Effect of Sodium-Glucose Cotransporter 2 Inhibitors on the 24-Hour Ambulatory Blood Pressure in Patients With Type 2 Diabetes Mellitus and Hypertension: An Updated Meta-Analysis

OBJECTIVE

Sodium-glucose cotransporter 2 inhibitors (SGLT2i), initially developed for type 2 diabetes mellitus (DM) treatment, have shown potential benefits beyond glycemic control, including a positive impact on the blood pressure (BP). This meta-analysis aimed to evaluate their effects on patients with type 2 DM and hypertension.

METHODS

We searched the PubMed, Google Scholar, and Cochrane databases for relevant randomized controlled trials published until May 31, 2023. Ten randomized controlled trials involving participants with confirmed type 2 DM were selected. The intervention group received SGLT2i, whereas the control group received a placebo or standard care. The primary outcomes were the 24-hour ambulatory systolic BP (SBP) and diastolic BP (DBP).

RESULTS

The results showed a significant reduction in the 24-hour ambulatory SBP (weighted mean difference, -5.08 mm Hg; 95% confidence interval, -7.02 to -3.14; P <.00001) and DBP (weighted mean difference, -2.73 mm Hg; 95% confidence interval, -4.25 to -1.20; P =.0005) with the use of SGLT2i compared with that using the placebo. However, a high-heterogeneity level was observed in both analyses (SBP, I2 = 83%; DBP, I2 = 91%). Sensitivity analysis excluding specific studies reduced heterogeneity while maintaining statistically significant and clinically relevant reductions in the BP.

CONCLUSION

In conclusion, this meta-analysis proves that SGLT2i significantly reduce the 24-hour ambulatory BP. SGLT2i may be considered an effective treatment option for lowering the BP in addition to standard care in patients with hypertension and type 2 DM.

Influence of Sapindus mukorossi extract in comparison to 17% EDTA as final root canal irrigant on the sealer penetration and microleakage of dentinal tubules

OBJECTIVE

The study evaluated the effect of Sapindus mukorossi (SM) extract as a final root canal irrigant on sealer penetration (SP) in dentinal tubules and microleakage.

MATERIALS AND METHODS

Samples were selected based on inclusion and exclusion criteria. An access opening in all samples was performed and the working length was decided using pro taper for canal finishing along with constant irrigation. Specimens were randomly divided into 3 groups. Group 1 was irrigated with 3 ml of 17% EDTA; group 2 was irrigated with SM irrigant and group 3 samples were irrigated with 0.9% saline. After obturation, samples were vertically placed in 1% methylene blue dye cut in half longitudinally, and viewed under a stereomicroscope. Analysis of SP in the dentinal tubule was assessed using scanning electron microscopy (SEM). For microleakage assessment, mean and standard deviation were reported and One-Way ANOVA was applied. SP was compared using Kruskal-Wallis' test. For inspecting the interaction between SM/EDTA and NaOCl, Fisher's exact test was applied. No statistically significant difference between microleakage in any of the tested groups was observed. The control group showed minimum leakage as compared to EDTA and SM.

RESULTS

The results displayed that there was no significant difference, (p=0.67), between dentinal tubule SP at 2 mm. A significant difference between dentinal tubule SP among groups at 5 mm was observed (p<0.05).

CONCLUSIONS

SM ethanolic extract showed comparable outcomes of smear layer removal and sealer penetration to 17% EDTA, as a final irrigant in root canal cleaning. Therefore, SM has the potential to be used as an adjuvant final irrigant in conjunction with NaOCl.

Community based assessment on Knowledge, Attitude and Practices (KAP), Risk Factors and One Health Perspective of Brucellosis in rural and urban settings of Pakistan: A Cross-Sectional Study

Bovine brucellosis is an endemic zoonotic infection of ruminants in Pakistan with detrimental impacts on livestock economy. The major losses caused by brucellosis in animals include abortions, week calves, infertility, and reduced milk production. Regardless of the prevalence of the disease, limited data is available about brucellosis in Pakistan. The present study aimed to access the one health concept in prospective of Brucellosis among small-scale dairy farmers by examining knowledge, attitude and practices at the farms and household level that might pose a risk for humans contracting brucellosis. A community-based cross-sectional survey was conducted among small household dairy farms (n=333) in rural and urban areas of district Rawalpindi and Islamabad. The results revealed almost 74.17% of the participants knew about animal brucellosis and about 69.97% of the participants were able to identify the symptoms of animal brucellosis. 58.26% of participants showed knowledge about the transmission of disease from animals to humans. A majority (70.87%) of participants used the raw milk for making other dairy products. Most household farmers are unaware of routes of transmission and major risk factors of brucellosis. Almost all the participants, except veterinarians, including butchers, dairy farm owners and workers, slaughterhouse owners and workers and farmers were involved in at least one risky practice. The moderate knowledge and poor understanding of the disease emphasize the need to initiate awareness programs to educate the farmers who are at high risk along with the improvement of vaccination programs for animals and strict implementation of brucellosis eradication policy which should be devised by government.

Simultaneous malignant hyperthermia reactions in two siblings during living donor liver transplantation

We report a case of simultaneous malignant hyperthermia reactions occurring in two siblings during living donor liver transplantation. This report highlights the conflicting goals in the clinical management of liver transplantation and malignant hyperthermia, including the use of total intravenous anaesthesia and dantrolene in the face of the potential for drug-induced hepatotoxicity in the remnant liver or transplanted liver graft, as well as cautious fluid management needed for liver transplantation balanced against the liberal fluid therapy required to prevent acute kidney injury associated with malignant hyperthermia. The logistical challenges of managing this emergency in two closely related patients are discussed, including rapid preparation of two vapour-free anaesthesia machines, the need for availability of additional dantrolene and the requirement for additional personnel. Prompt recognition, immediate removal of the triggering agents and conversion to total intravenous anaesthesia helped to curtail the malignant hyperthermic reactions in our patients, both of whom made a full recovery.

