakistan.

Metal-Organic Framework-Based Composites for the Detection and Monitoring of Pharmaceutical Compounds in Biological and Environmental Matrices.

The production of synthetic drugs is considered a huge milestone in the healthcare sector, transforming the overall health, aging, and lifestyle of the general population. Due to the surge in production and consumption, pharmaceutical drugs have emerged as potential environmental pollutants that are toxic with low biodegradability. Traditional chromatographic techniques in practice are time-consuming and expensive, despite good precision. Alternatively, electroanalytical techniques are recently identified to be selective, rapid, sensitive, and easier for drug detection. Metal-organic frameworks (MOFs) are known for their intrinsic porous nature, high surface area, and diversity in structural design that provides credible drug-sensing capacities. Long-term reusability and maintaining chemo-structural integrity are major challenges that are countered by ligand-metal combinations, optimization of synthetic conditions, functionalization, and direct MOFs growth over the electrode surface. Moreover, chemical instability and lower conductivities limited the mass commercialization of MOF-based materials in the fields of biosensing, imaging, drug release, therapeutics, and clinical diagnostics. This review is dedicated to analyzing the various combinations of MOFs used for electrochemical detection of pharmaceutical drugs, comprising antibiotics, analgesics, anticancer, antituberculosis, and veterinary drugs. Furthermore, the relationship between the composition, morphology and structural properties of MOFs with their detection capabilities for each drug species is elucidated.

Predicting Mental Health of Best Human Capital for Sustainable Organization through Psychological and Personality Health Issues: Shift from Traditional to Novel Machine Learning-Supervised Technique Approach.

Researchers in the past discussed the psychological issue like stress, anxiety, depression, phobias on various forms, and cognitive issues (e.g., positive thinking) together with personality traits on traditional research methodologies. These psychological issues vary from one human to other human based on different personality traits. In this paper, we discussed both psychological issues together with personality traits for predicting the best human capital that is mentally healthy and strong. In this research, we replace the traditional methods of research used in the past for judging the mental health of the society, with the latest artificial intelligence techniques to predict these components for attaining the best human capital. In the past, researchers have point out major flaws in predicting psychological issue and addressing a right solution to the human resource working in organizations of the world. In order to give solution to these issues, we used five different psychological issues pertinent to human beings for accurate prediction of human resource personality that effect the overall performance of the employee. In this regard, a sample of 500 data has been collected to train and test on computer through python for selecting the best model that will outperform all the other models. We used supervised AI techniques like support vector machine linear, support vector machine radial basis function, decision tree model, logistic regression, and neural networks. Results proved that psychological issue data from employee of different organizations are better means for predicting the overall performance based on personality traits than using either of them alone. Overall, the novel traditional techniques predicted that sustainable organization is always subject to the control of psychological illness and polishing the personality traits of their human capital.

Healthy ageing: Assessment of health-promoting lifestyle among the elderly population in Karachi Pakistan.

BACKGROUND: The growth in the elderly population is predicted to expand exponentially and developing countries like Pakistan have about two-third of the global elderly population. It is vital to maintain the health of the elderly aged population to reduce disabilities and health-care cost. AIM: This study aimed to determine the health promotion practices among the older aged population in Pakistan and to explore the factors associate with adopting healthy lifestyle practices. MATERIALS AND METHODS: This was a cross-sectional study spanning from 2019 to 2020 conducted on 317 participants of age more than 60 years in Pakistan. The participants included healthy attendants of patients visiting the outpatient clinics of different disciplines in the Liaquat National Hospital Karachi through purposive sampling technique. The health-promoting practices were assessed using Health-Promoting Lifestyle Profile II Questionnaire. The factors that determined the healthy practices among the elderly population were identified using independent t-test and analysis of variance and Tukey test, with a significance level of P < 0.05. IBM SPSS Statistics 22 was used for data entry and analysis. RESULTS: The highest subscale was detected from interpersonal relationships and spiritual growth. The lowest score was detected from physical activity. The scores differed significantly by occupation, education, and the marital status of the participants. Females, unmarried people, those who were less educated, and participants relying on others for financial support had lower health-promoting lifestyle scores. CONCLUSION: The overall health-promoting practices were good among the old-aged population of Pakistan. These practices differed particularly for physical activity, spiritual growth, and interpersonal relationships.

Serological Screening of Suspected COVID-19 Patients in Pakistan.

