Valve-in-Valve Transcatheter Aortic Valve Replacement Versus Redo-Surgical Aortic Valve Replacement in Patients With Aortic Stenosis: A Systematic Review and Meta-analysis.

Aortic stenosis is a common and significant valve condition requiring bioprosthetic heart valves with transcatheter aortic valve replacement (TAVR) being strongly recommended for high-risk patients or patients over 75 years. This meta-analysis aimed to pool existing data on postprocedural clinical as well as echocardiographic outcomes comparing valve-in-valve (ViV)-TAVR to redo-surgical aortic valve replacement to assess the short-term and medium-term outcomes for both treatment methods. A systematic literature search on Cochrane Central, Scopus, and Medline (PubMed interface) electronic databases from inception to August 2023. We used odds ratios (OR) for dichotomous outcomes and mean differences (MD) for continuous outcomes. Twenty-four studies (25,216 patients) were pooled with a mean follow-up of 16.4 months. The analysis revealed that ViV-TAVR group showed a significant reduction in 30-day mortality (OR 0.50, 95% confidence interval [CI] 0.43 to 0.58, p <0.00001), new-onset atrial fibrillation (OR 0.34, 95% CI 0.17 to 0.67, p = 0.002), major bleeding event (OR 0.28, 95% CI 0.17 to 0.45, p <0.00001) and lower rate of device success (OR 0.25, 95% CI 0.12 to 0.53, p = 0.0003). There were no significant differences between either group when assessing 1-year mortality, stroke, myocardial infarction, postoperative left ventricular ejection fraction, and effective orifice area. ViV-TAVR cohort showed a significantly increased incidence of paravalvular leaks, aortic regurgitation, and increased mean aortic valve gradient. ViV-TAVR is a viable short-term option for elderly patients with high co-morbidities and operative risks, reducing perioperative complications and improving 30-day mortality with no significant cardiovascular adverse events. However, both treatment methods present similar results on short-term to medium-term complications assessment.

Asymptomatic Hyperuricemia as an Independent Risk Factor for Myocardial Infarction in Adult Population: A Four-Year Follow-Up Study.

Introduction A condition in which uric acid levels are elevated but there are no accompanying symptoms is known as asymptomatic hyperuricemia. As a result of the disparity in opinions and findings between the studies, the guidelines regarding whether or not asymptomatic hyperuricemia should be treated are unclear. Material and methods Between the months of January 2017 and June 2022, this research was carried out in the community in collaboration with the internal medicine unit and the public health unit of Liaquat University of Medical and Health Sciences. After obtaining informed consent from each participant, the researchers enrolled 1,500 patients in the study who had uric acid levels that were greater than 7.0 mg/dL. These patients ranged in age from 40 to 70 years old and were of either gender. As a control group, 1,500 patients were recruited who did not have abnormally high levels of uric acid. Patients were monitored for a total of 48 months or until the occurrence of a major cardiovascular event (MACCE) or death from all causes, whichever occurred first. Death, cardiovascular mortality, non-fatal myocardial infarction, and non-fatal stroke were the four categories that made up the primary outcome, also known as MACCEs. Results In the hyperuricemic group, the incidence of myocardial infarction that did not result in death was significantly higher than in the non-hyperuricemic group (1.6% vs. 0.7%; p-value, 0.04). However, the result was not significant for deaths from all causes, deaths from cardiovascular disease, or strokes that did not result in death. Conclusion Asymptomatic hyperuricemia is a potential threat to one's health that can lead to cardiovascular diseases and may go undiagnosed in some cases. It is important to remember that hyperuricemia can lead to delirious complications, so efforts should be made to perform routine monitoring and management of the condition.

Relationship Between Mental Health Disorders and Readmissions Following Total Joint Arthroplasty: A Systematic Review and Meta-Analysis.