Identification of locally isolated entomopathogenic Fusarium species from the soil of Changa Manga Forest, Pakistan and evaluation of their larvicidal efficacy against Aedes aegypti

Dengue fever vectored by the mosquito Aedes aegypti is one of the most rapidly spreading insect-borne diseases. Current reliance of dengue vector control is mostly on chemical insecticides. Growing insecticide resistance in the primary mosquito vector, Aedes aegypti, limits the effectiveness of vector control through chemical insecticides. These chemical insecticides also have negative environmental impacts on animals, plants and human health. Myco-biocontrol agents are naturally occurring organisms and are found to be less damaging to the environment as compared to chemical insecticides. In the present study, entomopathogenic potential of local strains of fungi isolated from soil was assessed for the control of dengue vector. Local fungal isolates presents better alternative to introducing a foreign biocontrol strain, as they may be better adapted to environmental conditions of the area to survive and may have more entomopathogenic efficacy against target organism. Larvicidal efficacy of Fusarium equiseti and Fusarium proliferatum was evaluated against Aedes aegypti. Local strains of F. equiseti (MK371718) and F. proliferatum (MK371715) were isolated from the soil of Changa Manga Forest, Pakistan by using insect bait method. Larvicidal activity of two Fusarium spp. was tested against forth instar larvae of A. aegypti in the laboratory, using concentrations 105, 106, 107 and 108 conidia /ml. LC50 values for F. equiseti after 24h, 48h, 72h and 96h of exposure were recorded as 3.8x 108, 2.9x107, 2.0x107, and 7.1x106 conidia /ml respectively while LC50 values for F. proliferatum were recorded as 1.21x108, 9.6x107, 4.2x107, 2.6x107 conidia /ml respectively after 24h, 48h, 72h and 96h of exposure. The results indicate that among two fungal strains F. equiseti was found to be more effective in terms of its larvicidal activity than F. proliferatum against larvae of A. aegypti.

Sociodemographic and Clinical Features in Patients Presented With Accidental and Deliberate Self-Poisoning: A Comparative Study from Lady Reading Hospital Medical Teaching Institution, Peshawar, Pakistan

Objectives

To evaluate the sociodemographic and clinical characteristics of patients presented with acute self-poisoning at a tertiary care hospital in Pakistan.

Methods and Patients

A comparative study was conducted at Lady Reading Hospital MTI between May 2018 to May 2019 for a duration of 12 months. All patients diagnosed with acute self-poisoning were included in the study. Patients with inconclusive diagnosis, who were dead prior to the arrival to the hospital, or had an incomplete history of poison exposure were excluded from the study. At the time of arrival to the emergency department, the patient was first stabilized. Patients were grouped into two according to the type of exposure, i.e., accidental self-poisoning and deliberate self-poisoning (DSP). Sociodemographic and clinical characteristics of patients were recorded in a preformed proforma. The data were analyzed using Statistical Package for the Social Sciences (SPSS) Version 26 (IBM Corp., Armonk, NY, USA).

Results

The mortality rate in patients with accidental poisoning was 9.62%, whereas it was 26.28% in DSP patients. Data were stratified according to the mode of poisoning, i.e., accidental vs DSP, and variables were assessed in patients who did not survive. It was found that 60% of patients who died in the accidental group were aged 0-15 years. In contrast, only one patient between aged 0-15 years died in the DSP group and the majority of the deaths occurred in those aged 25.1-35 years (31 [75.6%]).

Conclusions

In conclusion, women more often attempted suicide, whereas males suffered accidental poisoning more frequently. Firstly, we found a female predominance in the DSP group, whereas males were more prevalent in with young children experiencing accidental poisoning. Longer time from ingestion of poison to the arrival is associated with poor patient prognosis.

Physical and Psychological Symptoms Associated With Premenstrual Syndrome and Their Impact on the Daily Routine of Women in a Low Socioeconomic Status Locality

Introduction

The constellation of the physical and psychological symptoms that appear several days before menstrual period is regarded as the premenstrual syndrome (PMS). The current study evaluated the symptoms associated with PMS and their impact on the day-to-day activities of women.

Methodology

An observational cross-sectional study was conducted at a squatter settlement in Karachi, Pakistan, from January 2019 to February 2020. Amenorrheic, pregnant women, and women who were on birth control at the time of data collection were excluded from the study. The demographics, symptoms of PMS experienced by the participants, and the impact of PMS symptoms on the daily lives of women were recorded. Statistical Package for the Social Sciences v.25 (IBM Corp., Armonk, NY) was used for data analysis. 

Results

The mean age ± standard deviation of 23.93 years ± 9.41 years was recorded. As many as 213 (63%) women reported dysmenorrhea, followed by fatigue in 108 (32%), bloating in 64 (18.9%), and back pain in 45 (13.3%) women. Irritability and anxiety were experienced by 134 (39.6%) and 117 (34.6%) women, respectively. When asked about their attitude and perception towards menstruation, more than four-fifth respondents confessed that they feel impure when they are experiencing their monthly period. About 38 women (11.2%) believed that menstruation is God’s way of punishing the womankind. For the question, “Do you feel that your normal routine is significantly disturbed during your period?”, 40% responded in affirmation.

Conclusion

The findings of the current study reflected a generally negative attitude towards menstruation, which significantly affected the routine lives of women in our setting. The study further concluded that dysmenorrhea, fatigue, irritability, and anxiety were the most common symptoms of PMS experienced by women.

Endocrinological Manifestations of Sanjad-Sakati Syndrome

Sanjad-Sakati syndrome (SSS), also known as hypoparathyroidism-retardation-dysmorphism (HRD) syndrome, is a very rare genetic disorder with an autosomal recessive mode of inheritance, mostly seen in children of Middle Eastern origin. Hypoparathyroidism remains the most characteristic endocrinological feature of SSS; but not the only one. This review outlines and elucidates other endocrinological manifestations that may be seen with this syndrome.

Impact of Diabetes-related Self-management on Glycemic Control in Type II Diabetes Mellitus

INTRODUCTION

 Self-care activities are behaviors adopted in order to enhance one's health. Self-care behaviors and activities are studied in their role to enhance glycemic control, reduce diabetes-related complications, and contribute to enhancing overall quality of life in people with diabetes. The aim of this observational study was to evaluate the impact of diabetes self-care activities and behaviors on glycemic control in people with diabetes.

METHODS

 This observational, cross-sectional study was conducted at the outpatient department of a secondary care hospital in Karachi, Pakistan from 1st September 2019 till 30th November 2019. Patients with known type II diabetes of age ≥45 years visiting the hospital for routine follow-up visit were included. Diabetes Self-Management Questionnaire (DSMQ) in Urdu version was used to assess their status of self-management. For data entry and statistical analysis SPSS for Windows version 21.0 was used.

