Impact of oral/dental disease burden on postoperative infective complications: a prospective cohort study.

OBJECTIVES: This prospective cohort study aimed to assess the association between dental disease burden and postoperative infective complications (POICs) in patients undergoing major surgical procedures under general anaesthesia. METHODS: Pre-surgical dental assessment was undertaken on patients planned for major surgery. Demographic and surgical variables including putative risk factors for POICs and POIC status were documented. The univariable association between POIC status and each factor was examined. Those variables associated at P value ≤ 0.2 were candidates for inclusion in multiple logistic regression models. Backward stepwise variable selection was used to identify the independent predictors for POIC in the best fitting logistic regression model. The area under the receiver operating curve (AUC) was used to quantify the model's global classification performance. RESULTS: Among the 285 patients, 49 patients (17.2%) had POICs. The independent predictors for POIC were expected length of hospital stay (4-6 days; odds ratio [OR] = 4.80, 95% confidence internal [CI]: 1.30-17.70, P = 0.018, 7-9 days; OR = 5.42, 95% CI: 1.51-19.41, P = 0.009, ≥ 10 days; OR = 28.80, 95% CI: 4.12-201.18, P < 0.001), four or more decayed teeth (OR = 6.03, 95% CI: 2.28-15.94, P < 0.001) and visible tongue plaque (OR = 3.21, 95% CI: 1.54-6.70, P = 0.002). The AUC was 0.78 (95% CI: 0.71-0.85) indicating good discrimination. A simple screening tool for POIC was developed. CONCLUSIONS/CLINICAL RELEVANCE: In addition to systemic/surgical factors, this study identified clinically detected decayed teeth and visible tongue plaque as independent predictors for POICs. Preoperative dental assessment/care might be beneficial to assess risk for POICs and improve postoperative outcomes.

Flood 2022 in Pakistan: Managing medical flood relief camps in a developing country.

Floods are the most common natural disasters in the world. Currently Pakistan is in an acute emergency situation due to the recent flood that occurred as a result of the monsoon rains in July-August 2022. Unfortunately, the country was already under an economic crisis and was just recovering from the COVID pandemic when this devastating calamity struck. Almost one-third of the country's land was affected, with millions of houses damaged and property lost. As the victims are displaced and local health units are flooded, their medical needs are being met through medical flood relief camps arranged by public and private sector welfare organizations. Due to a lack of disaster preparedness and policies, most of the healthcare workers are untrained to manage medical flood relief camps and are hence learning from experience rather than following any standardized policy guidelines. We did not find any guidelines for organization and management of a flood relief camp in previous literature. As natural disasters continue to cause mass destruction every few years, there is a need to devise policies and procedures for disaster preparedness and hazard reduction. This paper is thus an effort to provide the best possible delivery of acute health services in a developing country during and after a flood in the transit phase, while the government and other non-governmental organizations (NGOs) help communities rebuild their health system.

COVID-19 Antibodies in Vaccinated Healthcare Workers: The Security Currency.

Background The coronavirus disease 2019 (COVID-19) vaccinations have brought new hope to the world and have a significant psychosocial impact on communities as well as healthcare systems around the globe. This study aimed to assess the antibody titer level among healthcare workers after at least six weeks of the second dose of the COVID-19 vaccine. Methods Participants of the study were healthcare workers of a tertiary care cardiac center including doctors, nursing staff, paramedics, and office staff. All participants were fully vaccinated with recommended double dose of available vaccine at least six weeks before the study. A blood sample of five milliliters was collected from all the participants by a trained phlebotomist at a local laboratory, and COVID-19 antibodies titer level was assessed using Food and Drug Administration (FDA) approved kit with a standard range of 1.0. This qualitative assay detects IgG and IgM as total antibodies targeted against nucleocapsid antigen performed on a fully automated cobas® 6000 analyzer (F. Hoffmann-La Roche Ltd, Basel, Switzerland) using electrochemiluminescence technology. COVID-19 antibodies titer levels were categorized as ≤100, 101-250, and >250. Results A total of 151 healthcare workers were included, of which 70.2% (106) were male. The history of COVID-19 infection before vaccination was found in 41.1% (62). The mean duration since the last dose of the vaccine was 89.6±40.07 days. In total 71.5% (108) had antibodies titer level of >250, which were mostly found in participants of younger age and who had previous COVID-19 infection. However, antibodies titer level of >250 were observed in 84% (21/25) at 61 to 90 days of vaccination, which declined to 80% (20/25) after 91 to 120 days and to 57.1% (32/56) after >120 days of vaccination. Conclusions Good antibodies titer levels were observed in vaccinated healthcare workers, especially in those who were younger and had previous COVID-19 infection.

