Chlorine gas hazardous material incident in Karachi, Pakistan: A clinical experience from an emergency department of a tertiary care hospital.

OBJECTIVE: To determine the clinical characteristics, management and outcomes of patients presenting with chlorine gas exposure in an emergency setting. METHODS: The single-centre, retrospective cross-sectional study was conducted at the emergency department of Aga Khan University Hospital, Karachi, and comprised data of all patients who presented on March 06, 2020, due to acute chlorine gas exposure after a specific industrial accident. Demographic and clinical data was recorded from the medical record files. The association between risk factors and complications was explored. Data was analysed using SPSS 20. RESULTS: There were 51 male patients with a mean age of 33.10±8.37 years. The most commonly affected organ system was respiratory 49(96%), with 43(84.3) having shortness of breath. Eye irritation was found in 44(86.3%) cases and the central nervous system was involved in 14(27.4%). Most of the patients were admitted from the emergency department 36(70%). Regarding treatment, 1(1.9%) patient each required invasive and non-invasive mechanical ventilation. Complications included toxic pneumonitis 3(5.9%) and pneumomediastinum 1(1.7%). No correlation was found between smoking and complications (p>0.05). CONCLUSIONS: Most patients showed complete resolution of symptoms after receiving supportive treatment, while complications were rare and there was no mortality.

Predictors of abnormal electroencephalogram and neuroimaging in children presenting to the emergency department with new-onset afebrile seizures.

BACKGROUND: Electroencephalogram and neuroimaging in pediatric patients with new-onset afebrile seizures are performed to detect any underlying pathological severe condition that may require emergent neuro-intervention and guide prognosis. This study aims to determine the predictors of abnormal EEG and neuroimaging in children presenting to the emergency department with new-onset afebrile seizures. METHODS: This single-center cross-sectional study was conducted at a tertiary care hospital in Karachi, Pakistan, from July 01, 2019, to June 30, 2021. All patients aged one month to 18 years who presented with new-onset afebrile seizures were included. Demographic and clinical data were recorded, including age, gender, seizure type, duration of seizure, associated signs and symptoms, and disposition. Multivariable regression analysis was applied to determine the predictors of abnormal EEG and CT scan or MRI findings. RESULTS: Out of 201 participants, most patients were in the infantile age group (41.3%), with an equal gender distribution. The most common type of seizure was generalized onset 152 (75.6%). EEG was performed on a total of 126 patients (62.7%) and out of these patients, 67 patients (53.1%) had abnormal findings. In a multivariable analysis, the age group of 5 to 10 years and seizure duration of more than 5 min were significantly associated with higher odds of abnormal EEG findings. In contrast, only the focal onset of seizure was significantly associated with higher odds of abnormal neuroimaging findings. CONCLUSION: The study emphasizes the need for a protocol regarding the performance of EEG and neuroimaging in children presenting to the ED with new-onset afebrile seizures that would aid emergency physicians in the direction of appropriate management, thus ensuring a better quality of patient care and outcomes.

Etiology and outcomes of new onset seizure in adult patients: A clinical experience from emergency department of a tertiary care center.

Objectives: To identify the etiology and outcomes of new onset seizure in adult patients presenting to the Emergency Department (ED), to improve knowledge among healthcare providers regarding diagnosis and hence improve the outcomes. Methods: This was a descriptive retrospective study conducted at the Emergency Department of Aga Khan University Hospital, Karachi, Pakistan. Adult patients (18 years and above), presented to the ED from January 01, 2019 to June 30, 2020, with new onset seizure were included consecutively. Descriptive data on patient demographics, seizure types, investigations performed, final diagnosis and disposition were collected retrospectively from patient's file and electronic record. Etiologies of seizure were classified as structural (metabolic, trauma, infection), genetic or idiopathic. The immediate outcomes were reported as hospitalization or discharge from the ED. Results: In total 198 patients with new onset seizure were included. Majority of the patients were found in middle age group i.e., 35 to 65 years (44.4%). Gender distribution showed slightly higher percentage of females (55.1%). Generalized tonic clonic seizures were found to be the most common type of seizures (74.2%), followed by generalized tonic (12.1%) and focal onset aware seizures (7.5%). Out of total patients no cause was identified in eight patients (4%), whereas in total confirmed causes of new onset seizures, structural lesions of brain were found to be the most common cause (89.6%%), including neurological (23.6%), infectious (4.2%), systemic (13%), metabolic (7%) and toxicological (4%) causes respectively. Conclusion: This study explores the various etiologies of new onset seizures in adult patients presenting to the ED. The study emphasizes the need for a local guideline for the investigation of new onset seizures in adult patients that would direct emergency physicians in respect of appropriate management, thus to ensure better quality of patient care and outcomes.