RESULTS

 There were 174 (54.9%) males and 152 (47.9%) were of age 45-60 years. Glycemic control was good (HbA1c <7%) in 125 (39.4%) and poor (HbA1c ≥7%) in 192 (60.6%) patients. Patients with good glycemic control scored significantly better on DSMQ overall (5.53 ± 0.35 vs. 4.32 ± 0.61; p<0.0001), and on three sub-scales - dietary control (4.24 ± 1.04 vs. 3.63 ± 0.98; p<0.0001), physical activity (4.16 ± 0.56 vs. 3.47 ± 1.17; p<0.0001), and healthcare use (4.22 ± 0.78 vs. 3.98 ± 0.65; p=0.003).  Conclusions: The self-care activities that impact glycemic control in patients with diabetes include dietary control, physical activity, and healthcare use.

Comparison of Oral versus Intravenous Proton Pump Inhibitors in Preventing Re-bleeding from Peptic Ulcer after Successful Endoscopic Therapy

Introduction Perforation, obstruction, and bleeding remain the most frequently encountered complications of peptic ulcer disease (PUD). Bleeding may be in the form of hematemesis or melena. The treatment of choice in patients with a bleeding peptic ulcer is endoscopic ligation to maintain the hemostatic balance followed by the administration of proton pump inhibitors (PPIs). This study focuses on the evaluation and comparison of intravenous (IV) and oral PPIs in terms of prevention of re-bleeding after successful endoscopy for peptic ulcers. Methods A prospective, comparative study was conducted in a tertiary care hospital in Pakistan from January 1, 2018 to June 30, 2019. The trial included known cases of PUD admitted with active upper gastrointestinal bleeding (UGIB). They were randomly divided into two groups: one received oral pantoprazole and the other was administered IV pantoprazole. The outcomes for both groups were compared. Data was entered and analyzed using Statistical Package for the Social Sciences (SPSS) software version 23.0 (IBM, Armonk, NY) Results There were 96 (48%) patients in the IV pantoprazole group and 104 (52%) in the oral group. From 24 hours after the medication onwards, the IV pantoprazole group showed a significant improvement in hemoglobin (Hb) levels (p: 0.01); the group also showed improvement in supine systolic BP at 48 hours (p: 0.04) and in diastolic BP at both 12 and 48 hours as compared to the oral pantoprazole group (p: 0.05). The mean duration of hospital stay, need for blood transfusion and repeat endoscopy, re-bleeding, and mortality rates were similar for both groups (p: >0.05). Conclusion We could not find any statistically significant difference between oral and IV routes of pantoprazole administration in the prevention of rebleeding when used after successful therapeutic endoscopy in patients with bleeding PUDs.

N-acetylcysteine in the Management of Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Introduction

Chronic obstructive pulmonary disease (COPD) is a preventable disease of the airways characterized by limited airflow. Acute exacerbations of COPD (AECOPD) may be precipitated by noxious stimuli. N-acetylcysteine (NAC) has mucolytic, antioxidant, and anti-inflammatory activity. We conducted this study to evaluate the effect of adding high-dose NAC to the protocol treatment of AECOPD.

Methods

In this single-center, prospective, interventional study, patients admitted with AECOPD, airflow obstruction on spirometry, and who were current smokers with 10 or more packs per year were included after attaining informed consent. NAC granules 600 mg twice daily orally (high dose) were included in the regimen of 25 randomly selected patients and the other 25 were managed without NAC. An improvement in clinical and biochemical markers was observed on day three and day seven. For statistical analysis, SPSS for Windows version 21.0 (IBM Corp., Armonk, NY) was utilized.

Results

The study was completed by 21 patients in the NAC group and 19 in the non-NAC group. In the NAC group, there was a significant improvement in the mean partial pressure of oxygen (PaO₂) both on day three (p=0.03) and day seven (p=0.01). The mean partial pressure of carbon dioxide (PaCO₂) was at the borderline in the two groups on day three; however, on day seven, the NAC group showed significantly improved PaCO₂ as compared to the non-NAC group (p=0.007). There were significant improvements in oxygen saturation of the NAC group on day seven (p=0.02). There were significant improvements in clinical signs, including wheezing and dyspnea and the need for nasal oxygen support (p≤0.05).

Conclusion

The addition of 600 mg twice daily NAC (high dose) to the protocol treatment of patients with acute exacerbation of COPD may have beneficial outcomes. In the future, the role of high-dose NAC in AECOPD must be studied through multicenter, double-blinded, placebo-controlled trials with larger sample sizes in order to either establish or invalidate this association.

Noninvasive Positive Pressure Ventilation in Patients with Acute Respiratory Failure Secondary to Acute Exacerbation of Chronic Obstructive Pulmonary Disease

Introduction

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) is a leading cause of poor quality of life and mortality in developing countries. Noninvasive positive pressure ventilation (NIPPV) remains the first-line intervention in hospitalized patients with acute respiratory failure (ARF) due to AECOPD. However, NIPPV may fail in some patients. This study was conducted to assess the frequency of NIPPV failure and clinical parameters and outcomes in AECOPD patients with failed NIPPV and their conversion to invasive positive pressure ventilation (IPPV).

Methods

This prospective observational study was conducted in the pulmonology unit of a tertiary care hospital in Pakistan. AECOPD patients with ARF who were candidates of NIPPV were included after securing informed consent. Their demographic characteristics, clinical parameters, and in-hospital outcomes were recorded on a semi-structured proforma. For statistical analysis, SPSS software version 22.0 for Windows (IBM, Armonk, NY) was used.

Results

With 24 hours of NIPPV, 73 (70.2%) patients improved and the remaining 31 (29.8%) were shifted to IPPV. Patients in the IPPV group had higher systolic blood pressure (BP) [133.8 mmHg (±21.2) vs. 121.1 mmHg (±8.3); probability value (p): <0.000] and lower diastolic BP [68.7 mmHg (±13.4) vs. 76.2 mmHg (±10.8); p: 0.003]. Their pH was more acidic [7.20 (±0.13) vs. 7.42 (±0.01); p: <0.000], heart rates were high [131.1 (±10.5) vs. 100.2 (±7.5); p: <0.000], and the percentage of oxygen saturation was low [90.7 (±3.0) vs. 93.4 (±4.5); p: 0.004]. Patients who were managed on NIPPV throughout their hospital stay required respiratory support for fewer days [3.2 (±1.3) vs. 4.1 (±1.8); p: 0.005], and their hospital stay was shorter [3.5 (±1.2) vs. 5.3 (±2.5) days; p: <0.000]. Mortality rate in the NIPPV group was significantly lower (1.4% vs. 12.9%; p: 0.01).