OBJECTIVE: To determine the antibody levels (IgM and IgG), using ELISA in suspected patients of COVID-19. STUDY DESIGN: Descriptive cross-sectional study. Place & Duration of Study: Real Time PCR Diagnostic and Research Laboratory, Peshawar, Khyber Pakhtunkhwa, Pakistan, from May to July 2020. METHODOLOGY: A total of 94 blood specimens were collected from suspected COVID-19 patients. The antibody levels (IgG and IgM) were determined, using a COVID-19 ELISA IgG and IgM kit. RESULTS: Out of a total 94 serum specimens, specimens were predominantly collected from males (70.2%, n=66) as compared to females (29.8%, n=28). Amongst six different age groups, the majority of the samples were found in the 31-45 years, 16-30 years, and 46-60 years groups, 42.6% (n=40), 23.4% (n=22) and 22.3% (n=21), respectively. Of the 94 suspected COVID-19 patients' serum specimens, IgG and IgM were detected in 29.8% (n=28) and 39.4% (n=37), specimens, respectively. The IgG antibodies were detected more in males (60.0%, n=18) than females (40.0%, n=12) samples. Similarly, IgM antibodies were also found more frequently in males (61.1%, n=22) as compared to females (38.9%, n=14). CONCLUSION: Detection of antibodies in COVID-19 infected patients provides vital clinical information for clinicians and could be used for the identification of suspected cases. Moreover, males were more prone to disease compared to females, and the 31-45 years age group was also more affected. Key Words: Serological assays, IgG, IgM, Peshawar, Pakistan.

Detection of SARS-CoV-2 using real-time polymerase chain reaction in different clinical specimens: A critical review.

Coronavirus disease 2019 (COVID-19) is a disease caused by a new strain of coronavirus named as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Globally, since the outbreak, more than seven million confirmed cases of COVID-19 have been reported. The rapid spread and increase in the number of new cases is due to person-to-person transmission. To further control its transmission, early laboratory diagnosis of both asymptomatic and symptomatic patients is crucial. Presently, the COVID-19 diagnosis of infected individuals is dependent on computed tomography scanning and real-time polymerase chain reaction (PCR). The latter is considered more sensitive and efficient for early diagnosis. In this review, general comparisons are made (cases, fatality rate, incubation period, clinical features, and reservoirs) and diagnostic laboratory procedures (specimens, extraction methods, and positive rates by real-time PCR) are compared between SARS, Middle East Respiratory Syndrome, and SARS-2. In total, 8982 SARS-2 suspected patients specimen data were retrieved, in which 40.9% (n = 3678) were detected as positive by real-time PCR. The specimen-wise high detection rate was observed from bronchoalveolar lavage, followed by saliva, nasal swabs, and sputum. As the COVID-19 cases are persistently increasing, the selection of appropriate specimens and laboratory assay would help in rapid and timely diagnosis.

Detection of SARS-CoV-2 using real-time polymerase chain reaction in different clinical specimens: A critical review

Coronavirus disease 2019 (COVID-19) is a disease caused by a new strain of coronavirus named as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). Globally, since the outbreak, more than seven million confirmed cases of COVID-19 have been reported. The rapid spread and increase in the number of new cases is due to person-to-person transmission. To further control its transmission, early laboratory diagnosis of both asymptomatic and symptomatic patients is crucial. Presently, the COVID-19 diagnosis of infected individuals is dependent on computed tomography scanning and real-time polymerase chain reaction (PCR). The latter is considered more sensitive and efficient for early diagnosis. In this review, general comparisons are made (cases, fatality rate, incubation period, clinical features, and reservoirs) and diagnostic laboratory procedures (specimens, extraction methods, and positive rates by real-time PCR) are compared between SARS, Middle East Respiratory Syndrome, and SARS-2. In total, 8982 SARS-2 suspected patients specimen data were retrieved, in which 40.9% (n = 3678) were detected as positive by real-time PCR. The specimen-wise high detection rate was observed from bronchoalveolar lavage, followed by saliva, nasal swabs, and sputum. As the COVID-19 cases are persistently increasing, the selection of appropriate specimens and laboratory assay would help in rapid and timely diagnosis

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Bacterial Spectrum and Antimicrobial Profile of Pediatric Blood Stream Infection at a Tertiary Care Hospital in Pakistan.