Nasopharyngeal Tuberculosis.

Tuberculosis is a well-known communicable infectious disease and can involve almost any organ of the body. Upper respiratory tract involvement is seen in only 1.9% and involvement of the nasopharynx is even rarer, accounting for only 0.1%. The occurrence of nasopharyngeal tuberculosis (NPTB) is very rare even in endemic areas. Herein, we report two cases of NPTB in which patients had the previous history of chronic ear infection; and later were found to have NPTB. Initial symptoms of NPTB can be vague and easily be misdiagnosed. The literature is scarce on NPTB. To the best of our knowledge, no such cases have ever been reported from Pakistan. Although the incidence of NPTB is very low since we live in a country where tuberculosis incidence is really high, its possibility should be kept in mind as one of the differential diagnoses. Key Words: Nasopharyngeal, Tuberculosis, Otitis media, Fungal, Infection.

Use of Steroids in COVID-19 Patients: What is known?

COVID-19 pandemic has exaggerated the role of steroids in the standard of care despite minimum direct evidence of their efficacy in COVID-19 patients and their well-known adverse effects. The literature abounds on the side effects of steroids affecting different organ systems of the body. COVID-19 patients, who are on long-term steroids, are more susceptible to their adverse effects. We, herein, briefly review the potential uses and the adverse effects of steroids on different organ systems of the body. Key Words: Steroids, COVID-19, Adverse effects.

Clinical profile and outcomes of adult oncological patients presenting to the emergency department of a tertiary care hospital.

OBJECTIVE: To determine the clinical presentations, diagnosis, and outcomes of oncological patients presenting to the emergency department of a tertiary care hospital. METHODS: The single-centre, cross-sectional study was conducted at the emergency department of the Aga Khan University Hospital, Karachi, from January 1 to December 31, 2018, and comprised all adult patients with diagnosed solid or haematological malignancy. Demographical and clinical data was recorded from medical record files. The immediate outcomes were reported as hospitalisation or discharge from the emergency department. Data was analysed using SPSS 20. RESULTS: Of the 320 patients, 167(52.2%) were females. Overall, 214(66.9) patients were aged 35-64 years. Most of the patients had solid organ malignancy 276(86.2%), with the most common being breast carcinoma 60(18.8%). Among haematological malignancies, B-cell lymphoma 32(10%) was the most common. The most common symptoms at presentation were vomiting 78(24.4%), fever 77(24.1%), and generalised weakness 66(20.6%). Of the total, 240(75%) patients were admitted and 80(25%) were discharged. The most common discharge diagnosis was chemotherapy-induced vomiting, followed by febrile neutropenia and malignant hypercalcaemia. There were 26(10.8%) deaths among the in-patients. CONCLUSIONS: Cancer patients presented to the emergency department with diverse signs and symptoms. It is essential for physicians in the emergency department to be familiar with their presentations in order to initiate prompt and timely management plans for better clinical outcomes.

Etiology of acute undifferentiated fever in patients presenting to the emergency department of a tertiary care center in Karachi, Pakistan.