BACKGROUND: There is limited evidence exploring the relationship between mental health disorders and the readmissions following total joint arthroplasty (TJA). Therefore, we conducted a meta-analysis to evaluate the relationship between mental health disorders and the risk of readmission following TJA. METHODS: We searched PubMed, Cochrane, and Google Scholar from their inception till April 19, 2022. Studies exploring the association of mental health disorders and readmission risk following TJA were selected. The outcomes were divided into 30-day readmission, 90-day readmission, and readmission after 90 days. We also performed subgroup analyses based on the type of arthroplasty: total hip arthroplasty (THA) and total knee arthroplasty (TKA). A total of 12 studies were selected, of which 11 were included in quantitative analysis. A total of 1,345,893 patients were evaluated, of which 73,953 patients suffered from mental health disorders. RESULTS: The risk of 30-day readmission (odds ratio = 1.43, 95% CI 1.14-1.80, P = .002, I2 = 87%) and 90-day readmission (OR = 1.35, 95% CI 1.22-1.49, P < .00001, I2 = 89%) was significantly associated with mental health disorders. On subgroup analyses, 30-day readmission was significantly associated with THA (OR = 1.29, 95% CI 1.04-1.60, P = .02), but not with TKA (OR = 1.44, 95% CI 0.51-4.06, P = .50). Similarly, 90-day readmission was significantly associated with both THA (OR = 1.21, 95% CI 1.14-1.29, P < .00001) and TKA (OR = 1.33, 95% CI 1.17-1.51, P < .0001). CONCLUSION: Mental health disorders are significantly associated with increased 30-day and 90-day readmissions. Increasing awareness regarding mental health disorders and readmission in arthroplasty will help in efficient preoperative risk stratification and better postoperative management in these patients.

Intermediate Autosomal Recessive Osteopetrosis With an Unusual Absence of Fractures.

Background: Osteopetrosis includes a variety of rare inherited skeletal disorders characterized by increased bone density and thickness. It has different clinical forms, including infantile autosomal recessive, intermediate autosomal recessive, and late-onset autosomal dominant forms. Intermediate autosomal recessive osteopetrosis (IARO) displays high variability. Case Report: A 10-year-old male presented to our pediatrics emergency department with abdominal distension, low-grade fever, and swelling of the right maxilla with associated discharge. His local physician had treated the lesion with drainage and aspiration of pus without improvement. Examination revealed pallor, hepatosplenomegaly, poor dentition, and dental caries. Eye examination showed reduced visual acuity, absent color vision, nystagmus, and bilateral optic nerve atrophy. Laboratory investigations showed anemia and thrombocytopenia. Radiography yielded classic features of osteopetrosis. Detailed intraoral examination revealed an area of exposed necrotic bone in the alveolar region of the right maxilla, leading to a diagnosis of IARO with underlying osteomyelitis. The intraoral wound was treated with bismuth iodoform paraffin paste dressing, and the infection was treated with antibiotics. Anemia and thrombocytopenia were managed supportively by transfusion of packed red blood cells and platelets. Conclusion: IARO commonly presents with multiple fractures, so the absence of fractures in our patient was unusual. Studies evaluating the intermediate variant are meager; hence, documenting its various presentations is essential to aid physicians in making early diagnoses. Osteomyelitis of the jaws is a feared complication in these patients. Therefore, practitioners need to be cautious of infections of dental origin.

Role of Serum Homocysteine and Outcome in Patients With Traumatic Brain Injury.

Background There have been indications of a correlation between serum homocysteine (Hcy) levels and poor patient outcomes in traumatic brain injury (TBI). Thus, we aimed to explore the role of serum Hcy in influencing the outcome post TBI. Methods A case-control study was conducted at Liaquat University of Medical and Health Sciences (LUMHS) between January 15, 2022 and July 1, 2022. All patients between the ages of 18 and 75 years who presented with TBI, irrespective of severity, were included in the study. All patients with neurological disorders and infections, including but not limited to cerebral tuberculosis, Alzheimer's disease, epilepsy, brain cancer, Parkinson's, and stroke, were excluded from the study. For comparison, healthy controls with similar demographics were enrolled in the study. All patients and controls underwent biochemical evaluation of serum Hcy and neurological assessment at presentation. In addition, all sociodemographic and clinical parameters, including the Glasgow Outcome Score (GOS), were collected in a predefined pro forma. Results A total of 175 patients were included who had experienced TBIs, along with an equal number of healthy controls. The most common etiology was road traffic accidents in 82 (46.9%) patients. The mean Glasgow Coma Score (GCS) at presentation was 5.78 ± 1.72. The mean Hcy levels were 31.4 ± 7.97 µmol/L in TBI patients and 11.12 ± 5.87 µmol/L in the control healthy patients (p=0.001). It was found that the severity of hyperhomocysteinemia (HHcy) was significantly related to the worst outcome possible, i.e., death (p=0.001). Conclusion The study concluded that patients who had suffered from a TBI had significantly higher serum Hcy levels. Furthermore, the study highlighted that the patients with the worst outcomes had more severe hyperhomocysteinemia (HHcy) than those with better outcomes. Moreover, patients with low GOS scores were more likely to have HHcy.