Conclusions

Deranged blood pressure, increased heart rate, acidemia, and a low percentage of oxygen saturation are crucial clinical and biochemical parameters that can predict the success of NIPPV with 24 hours of therapy in patients with AECOPD and secondary ARF. Patients who do not improve with 24 hours of NIPPV therapy usually have poor in-hospital outcomes including mortality.

Serum Sodium Profile of Congestive Heart Failure Patients and its Impact on Their Outcome at Discharge

Introduction

Patients with congestive heart failure (CHF) readily present with electrolyte imbalance which commonly includes deficiencies of sodium, potassium, and magnesium. Hyponatremia occurs in advanced stages of CHF and is associated with adverse disease outcome-longer hospital stay, severity of CHF, and increased risk of mortality.

Methods

In this observational, single-center, prospective, case-control study adult patients admitted with clinical diagnosis of CHF were included after informed consent. Their demographic, clinical, and biochemical profile was attained. Patients with low serum sodium (hyponatremia) were grouped as "cases" and patients with normal serum sodium profile (normonatremia) were grouped as "controls". Factors associated with both groups and their hospital outcome were compared. SPSS for Windows version 16 (SPSS Inc., Chicago, IL, USA) was utilized.

Results

Hyponatremia (serum sodium <135 mmol/L) was present in 58/189 (30.7%) patients admitted with CHF. Younger patients with non-ischemic CHF, and history of previous diagnosis, treatment, and hospitalization due to CHF were more likely to be affected. Diabetic nephropathy, chronic kidney disease, salt-restricted diet, drugs including furosemide, spironolactone, and angiotensin-converting enzyme inhibitors, low serum potassium, and reduced GFR were also related to hyponatremia. Hyponatremic CHF patients showed adverse hospital outcome on all parameters including higher death rate (12% vs. 0.8%), longer duration of hospital day, and deranged blood pressures and severe CHF at the time of discharge.

Conclusion

Hyponatremic CHF patients are associated with prolonged hospital stay, more severe form of CHF, and deranged blood pressures. Overall, hyponatremia is an indirect clinical indicator of circulatory dysfunction and should guide a clinician for closer observation as outcomes could be poor. These patients also have higher in-hospital mortality risk.

The Spectrum of Pediatric Cardiac Procedures and Their Outcomes: A Six-month Report from the Largest Cardiac Facility in Sindh, Pakistan

Introduction

Congenital heart disease (CHD) is the most common birth defect globally, with low-to-middle income Asian countries registering the highest incidence. Every year, 60,000 babies are born with varying severity of CHD in Pakistan. But the country has only three pediatric intensive care units (PICU) fully dedicated to child cardiac surgery patients. The focus of this study is to analyze the spectrum of pediatric cardiac surgical procedures performed for the management of CHD and their outcomes in a cardiac PICU in Pakistan.

Methods

In this analysis, all surgical records of children admitted to the PICU of National Institute of Cardiovascular Diseases (NICVD), Karachi, from October 2018 to March 2019 were included. It is a 14-bed, state-of-the-art cardiac PICU, which provides high-quality care to critical post-surgical patients.

Results

The surgical records of 537 patients were extracted for the purpose of our study, which accounted for 89.5 of post-operative patients admitted in the PICU per month and three per day. Tetralogy of Fallot (TOF) was the most commonly treated anomaly (n = 161; 29.9%) in the facility, followed by ventricular septal defect (n = 107; 19.9%). The overall mortality rate was 5.4% (n = 29), out of which 27.5% (n = 8) were TOF-related.

Conclusions

There is a very high burden of patients on the cardiac PICUs in low-to-middle income Asian countries. Despite the lack of resources, the high- quality care provided by pediatric cardiac critical-care specialists at these PICUs has ensured favorable outcomes and a mortality rate as low as that in any of the developed countries.

Severity of Caregiver Stress in Relation to Severity of Disease in Persons with Parkinson's

Introduction

Parkinson’s disease (PD) is a progressive neurological disorder. It presents with motor symptoms and gradually progresses to cognitive impairment. It has debilitating impact not only on the psychological health of the patient but also of the caregivers. The aim of this study is to evaluate the stress level among caregivers of PD and assess its correlation with the disease factors including duration, severity, and presence of on-off phenomenon.

Methods

One hundred and fifty-six patients of Parkinson’s disease and their caregivers were enrolled. Severity of Parkinson’s disease was assessed using Hoehn and Yahr Scale. Caregiver stress was evaluated using Caregiver Burden Inventory. Data was entered and analyzed using Statistical Package for the Social Sciences (SPSS) version 22.0 (IBM Corp., Armonk, NY, USA).

Results

There were 112 (71.8%) women and 44 (28.2%) men in the caregiver group. Their mean age was 47.75 ± 11.98 years. There were 98 (62.8%) stressed caregivers and 58 (37.2%) non-stressed caregivers. In patients with stage 4 and 5 PD, 67-80% caregivers were stressed as compared to only 28% caregivers of stage 1 PD (p-value = 0.0008). Duration of Parkinson’s disease more than 10 years and presence of on-off phenomenon was also significantly associated with higher stress in the caregivers (p-value < 0.00001; p-value = 0.002, respectively). Among the stressed caregivers, 85 (86.7%) were women and only 13 (13.3%) were men (p-value < 0.0001).

Conclusion

Psychological health of caregivers of persons with Parkinson’s is bleak. As the disease progresses, they further succumb to debilitating stress and depression. Qualitative and quantitative studies must be conducted in Pakistan to understand the psychosocial status of Parkinson’s disease caregivers and plan strategies to improve their quality of life.

Comparison of the Status of Sleep Quality in Basic and Clinical Medical Students

Introduction

Academic pressure and its associated stress are responsible for disturbances in the circadian cycle of the students. Adequate sleep has crucial role in enhancing cognitive skills especially memory retention. Poor night time sleep quality and consequent daytime sleepiness affects physical and cognitive health of the students. In this study, sleep quality among medical students is evaluated.

