True brachial artery aneurysm: A systematic review.

Objective: To identify and critically appraise literature on true brachial artery aneurysm, exploring its demographic characteristics, aetiologies, clinical manifestations and different methods of repair along with complication rates to determine future treatment strategies. METHODS: The systematic review was conducted at Liaquat National Hospital, Karachi, from September 30, 2021, to November 30, 2022, in line with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Literature was searched on MEDLINE, EMBASE and Cochrane databases for relevant studies in English language or with English translation published till May 31, 2022. The key words used for the search were "brachial artery aneurysm". Data was noted on a proforma and was subjected to descriptive analysis. RESULTS: Of 113 articles, 6 (5.3%) were retrospective studies, 7 (6.1%) were case series and 100 (88.4%) were case reports. The total number of patients involved was 157 with mean age 43.1±23.4 years (range: 2 months to 84 years). The gender was mentioned for 152(96.8%) patients; 111(73%) males and 41(27%) females. The mean diameter of true brachial artery aneurysm was 36.2 ±17.5mm and 106(67.5%) patients presented with localised swelling, 65(41.4%) with pain, 41(26.1%) with distal ischaemic symptoms, and 28(17.8%) with median nerve compression. True brachial artery aneurysms were more common in renal failure patients having a history of arteriovenous fistula creation in the affected limb and were on immunosuppressant drugs due to renal transplant 81(51.5%). Less common causes included primary/idiopathic 27(17.1%), trauma 13(8.2%), connective tissue disorders 8(5%) and vasculitis 7(4.5%). The treatment of choice was aneurysmectomy in 142(90.4%) cases, with revascularisation of limb primarily with reversed great saphenous vein graft 79(50.3 %), followed by end-to-end anastomosis of brachial artery 17(10.8%) and synthetic grafting 17(10.8%). Endovascular intervention was performed in 6(3.8%) cases to exclude true brachial artery aneurysm, and to re-establish adequate blood flow to the associated limb. Conclusion: True brachial artery aneurysm, although a rarity, may lead to significant neurological and vascular problems if ignored. Arteriovenous fistula and immunosuppression are identified as two significant risk factors in the development of true brachial artery aneurysm. Therefore, an effective long-term follow up in renal failure patients is recommended to prevent its complications. Open surgical repair has been the most preferred mode of treatment, but further significant studies are needed to explore and compare different modes of surgical intervention, like open versus endovascular, to plan future treatment strategies.

Trends and Immediate Outcomes of Syncope During Pregnancy: A Narrative Review.

Pregnancy-related syncope presents special difficulties due to the rapid physiological changes that occur throughout gestation. This narrative review provides a thorough summary of the patterns and pregnancy outcomes secondary to syncope during pregnancy. There is an increase in syncope burden during pregnancy, and hence it is critical that medical professionals understand the significance of syncope during pregnancy. Syncope can have a negative impact on the health of the mother as well as the fetus. Therefore, this review summarizes data from studies on syncope in pregnancy. It includes observational studies, case reports, and review articles. Early detection and proper management are very important because pregnant women who experience cardiac syncope are at risk of unfavorable neonatal and maternal outcomes. The review reveals diverse trends in syncope incidence during pregnancy, emphasizing the need for a nuanced understanding of temporal variations. Risks of injury, uteroplacental insufficiency, psychological effects, interruptions in prenatal treatment, possible aggravation of pre-existing diseases, and lifestyle changes are examples of immediate maternal repercussions. Pregnancy-related syncope is a complex condition that affects the health of the mother and the fetus. The study stresses the need for careful clinical treatment due to the rapid results and the diversity in incidence patterns. The unique component of a possible relationship to the brain health of offspring justifies further investigation in this area.

Exploring the role of gut microbiota in autoimmune thyroid disorders: a systematic review and meta-analysis.