A Comparative Study of Luteinizing Hormone Levels in Polycystic Ovarian Syndrome With Hyperandrogenism: Metformin Versus Oral Contraceptive Pills.

Introduction The primary objective of the study was to compare the serum luteinizing hormone (LH) levels in patients with hyperandrogenism on metformin and combined oral contraceptive pills. Secondarily, the study also assessed the serum testosterone, body mass index (BMI), and the time to achieve regular menstruation were also assessed. Methods A quasi-experimental study was conducted at the Department of Medicine, Liaquat University of Medical & Health Sciences (LUMHS) between June 1, 2019 and May 30, 2020. A total of 200 women fulfilling the clinical and biochemical criteria for the polycystic ovarian syndrome (PCOS) were enrolled, 100 in each group. Considering the inclusion criteria, the patients were picked up from the gynecology outpatient department. After taking a detailed history and physical, abdominal, and pelvic examination, pelvic ultrasonography along with biochemical evaluations of serum LH and testosterone were done in selected patients. Metformin was started at an oral dose of 500 mg daily and maintained at 1500 mg for six months in group A, and oral contraceptive pills were given for a period of six months in group B. Besides body weight and hirsutism, serum LH levels, serum prolactin levels, and serum testosterone levels were performed at the start of the treatment and then repeated after three months and after six months. After six months of menstrual cyclicity, changes in serum LH levels and body weights were assessed in the two groups and the rate of conception in the Metformin group. Results A total of 200 women were enrolled and equally divided into metformin and oral contraceptive groups. Follow-up revealed that a significantly higher number of patients achieved regular menstruation in the metformin group as compared to the oral contraceptive groups (p = 0.03). In the metformin group, 72 patients achieved regular menses, while in the oral contraceptive groups, about 58 patients achieved regular menstruation. Both metformin and oral contraceptive therapy were effective in improving patient outcomes in terms of serum LH, testosterone levels, and BMI. However, metformin had considerably higher rates of improvement as compared to oral contraceptive group patients. The mean serum LH level decreased from 38 mIU/ml to 17.6 mIU/ml in the metformin group (p < 0.0001), while the mean serum LH level reduced from 37.5 mIU/ml to 27.7 mIU/ml in the oral contraceptive group (p < 0.01). The change in serum testosterone level after six months was 2.98 ± 0.75 in the metformin group (p < 0.001) and 1.50 ± 0.64 in the oral contraceptive group (p < 0.01). Conclusion We revealed that both metformin and oral contraceptives are effective in improving symptomatology in PCOS patients. However, a significantly higher number of patients achieved normal menses with metformin than with oral contraceptives. Moreover, metformin had considerably higher rates of improvements in serum LH levels and serum testosterone levels as compared to oral contraceptive group patients.

Depression and Anxiety in Patients With a History of Traumatic Brain Injury: A Case-Control Study.