Methods

It was an observational, cross-sectional study conducted with undergraduate medical students. Pittsburgh Sleep Quality Index (PSQI) was used to assess the sleep quality. The data was analyzed using Statistical Package for the Social Sciences (SPSS) 22.0 (IBM Corp., Armonk, NY, USA).

Results

Of 281 students, 155 (55.16%) were pre-clinical students and 126 (44.83%) were clinical students; 207 (73.66%) were female students and 74 (26.33%) were male. The overall frequency of poor sleepers was 172 (61.2%); 95 (55.2%) of these were clinical sciences and 77 (44.8%) were basic sciences students. Sleep latency, duration, and efficiency were more impaired in clinical students (p-value ≤ 0.05). Use of sleep medications and daytime dysfunction was more common in clinical students (p-value ≤ 0.05).

Conclusion

Medical students are continuously under high academic stress and pressure. Adequate sleep is essential for them to refresh them every day and help in learning and memory processing. Medical students in advance years of education have worse sleep quality than those in early years. Efforts should be taken to improve their sleep quality in order to protect the psychological and emotional health of future doctors.

Depression, Anxiety, and Stress Among Final-year Medical Students

Introduction

The overall environment of the medical school is often considered very stressful. It projects negative effects not only on the academic performances of medical students but also deteriorate their physical health and psychosocial wellbeing. The aim of this study was to determine the frequency of depression, stress, and anxiety among final year medical students.

Methods

This observational study was conducted in public and private medical colleges in February 2019. The instrument utilized in this study was Depression, Anxiety, and Stress Scale (DASS-21). Factors predisposing to depression, stress, and anxiety were also recorded. Data were entered and analyzed using SPSS v. 21.

Results

The mean scores of depression, anxiety, and stress were 18.00 ± 11.5, 19.15 ± 11.2, and 20.92 ± 11.2, respectively. The mean score of anxiety and stress was higher in private college students, while that of depression was higher in public college students. Overall, 57.6% of the students suffered from moderate to extremely severe depression, 74% of the students suffered from moderate to extremely severe anxiety, and 57.7% students had moderate to extremely severe stress. The common reasons to high stress and anxiety included the pressure of passing exams, the pressure of living up to family’s expectations, fear of stepping into the real world of medicine, and dissatisfaction with the administration.

Conclusion

The incidence of psychological illnesses including anxiety, stress, and depression is high among the medical students of Pakistan. Reasons predisposing the students to these illnesses must be efficiently tackled.

Cephalic tetanus presenting with bilateral facial palsy

We discuss the case and differential diagnoses of an elderly man who presented with bilateral facial palsy. He had injured his forehead in the garden during a fall on his face and the open wound was contaminated by soil. He then presented to the emergency department with facial weakness causing difficulty speaking. The penny dropped when he started developing muscle spasms affecting his lower jaw a day after admission. It also became clear that he could not open his mouth wide (lock jaw). The combination of muscle spasms and lock jaw (trismus) made tetanus the most likely possibility, and this was proven when he had samples taken from his wound and analysed under the microscope, which showed Clostridium tetani bacilli. C. tetani spores are widespread in the environment, including in the soil, and can survive hostile conditions for long periods of time. Transmission occurs when spores are introduced into the body, often through contaminated wounds. Tetanus in the United Kingdom is rare, but can prove fatal if there is a delay in recognition and treatment.

Incidence of Anxiety and Depression Among Patients with Type 2 Diabetes and the Predicting Factors

Introduction

Diabetes mellitus (DM) is a chronic, progressive metabolic illness which is commonly complicated by coexistence of depression and anxiety. This study aimed to assess the prevalence of anxiety and depression among diabetic patients and the factors predicting this coexistence.

Methods

It was a cross-sectional, observational study which included patients of type 2 DM admitted in the hospital due to diabetes-related condition - diabetic foot infections/ulcers, hyperosmotic hyperglycaemic state (HHS), and hypoglycaemic coma/seizure. Anxiety and depression were measured by using the Hospital Anxiety and Depression Scale (HADS). Data was entered and analysed using SPSS version 22.0 (IBM Corp., Armonk, NY, USA).

Results

Mean anxiety score of the participants was 10.88 ± 4.075 and mean depression score was 11.82 ± 4.049. There were 72 (50.7%) patients who had anxiety and 70 (49.2%) patients who had depression. Higher scores of anxiety and depression were statistically significant in female gender, older participants, individuals with longer duration of diabetes, those taking non-insulin treatment, and individuals with painful neuropathy, nephropathy, and foot ulcers.

Conclusion

The incidence of depression and anxiety among hospitalized patients of diabetes mellitus is high. The coexistence of these two chronic debilitating illnesses is worsening the overall quality of life. It is very important to diagnose and manage anxiety and depression in patients with type 2 DM to ensure higher quality of life and life expectancy.

Assessment of Clinical Empathy Among Medical Students Using the Jefferson Scale of Empathy-Student Version

Introduction

Clinical empathy is the ability to comprehend the perspectives, feelings, and situation of the patients. Clinical empathy instills a sense of satisfaction in the patient. It also facilitates the healthcare provider (HCPs) in taking more sincere and logical clinical decisions. Although there have been numerous studied conducted to explore the pattern of clinical empathy among medical students, the results are mixed and not consistent.

Methods

This is a cross-sectional, observational study conducted among medical students of Ghulam Muhammad Mahar Medical College in August 2018. Two hundred and seven out of 500 students of all five years completed the study after informed consent. All students completed the 20-item Jefferson Scale of Empathy-Student Version (JSE-S). Data were entered and analyzed using SPSS version 22 (SPSS Inc, Chicago, IL, USA). The internal consistency of JSE-S was 0.71. Frequencies and percentages were calculated for students’ ages and genders. Mean and standard deviation (SD) were calculated for continuous variables. Group comparisons of the empathy scores were conducted using t-test and one-way analysis of variance (ANOVA). p<0.05 was considered as the significant level.

Results

There were 93 (44.9%) male and 114 (55.1%) female students. Their mean ± SD age was 20.85 ± 2.27 years (range: 17 to 26 years). The mean ± SD empathy score of all students was 98.11 ± 12.31 (range: 20-140). The mean empathy score was categorized according to gender, year of education, and career preference. Females showed a significantly higher empathy score. The lowest empathy was seen for the final year and the highest for the first year. On all three subscales of (JSE-S) - perspective taking, compassionate care, and walking in patients’ shoes - students with “people-oriented” career preference scored higher.