Background: Autoimmune thyroid diseases (AITDs) are characterized by unique immune responses against thyroid antigens and persist over time. The most common types of AITDs are Graves' disease (GD) and Hashimoto's thyroiditis (HT). There is mounting evidence that changes in the microbiota may play a role in the onset and development of AITDs. Objective: The purpose of this comprehensive literature study was to answer the following query: Is there a difference in microbiota in those who have AITDs? Methods: According to the standards set out by the PRISMA statement, 16 studies met the requirements for inclusion after being screened for eligibility. Results: The Simpson index was the only diversity measure shown to be considerably lower in patients with GD compared to healthy participants, whereas all other indices were found to be significantly greater in patients with HT. The latter group, however, showed a greater relative abundance of Bacteroidetes and Actinobacteria at the phylum level, and consequently of Prevotella and Bifidobacterium at the genus level. The strongest positive and negative relationships were seen for thyroid peroxidase antibodies and bacterial load. Conclusion: Overall, both GD and HT patients showed significant changes in the gut microbiota's diversity and composition. Systematic review registration: https://www.crd.york.ac.uk/PROSPERO/, identifier CRD42023432455.

Novel putative biomarkers for infective endocarditis by serum proteomic analysis: a comprehensive review of literature.

Infective endocarditis (IE) is a challenging condition with high mortality. Prompt detection of IE has become essential for early and immediate management. The authors aimed to comprehensively review the existing literature on novel putative biomarkers for IE through serum proteomic analysis. The literature reveals high levels of N-terminal-pro-B-type natriuretic peptide (NT-proBNP) levels in IE with staphylococcal etiology, valvular lesions, and when combined with cardiac troponin I (cTnI), had a more significant value for risk stratification. A higher pro-ADM level, copeptin, NT-proBNP, and the monocyte-to-high-density lipoprotein cholesterol ratio (MHR) all impacted mortality during the hospital stay. The biomarker matrix metalloproteinase-9 was utilized to predict new-onset embolic events in patients, thus serving as a predictive marker. Procalcitonin was an important diagnostic marker in IE complicated with severe infection. Interleukin-6 (IL-6), Interleukin-8 (IL-8), Interferon-γ, cTnI, and NT-proBNP were also discovered to be useful as prognostic indicators. Early diagnosis and appropriate treatment are possible using antiphospholipid antibodies as a diagnostic test for definite IE. It is also concluded that antineutrophilic cytoplasmic antibody positive individuals with IE had a lengthier hospital stay. These noninvasive biomarkers can identify patients at risk and provide appropriate and early clinical management. NT-proBNP, Cystatin C, troponins, IL-6, IL-8, S100A11, and AQP9 are examples of possible markers that appear promising for further research. In conclusion, large-scale validation studies should study these biomarkers further to establish their use in clinical settings.

Delivery Methods in Twin Gestations: Evaluating Outcomes, Risk Factors, and the Paradigm Shift Towards Elective Cesarean Deliveries.

During the past decade, there has been a consistent rise in the number of twin births and the number of overall cesarean sections (CS) worldwide. This is owed to a variety of social, economic, educational, and scientific factors. More women are opting to advance their professional careers and gain financial stability before having children. Although this approach is understandable, a new set of challenges are faced as a result, the most important of which has been infertility due to advanced maternal age and the subsequent use of assisted fertility treatments, which have been noted to cause multiple gestations. Twin gestations are considered high-risk pregnancies and are associated with an amplitude of potential complications. Arguably, the biggest decision an obstetrician must make when dealing with this population is choosing the most appropriate mode of delivery. Given the lack of clear guidance pertaining to twin deliveries, CSs may often be perceived as safer and are often preferred over vaginal deliveries (VD). In this narrative review, we aimed to compare the outcomes of different delivery methods (CS versus VD) to investigate whether CS is truly superior to VD. Data were collected from the past two decades and analyzed based on the neonatal and maternal outcomes for each delivery mode. Our results indicate that planned VD is just as safe as CS, if not superior, in most uncomplicated twin pregnancies. Thus, it is best to advise and encourage healthy expecting twin carriers to undergo VD and explore any hesitations or fears they might have. Furthermore, a detailed guideline regarding twin delivery is essential to establish and better navigate twin deliveries, lower the rate of unnecessary CSs, and reduce overall twin gestation morbidity and mortality.

The Impact of Virtual Reality (VR) Gaming and Casual/Social Gaming on the Quality of Life, Depression, and Dialysis Tolerance in Patients With Chronic Kidney Disease: A Narrative Review.

