Exploring the Indications, Levels, and Outcomes of Lower Extremity Amputation at a Tertiary Care Hospital in Pakistan.

BACKGROUND: Lower extremity amputation (LEA) is a surgical procedure performed to remove either a part or the entire lower limb due to medical conditions such as trauma, infection, peripheral vascular disease, or malignancy. The procedure is becoming increasingly common in Pakistan, with a bulk of patients presenting from rural areas in tertiary care centers. Understanding the indications, levels, and outcomes of LEA is essential for improving patient care and adopting preventive strategies, especially in developing countries. METHODOLOGY: This study was conducted at Dow University Hospital in Karachi, Pakistan. Retrospective data of 384 patients who underwent non-traumatic lower extremity amputations between January 2016 and December 2020 was collected to include relevant history and characteristics, amputation indication and level, type of anesthesia used, and outcome within hospital stay. The data was analyzed using descriptive statistics. RESULTS: The data is composed of a wide age range (18 to 91 years) of patients, including a male majority (76.3%, n = 293). The employment status of the patients was taken into consideration, with a reported high number of unemployed individuals (60.4%, n = 232). Diabetes mellitus (84.4%, n = 324) was a commonly reported past medical condition, followed by hypertension (4.4%, n = 17). Indications for amputation exceedingly recorded were diabetic foot ulcers (84.4%, n = 324), followed by infections (9.4%, n = 36) and peripheral arterial disease (3.6%, n = 14). The anesthetic approach that was observed most in these patients was regional anesthesia (74.7%, n = 287). Right-sided amputations (52.9%, n = 203) were dominant, with below-knee amputations leading by the level of amputation performed (42.5%, n = 163). Many patients delayed seeking treatment (71.6%, n = 275) and indicated denial of severity (18%, n = 69) as a reason for the delay. Regarding outcome, many patients were successfully discharged following treatment (85.9%, n = 330). CONCLUSION: Overall, LEAs are being frequently performed in developing countries, such as Pakistan, especially with a large population living with diabetes mellitus. The implications of this disease are reflected in this study population, with the majority of patients reporting delays in treatment due to reasons such as the unknown severity of the disease or financial burdens. The challenges faced by these individuals, especially in this country, can be tackled with widespread affordability and availability of care and education on early management.

Scoliosis and Gastroesophageal Reflux Disease in Adults.

Introduction Degenerative scoliosis most commonly presents with lower back pain. Literature suggests that adults who have degenerative scoliosis are at greater risk of both hiatal hernia and gastroesophageal reflux disease (GERD). The objective of this study was to evaluate scoliosis as being the risk factor of GERD in adults. Materials and methods This prospective study was conducted at Dow University of Health Sciences over a period of two years (May 2018 to April 2020). The investigation included 210 participants with spinal disorders. The mean age was 71.6±9.6 years. The X-rays of the participants' whole spine were taken in a standing position, in the sagittal and coronal planes. Symptoms of GERD were measured through the quality of life and utility evaluation survey technology (QUEST) score, taking six points as cutoff values. The evaluation was done using radiographs to determine any relationship between spinal disorders and GERD. Negative values were analyzed in a right-sided convex curve while positive values in the left-sided convex curve were viewed in the coronal plane. Degenerative scoliosis was explained as a lumbar/thoracolumbar Cobb angle of more than 10 degrees. Univariate and multivariate logistic regression analyses were done to assess the risk factors related to GERD. Results Out of 210 patients, 146 were found to have degenerative scoliosis at the level of the lumbar and thoracolumbar spine. Fifty-two patients had a right convex curve, and 94 had a left convex curve. Sixty-nine patients had GERD. According to the analysis of the multivariate logistic regression, the Cobb angle was highly related to GERD (p-value <0.05 and odds ratio of 1.031). The participants were grouped according to the Cobb angle of curve at the lumbar spine (less than 30 degrees with a large right-sided convex curve, 30 and more with a small curve, and more than 30+ degrees with a large left-sided convex curve). The study revealed that a large left-sided convex curve was highly related to GERD, with a p-value <0.05 and odds ratio of 10.935. Conclusions The left-sided large convex curve at the thoracolumbar or lumbar spine, especially when the Cobb angle was more than 30 degrees, was highly associated with GERD. Therefore, the symptoms of GERD should be monitored in the elderly population with degenerative scoliosis.

Electrocardiographic Abnormalities in Patients With Spinal Cord Injury With Deranged Lipid Profile.

