Association between body mass index (BMI) and severity of coronary artery disease in young onset acute coronary syndrome (ACS)

Funding Acknowledgements

Type of funding sources: None.

Background

A high body mass index (BMI) is seems to be associated with an increased incidence of coronary artery disease. If the affected person is young, the consequences are more tragic. There are variable information on the relation of incidence and severity of coronary artery disease in high BMI populations. We have examined the association between BMI and severity of coronary artery disease in young onset Acute Coronary Syndrome (ACS).

Methods

In this prospective observational study a total number of 150 patients, aged ≤45 years presented with acute coronary syndrome were enrolled to analyze association between Body Mass Index (BMI) and severity of coronary artery disease.

Results

The mean BMI in male was 24.6±3.6 and the mean BMI in female was 25.4±3.3. Among the 150 patients, 2(1.3%) was underweight, 78(52%) was normal, 60(40%) was overweight & 10(6.7%) was obese. All underweighted patients were diagnosed as STEMI. Among the normal BMI patients, 18(23.1%) had UA, 12(15.4%) had NSTEMI & 48 (61.5%) had STEMI. Among the overweight patients, 23(38.3%) had UA, 9(15%) had NSTEMI & 28(46.7%) had STEMI. And among the obese patients, 4(40%) had UA, 1 (10%) had NSTEMI & 5(50%) had STEMI. Considering involving coronary artery, left main coronary artery involvement was 0(0%), 6 (7.7%), 5 (8.3%) & 0(0%) in underweight, normal, overweight & obese patients respectively. Left anterior descending coronary artery involvement was 2(100%), 54 (69%), 45 (75%) & 7 (70%) in underweight, normal, overweight & obese patients respectively. Left circumflex coronary artery involvement was 1(50%), 33 (42%), 25 (41.7%) & 1 (9%) in underweight, normal, overweight & obese patients respectively. And right coronary artery involvement was 1(50%), 35 (44.9%), 31 (51.7%) & 5 (50%) in underweight, normal, overweight & obese patients respectively. In underweight patients 1(50%) had SVD and 1 (50%) had TVD. In normal BMI patients 40 (51.3%) had SVD, 11(14.1%) had DVD and 19 (24.4%) had TVD. In overweight patients 27 (45%) had SVD, 15 (25%) had DVD and 13 (21.7%) had TVD. And in obese patients 5 (50%) had SVD, 3(30%) had DVD and 0 (0%) had TVD. In all BMI group SVD was more common.

Conclusion

There is no statistically significant differences in severity of coronary artery in respect to body mass index (BMI), in patients presented with acute coronary syndrome.

1186 IMPROVED PERFORMANCE AGAINST SSNAP PARAMETERS FOR THROMBOLYSED STROKE PATIENTS FOLLOWING CHANGES IN PRACTICE

Background

The CQC inspection of the Royal Lancaster Infirmary (RLI) in May 2021 rated the performance of the stroke department unsatisfactory, leading to a number of changes. A retrospective audit was performed to determine the impact of these changes for thrombolysed stroke patients.

Aim

This retrospective audit assessed the performance of the stroke department at the RLI against the parameters set by the ‘Sentinel Stroke National Audit Program’ (SSNAP), comparing 6-month periods before and after the CQC inspection in May 2021.

Method

Using electronic medical records and SSNAP data, we reviewed every thrombolysed stroke patient at the RLI between November 2020 until April 2021 and from May 2021 until November 2021, assessing 10 parameters and comparing the results with SSNAP targets. Since May 2021, changes to practice introduced included opening a new, larger stroke unit located directly opposite the Emergency Department, ring-fencing stroke beds, doubling the number of stroke specialists and stroke consultants reviewing all suspected stroke patients face-to-face within working hours.

Results

46 patients were thrombolysed with 42 confirmed as having had ischaemic strokes on subsequent MRI imaging. All patients were discussed with a stroke consultant before thrombolysis. Mean time from arrival to CT improved from 51 to 34.5 minutes, admission to stroke unit from 7hr53 to 4hr36 and to thrombolysis from 2hr18 to 1hr22. The number of thrombolysis complications decreased from 5 to 2. Since the changes, the SSNAP grade for stroke unit admission improved from C to A and specialist assessments from E to B.

Conclusion

The changes implemented following the May 2021 CQC inspection have had a positive impact on the care of thrombolysed stroke patients and overall SSNAP grades at RLI. Improvements are still required and the next steps include improving the efficiency of thrombolysis times and further improving SSNAP grades.

The Frequency of Refractory Status Epilepticus and Its Outcome in a Tertiary Care Hospital in Pakistan: A Retrospective Study

Background

Refractory status epilepticus (RSE) is a common neurologic emergency with refractory cases leading to increased rates of morbidity and mortality in patients. The lack of previous studies on the incidence, causes, and management of refractory status epilepticus in the pediatric population from our region prompted us to investigate further in this study.

Methods

We included retrospective data of all patients admitted to the pediatric intensive care unit (PICU) with a provisional diagnosis of RSE at a tertiary care hospital in Karachi from February 2019 to February 2021. No personal identification data was used, and confidentiality of the data was maintained throughout the analysis. The Statistical Package for the Social Sciences (SPSS) software version 22.0 (IBM SPSS Statistics, Armonk, NY, USA) was used to pool data and perform a descriptive analysis.

Results

Among the 687 patients who presented to the PICU with seizures, 50 (7.27%) patients were eventually diagnosed with RSE during the two-year period. The majority of the patients were male and less than one year of age. Infectious causes predominated our data cohort, and a four-drug regimen consisting of phenytoin, levetiracetam, valproic acid, and midazolam was able to terminate RSE in the majority of the patients in our setting (70%). The mortality rate was noted to be 22% among patients with RSE.

Conclusion

Morbidity and mortality among pediatric RSE patients are high in our settings. Urgent emergency services and timely cause-directed intervention could improve outcomes.

Factors associated with loss of motivation and hesitation to work amongst frontline health care providers during the COVID-19 pandemic: A cross-sectional survey from a developing country

Background

The COVID-19 took over the world in 2020 and a lockdown has been imposed seeing its fast spread. Frontline health care workers (HCWs) were reported frequently with a lack of motivation, hesitancy and unwillingness to perform their duties during this pandemic. This cross-sectional survey aims to evaluate the factors associated with lack of motivation and increased hesitancy among the frontline HCWs to perform their duties during COVID-19 pandemic.