This comprehensive narrative review aims to investigate the impact of virtual reality (VR) and social gaming on the quality of life, depression, and dialysis tolerance in patients with chronic kidney disease (CKD), a growing global health concern affecting the quality of life and increasing mortality rates. Through a combination of exercise and video games, exergaming, and digital game therapy (DGT), sedentary risks can be mitigated and therapy adherence enhanced. Despite potential side effects such as exhaustion and nausea, research indicates that virtual therapeutic games improve motivation and dialysis tolerance, and even reduce brain activity in pain-associated regions during procedures. These methods are superior to traditional distraction techniques like music, movies, and toys. Exergaming, social gaming, and VR gaming can improve various health factors including depressive symptoms, functional capacity, muscle strength, fatigue, physical activity, mental health, motivation, engagement, cognition, and overall quality of life for CKD patients. Representing a novel approach to CKD management, these interventions promote physical activity, cognitive stimulation, and social interaction. Continued research and innovation will facilitate the integration of VR-based therapies into routine CKD care.

Long COVID syndrome: psychological and sexual dysfunction among survivors of COVID-19 infection.

Background: To explore the neuropsychiatric symptoms, sleep disturbances, and sexual dysfunction in patients with long COVID syndrome, which can help in building better follow-up strategies for coronavirus disease 2019 (COVID-19) survivors. Material and methods: A cross-sectional research was undertaken at the premises of a psychiatry unit at a tertiary care unit in Karachi, Pakistan, between August 2022 and April 2023. All individuals aged 18 years or older, who had a history of contracting COVID-19 infection in the last 12 months presented to the department of Psychiatry with neuropsychiatric symptoms were recruited. Using a predefined questionnaire, data was collected from the participants. A linear logistic regression was used to find the impact of age, sex, hospitalization, and duration of home isolation on the likelihood of persistent neuropsychiatric symptoms or sexual dysfunction. Results: A total of 457 patients were included. It was found that individuals were less likely to experience neuropsychiatric symptoms as age increased (OR=0.968, 95% CI: 0.949-0.986, P=0.001). Females were 4.8 times more likely to experience neuropsychiatric symptoms than males, and the association was extremely significant (OR=4.851, 95% CI: 3.085-7.626, P<0.0001). An increase in age raised the odds of having sleep disturbances among the survivors by 2.7 times (OR=2.672, 95% CI: 2.654-2.684, P<0.0001). The odds of having sleep disturbances were three times more likely in female participants as compared to male participants (OR=3.00, 95% CI: 1.771-5.094, P<0.0001). Conclusion: The majority of the COVID-19 survivors are presenting with persistent neuropsychiatric and sexual symptoms in our setting. Therefore, it is necessary to maintain proper follow-up with the survivors of COVID-19 and counsel the patients to inform the family physician if these symptoms persist for longer than a month. Increasing such practices of regular follow-ups with COVID-19 survivors can help in detecting early neuropsychiatric and sexual changes.

Resilience of primary healthcare system across low- and middle-income countries during COVID-19 pandemic: a scoping review.

INTRODUCTION: Globally, the coronavirus disease 2019 (COVID-19) pandemic tested the resilience of the health system and its shock-absorbing capacity to continue offering healthcare services. The available evidences does not provide comprehensive insight into primary health care (PHC) system functioning across low- and middle- income countries (LMICs) during the pandemic. Therefore, the objective of this scoping review was to generate evidence on the resilience of PHC systems in LMICs during the COVID-19 pandemic. METHODS: A scoping review was carried out utilizing an iterative search strategy using the National Library of Medicine (NLM) and the WHO COVID-19 electronic databases. Data from the identified studies in LMICs were charted in the Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist in the first step. The analysis framework was adapted and modified using COVID-19 and health systems resilience framework developed by Sagan et al., Blanchet et al., and the WHO position paper on 'Building health systems resilience for universal health coverage and health security during the COVID-19 pandemic and beyond'. A total of 26 documents were included on the basis of predefined eligibility criteria for our analysis. RESULTS: Our review explored data from 44 LMICs that implemented strategies at the PHC level during the COVID-19 pandemic. Most of the LMICs developed national guidelines on sexual, reproductive, maternal, newborn, child, and adolescent health (SRMNCAH). Most of the countries also transformed and reoriented PHC service delivery by introducing digital healthcare services to continue essential services. Task shifting, task sharing, and redeployment of retired staff were some frequently adopted health workforce strategies adopted by most of the countries. Only a few of the countries demonstrated the availability of necessary monetary resources to respond to the pandemic. CONCLUSIONS: The functionality of the PHC system during the COVID-19 pandemic was demonstrated by a variety of resilience strategies across the six building blocks of the health system. To strengthen PHC resilience, we recommend strengthening community-based PHC, cross-sectoral collaboration, establishing surveillance systems, capacity building in financial risk planning, and investing in strengthening the digital healthcare system.