Introduction Spinal cord injury (SCI) can lead to severe disability and neurogenic shock, arrhythmias, autonomic dysfunction, pressure ulcers, etc., of the autonomic nervous system. Therefore, in these patients, cardiovascular problems should be investigated frequently. This study was conducted to evaluate the electrocardiographic (ECG) abnormalities in patients with spinal cord injury having inappropriate lipid profiles and their relationship with each other. Materials and methods This cross-sectional study was held in the Internal Medicine Department of Mayo Hospital, Lahore, for a one-year duration from May 2020 to May 2021. It included 58 patients with spinal cord injury, 35 of whom had paraplegia, and 23 had tetraplegia. Fasting blood samples were taken for lipid profile analysis. Twelve-lead ECGs three times a day for one month were taken and analyzed in the context of previously available ECGs. Results Out of 58, the lipid profiles were found abnormal in 47 patients, 18 of whom had a normal ECG. The lipid profile was normal in 12, of which only one patient had ECG abnormalities. Cholesterol levels were found normal in 39 patients and deranged in 19 patients; low-density lipoproteins in nine patients, triglycerides in 18 patients, and high-density lipoprotein values in one patient were abnormal. Conclusions Sinus bradycardia was the most common ECG abnormality found in SCI patients with deranged lipid profiles. Further studies are needed in the future to validate the findings of this study.

Clinical Presentations and Outcomes of Coronavirus Disease 2019 in Patients With Solid Tumors.

Background Coronavirus disease 2019 (COVID-19) is a global health crisis. The literature suggests that cancer patients are more prone to be affected by COVID-19 because cancer suppresses the immune system and such patients usually present poor results. The objective of this study is to present all clinical, laboratory, and demographic characteristics of COVID-19 patients with solid tumors. Methodology This study was conducted at the Dow University of Health Sciences for a period of six months from April 2020 to September 2020. In this study, we included a total of 1,519 confirmed patients diagnosed with solid tumors via polymerase chain reaction. The mortality timeline within 30 days of contracting the virus was considered, and the median age of the included individuals was 61 years, with a range of 20-95 years. Of the patients included in the study, 49.4% (750) were men; moreover, 3.15% of our study population had prostate cancer, 10.20% had colorectal cancer, 2.76% had breast cancer, and 10.46% had lung cancer. Of the patients, 25.93% presented with at least one comorbidity. For 73% of the patients, at least one direct therapy for COVID-19 was included in the treatment; 56.6% of the patients were hospitalized, and 11.32% were admitted to the intensive care unit. Results The mortality rate was 4.74% in the first 30 days after diagnosis, where 72 patients died. The findings of the first multi-variation model showed that males at older ages who were diabetic and going through cytotoxic therapy were prone to die within the first 30 days. However, the 30-day mortality rate was lower in patients diagnosed with prostate and breast cancer. The second set incorporated laboratory factors, where we found that higher values of leukocytosis, thrombocytopenia, and lymphocytopenia were correlated with higher rates of mortality within 30 days. Conclusions We conclude that there is a higher mortality rate of COVID-19 in patients with solid tumors than in the general population. However, it was found to be lower in the Pakistani population compared with the Chinese and Western populations. Intensive care can decrease mortality rates in COVID-19 and cancer patients.

Postpartum Ischemic Stroke: A Rare Case.

The risk of stroke is increased during pregnancy and the postpartum period. It can lead to significant maternal morbidity and mortality. The physiologically mediated hemodynamic changes in circulation and vascular tissue, and the increased coagulability account for this increased risk of stroke. Pregnancy-related strokes can be hemorrhagic or ischemic. We present a rare case of postpartum ischemic stroke. A 25-year-old female with no known comorbidities and a history of cesarean section 10 days back presented with a right-sided weakness and sensory loss for one day. An MRI of the head revealed a large area of restricted diffusion on diffusion-weighted 1 (DW1) image in the left parietal region with comparable low signals on apparent diffusion coefficient (ADC) map and a small area of blooming suggesting hemorrhage on susceptibility-weighted 1 (SW1) image. This area appeared hypointense on T1 and hyperintense on fluid-attenuated inversion recovery (FLAIR) and T2 images. These findings suggested acute ischemic infarction. She was started on antiplatelet therapy, and subsequently, her weakness improved. She was discharged upon improvement in her symptoms and was asked to follow up in the outpatient department. Numerous studies have shown an increased risk of ischemic stroke in the immediate postpartum period in women who undergo a cesarean section. Thus, we conclude that clinicians should be aware of this complication and high-risk patients should be identified and monitored more aggressively in their immediate postpartum period.

A Rare Case of Dengue Fever Presenting With Acute Disseminated Encephalomyelitis.