Knowledge, attitude and practice of wearing mask in the population presenting to tertiary hospitals in a developing country.

BACKGROUND: In the era of COVID-19 where there is emphasis on the importance of wearing a mask, wearing it rightly is equally important. Therefore, the purpose of this study was to assess the knowledge, attitude and practice of wearing a mask in the general population of a developing country at three major tertiary care hospital. MATERIALS AND METHODS: Participants of this cross-sectional study were patients and attendants at three major tertiary care hospital of Karachi Pakistan. Selected participants, through non-probability convenient sampling technique, were interviewed regarding knowledge, attitude, and practice of wearing mask using an Urdu translated version of a questionnaire used in an earlier study. Three summary scores (0 to 100) were computed to indicate participants' mask wearing practice, technique of putting it on, and technique of taking if off. Collected data were analyzed with the help of IBM SPSS version 19. RESULTS: A total of 370 selected individuals were interviewed, out of which 51.9% were male and mean age was 37.65±11.94 years. For more than 90% of the participants, wearing a face mask was a routine practicing during the pandemic. The mean practice score was 65.69±25.51, score for technique of putting on a face mask was 67.77±23.03, and score of technique of taking off a face mask was 51.01±29.23. Education level of participant tends to have positive relationship with all three scores, while presence of asthma or chronic obstructive pulmonary disease (COPD) as co-morbid had negative impact on mask wearing practice. CONCLUSION: We have observed suboptimal knowledge, attitude and practice of wearing mask among the selected individuals. There is a continued need to spread awareness and educate general population about the importance of using a face mask, as well as the proper technique of wearing and taking off a face mask.

Home Management of COVID-19 Patients: A Successful Model in Non-severe COVID-19 Patients in the Developing World.

Background Around 80-85% of coronavirus disease 2019 (COVID-19) cases were reported to have mild disease and home treatment of such patients was proved to be effective without significant morbidity or mortality. Therefore, the aim of this study was to assess the outcome of home management of non-severe COVID-19 infection in healthcare providers in the developing world. Methods This observational cohort study was conducted at the National Institute of Cardiovascular Diseases from June 2020 till January 2021. It included health care workers who tested positive for COVID-19 with non-severe infection and received home treatment. The COVID-19 management team monitored their symptoms and oxygen saturation over the phone. Need-based lab tests, X-rays, home proning, steroids, and oxygen were administered along with the standard intuitional management strategies. Study outcomes included duration of recovery, need for hospitalization, and expiry. Results A total of 128 patients were included, out of which 98 (76.6%) were male, and the mean age was 32.9 ± 5.9 years. Fever was the most common symptom, seen in 89.8% of patients. Most of the patients (85.9%) had no pre-existing comorbidities. Five patients received home oxygen therapy, seven received steroid therapy, and one received home pruning. The average time of recovery was 13.8 ± 8.1 days with no mortality; however, 14 (10.9%) patients were hospitalized due to worsening of symptoms. Conclusion Home treatment for COVID-19 patients with mild to moderate disease after appropriate risk assessment can be a safe and effective option to preserve hospital capacities for more needy and severely ill patients.

Perceptions Regarding COVID-19 Vaccination Among a Representative Pakistani Population Coming to Tertiary Care Cardiac Hospital.

BACKGROUND: The deleterious effects caused by coronavirus disease 2019 (COVID-19) infection have been compounded by COVID-19 vaccine hesitancy throughout the world, including Pakistan. We are lacking representative national data regarding the COVID-19 vaccine acceptance. This study aims to determine COVID-19 vaccination acceptance rates and predictors of its acceptance and hesitancy among a representative Pakistani population. METHODS: This cross-sectional study was conducted at the National Institute of Cardiovascular Disease, Karachi, from March 2021 to April 2021. Participants included patients, and their attendants visiting the outpatient clinics and healthcare workers of the institute. Participants were labeled as 'acceptant' or 'hesitant' based on their responses of 'yes' or 'no' and 'not sure' on the willingness to get vaccinated, respectively. The Chi-square test was used to calculate the significant association between different variables. A p-value ≤0.05 was set as a level of significance for all statistical analyses. RESULTS: Overall, 1500 participants were enrolled with a vaccine acceptance rate of only 49%. Factors like male gender, unmarried and employed status, higher education, high socioeconomic class, Punjabi and Sindhi ethnicity, medical professional, and self or family exposure of COVID-19 were positively related to COVID-19 vaccine acceptance. The commonest stated reason for the vaccine hesitancy was distrust in vaccine efficacy or fear of vaccine adverse effects. CONCLUSION: Vaccine hesitancy remains a serious challenge in our population, related to multiple demographic and thought factors. Focused actions and modification of these factors are the keys to conclude this COVID pandemic.