Healthcare Cost and Outcomes Associated With Surgical Site Infection and Patient Outcomes in Low- and Middle-Income Countries.

Surgical site infection (SSI) is a growing global concern. The principal explanation for this is its adverse clinical outcomes, such as morbidity and mortality. However, the link between the economic burden of SSIs and patient outcomes needs to be sufficiently characterized. This review aims to describe the financial implications of SSIs on patient outcomes in low- and middle-income countries (LMIC). Despite the heterogeneity in study designs from multiple LMIC countries, there is a significant correlation between SSI-associated healthcare costs from increased length of stay (LOS), readmissions, reoperations, and adverse patient outcomes. This varies based on the size, degree of infection, or other patient comorbidities. SSIs are much more prevalent in LMICs. The additional financial burden incurred in managing SSIs reinforces the need to prioritize practicing interventions to prevent this complication, which resource-limited health institutions are unequipped to do and consequently have significant adverse patient outcomes.

Immunomodulatory Therapy for Giant Cell Myocarditis: A Narrative Review.

Giant cell myocarditis (GCM) is a rare, often rapidly progressive, and potentially fatal disease because of myocardium inflammation due to the infiltration of giant cells triggered by infectious as well as non-infectious etiologies. Several studies have reported that GCM can occur in patients of all ages but is more commonly found in adults. It is relatively more common among African American and Hispanic patients than in the White population. Early diagnosis and treatment are critical. Electrocardiogram (EKG), complete blood count, erythrocyte sedimentation rate, C-reactive protein, and cardiac biomarkers such as troponin and brain natriuretic peptide (BNP), echocardiogram, cardiac magnetic resonance imaging (MRI), myocardial biopsy, and myocardial gene profiling are useful diagnostic tools. Current research has identified several potential biomarkers for GCM, including myocarditis-associated immune cells, cytokines, and other chemicals. The standard of care for GCM includes aggressive immunosuppressive therapy with corticosteroids and immunomodulatory agents like rituximab, cyclosporine, and infliximab, which have shown promising results in GCM by balancing the immune system and preventing the attack on healthy tissues, resulting in the reduction of inflammation, promotion of healing, and decreasing the necessity for cardiac transplantation. Without immunosuppression, the chance of mortality or cardiac surgery was 100%. Multiple studies have revealed that a treatment combination of corticosteroids and immunomodulatory agents is superior to corticosteroids alone. Combination therapy significantly increased transplant-free survival (TFS) and decreased the likelihood of heart transplantation, hence improving overall survival. It is important to balance the benefits of immunosuppression with its potentially adverse effects. In conclusion, immunomodulatory therapy adds significant long-term survival benefits to GCM.

Supratotal Resection: An Emerging Concept of Glioblastoma Multiforme Surgery-Systematic Review And Meta-Analysis.

BACKGROUND: The severe neurologic tumor known as glioblastoma (GBM), also referred to as a grade IV astrocytoma, is rapidly progressive and debilitating. Supratotal resection (SpTR) is an emerging concept within glioma surgery, which aims to achieve a more extensive resection of the tumor than is possible with conventional techniques. METHODS: We performed a language-independent search of PubMed, Scopus, and Cochrane CENTRAL to identify all available literature up to August 2022 of patients undergoing SpTR assessing survival outcomes in comparison to other surgical modalities. RESULTS: After screening for exclusion, a total of 13 studies, all retrospective in design, were identified and included in our meta-analysis. SpTR was associated with significantly increased overall survival (hazard ratio 0.77, 95% CI 0.71-0.84; P < 0.01, I2 = 96%) and progression-free survival (hazard ratio 0.2, 95% CI 0.07-0.56; P = 0.002, I2 = 88%). CONCLUSION: SpTR is associated with greater overall survival and PFS when compared with other glioblastoma surgeries like GTR or SubTR.