Dengue fever is a viral infection transmitted by mosquitoes with a clinical spectrum that ranges from asymptomatic infection to dengue shock syndrome. Neurologic manifestations are rare. We report a case of dengue fever presented with acute disseminated encephalomyelitis. An 18-year-old boy presented with high-grade fever, generalized headache for three days, intermittent altered sensorium, nausea, and vomiting for one day. Dengue-IgG and Dengue-IgM were positive. Magnetic resonance imaging (MRI) showed abnormal signal intensity areas in the bilateral deep white matter at centrum semiovale more on the right side, which seemed hypointense on T1 and hyperintense on T2 and fluid-attenuated inversion recovery (FLAIR) images, with open ring enhancement on contrast-enhanced T1 image, and peripheral diffusion restriction on diffusion-weighted 1 (DW1) image. These features were suggestive of acute disseminated encephalomyelitis. He improved within a week of taking IV methylprednisolone 1 g once daily for five days and supportive care. Follow up MRI after three weeks showed the resolution of all abnormalities. Thus we conclude that patients with acute disseminated encephalomyelitis should be checked for dengue fever, especially in areas of high prevalence, for early diagnosis and appropriate treatment and to prevent excessively aggressive surgery and/or treatment for such abnormal MRI findings.

Coronavirus Disease 2019-Related Acute Ischemic Stroke: A Case Report.

Coronavirus disease 2019 (COVID-19) is an active worldwide pandemic with diverse presentations and complications. Most patients present with constitutional and respiratory symptoms. Acute ischemic stroke remains a medical emergency even during the COVID-19 pandemic. Here we present a case of a patient with COVID-19 who presented with acute ischemic stroke in the absence of common risk factors for cerebrovascular accidents. A 70-year-old male patient, with no prior comorbidities, presented to the emergency department (ED) with fever, cough, and shortness of breath for four days, and altered level of consciousness and right-sided weakness with the sensory loss for one day. On examination, the patient had a score of 8/15 on the Glasgow coma scale (GCS). There was a right-sided sensory loss and weakness in both upper and lower limbs with a positive Babinski's sign. The pulmonary examination was remarkable for bilateral crepitation. On blood workup, there was leukocytosis and raised c-reactive protein (CRP). D-dimer, ferritin, thyroid-stimulating hormone (TSH), vitamin B12, and hypercoagulability workup were normal. Transthoracic echocardiography was also normal. COVID-19 polymerase chain reaction (PCR) detected the virus. Chest x-ray showed infiltrations in the left middle and both lower zones of the lungs in the peripheral distribution. Computed tomography (CT) scan of the chest showed peripheral and mid to basal predominant multilobar ground-glass opacities. CT scan of the head showed a large hypodense area, with a loss of gray and white matter differentiation, in the left middle cerebral artery territory. Magnetic resonance imaging (MRI) of the head showed abnormal signal intensity area in the left parietal region. It appeared isointense on T1 image and hyperintense on T2 image. It also showed diffusion restriction on the diffusion-weighted 1 (DW1) image with corresponding low signals on the apparent diffusion coefficient (ADC) map. These findings were consistent with left middle cerebral artery territory infarct due to COVID-19. The patient was intubated in the ED. He was deemed unfit for thrombolysis and started on aspirin, anti-coagulation, and other supportive measures. Patients with COVID-19 should be evaluated early for neurological signs. Timely workup and interventions should be performed in any patient suspected of having a stroke to reduce morbidity and mortality.

Correlation of Hemoglobin A1c With Wagner Classification in Patients With Diabetic Foot.