Materials and methods

A total of 239 HCWs were included in this web-based cross-sectional study, who have worked during the COVID-19 pandemic. The anonymous online questionnaire was sent to all faculty, trainees and staff of Aga Khan University Hospital in Karachi, Pakistan. The survey was conducted from September 2020 to January 2021 during the COVID-19 pandemic. All data was exported into Statistical Package for Social Sciences Version 19 for multivariate analysis.

Results

The risk of getting infected was strongly reported by 180 participants, and it was associated with higher hesitation to work (aOR = 6.09 [2.55–14.59]). Fifty-one participants felt that lack of knowledge about prevention and protection was associated with lower motivation to work (aOR = 0.66 [0.35–1.25]). Participants reported higher hesitation due to the burden of changed quality of work, physical exhaustion, mental exhaustion and altered sleep patterns. Sense of feeling protected by their hospitals was a motivating factor, and participants receiving adequate support reported higher motivation to work (aOR = 2.60 [1.32–5.14]).

Conclusion

Fear of infection, increased working hours, and inadequate support of the workplace played a key role in escalating the hesitancy among HCWs to perform their duties. Lack of disease knowledge and paucity of personal protective equipment further lowered the motivation levels of HCWs to work effectively during the COVID-19 pandemic.

•

The COVID-19 took over the world in 2020 and a lockdown has been imposed seeing its fast spread. Frontline health care workers (HCWs) were reported frequently with a lack of motivation, hesitancy and unwillingness to perform their duties during this pandemic.

•

This cross-sectional survey aims to evaluate the factors associated with lack of motivation and increased hesitancy among the frontline HCWs to perform their duties during COVID-19 pandemic.

•

Fear of infection, increased working hours, and inadequate support of the workplace played a key role in escalating the hesitancy among HCWs to perform their duties.

Voxelotor versus other therapeutic options for sickle cell disease: Are we still lagging behind in treating the disease?

Background

Objectives

Discussion & Conclusion

Comparison of Quality of Life of Medical Students in Annual and Modular System in Public Sector Medical Colleges in Karachi, Pakistan

Background: The annual system is regarded as the oldest but foundational trends of teaching, with its curriculum based on subject wise learning and clinical rotations accordingly. The modular system has a curriculum that encompasses modules based on different organ systems and processes, with the basic and clinical sciences taught cohesively. Methods: A cross-sectional study was carried out, including 404 students of three different public sector medical colleges in Karachi. QoL was measured using the WHOQOL-BREF questionnaire, which comprised of 26 items. Data analysis was done via SPSS v.20. Kruskal Wallis test and Mann-Whitney U test was used to compare scores among different years of medical study and between different curricular systems, respectively. Results: Out of 404 students, 81.3% were females, 18.3% were males. The mean age of the sample was 21.23±1.29 years. According to the year of study, significant differences were observed in physical health and overall QoL domain (p<0.05), with 3rd-year students having the highest scores. When comparing annual and modular systems, the modular system yielded a better QoL with a mean score of 83.34. The overall QoL of students in clinical years was found to be significantly better (p<0.05) than the students present in preclinical years. Conclusion: Overall QoL score in the modular system was slightly higher than the annual system, but a significant difference was noted only in the environmental domain between the two systems. It was also noted that the QoL of students in clinical years was better than preclinical years.

Perception, Willingness, Barriers, and Hesitancy Towards COVID-19 Vaccine in Pakistan: Comparison Between Healthcare Workers and General Population

Background Vaccine hesitancy has been a huge challenge in controlling preventable diseases. With the emergence of coronavirus disease 2019 (COVID-19) vaccines, it is vital to know their acceptance rates among the masses. No comparative data is available on the current subject from Pakistan yet. Therefore, this study aimed to evaluate the acceptance of a potential COVID-19 vaccine among the general population and healthcare workers (HCWs) of Pakistan, along with their perceptions and barriers to acceptance. Methods An online cross-sectional study was carried out in Pakistan from December 19, 2020, to January 10, 2021, using convenience sampling. A self-administered questionnaire consisting of 31 items was distributed after informed consent. Inclusion criteria consisted of HCWs and non-HCWs (general population) aged 18 years and above, residing in Pakistan. All analyses were done using Statistical Package for Social Sciences (SPSS) version 23.0 (IBM Corp., Armonk, NY, USA). Chi-square and T-test were used and a p-value of less than 0.05 was considered significant for all cases. Results Of the 404 respondents (n=196 general population and n=208 HCWs), 73.5% were willing to get a proven, safe, and effective COVID-19 vaccine if it was free of cost. This was reduced to only 64.3% if the vaccine was not free and had to be paid for. A total of 168 (41.6%) participants agreed to get vaccinated immediately, while 149 (36.9%) participants concurred to get it on a delayed basis. Eighty-seven (21.5%) participants refused to receive the COVID-19 vaccine, amongst which a significant majority (p<0.001) of the participants were from the general population. Doctors or scientists/scholarly journals were found to be the most trusted source of information (67.6%; n=273), while fear of unknown side effects (45.5%; n=184) was found to be the most common barrier towards COVID-19 vaccination. More than half (53.5%) participants believed that the vaccine is safe, effective, and has minimal side effects, amongst which a significantly large fraction (p<0.001) belonged to the HCWs. Conclusion The acceptance rate of a safe, effective, proven, and free COVID-19 vaccine was 73.5%. The fear of unknown side effects was the most common barrier to COVID-19 vaccine uptake. The general population demonstrated less knowledge, more false perceptions, and barriers to COVID-19 vaccine. Adequate measures should be taken to educate the masses about the COVID-19 vaccine, and its safety, and further studies are required.

Rare Case of Budd-Chiari Syndrome in a Young Child: A Diagnostic Conundrum

Budd-Chiari syndrome (BCS) is an uncommon vascular disorder in which venous thrombosis prevents the venous outflow of the liver. The obstruction is primarily at the level of hepatic veins and inferior vena cava. Here, we present a case of a two-and-a-half-year-old male child who presented with complaints of abdominal distension for two months and fever and watery diarrhea for one month. Physical examination showed the patient was anemic with palmar erythema. He was started on an empirical treatment of cefotaxime, metronidazole, and amikacin. Sensitivity and culture reports for blood and urine samples were negative, but abdominal computed tomography (CT) scan showed characteristic findings for BCS with caudate lobe hypertrophy. After the symptomatic treatment of the patient, a liver transplant was suggested as a last resort.