Background The burden of psychiatric illness following a head injury may have implications on the disease prognosis. The present study evaluated the association of depression and anxiety with traumatic brain injury (TBI). Methods A case-control study was conducted in Karachi, Pakistan, from 2nd July 2021 and 30th January 2022, including individuals of age 18 and above of both genders, with or without a mild head trauma history, forming the case and control groups, respectively. Individuals with previous head trauma/congenital neurological dysfunction were excluded. A mental health assessment of the participants was carried out with two scales, the Generalized Anxiety Disorder-7 (GAD-7) scale and the Public Health Questionnaire-9 (PHQ-9) scale. Other parameters like age, gender, socioeconomic status, education status, and comorbidities were also documented. Results A total of 62 participants were enrolled with 31 cases and 31 controls. The majority were males aged between 18 and 39 years. About 29% of the patients with a history of mild TBI had moderate to severe depression while only 22.6% of them did not have depression or had minimal depression. We found that about 29.3% of patients with TBI had severe anxiety as compared to the only two healthy controls. The majority of the control group participants did not have anxiety. Conclusion Traumatic head injuries and their long-term side effects can predispose patients to a myriad of psychiatric comorbidities. In this study, we found definitive evidence that both anxiety and depression had a significantly higher incidence in cohorts that suffered from mild TBI. However, we recommend large-scale and multicenter studies in the future to explore these relationships more thoroughly and comprehensively.

Laparoscopic Versus Open Appendectomy for Patients With Perforated Appendicitis.

Introduction Acute appendicitis can lead to perforation which can be lethal. The present study assessed the outcomes of laparoscopic appendectomy versus open appendectomy in patients with perforated appendicitis. Methodology A comparative study was conducted at the Department of Surgery, Liaquat University of Medical & Health Sciences (LUMHS), between March 2, 2019 and July 7, 2020. The inclusion criteria consisted of a diagnosis of perforated appendicitis. Exclusion criteria consisted of intellectual disability hindering the procurement of informed consent, pediatric patients < 15 years of age, patients with an appendicular mass or abscess unsuited for laparoscopic appendectomy, severe sepsis or septic shock on presentation, and pregnant women. Patients were allocated to either open appendectomy (Group A) or laparoscopic appendectomy (Group B). The data gathering proforma recorded demographics, surgical findings, operating room (OR) time, length of inpatient care, requirement of analgesic, and any adverse events following surgery. All of the surgeries were conducted by an experienced surgical consultant with an experience of at least five years. Results A total of 85 patients were included in the laparoscopic appendectomy group, while 101 cases were included in the open appendectomy group. The use of analgesics thrice a day to manage the postoperative pain was significantly associated with the open appendectomy (p < 0.0001). Moreover, the postoperative length of hospitalization was substantially greater in patients who underwent open appendectomy than those who underwent laparoscopic procedure (p < 0.0001). Wound-related complications were considerably lower in patients who had laparoscopic appendectomy as compared to those who had open appendectomy (23.53% versus 40.5%; p = 0.013).  Conclusion The length of stay was significantly lower in patients who underwent laparoscopic appendectomy. Moreover, laparoscopic appendectomy was also associated with a lower rate of wound infection postoperatively, thus giving the former an edge over the latter. Despite the finding that the postoperative pain was not considerably different between the two groups, patients who underwent open appendectomy group required significantly more painkillers to manage the postoperative pain.

Immediate Catheter Drainage Versus Delayed Drainage in the Management of Infected Necrotizing Pancreatitis.

BACKGROUND:  Immediate or delayed catheter drainage of infected pancreatic necrosis remains a subject of debate. The present study aimed to evaluate the optimum timing for drainage in patients with infected necrotizing pancreatitis.  Methods: A prospective, observational study was undertaken at the Department of Surgery, Liaquat University of Medical & Health Sciences (LUMHS), between 1st March 2018 and 6th July 2020. All patients 18 years or older presenting with acute pancreatitis (AP) in whom necrotizing pancreatitis was confirmed or suspected were enrolled in the study. The exclusion criteria included prior intervention for necrotizing pancreatitis. Those who were diagnosed with infected necrotizing pancreatitis were labeled as Group A and Group B. Group A patients underwent immediate catheter drainage (within 24 h of admission) while Group B patients underwent delayed drainage (after 24 h). Clinical outcome variables including complication rate, mortality, length of hospital, and intensive care unit (ICU) stay were collected in a predefined pro forma. RESULTS:  One hundred and thirty patients were enrolled in the study. There were 65 patients in each group. The present study revealed no significant differences in patient outcomes in the immediate drainage group vs. the postponed drainage group. Overall, the mortality rate was 15.38% in Group A while the mortality rate was a little lower in Group B, i.e. 10.77% (p=0.44). The acute onset multiple organ failure was lower in Group A as compared to Group B, however, the difference was statistically insignificant (p=0.08). The rate of wound infection rate was 10.77% and 15.38% in Group A and Group B, respectively (p=0.61). CONCLUSION:  In the present study, we failed to find any significant difference between the immediate and postponed drainage group in terms of patient outcome. As per current findings, the timing of drainage did not impact the prognosis of patients with necrotizing pancreatitis.