Introduction Diabetic foot is a common complication of diabetes mellitus (DM). The Wagner classification is mostly used to grade its severity. The correlation between the hemoglobin A1c (HbA1c) and the Wagner classification is still controversial. Therefore, the purpose of this study is to determine the correlation of HbA1c with Wagner classification in patients with diabetic foot. Materials and methods This cross-sectional study was conducted at a major hospital in Shaheed Benazirabad in which 88 patients aged 18-65 years, of either gender, with a known history of DM type I or type II, and diagnosed with diabetic foot were enrolled for six months. Blood samples were collected to check the HbA1c levels. Wagner classification grading was performed after the examination of diabetic foot ulcers. Demographics such as age, gender, duration of DM, and other risk factors of foot ulcers were also noted. The mean and standard deviation for continuous variables, such as age and HbA1c level, and the frequency and percentage for categorical variables, such as distribution of age, distribution of HbA1c, gender, duration of DM, grades of Wagner classification, and other risk factors of foot ulcers, were calculated. The correlation of HbA1c with Wagner classification was also calculated by applying the chi-square test and taking p ≤ 0.05 as significant. Results The mean age of the study population was 47.4 ± 10.6 years. Of the 88 patients, 15 (17.04%) were 25-35 years of age, 34 (38.63%) were 36-50 years of age, and 39 (44.31%) were 51-65 years of age; 45 (51.13%) patients were males and 43 (48.86%) patients were females. The mean HbA1c level of the study population was 9.07 ± 1.65%; 5 (5.68%) patients had 6.5-7.5%, 34 (38.63%) patients had 7.6-8.5%, 24 (27.27%) patients had 8.6-9.5%, and 25 (28.41%) patients had an HbA1c level of >9.5%. Twelve (13.63%) patients had ≤ 7 years, 18 (20.45%) had 8-15 years, and 58 (65.9%) had >15 years of duration of DM. Zero (0%) patients had grade 0, 1 (1.13%) patient had grade 1, 6 (6.81%) patients had grade 2, 29 (32.95%) patients had grade 3, 32 (36.36%) patients had grade 4, and 20 (22.72%) patients had grade 5 of Wagner classification. 23 (26.13%) patients had foot abnormalities, 19 (21.59%) patients had nephropathy, 13 (14.77%) patients had neuropathy, 14 (15.91%) patients had hypertension, 9 (10.22%) patients had retinopathy, 3 (3.41%) patients had foot ulcers/toe amputation, 2 (2.27%) patients had a cognitive deficit, and 5 (5.68%) patients had cardiovascular diseases. The correlation of HbA1c with Wagner classification was found statistically significant with p < 0.00001. Conclusions The older age, male gender, longer duration of DM, increased HbA1c, and previously existing foot abnormalities in diabetic patients are the risk factors of diabetic foot. The monitoring of HbA1c can help predict the diabetic foot in the aforesaid high-risk diabetics because the HbA1c linearly rises with the higher grades of Wagner classification of diabetic foot. Subsequently, the strict control of HbA1c as well as patient education about proper foot care can help prevent diabetic foot and its complications. However, more studies on larger scales are needed to establish the factual relationship between HbA1c and Wagner classification.

Correlation of Homocysteine Level and Age in Patients with Ischemic Stroke.

Introduction Hyperhomocysteinemia is associated with atherosclerosis, as it can be seen in inborn errors of methionine metabolism. Likewise, many studies have also reported more modest increases in serum homocysteine levels in other atherosclerotic disorders like cardiovascular disease and all types of stroke with a positive correlation with age. But overall literature is controversial. Therefore, this study is being conducted to further investigate the relationship between homocysteine ​​levels and age in patients, especially those with ischemic stroke. Material and methods This cross-sectional study is conducted at a major hospital in Karachi in which all patients with ischemic stroke, diagnosed within 24 hours on CT, and age 40-75 years of both genders were enrolled for six months. Other demographics were also noted like gender, smoking status, and comorbidities (diabetes mellitus [DM], hypertension [HTN]). The homocysteine level was also checked by collecting non-fasting blood. Vitamin B12 level was not checked. The age, weight, height, body mass index (BMI), and homocysteine level's means and standard deviations and the gender, DM, hypertension, and smoking status frequencies and percentages were calculated. The correlation coefficient of homocysteine level and age was also calculated. Stratification was done to see the effects of gender, BMI, DM, and HTN on homocysteine levels by applying the chi-square test. Results The mean age of the patients was 55.60 ± 11.45 years. Gender distribution showed that 111 (62.40%) patients were male, and 67 (37.60%) patients were female. Diabetic, hypertensive, and smoking status of the patients was 58 (32.60%), 96 (53.90%), and 53 (29.80%), respectively. The mean homocysteine level was 14.61, with a standard deviation of 1.47. Pearson's correlation test showed that there is no statistically significant correlation between homocysteine levels and age. But a significant linear relationship was found of homocysteine levels with DM and HTN.  Conclusion Further investigation of the relationship of homocysteine ​​levels with age, diabetes mellitus, and hypertension, and the role of homocysteine as a risk factor for ischemic stroke should be carried out on a larger scale to prove its accuracy. The benefits of screening for homocysteine ​​levels also need to be studied in the elderly, especially those with diabetes mellitus and hypertension, which can lead to timely prevention of strokes and ischemic heart disease with vitamin B supplements, and other appropriate interventions.

Validity of National Institutes of Health Stroke Scale for Severity of Stroke to Predict Mortality Among Patients Presenting With Symptoms of Stroke.