Open, Laparoscopic, and Robotic Approaches to Treat Colorectal Cancer: A Comprehensive Review of Literature.

Surgery is usually required to treat colorectal cancer (CRC). Medical technology has advanced, providing various approaches to tackle this disease. Different surgeries are available, such as laparoscopic surgery, single-incision laparoscopic surgery, natural orifice transluminal endoscopic surgery, and robotic surgery. Laparoscopic surgery has several benefits including reduced blood loss and shorter recovery time. It can also improve lung function and minimize complications. However, it requires more time to perform and has a higher risk of complications during the procedure. Robotic surgery provides a three-dimensional view of the surgical area allowing for greater precision in rectal surgeries and access to difficult-to-reach pelvic regions. This method utilizes robotics technology which reduces surgical time and speeds up recovery for patients. There are various surgical options available for treating CRC; however, laparoscopic surgery and robotic surgery offer unique advantages despite their own drawbacks. As technology continues to evolve, medical techniques will continue improving existing methods while providing new options resulting in better outcomes for patients. Compared to laparoscopy, robotic surgery has a lower rate of operative conversions and a shorter learning curve. However, it also has some drawbacks, such as a longer docking time, lack of tactile sensation, and higher cost. Therefore, the choice of surgical method should depend on patient characteristics, surgeon preference and expertise, and available resources. Currently, specialized centers offer robotic surgeries which are more expensive and take longer compared to open and laparoscopic approaches. Nonetheless, they are considered safe and feasible when compared to traditional surgery. Short-term outcomes for robotic surgeries are better, while long-term postoperative complication rates remain similar. However, there is a need for additional well-defined randomized control trials conducted across multiple centers to validate the use of robotic surgery over open and laparoscopic approaches. Improving patient care and outcomes is the objective of this comprehensive literature overview on surgical approaches for CRC.

Preparation and biological evaluation of radio conjugated cephradine complex for infection imaging.

Antimicrobial resistance is a major challenge in the field and threat to human life. Many patients are suffering from cancer, infection and other diseases simultaneously. Therefore, early detection of infection can lead to treatment of these patients with an appropriate antibiotic. Hence, the development of a specific imaging molecule can increase the speed of infection analysis and thereby application of proper antibiotic. The present work involves the optimization of labelling conditions for an antibiotic of cephalosporin family, cephradine with technetium-99m (99mTc) and establishment of quality control tests. Labelling of cephradine was also determined by applying MALDI-TOF mass spectrometry. Evaluation of in vitro binding with S. aureus bacteria was carried out. Animal model was used to conduct in vivo binding studies. For this, infected animals were injected with the radiolabelled ligand and images were captured by Gamma camera, to observe target to non-target uptake of radiolabelled complex. Furthermore, we optimized various parameters to achieve best labelling efficacy and stability of cephradine. Our results show that cephradine can be used as potential infection imaging agent for advanced clinical care.

Catheter-Related Bloodstream Infection With Femoral Central Access Versus Internal Jugular Access in Patients Admitting to Medical Intensive Care Unit.