Prevalence of Gallstones in Ulcerative Colitis and Crohn's Disease: A Systematic Review and Meta-Analysis.

The meta-analysis aimed to investigate the prevalence of gallstones (GS) in Inflammatory bowel disease (IBD), especially ulcerative colitis (UC). A systematic and thorough search was conducted on online electronic databases (PubMed/Medline, Cochrane Library, and Google Scholar) from the databases' inception to April 30th, 2022. Review Manager 5.4.1 (The Nordic Cochrane Centre, The Cochrane Collaboration, Copenhagen) was used for all statistical analyses and forest plots. Only studies that met inclusion criteria were selected. The selected studies were pooled using a random-effect model and the results were reported in the odds ratio (OR) with their corresponding 95% confidence interval (CI). Ten studies met the final inclusion criteria and were analyzed. Patients with UC had significantly higher prevalence of GS than those in the control group (OR=1.67 [1.32-2.11]; p < 0.0001; I2=58%). There was also significant prevalence of GS in Crohn's disease (CD) than those in control group (OR=2.22 [1.82, 2.69]; p < 0.00001; I2=31%). Analysis also showed the prevalence of GS in studies conducted in Asia (OR=2.00 [1.48, 2.70]; p < 0.00001; I2=80%) and Europe (OR= 1.84 [1.32, 2.55]; p = 0.0003; I2=45%) compared to the control group. This study provided a conclusive answer to whether GS is significant in UC or not. Our meta-analysis provides a well-powered estimate that there is a prevalence of GS in UC. CD is also significantly associated with GS.

Mysterious dengue-like virus: A case report from Pakistan.

Recently, in Pakistan, several cases of mysterious dengue-like illness are being reported, which has concerned the authorities and requires prompt action. We present a case of a 52-year-old female patient presenting with a history of continuous fever, documented up to 104 F, for 5 days. The symptoms were associated with headache, nausea, retro-orbital headache, arthralgia, and myalgia. Currently, to the best of our knowledge, this is the first reported case in the literature for the endemic mysterious virus and may serve as the groundwork for future studies.

Correlation of Depression and Anxiety With Rheumatoid Arthritis.

Background Psychiatric comorbidity with a chronic disease is linked with poor patient outcomes. Therefore, the current research assessed the correlation of rheumatoid arthritis (RA) with depression and anxiety disorders.  Methodology A prospective observational study was undertaken at a public sector hospital between December 2020 to June 2021. All individuals who presented with rheumatoid arthritis were included in the study. A healthy cohort acted as the control group. Depression and anxiety were assessed using the Hamilton depression rating scale (HDRS) and the Hamilton anxiety rating scale (HAM-A), respectively. The patients were inquired about their gender, age, and duration of RA. Further stratification was done using the Chi-squared test. A p-value of <0.05 was decided as the cut-off for significance. All data from the patients were collected in a predefined pro forma.  Results A total of 169 patients with RA and 85 healthy controls were enrolled in the study. The mean depression score among patients with RA was 19.65 ± 1.44 versus 14.4 ± 1.31 in the control group (p<0.001). Moreover, the mean anxiety score in patients with RA was 19.44 ± 2.4. About 71% of patients with RA were diagnosed with psychiatric issues, while only 7.1% of individuals in the control group had either depression or anxiety (p<0.0001). Furthermore, it was found that the majority of the patients with RA had depression with a frequency of 70 (58.3%), while only six participants in the control group had depression. None of the participants had moderate or severe depression. However, 16 (69.6%) patients with RA had major anxiety issues. In 27 patients, mixed anxiety-depression disease was diagnosed. Out of these, 23 (85.2%) had the depression-dominant mixed disorder.  Conclusion The present study highlighted the alarming incidence of depression and anxiety among patients with RA. Furthermore, it also indicated the relationship between severity of psychiatric comorbidity with chronic rheumatoid arthritis in our population. Further large-scale studies are needed to ascertain the demographic confounders that may help predict psychiatric disorders among patients with RA.

