Use of physician-modified inverted limb in conjunction with Zenith fenestrated stent graft to rescue failed previous endovascular and open repair.

OBJECTIVE: To evaluate outcomes and performance of inverted limbs (ILs) when used in conjunction with Zenith fenestrated stent grafts (Zfens) to treat patients with short distance between the lowest renal artery (RA) and aortic or graft bifurcation (A/GB). METHODS: This study was a multicenter, retrospective review of prospectively maintained database of patients with complex aortic aneurysms, failed endovascular aneurysm repair (EVAR), or open surgical repair (OSR) with short distance between LRA and A/GB treated using a combination of Zfen and an IL between 2013 and 2023. Endpoints included technical success, aneurysm sac regression, long-term device integrity, and target vessel patency. We defined technical success as implantation of the device with no endoleak, conversion to an aorto-uni-iliac or OSR. RESULTS: During this time, 52 patients underwent endovascular rescue of failed repair. Twenty (38.5%) of them required relining of the failed repairs using IL due to lowest RA to A/GB length restrictions. Two patients had undergone rescue with a fenestrated cuff alone but developed type III endoleaks. One patient with no previous implant had a short distance between the lowest RA and aortic bifurcation to accommodate the bifurcated distal device, and two patients had failed OSR or anastomotic pseudoaneurysms. The majority (94%) were men with a mean age of 76.8 ± 6.1 years. The mean aortic neck diameter and aneurysm size were 32 ± 4 cm and 7.2 ± 1.3 cm, respectively. The median time laps between initial repair and failure was 36 months (interquartile range [IQR], 24-54 months). Sixteen patients (80%) were classified as American Society of Anesthesiologists class III, whereas four were class IV. Seventy-eight vessels were targeted and successfully incorporated. Technical success was 100%, and median estimated blood loss was 100 mL (IQR, 100-200 mL). Mean fluoroscopy time and dose were 61 ± 18 minutes and 2754 ± 1062 mGy, respectively. Average hospital length of stay was 2.75 ± 2.15 days. Postoperative complication occurred in one patient who required lower extremity fasciotomy for compartment syndrome. At a median follow-up of 50 months (IQR, 18-58 months), there were no device migration, components separation, aneurysmal related mortality, and type I or type III endoleak. Aneurysm sac regression (95%) or stabilization (5%) was observed in all patients, including in four patients (25%) with type II endoleak. CONCLUSIONS: The use of IL in conjunction with Zfen to treat patients with short distance between the lowest RA and A/GB is safe, effective, and has excellent long-term results. The technique expands the indication of Zfen, especially in patients with failed previous EVAR.

Racial and sex disparities in inpatient outcomes of patients with ruptured abdominal aortic aneurysms in the United States.

BACKGROUND: Ruptured abdominal aortic aneurysm (AAA) is a medical emergency that requires immediate surgical intervention. The aim of this analysis was to identify the sex- and race-specific disparities that exist in outcomes of patients hospitalized with this condition in the United States using the National Inpatient Sample (NIS) to identify targets for improvement and support of specific patient populations. METHODS: In this descriptive, retrospective study, we analyzed the patients admitted with a primary diagnosis of ruptured AAA between January 1, 2016, and December 31, 2020, using the NIS database. We compared demographics, comorbidities, and in-hospital outcomes in AAA patients, and compared these results between different racial groups and sexes. RESULTS: A total of 22,395 patients with ruptured AAA were included for analysis. Of these, 16,125 patients (72.0%) were male, and 6270 were female (28.0%). The majority of patients (18,655 [83.3%]) identified as Caucasian, with the remaining patients identifying as African American (1555 [6.9%]), Hispanic (1095 [4.9%]), Asian or Pacific Islander (470 [2.1%]), or Native American (80 [0.5%]). Females had a higher risk of mortality than males (OR, 1.7; 95% confidence interval [CI], 1.45-1.96; P < .001) and were less likely to undergo endovascular aortic repair (OR, 0.70; 95% CI, 0.61-0.81; P < .001) or fenestrated endovascular aortic repair (OR, 0.71; 95% CI, 0.55-0.91; P = .007). Relative to Caucasian race, patients who identified as African American had a lower risk of inpatient mortality (OR, 0.50; 95% CI, 0.37-0.68; P < .001). CONCLUSIONS: In this retrospective study of the NIS database from 2016 to 2020, females were less likely to undergo endovascular intervention and more likely to die during their initial hospitalization. African American patients had lower rates in-hospital mortality than Caucasian patients, despite a higher burden of comorbidities. Future studies are needed to elucidate the potential factors affecting racial and sex disparities in ruptured AAA outcomes, including screening practices, rupture risk stratification, and more personalized guidelines for both elective and emergent intervention.