Cardiac manifestations of the coronavirus disease-19: a review of pathogenesis, clinical manifestations, diagnosis, and treatment

The coronavirus disease-19 (COVID-19), first appearing in Wuhan, China, and later declared as a pandemic, has caused serious morbidity and mortality worldwide. Severe cases usually present with acute respiratory distress syndrome (ARDS), pneumonia, acute kidney injury (AKI), liver damage, or septic shock. However, with recent advances in severe acute respiratory syndrome-coronavirus-2 (SARS-CoV-2) research, the virus´s effect on cardiac tissues has become evident. Reportedly, an increased number of COVID-19 patients manifested serious cardiac complications such as heart failure, increased troponin, and N-terminal pro-B-type natriuretic peptide levels (NT-proBNP), cardiomyopathies, and myocarditis. These cardiac complications initially present as chest tightness, chest pain, and heart palpitations. Diagnostic investigations such as telemetry, electrocardiogram (ECG), cardiac biomarkers (troponin, NT-proBNP), and inflammatory markers (D-dimer, fibrinogen, PT, PTT), must be performed according to the patient´s condition. The best available options for treatment are the provision of supportive care, anti-viral therapy, hemodynamic monitoring, IL-6 blockers, statins, thrombolytic, and anti-hypertensive drugs. Cardiovascular disease (CVD) healthcare workers should be well-informed about the evolving research regarding COVID-19 and approach as a multi-disciplinary team to devise effective strategies for challenging situations to reduce cardiac complications.

Clinical Presentation, Management and In-Hospital Outcome of COVID-19 among Non-Healthcare Personnel and Healthcare Personnel in a Tertiary Cardiac Care Hospital

The huge numbers of non-healthcare personnel (non-HCP) who get infected by corona virus disease 2019 (COVID-19) not only paralyze health care systems but also put health care personnel (HCP) at potential risk globally. Objective of the study was to compare the Healthcare personnel (HCP) and non-HCP COVID-19 cases. This prospective observational study was carried out in National Heart Foundation Hospital and Research Institute of Bangladesh from March 08, 2020 to July 20, 2020. During this study period all admitted non-HCP who subsequently was diagnosed as COVID-19 positive by rRT-PCR and HCP of this hospital, who experienced fever or respiratory symptoms or came in close contact with COVID-19 patients at home or their workplace and become COVID-19 positive, were included. Out of 320 infected patients, 181(56.6%) patients were non-HCP and 139(43.4%) were HCP. Non-HCP were older than HCP (Mean age: 52.95±13.82 years vs. 34.08±11.11 years; p=0.001). Non-HCP were predominantly male and HCP were predominantly female (73.5% vs. 41% & 26.5% vs. 59%; p=0.001). Non-HCP had more risk factors and co-morbidities than HCP (p=0.001). Typical symptoms of COVID-19 such as fever and cough were prevalent in HCP. More aggressive treatment was required for non-HCP. Non-HCP had more severe disease and higher case fatality rate (9.4% vs. 0.7%; p=0.001) than HCP. Disease severity (OR 0.03, 95% CI 0.01-0.15) and DM (OR 0.09, 95% CI 0.01-0.94) were the independent predictor of mortality. Non-HCP was older in age, predominantly male and had more co-morbidities than HCP. Typical symptoms of COVID-19 were prevalent in HCP. Non-HCP had more severe disease and higher case fatality rate than HCP.

Restless Leg Syndrome in Patients with Liver Cirrhosis! Its Frequency, Severity, and Correlation

BACKGROUND

Restless leg syndrome (RLS) has been recognized as a typical additional manifestation among patients with cirrhosis of the liver. RLS prevalence in liver cirrhosis further worsens the quality of life, which has already been compromised with the disease-related complications of cirrhosis itself.

AIMS

The study aimed to determine the frequency and severity of Restless Leg Syndrome (RLS) among patients with cirrhosis of the liver and to correlate its severity with the severity of cirrhosis.

METHODS

This prospective cross-sectional study was carried out at Ruth K.M. Pfau Civil Hospital (Karachi, Pakistan) from December 2019 to February 2020. Three hundred and fifteen cirrhotic patients with any etiology were included in the study after informed written consent. Restless leg syndrome with its severity was determined in all cirrhotic patients. For continuous variables, means and medians with standard deviations were calculated, while percentages and proportions were used for discrete variables. Spearman correlation was used to find significance between RLS Severity Score (RSS) and Model of End-stage Liver Disease MELD Score. A p value of < 0.05 was considered significant for all analyses.

RESULTS

The frequency of RLS among cirrhotic patients was 38.4%. More than half (54.5%) of the patients had severe RLS. Viral related hepatitis C and hepatitis B were the most common cause of cirrhosis of the liver (57.8% and 30.8%). A significant difference was found between as patients both with or without RLS in terms of age (p=0.003), gender (p=0.005), hemoglobin (p=0.00), and serum albumin (p=0.01). No significant association was found between RLS severity score and MELD Score (p=0.693).

CONCLUSION

Prevalence of RLS is very high among cirrhotic patients, but no correlation was found between the severity of RLS and cirrhosis. Further studies should be carried out to assess the quality of life in cirrhotic patients having RLS.

Use of Tocilizumab in COVID-19: A Systematic Review and Meta-Analysis of Current Evidence