Conclusion

JSE-S is a self-administered and self-perceived inventory, which reports declining empathy in medical students with ascending years of education. Qualitative studies that can assess the empathy levels from the patients’ perspective are the need of the hour to decide whether or not empathy is a real phenomenon.

Frequency of Depression and Anxiety Symptoms in Surgical Hospitalized Patients

Background Patients hospitalized for surgeries and those with chronic remitting health conditions develop hospital-induced anxiety and depression. Unfamiliar hospital environment, insufficient privacy, exposure to strange instruments, financial concerns, disease stress, and prolonged hospital stay contribute to this anxiety. The aim of this study was to assess the frequency of depression and anxiety in surgical patients. Material and methods This observational study was conducted among 50 patients hospitalized for 10 days or more in the surgical unit. All patients completed the Hospital Anxiety and Depression Scale (HADS). It has seven items for anxiety and depression each. Each item scores 0-3. A subscale score >8 denotes anxiety or depression. Data were entered and analyzed using SPSS v.20. Mean and standard deviation (SD) were calculated for descriptive data, and frequencies and percentages were calculated for categorical data. Results On the HADS, the mean ± SD score of anxiety was 11.84 ± 4.16 and that of depression was 12.78 ± 4.16. There were 64% severely anxious and 74% severely depressed hospitalized patients. More patients with less than two weeks of hospital stay were severely depressed than severely anxious (72.7% vs. 36.3%). There were 20% patients with moderate anxiety and depression with hospital stay longer than three weeks and 80% with severe anxiety and depression. Conclusion There is a high incidence of anxiety and depression in surgical patients. Patients at risk of developing these symptoms must be identified and psychological care should be provided to them.

Assessment of Burnout and its Factors Among Doctors Using the Abbreviated Maslach Burnout Inventory

Background Occupational burnout is an unwanted outcome of chronic workplace stressors which may be emotional or interpersonal. Chronic exposure to human suffering and long working hours have contributed to greater job stress and early burnout among healthcare providers. This study utilized the abbreviated Maslach Burnout Inventory (aMBI) to gauge the extent of overall burnout and on three subscales - perspective taking, compassionate care, and walking in patients' shoes - among interns, postgraduate trainees, and physicians of internal medicine. Materials and methods In this cross-sectional study, 71 internal medicine doctors - 40 interns, 22 postgraduate trainees, and nine physicians - completed aMBI with informed consent. It is a nine-item scale with three subscales - emotional exhaustion (EE), depersonalization (DP), and personal accomplishment (PA). Each subscale has three items that are marked on a seven-point Likert scale. Higher scores of EE and DP indicate higher burnout, and a higher score of PA indicates lower burnout. Overall burnout was taken as the sum of EE and DP. Data were entered and analyzed using SPSS v. 22. Results  There were 23 (32.4%) male and 48 (67.5%) female doctors with a mean age of 24.25 ± 13.17 years. The mean score of overall burnout was 22.51 ± 6.07 (range: 0-36) and PA was 15.35 ± 1.82 (range: 0-18). Overall moderate to high burnout was seen in 33.8% of doctors. On an individual subscale, 47.8% had high EE, 24% had high DP, and 25.4% reported high burnout on PA. Overall burnout had a statistically significant correlation with the marital status of the doctors, their working hours per week, their average on-call days per week, and their level of expertise. Conclusion There is a high degree of burnout among internal medicine physicians. Working hours and the number of on-call days per week were significant predicting factors. Interns reported the highest frequency of burnout.

Frequency of Workplace Burnout Among Postgraduate Trainees in a Teaching Hospital in Mirpur

BACKGROUND

Work-related stress and burnout among medical practitioners has been a frequently studied phenomenon. It reduces work efficiency and productivity and also has negative impacts on patient care. This study assessed the extent of work-related stress and burnout and the reasons behind this burnout among the Internal Medicine and Pulmonology residents of Mirpur, Azad Kashmir.

MATERIALS AND METHODS

This cross-sectional, observational study was conducted among the postgraduate trainees of Internal Medicine and Pulmonology in Mohi-uddin Islamic Medical College and Hospital, Mirpur, Azad Kahsmir. Out of the 70 trainees, 64 completed the study (response rate: 85.3%). The trainees recorded their sociodemographic profile including age, gender, marital status, name of the department, and year of training. Work-related stress and burnout were assessed using a 28-question-based Burnout Questionnaire adapted from the American Welfare Association. Reasons of burnout among the postgraduate trainees were recorded. Data were analyzed using SPSS v. 21.

RESULTS

There were 45 men (70.3%) and 19 women (29.6%). The mean age of the trainees was 29.25 ± 2.87 years. No stress and professional burnout was reported in 20.3% residents; 29.6% residents had stress but no professional burnout; 23.4% residents had fair chances of burnout; 14% residents had early burnout; and 12.5% residents had advanced burnout. Higher grades of burnout are more common among male residents, those who are married, and those in early years of postgraduate training. Common reasons of work-related burnout were reported to be long work hours (68.75%), decreased job satisfaction (54.7%), and lack of workplace facilities (45.3%).

CONCLUSION

Most of the residents in Mirpur have work-related stress and are at the verge of burning out. Large-scale studies, assessing more correlates, must be conducted in this region to give a better understanding of this phenomenon and help formulate plans to prevent and manage work-related stress and burnout among the postgraduate trainees.

Frequency of Pre-obesity and Obesity in Medical Students of Karachi and the Predisposing Lifestyle Habits

Background: The global incidence of pre-obesity and obesity is rising noticeably. Where medical students should be advocating healthy lifestyles, they are actually indulging in unhealthy eating habits and sedentary lifestyle. This is resulting in an increased incidence of obesity in this population.

Methods: It was a descriptive cross-sectional study conducted from September 2018 till January 2019 in four medical colleges of Karachi. Sociodemographic profile, body mass index (BMI), food habits, and exercise routine of the students were recorded. Data was entered and analyzed using SPSS version 22 (IBM Corp., Armonk, NY).