Introduction Cerebrovascular accident (CVA), also termed as stroke, is the third leading cause of mortality and the most common cause of disability globally. The National Institutes of Health Stroke Scale (NIHSS) is a valid assessment tool utilized to determine the severity of the stroke and can be used to prioritize patients to design treatment plans, rehabilitation, and better clinical outcomes. The primary objective of this study was to determine the validity of the NIHSS to predict mortality among patients presenting with symptoms of a stroke. Material and methods This was a descriptive case-series conducted over a period of six months between September 2019 and February 2020 at a tertiary care hospital in Nawabshah, Pakistan. The sample population included 141 patients admitted within 24 hours of the onset of symptoms of a stroke. A neurological examination of the patients was performed. On admission, stroke severity was evaluated with the NIHSS. After an initial clinical evaluation, patients underwent a non-enhanced computed tomography (CT) scan of the brain. The score of NIHSS and mortality at 72 hours were recorded on the pre-defined proforma by the investigators. All statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 23.0 (Armonk, NY: IBM Corp). Results The mean age of the participants was 52.37±8.61 years. 68.1% of patients were hypertensive, 29.1% were diabetic, and 36.9% of patients were found with hyperlipidemia. The mortality rate was 41.1%. The mean NIHSS score was 16.68±6.72 points. The findings of this study demonstrated that the score of 14.9% cases was good (0-6 points), the score of 29.1% cases was moderate (7-15 points), and the score of 56% cases was poor (≥16 points). There was a significant association of NIHSS score with mortality (p<0.001). Conclusions Baseline NIHSS score has a profound association with mortality after acute stroke. It can help clinicians decide whether to provide thrombolytic treatment, rehabilitation or a combination of both in these patients and decrease the mortality rate. However, more studies are needed to potentiate these conclusions.

Frequency of Extravasation on Pericatheter Retrograde Urethrogram in Patients Who Undergo Posterior Urethroplasty.

Introduction Urethroplasty is the gold standard treatment for urethral stricture disease resulting from pelvic fractures, urethral manipulation, and straddle injuries. Post-operative morbidity depends on the presence of urethral catheterization with or without a suprapubic catheter (SPC). Urethral healing at the anastomotic site can be easily assessed using retrograde pericatheter urethrography (RPU). Post-operative removal of the catheter is traditionally performed on the 21st day following urethroplasty. However, some controversy still exists regarding the best feasible time of proper urethral healing and its assessment utilizing simple techniques. The duration of anastomotic healing differs depending on the type of procedure performed, but whether there is any significant difference in duration of healing at the anastomotic site according to the etiology of short-segment stricture urethra is still a dilemma. Materials and methods This was a descriptive case-series conducted for a duration of six months from September 2019 to February 2020 at the urology department of a tertiary care hospital in Karachi, Pakistan. A sample population of 135 patients aged 20-50 years with posterior urethral stricture who underwent posterior urethroplasty with disease duration of >12 months was included in the study. All patients were put on the next operation theater (OT) list for urethroplasty. After surgery, the patients were catheterized and were kept in the ward under observation for 48 hours and discharged on the 2nd post-operative day. All patients were followed weekly and RPU was performed on the 21st day following urethroplasty to assess the presence of extravasation and the collected data was entered into the proforma by the investigators. All statistical analysis was performed using Statistical Package for Social Sciences (SPSS) version 23.0. Results The mean age of our participants was 32.8±6.02 years. The mean duration of the procedure was 26.3±7.14 months. Extravasation cases were observed in less than one-fifth (n=22 out of 135, 16.3%) of the posterior urethral stricture patients in our study. Conclusions It is to be concluded that extravasation is fairly common in patients who undergo posterior urethroplasty. The prevalence varies depending on the assessment method, likely reflecting the treatment of somatic symptoms.

Functional Outcomes of Cementless Total Hip Arthroplasty in Avascular Necrosis of the Hip: A Prospective Study.