Objectives Blood stream infections (BSIs) are the main cause of morbidity and mortality in children worldwide. The present study was carried out to determine the prevalence of BSI with a focus on the identification of the causative agent of BSI, and to further evaluate the antibiotic susceptibility profile of the causing bacterial pathogens.Methods A cross-section study was carried out at the tertiary care hospital in Peshawar, Pakistan from January to December, 2018. Blood samples were collected in BACTECTM bottles and standard microbiological protocols were applied for the isolation and identification of bacterial strains. The antibiotic susceptibility tests were performed using disc diffusion method as per the 2014 guideline of Clinical Laboratory Standard Institute (CLSI).Results Of 567 blood cultures in total, 111(19.6%) were positive for BSI. Male children were 64 % (71/111) and female children were 36% (40/111). For the causative predominant group of microorganisms, Gram-negative bacteria were identified in 79 (71.1%) isolates, and Gram-positive bacteria in 32 (28.9%) isolates. The common bacteria of isolates were S. typhi (n=35, 31.5%), E. coli (n=19, 17.1%), S. aureus (n=18, 16.2%), K. pneumonia (n=12, 10.8%), and Enterococcus species (n=7, 6.3%). The 36.7% (29/79) isolates of Gram-negative bacteria were ESBL producers, and 61.1% (11/18) of S. aureus isolates were methicillin resistant. Overall, 72.9% isolates were multidrug resistant.Conclusions Gram-negative bacteria were the main cause of pediatric BSIs, where the predominant microorganism was S. typhi. Remarkably, majority of the S. typhi isolates were resistant to ciprofloxacin.

Isolated Idiopathic Right Common Iliac Artery Aneurysm Presenting as Acute Appendicitis in a 9-Year-Old Girl: A Case Report and Literature Review.

The prevalence of iliac artery aneurysms is extremely rare in children. The most common etiologies for developing an aneurysm in children are infections, inflammatory diseases, and trauma. An idiopathic or congenital etiology is the least common cause in the pediatric population. We report a case of a 9-year-old girl with no previous history of trauma, intervention, or family history of vascular diseases who presented with a sudden severe right lower quadrant pain suggesting appendicitis. Upon examination, a large tender pulsatile mass was felt in the right lower quadrant. Ultrasound and computed tomography scans revealed a large right common iliac aneurysm. The aneurysm was noted to have a high risk of rupture due to the sudden symptomatic presentation and its large size. Therefore, the patient underwent an urgent operation, during which an aneurysmal repair was performed with an interposition graft. Postoperative ultrasound imaging showed a patent graft and no residual aneurysm. The patient has been followed up for two years, and no complications were found.

Adsorption mechanism of Pb2+ ions by Fe3O4, SnO2, and TiO2 nanoparticles.

Nanosized sorbents for the removal of heavy metal ions are preferred due to high surface area, smaller size, and enhanced reactivity during adsorbate/adsorbent interactions. In the present study, Fe3O4, SnO2, and TiO2 nanoparticles were prepared by microemulsion-assisted precipitation method. The particles were characterized by BET surface area, X-rays diffraction (XRD), thermogravimetric analysis (TGA), Fourier transform infrared (FTIR) spectroscopy, transmittance electron microscopy (TEM), and X-ray photoelectron (XPS) spectroscopy. The respective particle sizes calculated from TEM were 7 nm (± 2), 10 nm (± 2), and 20 nm (± 3) for Fe3O4, SnO2, and TiO2. The adsorbents were employed for the adsorption of Pb2+ ions from the aqueous solutions. The respective maximum adsorption capacity for Fe3O4, SnO2, and TiO2 nanoparticles was 53.33, 47.21, and 65.65 mg/g at 313 K. Based on the exchange reaction taking place on the surfaces of Fe3O4, SnO2, and TiO2, it is concluded that Pb2+ ions are adsorbed in hydrated form. The X-ray photoelectron spectroscopy (XPS) studies also support the exchange mechanism and confirmed the presence of elements like Fe, Sn, Ti, Pb, and O and their oxidation states. Both Langmuir and Freundlich models in non-linear form were applied, however, based on RL values, the Langmuir model fits well to the sorption data. Moreover, adsorption parameters were also determined by using non-linear form of the Langmuir model along with statistical approaches to remove error. The qm and Kb values confirm better adsorption capacity and binding strength for Pb2+ ions as compared to the values reported in the literature.

Role of Interventional Radiology in the Management of Peripheral Vascular Malformations: A Tertiary Care Center Experience.