Results: The mean BMI of the study population was 21.717 ± 4.33 kg/m² (range: 16.24–38.19). The mean age was 21.345 ± 1.4709 years with a minimum of 17 years and maximum of 25 years. The combined frequency of pre-obese and obese students was 33.2%. Among these, there were more women (60.6%) than men (39.3%). Among these pre-obese and obese students, 55% had breakfast rarely to sometimes, 47.9% took four or more meals per day, 39.3% consumed fast food thrice weekly or more, and 58.1% consumed soft-drinks/juices alternate to every day. Among the students who indulged into binge eating when stressed, 56.9% were pre-obese to obese. The nutritional status of the study sample was significantly associated with female gender, living status with parents, irregular breakfast, infrequent daily meals, increased consumption of fast food and beverages, decreased consumption of red meat, sedentary lifestyle, and altered eating habits when stressed.

Conclusion: The incidence of pre-obesity and obesity is noticeably escalating among young adults. If this trend continues, obesity-related complications will form the major chunk of medical illnesses in the near future. Strategies are needed to nip this dilemma in the bud by indulging in healthy and clean eating habits and performing regular physical activity.

Ichthyosis Congenita, Harlequin Type: A Fatal Case Report

Harlequin baby is rare and it is the most severe kind of congenital ichthyosis. It manifests as severely keratinized skin with an autosomal recessive inheritance. Incidence of this disease is 1 in 300,000 live births. We report a new case of harlequin ichthyosis (HI) from Pakistan to contribute to the collective knowledge of this condition. HI is associated with ABCA12 gene mutation; hence, genetic screening and counseling to susceptible parents must be considered.

Chimeric Antigen Receptor T-Cell Therapy: A Beacon of Hope in the Fight Against Cancer

Despite significant advancements, relapses, and persistent malignancies are still a major challenge faced by the oncologists. Immunotherapy has shown remarkable potential in induction of sustained remission in refractory malignancies. Chimeric antigen receptor T-cell (CAR-T) therapy is a newer treatment methodology approved by the Food and Drug Administration (FDA). The chimeric pairing of an antigen receptor with the T-cell receptor (TCR) intracellular signaling domain allows cluster of designation 8 (CD8) cytotoxic T-cells to target cell surface makers independent of major histocompatibility complex (MHC) activation. Another essential feature which contributes to the broad applicability of CARs and expanding their potential targets is their ability to bind not only to proteins but also to carbohydrate and glycolipid structures. Their antigen-specific and targeted immune responses have shown promising outcomes in clinical trials particularly involving B-cell malignancies and solid tumors. High remission rates and low percentages of relapses have caused a paradigm shift in the treatment of relapsed or refractory cancers. Challenges include side effects such as cytokine release syndrome, on-target off-tumor toxicities, and replication of its success in treating solid tumors. The burden of side effects and hefty cost of treatment are major obstacles which could hinder its progress globally. Nevertheless, ongoing research would only result in a maximized therapeutic potential in addition to more patient- and cost-friendly treatment. In this review, we aim to provide the readers an overview of chimeric antigen receptor T-cell therapy, a relatively new advancement in the world of immuno-oncology and thereby also discussing its advantages, side effects and future challenges.

Is Chimeric Antigen Receptor T-cell Therapy the Future of Autoimmunity Management?

Clinical trials with chimeric antigen receptor (CAR) T-cell therapy in oncology have been promising. The spectrum of this novel therapy is being expanded to include autoimmunity. It ensures "targeted treatment," resulting in more selective outcomes, fewer toxic effects, and a permanent restoration of immune system imbalance. The preliminary results of preclinical and clinical studies support the application of CAR therapy in autoimmunity, especially in regulating adverse autoimmune responses. This novel therapy should be considered for the treatment of autoimmune diseases and further clinical studies should be conducted to study all aspects of this treatment modality.

Morbidity patterns and healthcare utilisation among older people in Malaysia: 1996-2015

OBJECTIVE

This article examines the trends in morbidities and healthcare utilisation in Malaysian older people aged 60 years and above.

STUDY DESIGN

This is a repeated cross-sectional study.

METHODS

Data from three nation-wide community-based surveys, which were conducted in 1996, 2006, and 2015 were analysed. Multivariate analysis was performed for 2015 data to identify factors associated with healthcare utilisation.

RESULTS

Analysis noted increasing trends in the prevalence of diabetes, hypertension, hypercholesterolaemia and obesity from 1996 to 2015. Decreasing trends were noted in the prevalence of current smokers and drinkers over this 20-year period, whereas health service utilisation increased with age in all surveys. In 2015, both inpatient and outpatient care are significantly associated with increasing age and diabetes.

CONCLUSIONS

Increasing trends of health problems and healthcare utilisation were observed among older people in Malaysia. Policymakers should plan for appropriate resources to meet the challenges of an ageing population in Malaysia.

Long-term functional outcomes after primary surgical repair of acute and chronic patellar tendon rupture: Series of 25 patients

OBJECTIVE

We aimed to evaluate the clinical outcomes after surgical repair of patellar tendon rupture (PTR) and compare the evolution of 2 types of rupture (acute and chronic) after the same rehabilitation protocol.

METHODS

This was a prospective cohort study of patients with PTR treated between January 2006 and January 2014 in the department of trauma surgery, Ibn Rochd university hospital, Casablanca.

RESULTS

We evaluated 25 patients (21 men) after a median follow-up of 75 months (range 29-120). The mean age was 34.7±8.59 years. Overall, 17 patients had acute rupture and 8 chronic rupture. Fifteen healthy volunteers (13 men) were recruited as a control group. Mean Knee Society Score (KSS) knee score was significantly higher after than before surgery (82.28±12.297 vs 20.64±7.6; P<0.0001) as was KSS function score (88.40±17.483 vs 23.40±8.98; P<0.0001). Pain measured on a visual analog scale was significantly lower after than before surgery (1.96±1.24 vs 6.60±1.26; P<0.0001). ROM and KSS knee and function scores were significantly lower on the operated than non-operated side after surgery. For both types of PTR, only knee extensor muscle strength was significantly lower on the operated than non-operated side and as compared with healthy volunteer knees.

CONCLUSIONS

Surgical repair of PTR with reinforcement and an early rehabilitation program demonstrate good results after a long follow-up. However, chronic PTR may need longer or a different rehabilitation protocol of the knee-extensor apparatus.