Vascular Surgery Role in Vascular Trauma: 11-Year Analysis of Peripheral Vascular Trauma Management at a Level-1 Trauma Center.

BACKGROUND: Vascular surgeons are increasingly relied upon in the management of complex peripheral vascular trauma. The degree however that vascular surgery (VS) is involved in vascular trauma care is not well established. We hypothesize that VS consultation is required in a high portion of complex lower extremity vascular trauma. METHODS: A single-center retrospective review of all consecutive patients who sustained traumatic arterial injury of the lower extremity requiring open operative repair at a level-1 trauma center (from February 2009 to May 2020) was performed. Patients who underwent surgical repair were stratified by the service that performed the operation (VS versus trauma surgery [TS]). Secondary outcomes assessed included location of arterial injury, type of repair, and clinical outcomes. RESULTS: A total of 111 patients underwent operative repair of lower extremity arterial injury (mean age 34.5 ± 15.5 years, 89% male). The most common vessels requiring intervention were the superficial femoral artery (n = 42, 38%), popliteal artery (n = 35, 31.5%), and tibial vessels (n = 19, 17.1%). The most common intervention required in patients was an autologous bypass (n = 85, 76.5%), followed by ligation (n = 9, 8.1%) and primary repair (n = 6, 5.4%). Most interventions overall required VS involvement (n = 95, 86%). VS performed a higher proportion of autologous graft procedures compared to TS (n = 79, 92.9% vs. n = 6, 7.1%). VS case load overall was likewise predominantly autologous grafts (n = 79/95, 83.2%). TS operated on a higher proportion of injuries to the tibial vessels (44% vs. 13%, P = 0.01), whereas VS intervened more frequently on popliteal injuries (36% vs. 6%, P = 0.02). With regard to the method of arterial repair, TS was more likely to perform ligation (38% vs. 3 %, P < 0.001) or primary repair (13% vs. 3%, P = 0.04) compared to VS. However, VS was more likely to perform repair with autologous graft (83% vs. 38%, P < 0.001). There were no significant differences in rates of mortality, limb loss, transfusions requirement, fasciotomy, deep venous thrombosis, hematoma formation, or length of stay between groups. Although, surgical site infections were more common in the TS group (38% vs. 15%, P = 0.04). CONCLUSIONS: Vascular surgeons play a large role in managing complex lower extremity vascular trauma. In particular, VS remains integral for the management of more difficult injuries (e.g., popliteal injuries) and is more likely to provide more complex repairs (e.g., autologous grafts).

Long-Term Outcomes of Open and Endovascular Axillosubclavian Interventions After Traumatic Injury Reveal High Rates of Limb Dysfunction.