Background and objectives A flare-up in coronavirus disease 2019 (COVID-19) cases threatens the health of people, and though there is no proven pharmacological treatment, many analytical studies have suggested that interleukin-6 (IL-6) levels are elevated in cases of severe COVID-19 and that the anti-IL-6 biologic agent tocilizumab may be beneficial. This is a critical review of studies aiming to assess the safety and efficacy of tocilizumab as compared to the standard regimen in patients with COVID-19. Materials and methods Online databases (PubMed and Cochrane) were searched until June 29, 2020, for original articles investigating the immunological response in COVID-19 and its treatment with tocilizumab. Data on multiple baseline characteristics and pre-specified endpoints were extracted and pooled using a random effect model. We used Review Manager version 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, 2014, Denmark) and Stata 11.0 (Stata Corporation LP, College Station, TX) for all analyses. Risk ratios (RR) and the weighted mean difference (WMD) with the corresponding 95% confidence interval (CI) were calculated. Results From a total of 1,246 identified articles, 13 studies were included after duplicate removal and narrowing based on title and abstract. Of the 13 included studies, seven case-control studies were shortlisted for meta-analysis (quantitative) and six-single arm studies were used in the discussion (qualitative). These studies had 766 patients (351 in the tocilizumab arm and 414 in the control arm). Their pooled analysis demonstrated that mortality was significantly lower in the tocilizumab group (RR=0.56 [0.34, 0.92]; p=0.02; I2=76%), as was the need for artificial invasive ventilation (RR=0.34 [0.12, 0.99]; p=0.05; I2=0%) as compared to the control group. No significant differences were observed between tocilizumab and control group in intensive care unit admissions (RR=0.73 [0.15, 3.59]; p=0.70; I2=60%) and risks of post-drug infection (RR=1.29 [0.41, 4.04]; p=0.66; I2=88%). In terms of efficacy outcome, improved oxygen saturation (RR=1.13 [1.04, 1.65]; p=0.02; I2=0%) was reported to be markedly significant in tocilizumab patients when compared with the standard care group. Conclusions Our results based on pooled studies show tocilizumab to be safe and efficacious in reducing mortality among critically ill COVID-19 patients. However, due to the limited number of observational studies, the positive findings should be viewed cautiously and warrant further investigation.

Prophylactic Mesh Placement for the Prevention of Incisional Hernia in High-Risk Patients After Abdominal Surgery: A Systematic Review and Meta-Analysis

Background and objectives

In high-risk populations, the efficacy of mesh placement in incisional hernia (IH) prevention after elective abdominal surgeries has been supported by many published studies. This meta-analysis aimed at providing comprehensive and updated clinical implications of prophylactic mesh placement (PMP) for the prevention of IH as compared to primary suture closure (PSC).

Materials and methods

PubMed, Science Direct, Cochrane, and Google Scholar were systematically searched until March 3, 2020, for studies comparing the efficacy of PMP to PSC in abdominal surgeries. The main outcome of interest was the incidence of IH at different follow-up durations. All statistical analyses were carried out using Review Manager version 5.3 (The Nordic Cochrane Centre, The Cochrane Collaboration, 2014) and Stata 11.0 (Stata Corporation LP, College Station, TX). The data were pooled using the random-effects model, and odds ratio (OR) and weighted mean differences (WMD) were calculated with the corresponding 95% confidence interval (CI).

Results

A total of 3,330 were identified initially and after duplicate removal and exclusion based on title and abstract, 26 studies comprising 3,000 patients, were included. The incidence of IH was significantly reduced for PMP at follow-up periods of one year (OR= 0.16 [0.05, 0.51]; p=0.002; I²=77%), two years (OR= 0.23 [0.12, 0.45]; p<0.0001; I²=68%), three years (OR= 0.30 [0.16, 0.59]; p=0.0004; I²= 52%), and five years (OR=0.15 [0.03, 0.85]; p=0.03; I²=87%). However, PMP was associated with an increased risk of seroma (OR=1.67 [1.10, 2.55]; p= 0.02; I²=19%) and chronic wound pain (OR=1.71 [1.03, 2.83]; p= 0.04; I²= 0%). No significant difference between the PMP and PSC groups was noted for postoperative hematoma (OR= 1.04 [0.43, 2.50]; p=0.92; I²=0%), surgical site infection (OR=1.09 [0.78, 1.52]; p= 0.62; I²=12%), wound dehiscence (OR=0.69 [0.30, 1.62]; p=0.40; I²= 0%), gastrointestinal complications (OR= 1.40 [0.76, 2.58]; p=0.28; I²= 0%), length of hospital stay (WMD= -0.49 [-1.45, 0.48]; p=0.32; I²=0%), and operating time (WMD=9.18 [-7.17, 25.54]; p= 0.27; I²=80%).

Conclusions

PMP has been effective in reducing the rate of IH in the high-risk population at all time intervals, but it is associated with an increased risk of seroma and chronic wound pain. The benefits of mesh largely outweigh the risk, and it is linked with positive outcomes in high-risk patients.

Giant Leiomyosarcoma Arising in Posterior Thigh: Management of a Rare Case

Leiomyosarcoma, primarily a tumor of smooth muscle origin, frequently originates from the uterus, retroperitoneum, and intra-abdominal region. Rarely, the tumor may arise from the conjunctiva, inferior vena cava, or oral cavity. Here we report a case of a 65-year-old male patient who presented with a swelling in the posterior thigh for six months. The swelling was progressively increasing in size for the last two months. Examination of thigh showed a swelling of 20×30 cm in size, which was firm, non-compressible, immobile, and not transilluminating. CT scan showed no metastasis in the liver, lung, or bone. The histopathology report showed poorly differentiated leiomyosarcoma involving the muscles of the posterior compartment of the left thigh. The tumor was resected, and the patient was referred to rehabilitation clinic. Early diagnosis of such cases is essential to improve the outcome in patients as these tumors can metastasize early.

COVID-19 and Liver Injury: A Systematic Review and Meta-Analysis

Background and Aims The prevalence and extent of liver damage in coronavirus disease 2019 (COVID-19) patients remain poorly understood, primarily due to small-sized epidemiological studies with varying definitions of "liver injury". We conducted a meta-analysis to derive generalizable, well-powered estimates of liver injury prevalence in COVID-19 patients. We also aimed to assess whether liver injury prevalence is significantly greater than the baseline prevalence of chronic liver disease (CLD). Our secondary aim was to study whether the degree of liver injury was associated with the severity of COVID-19. Materials and Methods Electronic databases (PubMed and Scopus) were systematically searched in June 2020 for studies reporting the prevalence of baseline CLD and current liver injury in hospitalized COVID-19 patients. Liver injury was defined as an elevation in transaminases >3 times above the upper limit of normal. For the secondary analysis, all studies reporting mean liver enzyme levels in severe versus non-severe COVID-19 patients were included. A random-effects model was used for meta-analysis. Proportions were subjected to arcsine transformation and pooled to derive pooled proportions and corresponding 95% confidence intervals (CIs). Subgroup differences were tested for using the chi-square test and associated p-value. Means and their standard errors were pooled to derive weighted mean differences (WMDs) and corresponding 95% CIs. Results Electronic search yielded a total of 521 articles. After removal of duplicates and reviewing the full-texts of potential studies, a total of 27 studies met the inclusion criteria. Among a cohort of 8,817 patients, the prevalence of current liver injury was 15.7% (9.5%-23.0%), and this was significantly higher than the proportion of patients with a history of CLD (4.9% [2.2%-8.6%]; p < 0.001). A total of 2,900 patients in our population had severe COVID-19, and 7,184 patients had non-severe COVID-19. Serum ALT (WMD: 7.19 [4.90, 9.48]; p < 0.001; I2 = 69%), AST (WMD: 9.02 [6.89, 11.15]; p < 0.001; I2 = 73%) and bilirubin levels (WMD: 1.78 [0.86, 2.70]; p < 0.001; I2 = 82%) were significantly higher in patients with severe COVID-19 when compared to patients with non-severe disease. Albumin levels were significantly lower in patients with severe COVID-19 (WMD: -4.16 [-5.97, -2.35]; p < 0.001; I2 = 95%). Conclusions Patients with COVID-19 have a higher than expected prevalence of liver injury, and the extent of the injury is associated with the severity of the disease. Further studies are required to assess whether hepatic damage is caused by the virus, medications, or both.