An audit of the effect of SGLT2 inhibitor cessation in a pre-admission clinic before and after Australian Diabetes Society guidelines.

Perioperative ketoacidosis is an important adverse event related to the use of sodium glucose co-transporter 2 inhibitor (SGLT2i). We compared perioperative outcomes in patients on SGLT2i, before and after protocolised pre-operative cessation of the drug. There were no cases of clinically detected diabetic ketoacidosis in the 96 patients included in the study. Withdrawal of SGLT2i did not appear to alter significantly pre-operative glycaemia.

Stenotrophomonas maltophilia Meningitis - A Case Series and Review of the Literature.

Stenotrophomonas maltophilia is an infrequent cause of acute bacterial meningitis and only a few cases have been reported in the literature. Infection is associated with morbidity and mortality, and its optimal management remains ill-defined. The aim of the current study is to review the management of S. maltophilia meningitis. We described two cases of S. maltophilia meningitis following neurosurgical procedures. The first patient was a 60-year-old female. She was admitted to the hospital with a left basal ganglia bleed and underwent placement of an external ventricular drain for the treatment of hydrocephalus. She developed S. maltophilia meningitis 20 days after surgery. She was successfully treated with a combination of trimethoprim-sulfamethoxazole and intravenous colistin and the removal of the drain. She successfully underwent a ventriculoperitoneal (VP) shunt placement at the therapeutic midway point. The second patient was a 35-year-old male with a history of intracranial aneurysm bleeding. He had undergone a craniotomy and placement of a ventriculoperitoneal shunt two years previously. His shunt was replaced twice due to blockage. The last replacement had occurred 15 days prior to the development of meningitis. He was treated with a combination of trimethoprim-sulfamethoxazole and ceftazidime (as well as undergoing another shunt replacement) and experienced an excellent recovery. S. maltophilia is a rare but important cause of nosocomial meningitis. It is strongly associated with prior hospitalization and neurosurgical intervention, which is also found in our case series. The management of S. maltophilia meningitis is a therapeutic challenge due to its high resistance to multiple antibiotics. Optimal therapy is based on antimicrobial sensitivity, and the trimethoprim-sulfamethoxazole-based combination has been shown to be successful. The duration of therapy is debatable, but like most gram-negative meningitis infections, therapy lasting up to three weeks appears to be adequate.

Infection of a Ventricular Septal Defect Patch with Acremonium Species.

A ventricular septal defect (VSD) patch infection with Acremonium species isolated from vegetation and blood culture is described. Antifungal treatment was discontinued after 3 months and patient developed relapse. Surgery with prolonged oral voriconazole was instituted with recovery. We emphasize importance of surgery and prolonged therapy to treat such infections.

Patients' insight of interpreting prescriptions and drug labels--a cross sectional study.

BACKGROUND: Errors in consuming drugs are associated with significant morbidity and mortality, besides an impact on the already overburdened health-care system. Misunderstanding drug labels and prescriptions plays an important role in contributing to adverse drug events. OBJECTIVE: To evaluate abilities to understand prescriptions and drug labels among patients attending tertiary care hospital in Karachi. METHODS: A cross sectional study was conducted at the Aga Khan University Hospital (AKUH), from January to March 2009. After informed consent, 181 adult patients and their healthy attendants were interviewed at AKUH using a standardized questionnaire, which ascertained patient demographics, factors that might increase exposure to health-care personnel as well as the basic knowledge and understanding of prescriptions and drug labels. RESULTS: Out of 181, majority 137(76%) had received graduate or post-graduate degrees. 16 (9%) had received no formal education; of which all were females and 89(84%) of the total females were housewives. Overall, 130(72%) followed only a single doctor's prescription. Majority failed to understand various medical terminologies related to dosage. In the high literacy group, 45(33%) understood once daily OD (p = 0.003), 27(20%) thrice daily TID (p = 0.05), 29(21%) twice daily BD (p = 0.01), 31(23%) thrice daily TDS (p = 0.002) and 43(31%) as needed SOS (p = 0.003) as compared to the group with no formal education, who were unable to comprehend the terms. The most common reason for using more than one prescription was decreased satisfaction with the doctor in 19(39%) and multiple co-morbids as responded by 17(35%) of patients. Knowledge regarding various medical terminologies used for dosage and routes of drug administration were also understood more frequently among the English medium respondents. The elderly identified medicine through color (47%, p<0.001), and were less likely to understand drug indications (p = 0.05) compared to younger subjects. CONCLUSION: Understanding of drug prescriptions is alarmingly low in the community, even amongst the educated. Care givers need to revisit this often ignored aspect of patient care.