BACKGROUND: Arterial axillosubclavian injuries (ASIs) are currently managed with open repair (OR) and endovascular stenting (ES). The long-term prognosis of patients with these and associated brachial plexus injuries is poorly understood. We hypothesize that OR and ES for ASI have similar long-term patency rates and that brachial plexus injuries would confer high long-term morbidity. METHODS: All patients at a level-1 trauma center who underwent procedures for ASI over a 12-year period (2010 to 2022) were identified. Long-term outcomes of patency rates, types of reintervention, rates of brachial plexus injury, and functional outcomes were then investigated. RESULTS: Thirty-three patients underwent operations for ASI. OR was performed in 72.7% (n = 24) and ES in 27.3% (n = 9). ES patency was 85.7% (n = 6/7) and OR patency was 75% (n = 12/16), at a median follow-up of 20 and 5.5 months respectively. In subclavian artery injuries, ES patency was 100% (n = 4/4) and OR patency was 50% (n = 4/8) at a median follow-up of 24 and 12 months respectively. Long-term patency rates were similar between OR and ES (P = 1.0). Brachial plexus injuries occurred in 42.9% (n = 12/28) of patients. Ninety percent (n = 9/10) of patients with brachial plexus injuries who were followed postdischarge had persistent motor deficits at median follow-up of 12 months, occurring at significantly higher rates in patients with brachial plexus injuries (90%) compared to those without brachial plexus injuries (14.3%) (P = 0.0005). CONCLUSIONS: Multiyear follow-up demonstrates similar OR and ES patency rates for ASI. Subclavian ES patency was excellent (100%) and prosthetic subclavian bypass patency was poor (25%). brachial plexus injuries were common (42.9%) and devastating, with a significant portion of patients having persistent limb motor deficits (45.8%) on long-term follow-up. Algorithms to optimize brachial plexus injuries management for patients with ASI are high-yield, and likely to influence long-term outcomes more than the technique of initial revascularization.

Complete resolution of vertebrobasilar dissection and aneurysm following treatment of subclavian steal physiology.

Subclavian steal syndrome results from subclavian artery stenosis that results in retrograde blood flow through the ipsilateral vertebral artery. Rarely, this retrograde flow can affect the vertebrobasilar junction and cause vertebrobasilar insufficiency, ischemia, and even aneurysm formation. We describe a unique presentation of a vertebrobasilar aneurysm presenting with subarachnoid hemorrhage in the setting of subclavian steal syndrome. The subclavian stenosis was endovascularly managed, with complete resolution of both retrograde flow and the dissection itself. Reestablishment of native flow mechanics in the subclavian artery may treat aneurysms at the vertebrobasilar junction, potentially eliminating the need for further interventions.

Venous thromboembolism and cannabis consumption, outcomes among hospitalized patients in the United States: A nationwide analysis.

Venous Thromboembolism (VTE) carries significant clinical implications, and with the rise in cannabis consumption, its potential influence on VTE outcomes warrants investigation. Using the National Inpatient Sample (NIS) database (2016-2019), we analyzed 2,217,184 hospitalized VTE patients. Among these, 1.8 % (38,810) reported cannabis use. We compared demographics, comorbidities, in-hospital outcomes, and quality metrics between cannabis users and non-users with VTE. Cannabis users were chiefly younger males (average age 45 in cannabis users vs. 62 in non-cannabis users) from lower-income brackets. Notably, 5.4 % discharged against medical advice. Although in-hospital mortality was initially lower for cannabis users (2.8 % vs. 5.1 %, OR 0.6, 95 % CI 0.69-0.94, p = 0.008), this difference became non-significant post-propensity-score matching (aOR 0.9, 95% CI 0.72-1.10, p = 0.3). Non-users faced higher in-hospital complications, a trend that persisted post-PSM. Among cannabis users, key mortality predictors were peripheral vascular disease, acute kidney injury, vasopressor use, cardiogenic shock, myocardial infarction, invasive ventilation, and surgical embolectomy. Cannabis users also had a shorter hospital stay (4.2 vs. 5.4 days) and slightly reduced costs ($27,472.95 vs. $31,660.75). The significantly younger age of VTE patients who use cannabis, coupled with the considerable proportion discharging against medical advice, underscores the urgency for tailored care interventions. Additional research is vital to comprehensively understand the interplay between cannabis consumption and VTE outcomes.

A hybrid approach to previously excluded, expanding internal iliac artery aneurysms.

Previously excluded internal iliac artery (IIA) aneurysms can continue to expand and pose a risk of rupture. In this case series, we present three patients with previously excluded, expanding IIA aneurysms after endovascular stent coverage or open surgical ligation of the proximal IIA. We describe a hybrid approach to treat these patients safely and effectively.

Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy for Peritoneal Carcinomatosis.