OBJECTIVE: Our study aimed at identifying the characteristics and etiology of various causes of acute undifferentiated fever in patients presenting to the emergency department of a tertiary care hospital. METHODS: This was a retrospective study conducted at the department of emergency medicine, Aga Khan University Hospital from January to June 2016. Adult patients presenting to Emergency department with acute undifferentiated fever were enrolled. Descriptive statistics were calculated in terms of mean±SD for continuous variables like age of the patients and duration of fever, whereas frequency and percentage were computed for categorical variables like gender and causes of fever. RESULTS: A total of one hundred and fifty five patients were included. Out of these 97 (62.6%) were males and 58 (37.4%) were females. Most patients (25.2%, n= 39) were diagnosed as malaria followed closely by dengue fever (n=33, 21.3%) and then enteric fever (n= 10, 6.5%). while 41.9% (n=65) were diagnosed as suspected viral fever based on clinical judgment and inconclusive laboratory results. CONCLUSION: Malaria was found to be the most common confirmed cause of acute undifferentiated fever followed by dengue and enteric fever. The provision of accurate epidemiological data will enable resources to be directed towards key areas and will be of practical importance to clinicians.

Diagnostic Efficiency of Multidetector Computed Tomography in the Evaluation of Clinically Equivocal Cases of Acute Appendicitis with Surgical Correlation.

Acute appendicitis is one of the most frequent causes of lower abdominal pain and requires immediate surgical intervention. The diagnosis often poses a lot of challenge even to experienced surgeon. Those patients with equivocal symptoms may require different imaging modalities like radiography, contrast examination and ultrasound with limited utility. Multidetector computed tomography (MDCT) used in suspected acute appendicitis has, however, resulted in improved diagnostic accuracy and also reduction of negative surgeries. Objective We intend to determine the diagnostic efficiency of MDCT in clinically equivocal cases of acute appendicitis correlating it with surgical/histopathological findings. Materials and methods A group of 116 patients was included in this study. Spiral MDCT was performed in all these cases after administration of oral and intravenous contrast. All these patients underwent surgery and the CT findings were correlated with histopathology. Out of these 116 patients, 60 patients were male and 56 female. The age range was from three to seventy years and mean age was 28+1 years. Results The results proved that MDCT had a sensitivity of 97.5%, specificity of 97.0%, and accuracy of 97.4% for the diagnosis of appendicitis with one false positive and two false negative cases. The study showed 100% accuracy in diagnosing acute appendicitis in children. In 33 patients, an alternate cause was identified with CT. The alternate diagnosis made on CT findings was consistent with the final diagnosis in 27 (81.8%) of 33 patients in whom there was no evidence of acute appendicitis. The clinical diagnosis disagreed with the CT diagnosis in six patients (18.18%). Conclusion Our study verifies that MDCT plays an important role in evaluation and consequent management of equivocal cases of acute appendicitis. MDCT is also able to diagnose appendicitis or detect alternative diagnosis in pediatric population.

Institutional Review of Hemorrhagic Pelvic Emergencies Effectively Managed with Percutaneous Arterial Embolization.

OBJECTIVE: Our aim was to review the results of pelvic arterial embolization (PAE) performed in the interventional radiology suite. METHOD: The data of all patients in whom pelvic angioembolization was performed was collected from July 2011 to June 2017. Procedures were performed by an experienced interventional radiologist. The clinical and laboratory data, as well as the outcome data, were obtained from the medical records of our hospital. The following parameters were collected for each patient, including the age, gender, presenting symptoms, site of bleeding, catheters used for embolization, material used for embolization, previous computed tomography (CT) scan and/or focused assessment with sonography for trauma (FAST) ultrasound, average hemoglobin before the procedure, and patient clinical status on discharge. RESULT: A total of 37 patients underwent pelvic angiography for acute hemorrhage at our institution. They had contrast blush, active extravasation, or abnormal vascularity from the branches of the internal iliac artery and underwent therapeutic transcatheter embolization. A total of 29 patients (78.3%) were male and 8 (21.7%) were female. The average age was 30.0 years (range: 6-90 year). Of these, 16 patients (43.2%) presented with road traffic accidents (RTAs), six with gunshot injuries (16.2%), six with iatrogenic injuries (16.2%), four with a history of a fall (10.8%), two with bomb blast injuries (5.4%), one with a history of a glass injury (2.7%), one had a history of a roof falling on her during an earthquake, and one patient had a pelvic pseudoaneurysm secondary to an abscess. The type of embolic material used for embolization included coils in 16 patients, polyvinyl alcohol (PVA) particles were used in eight patients, both PVA particles and coils were used in 11 patients, and glue was used in one patient. All were successfully embolized. Thirty-four were discharged while three patients expired during the course of hospital stay due to other coexisting morbidities. CONCLUSION: The management of pelvic injuries has always been a topic of debate, with multiple methods reported to date but growing evidence supports the use of pelvic arterial embolization in hemorrhagic pelvic injuries. The formulation of a standardized protocol is the need of the day.