The Arduous Path to Diagnosis in a Patient With a Unique Cause of Gastroesophageal Reflux Disease.

In the following report, we document a case of gastroesophageal reflux disease (GERD) emerging from a peculiar etiology. A 20-year-old male presented to the out-patient department (OPD) of ear, nose & throat (ENT) of Dow University Hospital in Karachi, Pakistan, by referral from remote hospitals with a complaint of stomach upset. Upon a detailed historical assessment of the patient, the picture of a convoluted path to diagnosis emerged. Considering the patient's short stature and a bony mass on the mandible, a full body bone scan was ordered, uncovering a brown tumor. An elevated serum parathyroid hormone (PTH) level was detected in the presence of elevated serum calcium and low vitamin D levels. Upon subsequent computed tomography (CT) and magnetic resonance imaging (MRI), a cystic tumor of the pancreas was discovered in addition to a parathyroid adenoma which was promptly operated upon through a right-sided parathyroidectomy. The procedure successfully controlled the serum calcium levels of this patient which are suspected to have produced his gastroesophageal reflux-related symptoms. This case highlights the importance of accessible medical infrastructure and one of the unique causes of GERD.

Risk factors for blood transfusion in Cesarean section: A systematic review and meta-analysis.

OBJECTIVE: The current study has been conducted to identify the risk factors associated with blood transfusion in women undergoing cesarean section (C-section). A detailed account of the risk factors associated withblood transfusion will ultimately prevent unnecessary crossmatching in hospitals , leading to the conservation of declining blood supplies and resources without subjugating the quality of care. MATERIAL AND METHODS: We performed a rigorous literature search using electronic databases, including PubMed, Cochrane CENTRAL, and Embase, for studies evaluating the risk factors for blood transfusion in C-section published until March 31, 2021. The Newcastle-Ottawa Quality Assessment Scale was deployed to assess the methodologic quality of the included studies. Mean differences (MD) and odds ratios (OR) with 95% confidence intervals were calculated using Review Manager version 5.3. RESULTS: The search yielded 1563 records, 22 of which were eligible for inclusion, representing 426,094 women (10,959 in the transfused group and 415,135 in the non-transfused group). Participants in the transfused group had lower mean preoperative hematocrit (MD=-3.71 [-4.46, -2.96]; p<0.00001; I2=88%). Placenta previa (OR=9.54 [7.23, 12.59]; p<0.00001; I2=88%), placental abruption (OR=6.77 [5.25, 8.73]; p<0.00001; I2=72%), emergency C-section (OR=1.92 [1.42, 2.60]; p<0.0001; I2=75%), general anesthesia (OR=8.43 [7.90, 9.00]; p<0.00001; I2=72%), multiple gestations (OR=1.60 [1.24, 2.06]; p=0.0003; I2=85%), preterm labor (OR=3.34 [2.75, 4.06]; p<0.00001; I2=85%), prolonged labor (OR=1.68 [1.44, 1.96]; p<0.00001; I2=78%), unbooked cases (OR=2.42 [1.22, 4.80]; p=0.01; I2=80%), hypertensive disorders of pregnancy (OR=1.81 [1.72, 1.90]; p<0.00001; I2=71%), and fibroids (OR=2.32 [1.55, 3.47]; p<0.0001; I2=72%) were significantly higher in the transfused group compared to the non-transfused group. Chronic hypertension (OR=0.67 [0.29, 1.55]; p=0.36; I2=90%), maternal age (MD=0.09 [-0.27, 0.45]; p=0.62; I2=50%), maternal body mass index (MD=-0.14 [-0.81, 0.53]; p=0.67, I2=86%), diabetes (OR=0.93 [0.75, 1.15]; p=0.51; I2=52%), and malpresentation (OR=0.65 [0.38, 1.11]; p=0.13; I2=64%) were not significantly associated with an increased risk of blood transfusion in C-section in the two groups. CONCLUSION: Placenta previa, placental abruption, emergency C-section, booking status, multiple gestations, and preoperative hematocrit were the risk factors most significantly associated with blood transfusion, while a prior C-section did not increase the risk of transfusion.