Peritoneal carcinomatosis (PC) is a common presentation of several gastrointestinal and gynecological malignancies. Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS + HIPEC) is a treatment regimen recently introduced in Pakistan for PC. The goal of cytoreductive surgery is complete removal of macroscopic disease. HIPEC is administered following surgery, with the aim of eliminating disease at a microscopic level. In this study, 11 patients, who underwent CRS+HIPEC at the Shifa International Hospital, Islamabad, Pakistan, were selected. Disease severity was classified using PCI score. There were 54.5% women and 45.5% men with mean age of 48.5 ± 12.5 years. The mean PCI score was 20.3 ± 3.4. The mean time from diagnosis was 12.7 ± 11.6 months. A complete tumor resection (CC-0) was achieved in 10 (90.9%) patients, while the rest were CC-1. The duration of HIPEC circulation was 90 minutes in every patient. Postoperative morbidity was observed in 2 (18.2%) patients. No 30-day perioperative mortality was seen. It was concluded that with effective patient selection, surgical skills and center experience, CRS+HIPEC can have low perioperative morbidity and mortality, and complete cytoreduction leads to prolonged overall survival. Key Words: Peritoneal carcinomatosis, Cytoreductive surgery, Hyperthermic intraperitoneal chemotherapy.

Acute Esophageal Necrosis: An In-depth Review of Pathogenesis, Diagnosis and Management.

Introduction: Acute esophageal necrosis (AEN) is an uncommon but fatal cause of upper gastrointestinal bleeding. The complex pathophysiology of the disorder provides multiple points for intervention. Therefore, it is important to discuss the many multifaceted aspects of the disease. Methods: A scoping review was performed using PubMed, Google Scholar, and ClinicalTrials.gov. We reviewed literature from 1990 to 2021. The keywords used were 'acute esophageal necrosis', 'upper GI bleed', 'pathogenesis', 'EGD', 'prognosis'. Results and conclusions: The review summarized findings of 46 studies. AEN usually targets older males who have underlying cardiovascular disease. The middle part of the esophagus is commonly involved. The pathogenesis of AEN depends on conditions that increase risk of mucosal damage such as ischemia, lack of mucosal protection and excessive gastric reflux. Some medications are also responsible for the disease. Esophagogastroduodenoscopy is usually the gold standard for diagnosis. Findings suggestive of AEN include darkened, sharply demarcated circumferential areas. Supportive measures, including bowel rest, fluid supplementation and proton pump inhibitors are the cornerstone of therapy. A high index of suspicion should be maintained in patients with chronic health problems presenting with signs and symptoms of upper gastrointestinal bleeding because AEN can carry an unfavorable prognosis in these patients.

Extracorporeal Liver Support: An Updated Review of Mechanisms and Current Literature.

Introduction: Acute liver failure is a cause of major mortality in the United States. Although the liver possesses regenerative capabilities, liver transplantation is the mainstay of treating acute liver failure. This modality is associated with many financial and logistic challenges. In this regard, Extracorporeal Liver Support (ECLS) might help in reducing mortality as well as bridge a patient to liver transplant. In some cases, the sequelae of liver failure such as hepatic encephalopathy and multi-organ failure can be postponed long enough for the native liver to self-recover function. With this rationale, we sought to describe the mechanism of various ECLS modalities, provide an overview of the current evidence regarding its use and to highlight future advancements that could overcome hindrances in its use. Methods: A scoping review was performed using PubMed and other databases from 1990 to 2020 with the keywords: 'extracorporeal liver support', 'acute liver failure', 'acute on chronic liver failure', 'albumin dialysis', 'artificial' and 'bioartificial'. Results and conclusions: ECLS has shown significant improvements in bilirubin and urea levels. Various forms of ECLS might also reduce mortality due to liver failure. However, many complications, such as hypotension, anemia, bleeding issues, sepsis, can be anticipated. There are a few barriers to mainstream use of ECLS, such as specific design requirements and high cost that reduce the overall utility of this modality in a small group of liver transplant candidates. Furthermore, a multidisciplinary team approach is required to supervise ECLS, a luxury only available at major academic hospitals. Some advancements for overcoming these barriers include investigation of new scaffolding systems. In order to expand the usage of ECLS, clinical trials focusing on a comparison of different modalities of ECLS with renal replacement therapy in patients with liver failure should be promoted.