Severe hyperkalemia following adrenalectomy for aldosteronoma: prediction, pathogenesis and approach to clinical management- a case series

BACKGROUND

As the field of Primary Aldosteronism (PA) becomes ever expanded, diagnosis of PA is increasingly diagnosed by endocrinologists. With increased PA screening, many of the cases are now found in patients with complex co-morbidities in addition to their hypertension. Post adrenalectomy renal impairment with hyperkalemia is now increasingly seen in these complex patients, as evidenced by the numerous reports on this issue that have appeared within the past 3 years. We present a small case series to illustrate the breadth of the problem, along with a discussion about how such CKD/hyperkalemic events may be predicted.

CASE PRESENTATION

We present three cases of primary aldosteronism with long standing hypertension (more than 10 years) hypokalemia (2.0-3.0 mmol/l). Serum aldosterone was high with low renin activity leading to high aldosterone to renin ratio (ARR). They underwent abdominal CT scan revealing adrenal mass and adrenal vein sample confirmed lateralization. None of the patients had evidence of renal disease before surgery (as evident by normal eGFR and serum creatinine). Post adrenalectomy they had reduction in the blood pressure and became eukalemic. Serum aldosterone and renin activity were low leading to a low ARR. Case 1 developed hyperkalemia and increased serum creatinine 6 weeks post operatively which resolved with initiation of fludrocortisone and every attempt to discontinue fludrocortisone resulted in hyperkalemia and rising creatinine. Her hyperkalemia is under control with oral sodium bicarbonate. Case 2 developed hyperkalemia and increasing creatinine 2 months post operatively transiently requiring fludrocortisone and later on managed with furosemide for hyperkalemia. Case 3 developed renal impairment and hyperkalemia 2 weeks post operatively requiring fludrocortisone.

CONCLUSION

Post APA resection severe hyperkalemia may be a common entity and screening should be actively considered in high risk patients. Older age, longer duration of hypertension, impaired pre-op and post-op GFR and higher levels of pre-op aldosterone and are all risk factors which predict the likelihood of developing post-operative hyperkalemia. Fludrocortisone, sodium bicarbonate, loop diuretics and potassium binders can be used for treatment. Treatment choice should be tailored to patient characteristics including fluid status, blood pressure and serum creatinine. Potassium binders should be avoided in patients with history of recent abdominal surgery, opioid use and constipation. Serum electrolytes and creatinine should be monitored every 1-2 weeks after starting treatment to ensure an adequate response. Prolonged management may be necessary in some cases and at-risk patients should be counselled as to the meaning and importance of post-operative changes in measured renal function and potassium.

Design of enzyme-immobilized polymer brush-grafted magnetic nanoparticles for efficient nematicidal activity

Parasitic nematodes adversely affect agricultural industry and global health. An efficient and reusable nematicidal platform is developed by immobilization enzyme on the surface of magnetic NPs.

A kick in the shins: the financial impact of uncontrolled warfarin use in pre-tibial haematomas

Warfarin is increasingly prescribed in the elderly population for a number of medical conditions. Pre-tibial haematomas are a common cause of morbidity in this group. The aim of the study was to identify the proficiency of INR monitoring at a primary care level in correlation with their recommended INR range and to study the treatment outcome in this group. A retrospective single-centre study of patients diagnosed with pre-tibial haematomas was conducted over a two-year period. Length of hospital stay, time delay until operative intervention, blood transfusion and warfarin reversal requirements, social care input and cost to the NHS were considered. A total of 62 patients were admitted with pre-tibial haematomas of which 20 were on Warfarin. Females were predominantly more affected (5.6:1). The mechanism of injury was as a result of minor trauma. The mean INR level was 3.8 with a standard deviation of 3.1. Mean length of hospital stay was 11 days with a standard deviation of 13.6. Nine patients required skin grafting. Average cost for the acute episode was £3500 per patient. INR levels were significantly outwith the target range causing substantial patient morbidity and imposing a significant financial burden on the NHS. Tighter regulation at a primary care level should help reduce this risk.

Hepatic transaminase and alkaline phosphatase enzyme levels in HIV/HBV co-infected and HIV mono-infected patients in Maiduguri, Nigeria

BACKGROUND

Studies have shown that HIV-HBV co-infected patients have an increased risk of liver-related morbidity and mortality compared to their HIV-mono-infected counterparts. Furthermore, it has been reported that HIV-HBV co-infected patients have a significantly high incidence of drug-induced hepatotoxicity following commencement of HAART than HIV-mono-infected patients.

OBJECTIVES

To compare the levels of aspartate amino transferase (AST), alanine amino transferase (ALT) and alkaline phosphatase (ALKPO 4 ) enzyme levels between HAART naïve HIV-HBV co-infected patients and their HIV-mono-infected counterparts.

MATERIALS AND METHODS

A cross-sectional descriptive study in which 142 newly diagnosed HIV/HBV co-infected and HIV mono-infected adults were investigated for alkaline aminotransferase, aspartate aminotransferase and alkaline phosphatase enzyme levels.

RESULTS

The study subjects comprised of 80 (56.3%) females and 62 (46.7%) males. The age range of the study population was 15-65 years. The mean ages of male and female subjects were 45.5 ± 10.5 years and 39.1 ± 7.5 years respectively ( P < 0.05). Sixty-three (44.4%) study subjects were HIV/HBV co-infected while 79 (55.6%) were HIV mono-infected. The mean ALT enzyme level of HIV/HBV co-infected subjects was significantly higher than that of HIV mono-infected ones i.e., 42.12 IU/l vs. 27.86 IU/l, ( P = 0.038). However, there was no statistically significant difference in the mean AST (30.14 IU/l vs. 29.09 IU/l, P = 0.893) and ALKPO 4 (55.86 IU/l vs. 60.97 IU/l, P = 0.205) enzyme levels between HIV-HBV co-infected and HIV mono-infected subjects albeit the two enzymes were moderately elevated in both categories of subjects.

CONCLUSION

The significantly elevated ALT enzyme levels amongst HIV-HBV co-infected subjects suggest that HIV-HBV co-infected patients may have an increased risk of liver-related morbidity and mortality than their HIV mono-infected counterparts. Screening for serological markers of chronic HBV infection, as well as hepatic transaminase enzyme levels in all newly diagnosed HIV-positive patients is therefore recommended before commencement of HAART.