Epidemiological and Clinical Features of SARS-CoV-2: A Retrospective Study from East Karachi, Pakistan

Background

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has spread to almost every country on the globe, and each country is reporting the symptomatic presentation of their patients to give better insight into the various clinical presentations of SARS-CoV-2. However, the epidemiological literature from Pakistan is scanty.

Methods

We retrospectively analyzed data from 412 patients who were residents of East Karachi and tested positive for SARS-CoV-2 between February 26 to April 24, 2020. Patients' demographics, symptoms, travel and contact history, and outcomes were recorded. All statistical analysis was performed using the Statistical Package for the Social Sciences (SPSS) version 22 (IBM SPSS Statistics for Windows, IBM Corp, Armonk, NY).

Results

Most of the patients were male (64.6%), the majority (43.3%) belonging to the 21- to 40-year age group. Most of the patients (65.5%) were residents of Gulshan Iqbal. A total of 15.8% of the patients were admitted to the hospital, and 3.9% of patients expired. The three most common presenting symptoms were fever (74.8%), cough (60.4%), and flu (35.5%). The majority of patients (89.3%) gave a history of contact with SARS-CoV-2 patients.

Conclusion

The number of SARS-CoV-2 cases is rapidly increasing in Karachi, Pakistan. There is a need to educate the population about the most common sign and symptoms of the virus so that individuals can identify these symptoms and get themselves tested. The concerned authorities should devise an adequate and effective plan to flatten the infectivity curve.

Availability of Personal Protective Equipment (PPE) Among US and Pakistani Doctors in COVID-19 Pandemic

Background

The coronavirus disease (COVID-19) pandemic has put an excessive strain on healthcare systems across the globe, causing a shortage of personal protective equipment (PPE). PPE is a precious commodity for health personnel to protect them against infections. We investigated the availability of PPE among doctors in the United States (US) and Pakistan.

Methods

A cross-sectional study, including doctors from the US and Pakistan, was carried out from April 8 to May 5, 2020. An online self-administered questionnaire was distributed to doctors working in hospitals in the US and Pakistan after a small pilot study. All analysis was done using Statistical Package for Social Science (SPSS) version 23.0 (IBM Corp., Armonk, NY).

Results

After informed consent, 574 doctors (60.6% from Pakistan and 39.4% from the US) were included in the analysis. The majority of the participants were females (53.3%), and the mean age of the participants was 35.3 ± 10.3 years. Most doctors (47.7%) were from medicine and allied fields. Among the participants, 87.6% of doctors from the US reported having access to masks/N95 respirators, 79.6% to gloves, 77.9% to face-shields or goggles, and 50.4% to full-suit/gown. Whereas, doctors in Pakistan reported to have poor availability of PPE with only 37.4% having access to masks/N95 respirator, 34.5% to gloves, 13.8% to face-shields or goggles, and 12.9% to full-suit/gown. The reuse of PPE was reported by 80.5% and 60.3% physicians from the US and Pakistan, respectively. More doctors from Pakistan (50.6%) reported that they had been forced to work without PPE compared to doctors in the US (7.1%).

Conclusion

There is a lack of different forms of PPE in the US and Pakistan. Doctors from both countries reported that they had been forced to work without PPE. Compared to the US, more doctors from Pakistan reported having faced discrimination in receiving PPE.

Cardiac Manifestations of Coronavirus Disease 2019 (COVID-19): A Comprehensive Review

Since its origin in China, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has become a pandemic and spread to 209 countries. As coronavirus disease 2019 (COVID-19) is a very rapidly emerging disease, organ-specific studies related to it have been reported. Apart from respiratory findings, some studies have highlighted inflammatory consequences in the heart, kidney, and/or liver as well. Cardiac involvement in COVID-19 seems to be a result of an inflammatory storm in response to the infection. Moreover, direct viral invasion of cardiomyocytes, as well as a myocardial injury due to oxidative stress, may account for acute cardiac injury in COVID-19. Nevertheless, the mechanism of heart injury in COVID-19 is not clear yet. However, multiple studies that highlight the clinical features, laboratory findings, and prognosis of acute myocardial injury (AMI) in COVID-19-affected individuals have been published. In this review, we have summarized the findings of all those studies as well as the clinical features and management of cardiac injury discussed by some case reports.

Young-onset Amyotrophic Lateral Sclerosis with Rare Skin Manifestation: Case Report and Literature Review

Amyotrophic lateral sclerosis (ALS) is one of the most common motor neuron diseases (MND), which presents as muscle weakness, atrophy, spasticity, and, in extreme cases, may result in death due to respiratory failure. ALS has been reported with dermatological conditions such as bullous pemphigoid and decreased collagen. Hyperpigmentation usually occurs due to underlying adrenal or metabolic disorder, but no case of hyperpigmentation has been associated with MND. We report a case of a 25-year-old man who presented with signs of young-onset ALS (progressive weakness of both upper limbs) with hyperpigmentation of limbs. The patient did not have any other underlying etiology, which could have led to the development of hyperpigmentation Biopsy was negative for polymyositis and dermatomyositis. The patient was counseled about the nature of the disease and was advised regular follow-ups.