Background The current research focused on studying the pattern of catheter-related bloodstream infections (CRBSI) with femoral central access versus internal jugular access in patients admitted to the medical intensive care unit (ICU). Methods A cross-sectional study was conducted at the Department of Emergency Medicine, Shifa International Hospital, between March 4, 2022, and August 4, 2022. All individuals who presented to the ICU who needed a central venous catheter (CVC) for more than 48 hours were included. Catheter insertion was not permitted if the patient had a history of dermatitis or burns at the site of insertion or if the hemodialysis procedure necessitated the insertion of the catheter into a blood vessel. Three groups of patients were created: group A patients had been diagnosed with CRBSI; group B patients had catheter colonization (CC); and group C did not have CRBSI or CC. Standard microbiological methods were used to identify all of the bacteria collected from the cultures. All data was documented in a predefined pro forma. Results Overall, 20 (12.12%) patients had positive CRBSI, 68 (41.5%) had CC, and the remaining 46.3% of cultures were negative. Elderly populations were more prone to acquiring CRBSI showing a significant correlation between older age and CRBSI (p < 0.0001). CC was significantly associated with a longer duration of ICU stay, i.e., 30.3 ± 3.7 (p = 0.003). The absence of both CRBSI and CC was significantly associated with a lower duration of catheterization (11 ± 8.5 days in group C versus 22.1 ± 6.9 and 18.7 ± 7 days in groups A and B, respectively; p < 0.0001). Our study revealed a higher risk of CRBSI when the femoral access was compared to the internal jugular access (58.3% vs. 41.7%; p = 0.0008). The study did not find any significant association of CC with femoral or internal jugular access. Furthermore, a significantly higher rate of negative cultures was reported in patients with internal jugular access as compared to femoral vein access (85.8% vs. 14.2%; p = 0.007). Conclusion The need for routinely monitoring and observing the microbiological spectrum in patients receiving care in intensive care units is highlighted by the current investigation. The patients with internal jugular vein access had a decreased incidence of CRBSI and CC, while those with femoral access experienced CRBSI more frequently. Escherichia coli and Pseudomonas aeruginosa were the most frequently isolated germs, and both were resistant to various drugs that are used today. It is essential to regularly monitor the epidemiology of CRBSI in order to adopt preventative measures for infection prevention and control, such as staff education, strict hygiene standards, and a higher nurse-to-patient ratio.

Clinical Characteristics and Symptomatology Associated With Dengue Fever.

Background Early diagnosis and prompt treatment are critical to reducing overall morbidity and mortality associated with dengue fever. Thus, to better understand the condition, the present study was conducted to assess the clinical signs and symptomatology associated with dengue fever in patients in a tertiary care hospital. Methods This prospective observational study was conducted at a tertiary care hospital in Karachi, Pakistan between July and December 2021. All patients who tested positive for the dengue virus either based on antigen or antibodies were included in the study. Convenient sampling was used. A structured proforma was used for data collection. Microsoft Excel (Microsoft Corporation, Redmond, WA) and Statistical Package for the Social Sciences (SPSS, IBM Corp., Armonk, NY) were used for the entry and analysis of data, respectively. Results More than half of the patients were suffering from fever (82.5%), headache/body ache/joint pain (80.5%), and vomiting (55%). Bleeding was observed in 16 (8%) patients and was directly related to platelet count (OR: 0.981; 95% CI: 0.971-0.992), and more than half of the patients (56%) required platelet transfusion. Laboratory values included a mean platelet count of 145.22 ± 90.36 thousand, a mean total leukocyte count (TLC) of 6.87 ± 5.76 thousand, and a mean hemoglobin level of 13.71 ± 2.11 g/dl. Of the patients, 171 (85.5%) individuals tested positive for antigen nonstructural protein 1 (Ns1Ag), and 68 (34%) tested positive for either immunoglobulin G (IgG) or immunoglobulin M (IgM), or both dengue-specific antibodies. Those with dengue-specific antibodies were less likely to bleed as 6.2% were IgG and IgM positive and 31.2% were positive for both antibodies. The regression model showed a significant relationship between bleeding and platelet transfusion (p < 0.001), hospital stay (p < 0.005), and diarrhea (p < 0.001). Conclusion In conclusion, the study revealed that males were more frequently infected with the virus as compared to females. Furthermore, fever, headache/joint pain/body aches, diarrhea, and low platelet count are the major clinical and laboratory outcomes. Patients with a low level of platelets are more prone to bleeding, and platelet transfusion increased survival chances in such patients.

Evaluating the Impact of Positive Fluid Balance on Mortality and Length of Stay in Septic Shock Patients.