Vitamin D accelerates clinical recovery from tuberculosis: results of the SUCCINCT Study [Supplementary Cholecalciferol in recovery from tuberculosis]. A randomized, placebo-controlled, clinical trial of vitamin D supplementation in patients with pulmonary tuberculosis'.

BACKGROUND: Vitamin D enhances host protective immune responses to Mycobacterium tuberculosis by suppressing Interferon-gamma (IFN-g) and reducing disease associated inflammation in the host. The objectives of this study were to determine whether vitamin D supplementation to patients with tuberculosis (TB) could influence recovery. METHODS: Two hundred and fifty nine patients with pulmonary TB were randomized to receive either 600,000 IU of Intramuscular vitamin D3 or placebo for 2 doses. Assessments were performed at 4, 8 and 12 weeks. Early secreted and T cell activated 6 kDa (ESAT6) and Mycobacterium tuberculosis sonicate (MTBs) antigen induced whole blood stimulated IFN-g responses were measured at 0 and 12 weeks. Statistical comparisons between outcome variables at 0 and 12 weeks were performed using Student's t-test and Chi2 tests. RESULTS: After 12 weeks, the vitamin D supplemented arm demonstrated significantly greater mean weight gain (kg)+3.75, (3.16-4.34) versus+2.61 (95% CI 1.99-3.23) p 0.009 and lesser residual disease by chest radiograph; number of zones involved 1.35 v/s 1.82 p 0.004 (95% CI 0.15, 0.79) and 50% or greater reduction in cavity size 106 (89.8%) v/s 111 (94.8%), p 0.035. Vitamin D supplementation led to significant increase in MTBs-induced IFN-g secretion in patients with baseline 'Deficient' 25-hydroxyvitamin D serum levels (p 0.021). CONCLUSIONS: Supplementation with high doses of vitamin D accelerated clinical, radiographic improvement in all TB patients and increased host immune activation in patients with baseline 'Deficient' serum vitamin D levels. These results suggest a therapeutic role for vitamin D in the treatment of TB. TRIAL REGISTRATION: ClinicalTrials.gov; No. NCT01130311; URL: clinicaltrials.gov.

Cerebral venous sinus thrombosis: association with primary varicella zoster virus infection.

Varicella zoster virus (VZV) has been known to cause cerebral arterial vasculopathy and an acquired antibody-mediated coagulopathy associated with purpura fulminans and generalized thromboembolism. There are no published reports of cerebral venous sinus thrombosis (CVST) associated with primary VZV infection. We report 2 cases that highlight an unusual presentation of VZV infection: CVST with primary varicella infection. One patient had extensive CVST with coexistent middle cerebral artery involvement. Primary VZV infection can be associated with thrombosis of cerebral arteries and venous sinuses.

Pulmonary nocardiosis: a comparative analysis of Nocardia asteroides and non-asteroides species.

Our study compares the risk factors, clinical presentations and outcomes of pulmonary infections caused by Nocardia asteroides and non-asteroides species. We performed a retrospective cohort study comparing pulmonary infections by both species in patients presenting to a tertiary care hospital in Karachi, Pakistan. Forty-one patients were identified with pulmonary nocardiosis, with 58.5% belonging to the N. asteroids complex. The most common clinical findings were fever and a cough for both groups, with lobar infiltrates being the most common finding on chest radiographs. In vitro testing showed a sensitivity of all species to trimethoprim-sulfamethoxazole (TMP-SMZ), aminoglycosides, ceftriaxone and imipenem. The majority of the patients were treated with TMP-SMZ in combination with other drugs. The results of our study suggest that there is no significant difference in the risk factors, presentations and outcomes of pulmonary infections by N. asteroides and non-asteroides species. Immunocompromised patients are more likely to have unfavorable outcomes.