Accuracy of Pediatric Risk of Mortality (PRISM) III Score in Predicting Mortality Outcomes in a Pediatric Intensive Care Unit in Karachi

Background

With the advancements in medicine and increasing access to modern technology, pediatric intensive care units (PICU) are becoming a vital part of any health care setting. PICUs play a key role in saving the life of young patients. Various scales have been designed by researchers to aid in predicting the mortality of a patient admitted in PICU. Pediatric Risk of Mortality (PRISM) and Pediatric Index of Mortality (PIM) are among the most commonly used scales. Calculating the risk of mortality enables the physicians to classify the patients and helps in identifying which patients require more urgent care and resources. 

Methods

A hospital-based prospective study was carried out at PICU in a tertiary care hospital in Karachi from December 2017 to June 2019. All patients between the age of one month and 12 years were included in our study after informed consent from parents/guardians. A standard questionnaire was used and the PRISM III score was calculated at 24 hours of admission. All necessary investigations were carried out, and all statistical analyses were carried out using SPSS v.23 (IBM, Armonk, NY).

Results

A total of 407 patients were included in our study with the majority being males (54.5%). The mean age was 27±33 months. The mean duration of stay of patients in PICU was 80.15±36.58 hours. The mortality rate in our study was 37.35 % (n=152). The need for mechanical ventilation, use of inotropic drugs, higher temperatures, and low Glasgow Coma Scale scores were associated with poor survival. It was noted that as the PRISM III score increased, the mortality rate also increased. In our study, we found that PRISM III had good predictive power in our population. The area under the curve was 0.903±0.016 (p<0.001, 95% confidence interval: 0.872-0.934).

Conclusions

PRISM III score showed excellent accuracy and predictive ability in our population. There was no significant difference in observed and expected mortality rates in our study. In a resource-limited setting, the prediction models highlight the cases where more medical attention is required and also enable the physicians to assess the prognosis of the patient so adequate measures can be taken beforehand.

Neonatal Nonketotic Hyperglycinemia: A Rare Case from Pakistan

Nonketotic hyperglycinemia (NKH) is an autosomal recessive disorder caused by a defect in glycine cleavage enzyme. It leads to the accumulation of glycine in the body tissues, blood, and cerebrospinal fluid (CSF). Most NKH cases are diagnosed during the natal period of life and are fatal if not promptly diagnosed and managed. Here we present a case of a two-day-old child who presented with reluctant feeding and lethargy. She had reduced tone in all four limbs and a Glasgow Coma Scale score of 9. Keeping an infectious etiology in mind, she was started on cefotaxime and amikacin. The patient was shifted to the neonatal intensive care unit; however, no improvement in the patient's condition was seen and antibiotics were changed to linezolid and meropenem along with initiation of acyclovir. The patient's blood and CSF cultures were negative. Serum amino acid chromatography showed elevated levels of glycine, and a diagnosis of NKH was made. The patient was managed symptomatically but expired on the 22nd day of admission. The case highlights the importance of prompt diagnosis and management of aminoacidopathies. Nearly all metabolic disorders have similar clinical presentations, and an early diagnosis can improve the outcome in patients.

Compliance and Knowledge of Healthcare Workers Regarding Hand Hygiene and Use of Disinfectants: A Study Based in Karachi

Background

Hand hygiene is the cardinal step in combating various healthcare-associated infections. These infections are a cause of 37,000 deaths in Europe and 100,000 deaths in the United States annually. Thus, prevention of their spread is of utmost importance today. A study conducted in a tertiary care center in Karachi found that 17% of the medical professionals were aware of the World Health Organization (WHO) guidelines on hand hygiene while only 4.9% followed these hand-washing techniques. Lack of hand hygiene practice and awareness has raised a need to reassess infection control in hospitals. There is currently undisputed proof that adherence to hand cleanliness diminishes the danger of transmission of various infections.

Methods

A questionnaire-based cross-sectional study was conducted at Dr. Ruth K.M. Pfau Civil Hospital, Karachi in January 2019. Data from 212 participants who met the inclusion criteria were analyzed. A three-part questionnaire was used for the hospital staff who had been present at the hospital for at least six hours and had attended to the patients during the last three continuous working days. Staff members who visited the hospital but did not attend to any patients or those who had been present at the hospital for less than six hours were excluded. Collected data were analyzed using Statistical Package for Social Science (SPSS) version 23.0 (IBM, Armonk, NY).

Results

A total of 212 individuals (74 doctors, 66 nurses, 52 technicians, and 20 ward assistants) agreed to participate in our study, of which 124 were females. The compliance with hand disinfectant use before and after every patient contact was found to be 12.3%. The use of disinfectant was found to be more among males than females (mean 7.88 times for males vs. 6.20 for females) and the younger individuals were more compliant with hand hygiene practices; 62.73% of participants were aware of the WHO guidelines regarding hand hygiene and 65.56% were aware of hospital-acquired infections. However, nearly half of the participants (45.75%) had never attended a formal lecture on the subject and more than half (62.26%) of the participants were unenlightened about the complications of hospital-acquired infections.

Conclusions

Hand hygiene is a basic requirement for every medic and paramedic in a hospital setting today. Keeping in mind the drastic consequences of the spread of hospital-associated infections, it is evident that hand hygiene should be stressed upon. The rising incidence of nosocomial infections and their complications can be prevented by raising awareness about hand hygiene practices. There is a need to further investigate the application of and adherence to the basic guidelines on hand hygiene. Our results indicate that this issue should be tackled through a multidimensional approach.

Post-splenectomy Sepsis: A Review of the Literature

The spleen is an intraperitoneal organ that performs vital hematological and immunological functions. It maintains both innate and adaptive immunity and protects the body from microbial infections. The removal of the spleen as a treatment method was initiated from the early 1500s for traumatic injuries, even before the physiology of spleen was properly understood. Splenectomy has therapeutic effects in many conditions such as sickle cell anemia, thalassemia, idiopathic thrombocytopenic purpura (ITP), Hodgkin’s disease, and lymphoma. However, it increases the risk of infections and, in some cases, can lead to a case of severe sepsis known as overwhelming post-splenectomy infection (OPSI), which has a very high mortality rate. Encapsulated bacteria form a major proportion of the invading organisms, of which the most common is Streptococcus pneumoniae. OPSI is a medical emergency that requires prompt diagnosis (with blood cultures and sensitivity, blood glucose levels, renal function tests, and electrolyte levels) and management with fluid resuscitation along with immediate administration of empirical antimicrobials. OPSI can be prevented by educating patients, vaccination, and antibiotic prophylaxis. This article summarizes the anatomy and physiology of the spleen and highlights its important functions. It primarily focuses on the pathophysiology of OPSI, its current management, and prevention strategies.