Racial and ethnic characteristics and cancer-specific survival in Primary Malignant Cardiac Tumors.

Background: There is limited insight into the epidemiological characteristics and effect of race and ethnicity on Primary Malignant Cardiac Tumors (PMCTs). Objectives: Comparison of clinical characteristics and cancer-specific survival outcomes of major races in the United States from the Surveillance, Epidemiology and End-Result (SEER) registry. Methods: ICD-O-3 codes were used to identify PMCTs for the years 1975 to 2015. Three major races were identified-"White", "Black", and "Asian/Pacific Islander". Cancer-specific survival outcomes were compared using Kaplan-Meier analysis across and amongst races, based on tumor histology. A subgroup analysis of cancer-specific survival was performed between "Hispanics" and "non-Hispanics." Results: Seven hundred and twenty patients were identified-47% females and 79% White, mean age at diagnosis (47 ± 20 years). Black patients were significantly younger (39 ± 18 years) and presented more commonly with angiosarcomas (53%). Non-angiogenic sarcomas and lymphomas were the most common tumors in the White (38%) and Asian/Pacific Islander (34%) cohorts. For a median follow-up period of 50 (IQR3-86) months, cancer-specific survival (mean ± SD, in months) was worse in Blacks (9 ± 3) as compared to Whites (15 ± 1) and Asian/Pacific Islander (14 ± 1) (p-value; Black vs. White <0.001; Black vs. Asian/Pacific Islanders = 0.017, White vs. Asian/Pacific Islanders = 0.3). Subgroup analysis with 116 (16%) Hispanics (40% females; mean age of 40 ± 20 years) showed a longer mean cancer-specific survival of 16.9 ± 2.4 months as compared to 13.6 ± 1.1 months in non-Hispanics (p = 0.011). Conclusion: Black and non-Hispanic patients have poorer cancer-specific survival in PMCTs.

Middle Meningeal Artery Embolization: A Paradigm Shift in Approach of Chronic Subdural Hematoma.

Chronic subdural hematoma (SDH) is commonly seen in the aged population. It is hypothesized to occur due to damage to the dural border cells, resulting in an inflammation-proliferation reaction. Inadequate repair leads to the formation of an external layer of cells and fragile capillaries, which are vulnerable to damage, contributing to worsening of the condition. Conventionally, asymptomatic chronic SDH was managed by observation, while symptomatic cases by surgical evacuation. However, the recurrence rate of chronic SDH after surgical evacuation was high. The middle meningeal artery (MMA) provides blood supply to the dura mater and feeds the capillaries of the membranes covering the SDH. MMA embolization blocks blood flow to this system and promotes hematoma resolution. In this manuscript, we discuss the underlying pathophysiology and current management options for chronic SDH. We also discuss the existing literature on MMA embolization.

A rare cause of lower gastrointestinal bleeding treated with robotic colorectal surgery.

BACKGROUND: Metastatic melanoma to the colon is rarely diagnosed with an incidence of only 0.3% and more than 95% of cases identified post-mortem. Survival for patients with metastatic melanoma to the colon is poor, with 5-year survival rates of 26.5%. Nonetheless, surgical resection of the colonic metastatic melanoma lesions is recommended as it is associated with improved survival. Additionally, surgical resection is also indicated for palliative reasons, as symptom resolution is achieved in 90% of such patients. Use of the surgical robot has increased dramatically in the past decades, especially in the field of colorectal surgery. Furthermore, recent studies have demonstrated comparable outcomes between patients undergoing either laparoscopic or robotic-assisted colorectal surgery for cancer. Here, we describe the first case, to the authors knowledge, of a robot-assisted sigmoid colectomy for metastatic melanoma. CASE PRESENTATION: A 72-year-old male with a history of metastatic melanoma diagnosed in 2015 with a favorable response to immunotherapy presented to the emergency department with symptomatic lower gastrointestinal bleeding (LGIB). Endoscopy demonstrated a friable melanotic lesion of the sigmoid colon with biopsy demonstrating histopathologic evidence of metastatic melanoma. After further evaluation, the patient consented for an elective robot-assisted segmental colectomy for palliative intent. Diagnostic laparoscopy identified no evidence of further intra-abdominal metastatic disease. After identifying the metastatic lesion in the sigmoid colon, the mesentery of involved segment of sigmoid colon adjacent to the lesion was divided using the bipolar electrosurgical vessel sealer device. The colon was divided both proximal and distal to the lesion using a robotic stapler and a tension-free colo-colonic anastomosis was created intracorporeally. Postoperatively, the patient had an unremarkable course and was discharged home on post-operative day 3. On follow-up, the patient was doing well with resolution of preoperative LGIB. CONCLUSION:  This case highlights a rare presentation of metastatic melanoma to the colon in a patient presenting with LGIB. Furthermore, this case demonstrates the feasibility of the minimally invasive robotic-assisted approach for an uncommon pathology.