Peripheral vascular malformations (PVMs) represent a wide spectrum of vascular abnormalities occurring due to anomalous connections between arteries, veins, capillaries, and lymphatic channels at the microscopic level, in different combinations. They are rare and challenging to treat. Different operators may have different approaches based on their experience and expertise. Sclerotherapy either alone or in combination with embolization has been used as an independent method for the treatment of PVMs. Purpose The aim of this study is to assess the safety and efficacy of sclerotherapy and embolization, with or without surgery, for the treatment of peripheral vascular malformations, based on our approach. Materials and methods A retrospective review of all patients with PVMs treated in our interventional radiology department from 2011 to 2017 was carried out. Medical records, imaging, and follow-up notes were reviewed to evaluate the response to treatment and post-procedure complications. Results Thirty-four sessions were performed in 15 patients (eight male, seven female) with PVMs. Low-flow lesions were identified in 10, intermediate flow in one, and high flow in four patients. Sodium tetradecyl sulfate (STS) was used as the sclerotherapeutic agent in 10 (66.67%), glue with lipoidal in three (20.0%), and bleomycin in one patient (6.67%). Coils with PVA and a covered stent were used in one and a combination of coil, PVA, and gel foam was used in one patient. A marked response was seen in 11 and a partial response in four patients. One patient developed foot gangrene. Stent thrombosis was noted in one patient with no clinical consequences. Recurrence was seen in two patients, who were lost to follow up. Conclusion PVMs are complex lesions. Sclerotherapy with or without embolization is a safe and effective treatment modality, with clinical response approaching 100%.

Repair of Thoracoabdominal Aortic Aneurysm with Thrombosed Infrarenal Component: A Modified Hybrid Technique without Aortic Cross Clamping.

The authors report the successful repair of a Crawford type III thoracoabdominal aortic aneurysm (TAAA) with a thrombosed infrarenal component using a modified hybrid technique without aortic clamping in a high-risk patient. A 64-year-old male with a history of hypertension, diabetes, and severe chronic obstructive pulmonary disease presented with acute on chronic backache and bilateral short distance claudication. A computerized tomography scan demonstrated a large, nonleaking Crawford type III TAAA with thrombosed infrarenal component of the aneurysm. In addition, both common iliac arteries were occluded with the chronic thrombus. A single-stage, modified hybrid procedure involving an aortobifemoral bypass without aortic clamping, debranching of right renal, superior mesenteric, and celiac arteries as well as an endovascular repair of the thoracic aneurysm was performed. Unfortunately, despite a technically sound repair, the patient died postoperatively from a massive pulmonary embolism. TAAA with a thrombosed infrarenal aorta and bilateral common iliac arteries can be repaired using a single-stage modified hybrid procedure without aortic clamping in high-risk patients who cannot tolerate thoracotomy and aortic cross clamping.

First report on molecular characterization of Leishmania species from cutaneous leishmaniasis patients in southern Khyber Pakhtunkhwa province of Pakistan

OBJECTIVE@#To report presence of Leishmania major in Khyber Pakhtunkhwa of Pakistan, where cutaneous leishmaniasis (CL) is endemic and was thought to be caused by Leishmania tropica only.@*METHODS@#Biopsy samples from 432 CL suspected patients were collected from 3 southern districts of Khyber Pakhtunkhwa during years 2011-2016. Microscopy on Giemsa stained slides were done followed by amplification of the ribosomal internal transcribed spacer 1 gene.@*RESULTS@#Leishmania amastigotes were detected by microscopy in 308 of 432 samples (71.3%) while 374 out of 432 samples (86.6%) were positive by ribosomal internal transcribed spacer 1 PCR. Subsequent restriction fragment length polymorphism confirmed L. tropica in 351 and L. major in 6 biopsy samples.@*CONCLUSIONS@#This study is the first molecular characterization of Leishmania species in southern Khyber Pakhtunkhwa. It confirmed the previous assumptions that anthroponotic CL is the major CL form present in Khyber Pakhtunkhwa province. Furthermore, this is the first report of L. major from a classical anthroponotic CL endemic focus identified in rural areas of Kohat district in southern Khyber Pakhtunkhwa.

First report on molecular characterization of Leishmania species from cutaneous leishmaniasis patients in southern Khyber Pakhtunkhwa province of Pakistan

Objective To report presence of Leishmania major in Khyber Pakhtunkhwa of Pakistan, where cutaneous leishmaniasis (CL) is endemic and was thought to be caused by Leishmania tropica only. Methods Biopsy samples from 432 CL suspected patients were collected from 3 southern districts of Khyber Pakhtunkhwa during years 2011–2016. Microscopy on Giemsa stained slides were done followed by amplification of the ribosomal internal transcribed spacer 1 gene. Results Leishmania amastigotes were detected by microscopy in 308 of 432 samples (71.3%) while 374 out of 432 samples (86.6%) were positive by ribosomal internal transcribed spacer 1 PCR. Subsequent restriction fragment length polymorphism confirmed L. tropica in 351 and L. major in 6 biopsy samples. Conclusions This study is the first molecular characterization of Leishmania species in southern Khyber Pakhtunkhwa. It confirmed the previous assumptions that anthroponotic CL is the major CL form present in Khyber Pakhtunkhwa province. Furthermore, this is the first report of L. major from a classical anthroponotic CL endemic focus identified in rural areas of Kohat district in southern Khyber Pakhtunkhwa.