Adult-onset Primary Hemophagocytic Lymphohistiocytosis: Reporting a Rare Case with Review of Literature

Hemophagocytic lymphohistiocytosis (HLH) is an uncommon, aggressive hematological syndrome. It is caused by an increased and unchecked proliferation of T lymphocytes and histiocytes. These cells secrete a large number of inflammatory cytokines and infiltrate various tissues causing multi-organ system failure. HLH may be primary or associated with different types of infections, autoimmune disorders, or malignancies. Primary or familial HLH is fatal and is frequently considered a disorder of infants and young children. Only a few cases of primary HLH have been reported in adults. We present a case of a 37-year-old man who presented with fever, pancytopenia, and hepatosplenomegaly. Lymph node biopsy showed collections of histiocytes with lymphoplasmacytic cells. After excluding all the secondary causes a final diagnosis of primary HLH was made. The patient was started on HLH-2004 protocol (etoposide, cyclosporin A, dexamethasone) along with empiric antituberculous drugs as necrotic granulomas were also noted in the biopsy. HLH has a very poor prognosis and familiarity with clinical symptoms, and diagnostic criteria can aid in timely diagnosis.

An Atypical Variant of Apple Peel Atresia: Reporting a Rare Case

Apple peel intestinal atresia is a rare congenital malformation. It consists of a proximal jejunum ending in a blind pouch and distal small bowel wrapped around its vascular supply in a spiral fashion. A combination of type IIIb jejunoileal atresia (apple peel atresia) and type IV (multiple intestinal atresias) is a rare entity. The diagnosis and management of such complicated cases is a challenge, especially in resource-limited settings. We report a case of a four-day-old female who presented to the neonatal intensive care unit with complaints of vomiting, yellow discoloration of the skin, and failure to pass meconium since birth. The baby was born preterm (34 weeks) via spontaneous vaginal delivery. The physical examination concluded a jaundiced and dehydrated child with a soft, non-tender abdomen and absent gut sounds. X-ray abdomen showed two air-fluid areas in the left hypochondrium. The upper gastrointestinal gastrografin study revealed that contrast opacified the third part of the duodenum and no contrast was observed beyond it. On exploratory laparotomy, proximal jejunal atresia with four distal atresias in apple peel fashion and a viable 20 cm of small bowel was observed. The apple peel segments were supplied by mesenteric vessels. Unfortunately, our patient expired despite all supportive measures. The case highlights the significance of the prenatal and early postnatal diagnosis of such a complex combination of intestinal atresias for adequate and timely management.

Hydatid Cyst of Spleen Presenting with Vague Symptoms: A Diagnostic Conundrum

Hydatid cysts are caused by a tapeworm Echinococcus granulosus. They usually occur in the liver. When occurring in spleen they present with vague symptoms which make it difficult for the physicians to diagnose. We present a case of a 10-year-old male who presented with fever, abdominal pain, and burning micturition along with vomiting. Abdominal exam revealed no visceromegaly. Abdominal ultrasound (US) and computed tomography (CT) scan showed multiple hypoechoic and hypo-dense areas, respectively. Splenic abscess, abdominal tuberculosis (TB), pyelonephritis and malignancy were ruled out with appropriate investigations. The patient was not responding to triple therapy of antibiotics (ceftriaxone, metronidazole, and cloxacillin). A final diagnosis of hydatid cyst of spleen was made when serum echinococcus immunoglobulin G (IgG) antibodies were found to be positive. The patient was treated with albendazole and was discharged on improvement. It is vital to be vigilant and consider echinococcal hydatid cyst as a differential in the lesions of spleen, especially if the patient has a rural background.

Michelin Tire Baby Syndrome: A Rare Case with Review of Literature

Michelin tire baby syndrome (MTBS) is a benign hamartomatous condition with ring-like lesions present on the limbs and trunk. MTBS is a rare genodermatosis. According to our search, only 20 cases have been reported. We present a case of a six-month-old female child, with complaints of fever and seizures. Since birth, she had asymptomatic multiple, asymmetric skin folds on all four limbs, resembling “Michelin Man” logo of the French tire manufacturer. She had microcephaly with characteristic round face hypertelorism, depressed nasal bridge, hypertrichosis with low set ears, a thin down-turned vermillion border of the upper lip, and a short neck. MRI was normal. Clinically, the diagnosis of MTBS was made. In addition, the parents were counseled about the self-limiting course of this disorder. MTBS itself might not be a single disorder but may manifest as a clinical finding associated with other disorders; therefore, a regular follow up of these patients is usually advised.

Beta Thalassemia Major with Gaucher's Disease: A Rare Entity

Thalassemia is a genetic disorder due to deletion or mutation in the gene for alpha or beta chain of hemoglobin. Gaucher's disease (GD) is characterized by a deficiency of a lysosomal enzyme, glucocerebrosidase which occurs due to mutations in the GBA1 gene on chromosome 1. Thalassemia and GD have overlapping clinical manifestations and present with features such as anemia, hepatosplenomegaly, and skeletal involvement. This creates a diagnostic conundrum for physicians. We present a case of an 11-month-old female who presented with fever, increasing paleness, and labored breathing. She had a recent history of uncross-matched transfusion. The child showed signs of anemic failure. Physical exam findings strongly pointed towards hemolytic anemia due to thalassemia major. Genetic analysis confirmed homozygosity in Fr 8-9 mutation confirming beta thalassemia major. Bicytopenia along with visceromegaly indicated malaria or storage diseases. Enzyme analysis revealed low levels of beta-glucocerebrosidase with normal acid sphingomyelinase levels confirming GD. In our case, we report the association of beta thalassemia major with GD which is a rare entity. The report highlights the need for an independent assessment of disorders that have similar presentations to avoid missing an associated disorder.

Intrahepatic Kinetics of lndium-111-Labelled Platelets

The intrahepatic kinetics of 111indium-labelled platelets have been studied using dynamic gamma camera scintigraphy immediately following injection. Platelets labelled in saline with mIn-oxine or 111In-acetylacetonate underwent rapidly reversible hepatic sequestration, indicating that they were “activated”. Platelets labelled in plasma with 111In-tropolonate, however, did not display this phenomenon. On the assumption that plasma-labelled platelets display a normal initial bio-distribution, mean intrahepatic platelet transit time, as a factor of the transit time of 99m-Tc labelled red cells, was 1.45 ± SE 0.12 (n = 6), implying the normal presence of a small intrahepatic platelet pool. Unlike the liver, transit through the spleen was not sensitive to the labelling medium; thus the mean intrasplenic transit time of plasma-labelled platelets was 9.3 ± SE 0.7 min (n = 10), and of saline-labelled platelets 9.5 ± SE 0.3 min (n = 8).