Pet-Assisted Therapy for Delirium and Agitation in Hospitalized Patients with Neurocognitive Impairment: A Review of Literature.

Delirium leading to agitation is a common issue in elderly people and patients with underlying neurocognitive impairment. Despite use of medications to treat agitation, polypharmacy is a major concern and might lead to multiple side effects in this patient population. Therefore, it is imperative to investigate non-pharmacological methods that can provide solutions to the problem. The objective of this review was to evaluate the impact of pet-assisted therapy on elderly patients, with a major focus on agitation and delirium. For the purposes of this study, a scoping review was performed using PubMed, Google Scholar, and ClinicalTrials. We reviewed literature from 1980 to 2021. Out of the 31 studies reviewed, 14 commented on agitation with respect to pet-assisted interventions. Of these, eight studies (57%) reported a statistically significant reduction in agitation and/or delirium in patients who were exposed to pet therapy. Pet-assisted therapy can improve the standardized care in hospital-based settings for patients with neurocognitive impairment because of better companionship, reduced agitation and mood disorders, and better stability of hemodynamic status. These interventions can pave the way for better patient and hospital satisfaction.

COVID-19 Vaccine Hesitancy in the LGBTQ+ Population: A Systematic Review.

The coronavirus 2019 (COVID-19) pandemic has disproportionately impacted lesbian, gay, bisexual, transgender, queer (LGBTQ+) people. Despite developing safe and effective COVID-19 vaccines, LGBTQ+ communities still faces challenges due to inequitable access and vaccine hesitancy. Vaccine hesitancy is a delay in the acceptance or refusal of vaccines despite the availability of vaccination services. Various studies have explored and tried to address factors influencing vaccine hesitancy. However, the LGBTQ+ population remains under- and misrepresented in many of these studies. According to the few studies that have focused on the LGBTQ+ population, several factors influencing vaccine hesitancy have been identified, with the most common factors in studies being concern about vaccine safety, vaccine efficacy, and history of bad experiences with healthcare providers. In order to rebuild the confidence of LGBTQ+ people in vaccines, governments, healthcare policymakers, and healthcare providers need to start by acknowledging, and then resolving, these disparities; building trust; dismantling systemic suppression and discrimination; and prioritizing the inclusion of LGBTQ+ people in research studies and public health policies.

Demographic and Clinical Characteristics of Patients Presenting With Angiotensin-converting Enzyme Inhibitors Induced Cough.

Introduction Angiotensin-converting enzyme inhibitors (ACEi) induced cough is still the greatest challenge in the continued utilization of ACEi for management of hypertension. The clinical pattern and related risk factors predisposing patients to ACEi-induced cough have not been studied in Pakistani hypertensive patients as yet. Hence, this study was conducted. Methods In this prospective, observational study individuals of both genders, of age 18 years or more, known cases of hypertension, taking ACEi, and having a chronic cough (>14 days) without any respiratory etiology were included. Their demographic and clinical characteristics were recorded. All data were managed using SPSS for Windows version 20.0 (IBM Corp., Armonk, NY). Results Enalapril was the most frequently prescribed ACEi (n=58; 47.2%) in patients with ACEi-induced cough followed by captopril (n=28; 22.7%), lisinopril (n=23; 18.7%), and ramipril (n=14; 11.4%). Higher body mass index (p=0.002), smoking (p=0.008), and longer time from the start of ACEi to the occurrence of cough (p=0.04) were the significant determinants of ACEi-induced cough. There were 33 (26.8%) participants who planned to request their physician to prescribe them an alternate medication due to their cough. Conclusions Enalapril was the most commonly ACEi prescribed among patients with ACEi-induced cough. Higher BMI, smoking, and longer time from the start of ACEi to the occurrence of cough related to ACEi-induced cough.