Introduction Avascular necrosis occurs due to impaired blood supply to the bone. It can be caused by fractures, dislocations, chronic steroid use, chronic alcohol use, coagulopathy, congenital source, and many other factors. It mostly affects the femoral head (hip joint). Its management can be conservative or invasive. Total hip arthroplasty is the treatment of choice for third and fourth stage avascular necrosis that can be cemented or uncemented. The purpose of this study is to access the functional outcomes of cementless total hip arthroplasty in patients with avascular necrosis of the hip. Materials and methods This prospective study was conducted at a major metropolitan hospital in Karachi, Pakistan over a period of six months. A total of 30 patients of age <60 years, either gender, and a confirmed diagnosis of avascular necrosis of hip with no other associated hip pathologies were included in this study. Demographic features, comorbidities, level of activity, range of movement before the development of avascular necrosis, Charnley's class, and laterality were noted. Cementless press-fit extensively porous-coated acetabular cup with or without cancellous screws and cementless press-fit extensively hydroxyapatite coated femoral stem were used through modified Gibson's posterior approach. The patients were checked for early and late complications, the position of acetabular and femoral components by radiography, and overall performance by Harris Hip Score (HHS) and modified HHS over a period of 12 months. All statistical analyses were performed using Statistical Package for Social Sciences (SPSS) version 19.0 (IBM Corp, Armonk, NY). Results The mean age was 43.9±6.7 years with 21 (70%) patients ranging from 40 to 60 years of age. There were 22 (73%) male and 8 (27%) female patients. Nine (30%) patients had diabetes mellitus, eight (27%) had hypertension, two (7%) had other comorbidities, and eleven (37%) had no comorbidities. A total of 11 (37%) patients were highly active, 18 (60%) were moderately active, and 1 (3%) was non-active before developing avascular necrosis. There were 4 (13%) patients in Charnley's class I, 15 (50%) in Charnley's class II, and 11 (37%) in Charnley's class III. Fifteen (50%) patients were operated on the left side, seven (23%) on the right side, and eight (27%) bilaterally. No significant early or late complications were noted. Acetabular component was found to be anteverted in 22 (73%), retroverted in zero (0%), neutral in 8 (27%), <35o inclined in 0 (0%), 35o-50o inclined in 23 (77%), and >50o inclined in 7 (23%) patients, while femoral component was found neutral in 28 (93%), valgus in 2 (7%), and varus in zero (0%) patients on radiography at follow-up. On functional assessment, the HHS was 100% in 27 (90%) patients, 96% in 2 (7%) patients, and 83% in 1 (3%) patient with an average of 99.2%, while 29 (97%) patients had excellent and only 1 (3%) patient had a good outcome on modified HHS. Conclusions Cementless total hip arthroplasty, performed in patients <60 years of age and avascular necrosis of the hip with no other associated hip pathologies, has excellent functional outcomes with no pain, limping, physical deformity, difficulty in walking, difficulty in climbing stairs, difficulty using public transport, difficulty in sitting, or difficulty in wearing shoes and socks. They usually attain normal limb length and range of movement.

The Success Level of Hypospadias Repair in Adults.

Introduction Hypospadias is the abnormal opening of the urethra at the undersurface of the penis. Hypospadias repair is performed in such patients to treat the condition. The success level of hypospadias repair in adults still needs to be established on a larger scale. Therefore, we conducted this study to document the success level of hypospadias repair in adults in our setting to add to the literature. Materials and methods This prospective study was conducted at a major metropolitan hospital in Karachi over a period of six months. A total of 75 male patients aged between 20-50 years and diagnosed with hypospadias of any level with or without mild to moderate chordee were included. Demographic features such as age and the duration of hypospadias were noted. Hypospadias repair using a tubularized incised plate (TIP) urethroplasty technique was performed, and the patients were observed for three days in the ward and for three months in the outpatient department for any complications. The procedure was considered a success if there were no complications and no need for a second surgery; we also took into account patient satisfaction with the procedure to determine the success level. The mean and standard deviation were calculated for patient age and the duration of hypospadias. Frequency and percentages were calculated for distribution of patient age, distribution of the duration of hypospadias, and the success of hypospadias repair. The correlation of patient age and the duration of hypospadias with the success of hypospadias repair was also determined by applying the Chi-square test, and a p-value of ≤0.05 was considered to be statistically significant. Results The mean age and the duration of hypospadias for the study population were the same at 31.43 ± 8.47 years. Distribution of patient age and the duration of hypospadias was also the same with 51 (68%) patients of ≤35 years of age and 24 (32%) patients of >35 years of age. Hypospadias repair was successful in 52 (69.33%) patients but unsuccessful in 23 (30.66%). The stratification of patient age and the duration of hypospadias with the success of hypospadias repair showed a significant inverse relationship (p = 0.017). The data relating to patient age and the duration of hypospadias showed the same values as hypospadias is a birth defect. Conclusion Adult patients undergoing primary hypospadias repair generally show good outcomes. However, the chances of favorable outcomes gradually decrease with age. Hence, patients should be encouraged to undergo the procedure as early in their lives as possible. Patients who are middle-to-old aged should especially be counseled about the relatively higher risk of unsuccessful procedures. Further analysis is needed to confirm the validity of these findings.

Frequency of Blood Transfusion in Percutaneous Nephrolithotomy.