Prevalence of Vitamin D deficiency in Pakistan and implications for the future

BACKGROUND AND AIMS

vitamin D deficiency (25-hydroxyvitamin D) affects over one billion people worldwide. Vitamin D deficiency results in progression of osteoporosis as well as other conditions. Previous studies have shown high rates of vitamin D deficiency in Pakistan despite appreciable levels of sunshine. However, none have assessed vitamin D deficiency across all age groups, genders, incomes, and locations to guide future strategies.

METHODS

Questionnaire and blood sampling among 4830 randomly selected citizens.

RESULTS

High levels of deficiency among all age groups, genders, income levels, and locations. Amongst the selected citizens, 53.5% had vitamin D deficiency, 31.2% had insufficient vitamin D, and only 15.3% normal vitamin D.

CONCLUSION

High rates of vitamin D deficiency in Pakistan despite high levels of sunshine and previous Food Acts asking for food fortification with vitamin D. Public health strategies are needed to address high deficiency rates, including food fortification, i.e. nurture, alongside increasing exposure to sunlight, i.e. nature. This will involve all key stakeholder groups.

SOCS3-mediated regulation of inflammatory cytokines in PTEN and p53 inactivated triple negative breast cancer model

Somatic mutations or deletions of TP53 and PTEN in ductal carcinoma in situ (DCIS) lesions have been implicated in progression to invasive ductal carcinomas. A recent molecular and mutational analysis of breast cancers revealed that inactivation of tumor suppressors, p53 and PTEN are strongly associated with triple negative breast cancer. In addition, these tumor suppressors play important roles in regulating self-renewal in normal and malignant stem cells. To investigate their role in breast carcinogenesis, we knocked down these genes in human mammary cells and in non-transformed MCF10A cells. p53 and PTEN knockdown synergized to activate pro-inflammatory IL6/Stat3/NF-κB signaling. This resulted in generation of highly metastatic EMT-like cancer stem cells (CSCs) resulting in tumors whose gene expression profile mimicked that found in basal/claudin-low molecular subtype within the triple negative breast tumors. Constitutive activation of this loop in transformed cells was dependent on proteolytic degradation of SOCS3 resulting in low levels of this protein in basal/claudin low cell lines and primary tumors. In non-transformed cells, transient activation of the IL6 inflammatory loop induced SOCS3 expression leading to pathway inactivation. In transformed cells, enforced expression of SOCS3 or interfering with IL6 pathway via IL6R blockade inhibited tumor growth and metastasis in mouse xenograft models. Furthermore, circulating tumor cells were significantly reduced in tumor bearing animals when treated with anti-IL6R antibodies. These studies uncover important connections between inflammation and carcinogenesis and suggest that blocking pro-inflammatory cytokines may be utilized as an attractive strategy to target triple negative breast tumors which currently lacks molecularly targeted therapies.

Autophagy triggered by magnolol derivative negatively regulates angiogenesis

Angiogenesis has a key role in the tumor progression and metastasis; targeting endothelial cell proliferation has emerged as a promising therapeutic strategy for the prevention of cancer. Previous studies have revealed a complex association between the process of angiogenesis and autophagy and its outcome on tumorigenesis. Autophagy, also known as type-II cell death, has been identified as an alternative way of cell killing in apoptotic-resistant cancer cells. However, its involvement in chemoresistance and tumor promotion is also well known. In this study, we used a derivate of natural product magnolol (Ery5), a potent autophagy inducer, to study the association between the autophagy and angiogenesis in both in vitro and in vivo model system. We found that the robust autophagy triggered by Ery5, inhibited angiogenesis and caused cell death independent of the apoptosis in human umbilical cord vein endothelial cells and PC-3 cells. Ery5 induced autophagy effectively inhibited cell proliferation, migration, invasion and tube formation. We further demonstrated that Ery5-mediated autophagy and subsequent inhibition of angiogenesis was reversed when autophagy was inhibited through 3-methyl adenine and knocking down of key autophagy proteins ATG7 and microtubule-associated protein light chain 3. While evaluating the negative regulation of autophagy on angiogenesis, it was interesting to find that angiogenic environment produced by the treatment of VEGF and CoCl2 remarkably downregulated the autophagy and autophagic cell death induced by Ery5. These studies, while disclosing the vital role of autophagy in the regulation of angiogenesis, also suggest that the potent modulators of autophagy can lead to the development of effective therapeutics in apoptosis-resistant cancer.

Fluoroquinolone and macrolide co-resistance in clinical isolates of Campylobacter species: a 15-year study in Karachi, Pakistan

Fluoroquinolone and macrolide antibiotics are generally considered as first-line drugs for the treatment of severe campylobacteriosis. This study was conducted to analyse the trend of erythromycin and ofloxacin resistance among Campylobacter spp. isolated from stool specimens over a period of 15 years (1992-2007) at The Aga Khan University clinical laboratory in Karachi, Pakistan. A total of 83 396 stool specimens were processed, with a 14% isolation rate for enteric pathogens. The isolation rate of Campylobacter spp. was low during 1992-93 (6%-13%), peaked in 1996 (46%), then ranged from 20% to 40%. We report a rising trend in ofloxacin resistance, re-emergence of erythromycin resistance and indications of co-resistance to both drugs in clinical isolates of Campylobacter spp.

Hyperemesis gravidarum and fetal gender: a retrospective study

This retrospective study of 9,980 women who delivered at the James Paget Hospital, Norfolk, UK, over 5 years, aimed to primarily determine whether the incidence of hyperemesis gravidarum (HG) is higher in the presence of a female fetus. The results showed that more women with HG had a female fetus compared with women without HG. Also found was that heavy ketonuria was more prevalent in women with a female fetus compared with women with a male fetus, and the mean number of admissions per woman was also higher in women with a female fetus compared with women with a male fetus. It can be concluded that women presenting with HG are more likely to have a female fetus and that women with HG and a female fetus tend to a higher level of ketonuria and an increased number of hospital admissions.