Free Esophageal Perforation Following Hybrid Visceral Debranching and Distal Endograft Extension to Repair a Ruptured Thoracoabdominal Aortic Aneurysm.

Free esophageal perforation following a hybrid visceral debranching and distal endograft extension to repair a ruptured thoracoabdominal aortic aneurysm (TAAA) is a rare complication. The authors report a 56-year-old male who underwent elective thoracic endovascular aortic repair of a thoracic aneurysm. Four and a half years later, he presented with a new aneurysm extending from the distal end of the thoracic stent graft to the aortic bifurcation involving all the visceral arterial branches. The TAAA ruptured while he was awaiting an elective repair, and as a result, he underwent an emergency hybrid procedure. This involved debranching the visceral arterial branches including autotransplantation of the left kidney and distal endograft extension. Postoperatively, he developed free esophageal perforation secondary to ischemic necrosis requiring esophageal resection and gastric pull-up. The patient was well 6 months after the gastrointestinal restorative procedure. Thus, esophageal perforation following an emergency hybrid repair of ruptured TAAA is a rare complication, and a successful outcome depends on early recognition and surgical exclusion of the ruptured viscus.

Broadening of the red blood cell distribution width is associated with increased severity of illness in patients with sepsis.

BACKGROUND: Sepsis is a pro-inflammatory state caused by systemic infection. As sepsis progresses, multiple organ systems become affected with subsequent increase in mortality. Elevated red cell distribution width (RDW) has been seen with changes of other inflammatory markers and thus could potentially serve as a means of assessing sepsis severity. In this study, we examine the association of RDW with APACHE II score and in-hospital mortality. METERIALS AND METHODS: We conducted a retrospective study involving a cohort of patients with sepsis. The study period spanned 2 years with a cohort of 349 patients. Data were collected to determine if RDW is associated with APACHE II scores and in-hospital mortality in this cohort. RESULTS: RDW correlated weakly (r s = 0.27), but significantly (P < 0.0001) with APACHE II scores; coefficient of determination (r (2) = 0.09). The odds ratios for the association of RDW with APACHE II were calculated over the RDW range 12-20% at a dichotomized level of APACHE II, i.e., <15 and ≥15. At a RDW ≥16%, multivariate analysis including all potential confounders indicated that RDW was independently associated with an APACHE II score of ≥15. Similarly, mortality was associated with RDW ≥16%. CONCLUSION: A prognostic biomarker for sepsis in the form of a routine blood test may be of considerable clinical utility. The results of our study suggest that RDW may have value in differentiating between more severe and less severe cases of sepsis. Future studies with larger samples are needed to confirm these findings.

Retroperitoneal approach to abdominal aortic aneurysm repair preserves splanchnic perfusion as measured by gastric tonometry.

BACKGROUND: We investigated if minimizing bowel manipulation and mesenteric traction using the retroperitoneal approach in open abdominal aortic aneurysm (AAA) repair preserves splanchnic perfusion, as measured by gastric tonometry, and reduces the systemic inflammatory response and dysfunction of the various organs. METHODS: Patients undergoing elective AAA repair were randomized into three groups. Group I had repair via the retroperitoneal approach, while groups II and III were repaired via the transperitoneal approach with the bowel packed within the peritoneal cavity or exteriorized in a bowel bag, respectively. A tonometer was used to measure gastric intramucosal pH (pHi), as an indicator of splanchnic perfusion, just prior to aortic clamping, during clamping, and at 0.5, 1, 2, 4, 6, and 12 hr after clamp release. Multiorgan dysfunction syndrome (MODS) and systemic inflammatory response syndrome (SIRS) scores were calculated and systemic interleukins (IL-6 and IL-10) measured at predetermined intervals. RESULTS: Thirty-four patients were successfully randomized. The gastric pHi was significantly lower in group II (n=12) and group III (n=11) compared to group I (n=11) during aortic clamping and immediately after clamp release (p<0.05). The aortic clamp time, blood loss, MODS and SIRS scores, and systemic cytokine response were similar in all three groups. When the three groups were combined, there were significant positive correlations between the operation time, aortic clamp time, and amount of blood lost and transfused with plasma IL-6 levels and MODS score on the first postoperative day. CONCLUSION: The retroperitoneal approach for open AAA repair is associated with gastric tonometric evidence of better splanchnic perfusion compared to the transperitoneal approach.