Recurrent Sporadic Bilateral Retinoblastoma in a Child with 13q Deletion Syndrome.

13q syndrome is a chromosomal abnormality in which there is a pathognomic deletion of the genetic material on the long arm (q) of chromosome 13. Phenotypes of this syndrome are variable depending on the location of the deleted segment. The main manifestations of the syndrome include mental retardation, craniofacial dysmorphism, and increased susceptibility to tumors. We report a unique case of recurrent sporadic bilateral retinoblastoma (Rb) in a four-year-old boy carrying 13q (q12q14) interstitial deletion, which was treated successfully via enucleation and chemotherapy. Where most patients with familial Rb receive a single mutated Rb1 allele as the 'first hit', a small number of patients encounter interstitial deletion of the long arm of chromosome 13, resulting in the loss of the tumor suppressor Rb1 gene and presenting as sporadic cases.

Anatomical variations in upper arm vasculature pertinent to haemodialysis access creation: Are surgeons aware sufficiently?

There exist wide anatomical variations of upper limb. Their implication is perhaps greatest when it comes to failure of arteriovenous fistula (AVF) for chronic haemodialysis. Among arteries of forearm, brachial artery is of note, whose high bifurcation is associated with increased risk of failure. The superficial and accessory variants also cause difficulty for the surgeon. The single unpaired brachial vein and stenosis of cephalic vein compound the difficulties associated with AVF among many others. A thorough understanding of surgeons regarding normal anatomy and diverse variants holds high importance in context of deciding an appropriate site for arteriovenous (AV) anastomosis. Negligence in creation of fistula not only pose a threat to patients of end stage renal disease (ESRD) but also contributes to numerous other complications involving nerves and drug administration.

A Unique Manifestation of Bardet-Biedl Syndrome with Otolaryngologic Symptoms and Bronchopneumonia in a One-year-old Girl.

Bardet-Biedl syndrome (BBS) is a rare autosomal recessive genetic disorder. It is a congenital ciliopathy that has primary and secondary characteristics. Primary clinical features include rod-cone dystrophy, polydactyly, central obesity, genital abnormalities and mental retardation often presenting as learning difficulties. Secondary clinical features include developmental delay, speech deficit, brachydactyly/syndactyly, dental defects, ataxia, olfactory deficit, diabetes mellitus (DM) and congenital heart disease. BBS patients are friendly with a happy predisposition. Proper management, and regular examinations should be done in order to maintain healthy organ function and to avoid an early death. Renal failure is the most common cause of mortality in BBS patients.This case report illustrates the evaluation of a child with BBS, as well as the unique association of otolaryngologic symptoms and bronchopneumonia with it.

Diphenoxylate-atropine (Lomotil) Toxicity in Infantile Diarrhea: A Case Report of Therapeutic Failure.

Diphenoxylate-atropine (Lomotil) intoxication incidence was significantly high in the past, but seeing such cases in the present day of modern and advanced medicine, hints about the gaps in the practice of medicine. In our case, a general physician maltreated an infant for diarrhea with an adult dose of diphenoxylate-atropine (Lomotil), a Food and Drug Administration (FDA) unapproved drug, which caused labored breathing and pinpoint pupils. After being maltreated, at the time of presentation to the emergency room (ER), she was being misdiagnosed as a case of dehydration until doctors noticed miosis and reached the diagnosis of diphenoxylate-atropine (Lomotil) toxicity. Her condition completely reversed with a single dose of naloxone. Hence, this case highlights the need for basic knowledge about the dosage of drugs for different age groups, especially infants, along with the importance of adherence to the evaluation protocols for accurate management.

Opioids Use and Abuse: Prescription Practice, Attitude, and Beliefs among Doctors of Karachi.