Oral Ondansetron versus Domperidone for Acute Gastroenteritis Associated Vomiting in Young Children.

Introduction The management of vomiting and antiemetic therapy in young children with acute gastroenteritis (AGE) has not been standardized by any management guidelines. Antiemetic drugs including promethazine, prochlorperazine, metoclopramide, ondansetron, and domperidone are readily used in the emergency departments (EDs). The aim of this study was to compare the efficacy of ondansetron with domperidone in cessation of vomiting in pediatric AGE. Methods This open-label, two-arm trial was conducted in a pediatric ED in Pakistan. Children of age 1 to 60 months presenting with acute vomiting and no or mild-to-moderate dehydration associated with AGE were randomized into two groups. Group A children received ondansetron suspension orally at a dose of 0.15 mg/kg body weight. Group B received domperidone suspension orally at a dose of 0.5 mg/kg body weight. The primary outcome was the number of children in each group who did not have any episode of vomiting 24 hours posttreatment. The data were entered and analyzed using Statistical Package for the Social Sciences (SPSS) for Windows version 20.0 (IBM Corp., Armonk, NY). Results At 6 hours, 87% of children in the ondansetron group improved and their vomiting episodes ceased as compared to 81% of children in the domperidone group. The differences were statistically insignificant (p>0.05). At 24 hours, 95% in the ondansetron group had improved and only 85% in the domperidone group. The results were statistically significant favoring the end results of the ondansetron (p=0.01). Conclusions This study concluded that ondansetron is more efficacious than domperidone in cessation of vomiting associated with AGE and no or mild-to-moderate dehydration in children of age three months to five years.

Knowledge and Attitude of General Pakistani Population Towards Antibiotic Resistance.

Introduction The emergence and continuous spread of drug resistant bacteria has become one of the leading health concerns globally. Persistent failure to develop and/or discover new antibiotics along with irrational use of existing antibiotics is associated with rise in antibiotic resistance. There is poor understanding of antibiotics usage and their preciousness among the masses which result in careless utilization and hence, the emerging antibiotic resistance. The aim of this study is to evaluate the knowledge and attitude of Pakistanis towards antimicrobial resistance (AMR). Methods This observational cross-sectional survey was designed in the form of an online pro forma circulated in January 2019. It was a self-structured pro forma which included age, gender, and 10 questions - five to assess the knowledge and five to assess the attitude towards AMR. Each question was to be responded with a "Yes" or a "No." For knowledge assessing questions "do not know" was also an option. Data was entered and analysed using SPSS version 22 (IBM Corp., Armonk, NY). Results Of 1,132 participants, 837 (73.9%) thought that it was alright to stop antibiotics course whenever they felt better, 505 (44.6%) thought that frequent and unnecessary use of antibiotics actually decrease their effectiveness, and 208 (18.4%) participants thought it was correct to take antibiotics for cold and influenza. There were 157 (13.9%) participants who had not followed the duration of treatment as given in their doctor's prescription, 49 (4.4%) who had changed their antibiotic dose without doctor consultation, 467 (41.3%) who had reused leftover antibiotics from their previous prescription, 700 (61.8%) who had suggested it to their doctors to prescribe them antibiotics and 378 (33.4%) participants who had purchased antibiotics without any prescription in the last one year. Conclusion Pakistani individuals are not as knowledgeable about antibiotic resistance as severe the issue is in this region. Their attitude towards utilization of antibiotics is not very promising. It becomes essential to initiate antibiotic stewardship programs and educate the masses regarding efficacious and safe use of antibiotics in this region.