Isolated cryptococcal osteomyelitis in an immunocompetent patient.

Cryptococcosis is a rare infection in HIV-negative individuals. While the lungs and the central nervous system are most commonly infected, skeletal cryptococcosis is uncommon and isolated osteomyelitis due to Cryptococcus neoformans is quite rare. To our knowledge, only 47 cases of isolated cryptococcal osteomyelitis have been reported from 1974 to 2005. We report a case of isolated cryptococcal osteomyelitis in an immunocompetent patient, who received 12 weeks of fluconazole with complete recovery.

Rhinocladiella mackenziei as an emerging cause of cerebral phaeohyphomycosis in Pakistan: a case series.

Six cases of Rhinocladiella mackenziei cerebral phaeohyphomycosis are being reported for the first time in Pakistan. Identification was confirmed by DNA sequencing (isolates and fixed tissue). Diabetes, head trauma, immunosuppressive treatment, and postpartum state were present in 4 cases. Two survivals and 3 fatalities occurred, with 1 patient lost to follow-up.

Primary amebic meningoencephalitis caused by Naegleria fowleri, Karachi, Pakistan.

We report 13 cases of Naegleria fowleri primary amebic meningoencephalitis in persons in Karachi, Pakistan, who had no history of aquatic activities. Infection likely occurred through ablution with tap water. An increase in primary amebic meningoencephalitis cases may be attributed to rising temperatures, reduced levels of chlorine in potable water, or deteriorating water distribution systems.

Crimean-Congo hemorrhagic fever in a dengue-endemic region: lessons for the future.

Crimean-Congo hemorrhagic fever and dengue hemorrhagic fever are endemic in Pakistan. However, the overlap of geographic distribution and early clinical features between the two conditions make a reliable diagnosis difficult in the initial stage of illness. A 16-year-old boy presented with a history of hematemesis and high-grade fever. A preliminary diagnosis of dengue hemorrhagic fever was made and supportive treatment was instituted; however, the patient continued to deteriorate clinically. Dengue IgM antibody testing was negative on the third day of admission. Qualitative polymerase chain reaction test for Crimean-Congo hemorrhagic fever viral RNA was sent but the patient expired shortly after the results became available on the sixth day of admission. Considerable resources had to be expended on contact tracing and administration of ribavirin prophylaxis to all the health-care workers who had come in contact with the patient. It is crucial that Crimean-Congo hemorrhagic fever be recognized and treated at an early stage because of longer term financial and health implications for contacts such as health-care workers in the setting of a developing country. Increased surveillance of dengue and Crimean-Congo hemorrhagic fever cases is warranted for the derivation of reasonably reliable, cost-effective and prompt predictors of disease diagnosis. These predictors can help guide future decisions in the management of similar cases. Ultimately, such a strategy may translate into better cost containment in resource-poor settings. Institution of ribavirin prophylaxis in selected patients also merits consideration.

Extrapulmonary tuberculosis: a retrospective review of 194 cases at a tertiary care hospital in Karachi, Pakistan.

OBJECTIVE: To describe the types and treatment outcomes of the extra-pulmonary tuberculosis (EPTB) cases in a tertiary care hospital in a high burden tuberculosis country. METHOD: A retrospective case series study was conducted at Liaquat National Hospital (LNH), the largest private tertiary care hospital in Karachi, Pakistan. All cases diagnosed and treated as EPTB between November 2005 and February 2007 were included. Data was retrieved from medical records on demographics, clinical, laboratory, and outcome status. RESULTS: A total of 194 patients treated for EPTB were identified. Mean age of patients was 34 +/- 16.4 years, and 75% of patients were female. Lymph nodes and spine were the most common sites involved (60%). The cure rate was 40.7%. There was no difference in cure rate of males and females (p=0.99). CONCLUSION: EPTB is an important clinical problem in Pakistan. Due to lack of guidelines for diagnosis and duration of treatment in EPTB most physicians in Pakistan treat patients based on clinical symptoms and for prolonged duration of 12, to even as long as 24 months. The National TB Program, and chest and infectious disease societies must develop standardized guidelines for the diagnosis and treatment of EPTB.