Background Opioid analgesics, also known as narcotics, are medicinal drugs used primarily for the management of pain secondary to any type of cancer, severe injury or surgery. Due to the ease of availability, opioids are commonly abused. In 2015, reported deaths exceeded 33,000 Americans from opioid overdose. A survey in 2013 revealed nearly 1.6 million Pakistanis abusing prescription opioids for non-medical needs. Although commonly prescribed by primary care physicians, most of them are diffident to stand by all the recommended strategies to reduce the incidence of opioid abuse. Methods A cross-sectional study was conducted during the period of August through October 2018. A sample size of 365 was determined using a 95% confidence interval at a degree of precision of 5%. A 22-item questionnaire was given to doctors with at least two years practicing experience either from a private or a public healthcare setup. Doctors who had never prescribed opioids were excluded from the study. Out of the eligible participants, 15 refused to take part in the survey, and the co-operation rate was recorded as 95.8%. Collected data were analyzed using statistical package for social science (SPSS) version 22 for Windows. Frequencies, percentages, mean, standard deviation, and chi-square were used to explore the variables. The statistical significance level was considered at p < 0.5. Results Opioids were reported to be used mainly for treating acute pain (40.5%), chronic pain (24.7%) and both acute and chronic (34.8%). A minority of doctors (29%) screened their patients for opioid addiction. A significant association (p = 0.000) between the frequency of opioid prescription and prior screening for depression was determined. Surprisingly, only 23.2% clinicians frequently screened their patients for depression before prescribing opioids. The rate of counselling regarding drug tapering was found to be 71.6%. A majority, i.e., 88%, of the respondents anticipated the misuse of opioids they prescribe whereas 74% also held a belief that patients self-medicate their untreated pain. Participants reported addiction (54%) as the most common reason for abuse followed by the role of pharmaceutical companies (43%) and pharmacies (41%). About 80.2% clinicians believed that patients addicted to opioids could get well and return to their daily routine. Conclusion The rising opioid epidemic is a major concern for doctors prescribing opioids. Adaptation of medical school curricula and appropriate training can equip doctors for better management of patients requiring opioids. This includes the screening of patients using standard risk assessment tools for opioid abuse leading to a more controlled opioid prescription practice. Dissemination of these tools will boost doctors' confidence and may help in reducing morbidity and mortality from opioid abuse.

Recognition of Antibiotic Resistance in Spontaneous Bacterial Peritonitis Caused by Escherichia coli in Liver Cirrhotic Patients in Civil Hospital Karachi.

Introduction Spontaneous bacterial peritonitis (SBP) is the most common life-threatening infection in patients with ascites due to liver cirrhosis. The infection is most commonly caused by the bacterium Escherichia coli, commonly referred to as E. coli. Over the past few years, the incidence of antimicrobial resistance against E. coli has risen drastically, leading to increased morbidity and mortality. Methods This cross-sectional study was conducted to determine the pattern of resistance using variations of antibiotics against E. coli, to prevent its empirical usage and initiate an appropriate target antibiotic therapy. The data were collected from May 2017 to October 2017 and included a total of 184 patients. The patients had previously been diagnosed with chronic liver disease and had presented with E. coli-induced SBP in the medicine wards at Civil Hospital, Karachi, which is the largest tertiary care hospital in the city. All participants underwent diagnostic paracentesis, and the ascitic fluid samples were sent to labs for culture and sensitivity to antibiotics. Results The sample population consisted of 184 participants, of which two-thirds (63.6%; n=117/184) of the population consisted of males. The mean age of the participants was 47.6±10.7 years. More than half of the patients had hepatitis C (54.9%; n=101/184) while the remaining were diagnosed with hepatitis B (45.1%; n=83/184). The ascitic fluid showed varying percentages of resistance for drugs, with no resistance to imipenem and meropenem while ciprofloxacin showed the highest resistance in eradicating the bacterium, E. coli. Additionally, a statistical correlation was tested between drug resistance and factors like age, gender, duration of liver disease, and duration of ascites. Ciprofloxacin and tetracycline showed a positive correlation between the resistance of these drugs and the age, gender, and duration of chronic liver disease in the participants while trimethoprim/sulfamethoxazole, amoxicillin/clavulanic acid, and piperacillin/tazobactam showed a positive association with the duration of ascites. Conclusion A rapid diligent intervention of cirrhotic patients with complicated ascites is crucial to alleviate patient mortality. Due to the rising bacterial resistance, primarily, epidemiological patterns should be assessed and analyzed in our regional hospitals, and then, antibiotics should be prescribed meticulously.