Background Sepsis is accountable for major morbidity and mortality in patients with critical illnesses. The present research was undertaken to evaluate the correlation between fluid balance during hospitalizations and patient outcomes in patients with sepsis. Methods An observational study was undertaken at the Critical Care Department, Shifa International Hospital, Islamabad, Pakistan between December 2021 to April 2022. The patients included were over the age of 17 years, with a proven diagnosis of infection. These patients either had positive bacterial cultures, suffered from organ failure secondary to sepsis, or had clinically evident signs of infection. Patients who were discharged during the period of study were eliminated from the study population. All patients were informed of the process and signed consent was obtained. Basic demographic information was recorded, which included the existence of any comorbid conditions, organ failure, medication use, or infection history. The severity of critical illness was determined for every single patient along with organ damage. The final patient outcome was recorded as in-hospital mortality. Results A total of 307 patients were included in the study with a total of 165 (53.75%) male patients. The overall mortality rate was 39.74%. The mean length of hospitalization was 17.42 ± 8.3 days. A high SOFA score was significantly associated with quartile 4 with a mean score of 14.1 (p < 0.001). Similarly, a significantly higher APACHE score was found in patients in quartile 4 (p < 0.001) thus indicating a relationship between severity of illness and positive fluid balance. Upon further assessment, it was found that the 28th day and 90th day were significantly greater in quartile 4 in comparison to other quartiles. Similarly, the overall length of stays in the hospital and in the ICU were also significantly associated with greater fluid balance (p < 0.001).  Conclusion In our study, it was concluded that monitoring fluid balance in critically ill patients is very important. The highest 28-day and 90-day mortality were seen in patients with the greatest positive fluid balance. However, the cause of high mortality in this cohort could be multifactorial; therefore, the relationship of positive fluid balance with patient outcome remains debatable.

Rifaximin Therapy for Patients With Metronidazole-Unresponsive Clostridium difficile Infection.

Background Clostridium difficile infection (CDI) is a leading cause of hospital-acquired diarrhea. Rifaximin is an antibiotic that offers marginal resistance to C. difficile bacteria. This study was conducted to evaluate the efficacy of rifaximin in metronidazole non-responsive CDI patients. Methods A cross-sectional study was performed from August 2019 to May 2020 at the Lahore General Hospital, Lahore, Pakistan. A total of 200 cases were included. Patients who developed diarrhea after receiving antibiotics for seven days and a positive C. difficile toxin stool test as detected by the enzyme immunoassay (BioCheck, Inc., CA) were diagnosed with CDI. Only patients who were unresponsive to metronidazole therapy were enrolled in our analysis. Two groups were formed. The intervention group was administered 200 mg tablets of rifaximin three times a day for 10 days. For patients in the control group, no new treatment was started. The efficacy of rifaximin was defined in terms of the resolution of diarrhea after two weeks of therapy and a negative stool test. All data were recorded in a predefined pro forma. Results The mean age of 45.41 ± 8.54 years was found in the intervention group. The majority of the patients were aged 35-50 years. The majority of the patients had watery diarrhea, abdominal cramping, and loss of appetite on presentation. Rifaximin was found to be significantly effective in the resolution of symptoms of CDI, which was previously unresponsive to metronidazole (p<0.00001). it was found that the duration of diarrhea of more than three weeks was significantly associated with failure of therapy (p=0.03). Conclusion We concluded that rifaximin therapy is effective for patients of CDI non-responsive to metronidazole in more than 65% of the cases. Even though several new developments are made to address the concerned subject, such as microbiota transplantation, antibiotics, and immunotherapy, rifaximin can be considered for patients with metronidazole non-responsive CDI.

Risk Factors Associated With Rhegmatogenous Retinal Detachment.