Introduction Percutaneous nephrolithotomy (PNL) has replaced open surgery for the treatment of kidney stones due to its less invasive nature. Bleeding still occurs due to renal vascular injuries, dependent upon the access route of the procedure. Several other factors are also related to the increased risk of bleeding. This study aims to find the association between blood transfusion and other factors such as age, gender, body mass index (BMI), size of the stone, operative time, preoperative hemoglobin (Hb) level, stone surface area, hypertension, and diabetes mellitus. Materials and methods This was a descriptive cross-sectional study conducted over a period of six months between November 2019 and April 2020 at a tertiary care hospital in Karachi, Pakistan. The sample size of 131 patients was calculated using open-source epidemiological software (Open-Epi). Inclusion criteria included patients from both genders and ages between 26 and 70 years. Patients ≤25 years, having a liver disease or bleeding disorders, or refusing to participate in the study, were excluded. Laboratory data included preoperative routine complete blood count, serum creatinine (normal 0.5-1.5 mg/dL), platelet count, bleeding and coagulation profile, and urine culture. All patients also underwent renal ultrasound scans. Treatment was postponed until a negative urine culture was obtained from patients with a positive urine culture.  Results The mean age of the patients was 42.4 ± 15.65 years. One third (29.8%) of the patients were females. The stone size was 850 ± 121.43 mm², the mean operative time of the procedure was 125.76 ± 53.4 minutes, and the mean number of cell packs transfused was 1.10 ± 0.31 units. Blood transfusion was done in 24 (18.3%) of the patients. Gender, diabetes mellitus, stone size, preoperative Hb level, and operative time were significantly related to blood transfusion.  Conclusions Increased bleeding risk while performing PNL has been associated with many factors such as operating time, the gender of the patients, and stone size. Therefore, these factors should be controlled for the procedure to decrease the risk of bleeding and the need for blood transfusion. Furthermore, the kidney vasculature should not be compromised while performing the procedure.

Frequency of Venous Thromboembolism in Patients with Liver Cirrhosis.

Introduction The major hemostatic problem in cirrhotic patients is the increased risk of bleeding, but venous thromboembolism is also being reported as a noticeable feature of cirrhosis. Therefore, we conducted this study to determine the frequency of venous thromboembolism in patients with liver cirrhosis. Materials and methods This cross-sectional study took place at a major metropolitan hospital in Karachi for a period of six months. A total of 142 patients age 40 to 70 years, either gender and Child-Pugh class A to C liver cirrhosis for >3 months were enrolled in this study. The demographic features like age, gender, weight, height, body mass index (BMI), duration of symptoms, and Child-Pugh class were noted. The patients were examined for calf swelling, tenderness, and pitting edema. Venous thrombosis was diagnosed on ultrasound of the calf done by an experienced radiologist in patients having two or more than two of the above-stated findings. The mean and standard deviation were calculated for age, weight, height, body mass index (BMI), and duration of symptoms. The frequency and percentage were calculated for the range of age, gender, range of weight, range of height, range of BMI, range of duration of symptoms, Child-Pugh class, and venous thrombosis. Stratification was done of venous thrombosis with age, obesity, gender, Child-Pugh class, and duration of symptoms by applying the chi-square test and assuming p-value ≤0.05 as significant. Results The mean age of the study population was 60.73 ± 10.83 years and most patients, i.e., 95 (66.9%) were >60 years. There were 89 (62.7%) female and 53 (37.3%) male patients. The mean weight of the study population was 60.15 ± 5.11 kg and most patients, i.e., 81 (57%), weighed ≤60 kg. The mean height of the study population was 1.53 ± 0.59 m and most patients, i.e., 99 (69.7%) were ≤1.5 m. The mean BMI of the study population was 27.24 ± 5.02 kg/m2 and most patients, i.e., 81 (57%) were ≤30 kg/m2. The mean duration of symptoms of the patients was 5.63 ± 1.77 months and most patients, i.e., 86 (60.6%) had ≤6 months of duration of symptoms. Eighty-six (60.56%) patients had Child-Pugh class A, 39 (27.47%) patients had Child-Pugh class B, and 17 (11.97%) patients had Child-Pugh class C liver cirrhosis. Ten (7%) of the patients had venous thrombosis. Stratification of venous thrombosis with age, gender, obesity, Child-Pugh class, and duration of symptoms showed a significant linear relationship with gender (p-value= 0.040), obesity (p-value= 0.043), and Child-Pugh class (p-value= 0.001). Conclusions Venous thromboembolism is a frequent complication and a pathogenic factor in liver cirrhosis that should be given attention to in cirrhotic patients especially in male and obese patients of Child-Pugh class B and C. Low serum albumin and increased partial thromboplastin time (PTT) can have some role in its prediction and early prevention. But more studies are needed to establish this.

Paraphenylenediamine (Kala Pathar) Poisoning at the National Poison Control Center in Karachi: A Prospective Study.