Abruptio Placentae with Type II Respiratory Failure Secondary to Acute Interstitial Pneumonia Responsive to Steroids.

Acute Interstitial Pneumonia (AIP) is categorized as Idiopathic Interstitial Pneumonia (IIP), in which the cause is unknown. Ayoung female of 22 years presented in 34 weeks gestation with abruptio placentae (AP) and underwent Lower Segment Caesarian Section (LSCS) for AP. It progressed to type II respiratory failure secondary to AIPon 4th day post-surgery. It remained unresponsive when treated with noninvasive ventilation (NIV-BiPAP) along with antibiotics. Later, a trial treatment of pulse therapy of Methylprednisolone was executed on 7th day post-surgery which resulted in dramatic improvement in symptoms. It is uncommon to have type II respiratory failure secondary to AIP, and it is rarely steroid responsive.

UNIQUE PRESENTATION OF OSTEOPETROSIS.

Osteopetrosis is a rare hereditary disorder of osteoclast dysfunction leading to abnormally dense and sclerotic bones that are fragile and break easily. It can be inherited in various patterns like autosomal-dominant, autosomal-recessive or as X-linked traits, but the most grievous forms of its inheritance are the autosomal-recessive ones, which show early onset and are associated with very poor prognosis. We report here the case of an asymptomatic young boy, who was diagnosed as the case of autosomal recessive osteopetrosis on the basis of his genetic studies. The reason for his unusual asymptomatic disease was the location of mutation in TCIRG1 gene that was revealed from his genetic studies. Another unusual point about him was his survival at this age, which is surprisingly rewarding as patients with autosomal recessive osteopetrosis usually die earlier by the age of 2-3 years.

Sleep deprivation and its consequences on house officers and postgraduate trainees.

OBJECTIVE: To determine sleep deprivation and its consequences on doctors in tertiary care hospitals. METHODS: The cross-sectional study was conducted from February to May 2012 and comprised house officers and postgraduate trainees at 4 public and 1 private tertiary care hospitals in Karachi. The subjects were posted in wards, out-patient departments and emergencies. A proforma was designed with questions about duration of duty hours, sleep deprivation and its effects on quality of performance, and presence of anxiety, depression, medical errors, frequent cold and infections, accidents, weight changes, and insomnia. Duration of 1 hour was given to fill the proforma. SPSS 20 was used for data analysis. RESULT: The study comprised 364 subjects: 187 (51.37%) house officers and 177 (48.62%) postgraduate trainees. There were 274 (75.27%) females and 90 (24.72%) males. Of those who admitted to being sleep deprived (287; 78.84%), also complained of generalised weakness and poor performance (n = 115; 40%), anxiety (n = 110; 38%), frequent cold and infections (n = 107; 37%), personality changes (n = 93; 32%), depression (n = 86; 30%), risk of accidents (n = 68; 23.7%), medical errors (n = 58; 20%) and insomnia (n = 52; 18%). CONCLUSION: Having to spend 80-90 hours per week in hospitals causes sleep deprivation and negative work performance among doctors. Also, there is anxiety, depression and risk of accidents in their personal lives.