Background Even though significant improvements have been made in the field of ophthalmology, retinal detachment is still an ever-increasing issue in both developing and developed countries. The present study evaluated the risk factors of rhegmatogenous retinal detachment (RRD). Methodology A cross-sectional study was conducted at a tertiary care center between June 2020 and March 2021. A total of 100 patients diagnosed with RRD were enrolled in the study. Patients with inconclusive diagnoses and multiple comorbidities were excluded from the study. A detailed history was taken, including previous surgery and ocular trauma or infections. A comprehensive ocular examination was conducted by an experienced ophthalmologist, including a dilated fundus examination. The causes and type of RRD were documented. Results In the study, a majority of the patients were males, with a mean age of 37.84 (18.29) years and a range of 5-74 years. The majority of those with total RRD were males, i.e., 37%; however, the difference was statistically insignificant (p=0.476). The study revealed that most of the RRD were diagnosed in patients <45 years of age; however, the difference was not statistically significant (p<0.227). The most frequent cause of RRD was lattice degeneration. While 23% of patients with RRD had a history of ocular trauma, uncomplicated phaco was detected in 17 cases. It was found that patients aged less than 45 years more frequently reported ocular trauma as the cause of RRD (p=0.004). Similarly, the cause of RRD was also significantly associated with the type of RRD (p=0.001). Conclusion The present study concludes that lattice degeneration, ocular trauma, uncomplicated, and complicated phaco are the main predisposing factors associated with RRD. Furthermore, the majority of the patients were males in their late thirties. Age, gender, and eye involvement were not significantly associated with the type of RRD.

Correlation Between Site and Stage of Breast Cancer in Women.

Introduction Breast cancer is a worldwide public health issue and a primary cause of death among women. The present study aimed to assess the correlation between site and stage of breast cancer with respect to age among females. Methods A prospective observational study was conducted at the Medical Oncology Department, Jinnah Postgraduate Medical Centre, Karachi, Pakistan from May 2020 to June 2021. Female patients of 18 years or older with a confirmed diagnosis of breast cancer were included in the study. Histopathological reports were evaluated for tumor characteristics such as histological type, laterality, location, tumor size, grade, lymph node status, and stage of the tumor. Results The majority of the patients presented with advanced stages of tumor. Among all stages of breast tumor, the upper outer quadrant was the most frequent location of the tumor. The majority of the patients with cancer in the upper inner quadrant were diagnosed with stage I (28.57%) (p = 0.011). In contrast, the majority of the upper outer quadrant lesions were identified as stage III and stage IV (p < 0.0001). In patients of age <40 years, statistically significant differences in proportions of tumor location with respect to the stage of the tumor were observed (p = 0.018). Conclusion The upper outer quadrant and stage III of tumor are the most common site and stage of breast tumor in our population. There is a significant relationship between site and stage of breast tumor. Younger-aged patients had a significantly higher rate of cancers located in the upper outer quadrant in advance stages as compared to other quadrants.

The Efficacy of Fenofibrate in Addition to Atorvastatin in Patients of Type II Diabetes Mellitus.

Background The objective was to study the efficacy of atorvastatin in combination with fenofibrate as compared to atorvastatin in combination with saroglitazar in patients of diabetes mellitus type II with dyslipidemia.  Methodology A quasi-experimental study was done at the Diabetes and Endocrinology Ward, Hayatabad Medical Complex Peshawar, between January 2021 to June 2021. All patients aged 25 years and above with newly diagnosed diabetes mellitus (less than six months ago) with dyslipidemia, i.e., deranged lipid range, were eligible to participate. Patients with secondary hypertension, pregnancy, or any pulmonary disease were excluded from the study. Patients already taking anti-glycemic drugs were also ineligible to participate. Patients were divided into two groups. Group I patients received Atorvastatin 10mg plus Fenofibrate 145 mg, while Group II received the combination of the tab. Atorvastatin 10mg in addition to Saroglitazar 4g. Lipid profiles were studied at baseline and 24-month follow-up. All data were documented in a preformed proforma.  Results A total of 80 patients were enrolled in the study, with 40 patients in each group. In Group I (atorvastatin + fenofibrate), the mean cholesterol at 24-week follow-up was 254.51 ± 47.41 as compared to 230.45 ± 47.21 in Group II (p<0.0001). Similarly, total triglycerides, low-density lipoprotein (LDL), and very-low-density lipoprotein (VLDL) were significantly higher in Group I patients by 24-week follow-up as compared to Group II. The mean HDL levels in Group I changed from 40.21 ± 3.54 at baseline to 46.28 ± 6.25 at follow-up, while in Group II, the mean HDL levels altered from 39.54 ± 4.52 to 52.34 ± 7.54 (p<0.0001).  Conclusion Overall, both groups showed significant improvements in lipid profiles; however, when atorvastatin in addition to fenofibrate was compared with saroglitazar, it was found that the latter combination was more effective in improving the overall patient outcome.