Introduction Suicide by self-poisoning is a common cause of death, especially in the younger population. More specifically, hair-dye poisoning is being increasingly used for suicide. Paraphenylenediamine (PPD), also known as "Kala pathar", is a highly toxic ingredient present in hair-dye that can cause death. Therefore, this study is designed to assess the demographics, clinical features, laboratory findings, and outcomes of PPD poisoning in patients admitted to the National Poison Control Center in Karachi, Pakistan. Materials and methods We conducted a prospective study for a period of six months at the National Poison Control Center, Karachi, Pakistan. A total of eight patients with PPD poisoning with no cardiac, liver, or renal co-morbidities were included in this study. The demographic characteristics, clinical features, laboratory findings, mode of intoxication, and route of intoxication were noted in a proforma. Furthermore, hospitalization time, tracheostomy status, mechanical ventilation status, and mortality rates were also recorded. For continuous variables, the means and SDs were calculated. Whereas for categorical data, percentages were calculated. Results In our study, the mean age of the patients was estimated at 25.38 ± 3.77 years. It was deemed that the majority of poisoning cases were intentional in nature (75%). These suicide cases were more commonly observed in young females (75%) who belonged to a low socioeconomic class (87.5%). The preferred route of administration was oral (87.5%). In 87.5% of the patients, the characteristic clinical features such as cervicofacial edema, dysphagia, dysphonia, and stridor were noted. During the later clinical stages of poisoning, clinical features such as rhabdomyolysis (62.5%), chocolate-colored urine (87.5%), hepatitis (75%), and acute renal failure (12.5%) were noteworthy. The mean ± SD of total leukocyte count (TLC), creatine phosphokinase (CPK), aspartate aminotransferase (AST), alanine aminotransferase (ALT), serum creatinine and serum potassium were, respectively, noted at 10,500 ± 3,854.4 cells/mm3, 32.87 ± 11.36 IU/L, 1,239.1 ± 1,106.2 IU/L, 776.8 ± 1,149.8 IU/L, 2.125 ± 2.275 mg/dL, and 4.9 ± 1.094 mmol/L. In our patients, the mean intensive care unit stay was 8.25 ± 3.99 days. Emergency tracheostomy was performed in 25% of patients. Mechanical ventilation was required for 50% of our patients. Overall, the mortality rate observed in our study stands at 25%. Conclusion PPD poisoning is associated with a high rate of morbidity and mortality. Therefore, it is imperative for physicians to be mindful of the clinical characteristics and treatment options in order to optimally manage such cases of poisoning. In addition, the use of hair-dyes composed of highly lethal PPD should also be banned.

Frequency of Human Immunodeficiency Virus in Patients Admitted with Acute Stroke.

Introduction Stroke is a leading cause of chronic disability and death in both developing and developed countries. A significant proportion of stroke patients are human immunodeficiency virus (HIV) positive. About half of the HIV patients experience some sort of neurological deficit in their lifetimes. The exact reason for the occurrence of stroke in HIV infected patients is poorly understood. The purpose of our study is to determine the frequency of HIV among patients admitted with acute stroke. Materials and methods This cross-sectional study is conducted at a major metropolitan hospital in Karachi for six months. A total of 130 patients of stroke between the ages of 30 and 70 years of either gender were included in this study. A complete history was taken and a physical examination was performed. Each patient underwent a battery of tests that included HIV serology, lipid profile, electrocardiography (ECG), chest X-ray (posteroanterior (PA) view), and computed tomography (CT) scan of the brain. Carotid Doppler ultrasonography to assess carotid artery stenosis was also ordered. The means and standard deviations of age and cluster of differentiation 4 (CD4) cell count were calculated. The frequencies and proportions of gender, diabetes mellitus (DM), hypertension (HTN), smoking, obesity, dyslipidemia, carotid artery stenosis, and HIV status were calculated. Stratification was done by applying the chi-square test and assuming p-value ≤0.05 as significant. This helped analyze the association of age, gender, DM, HTN, smoking, obesity, dyslipidemia, and carotid artery stenosis to the frequency of HIV. Results The mean age of the study population was 55.54 ± 11.166 years. There were 39 (30%) patients <50 years of age while 91 (70%) patients were ≥50 years of age. Gender distribution showed that 86 (66.15%) patients were male, and 44 (33.85%) patients were female. Furthermore, 71 (54.62%) patients were hypertensive, 53 (40.77%) were diabetic, 62 (47.69%) were smokers, 49 (37.69%) were obese, 52 (40%) had dyslipidemia, and 77 (59.23%) had carotid artery stenosis. The frequency of HIV was noted at 24 (18.46%). The mean CD4 count was estimated at 241 ± 103.295 cells/mm3. Stratification showed a significant relationship between the frequency of HIV with only gender (p=0.01) and dyslipidemia (p=0.037). Conclusion HIV infection in patients with stroke is not uncommon. Patients who are male, younger in age, have dyslipidemia, belong to a low socioeconomic class, or have a bad sexual history are more likely to have HIV as an underlying cause of stroke. The exact pathogenesis of such a stroke and the role of antiretroviral therapy in the prevention and treatment of this group of stroke are not completely understood and need further analysis.