An outcome of emergency vascular surgery performed by general surgeons; our experience in a university hospital of Pakistan and can they substitute vascular surgeons?

OBJECTIVE: To measure the outcome of emergency vascular surgery performed by general surgeons, and to identify preventable causes of mortality. METHODS: The retrospective study was conducted at the General Surgery Department of Mayo Hospital, King Edward Medical University, Lahore, Pakistan, and comprised data between January 2014 and May 2019 related to cases regardless of age and gender that required emergency vascular surgery after diagnosis by a consultant surgeon at the surgical emergency. The cases were analysed from admission till discharge. Data was analysed using SPSS 20. RESULTS: Of the 135 cases, 127(94%) were males. The overall mean age was 28.8±11.5 years (range: 14-63 years). Mean duration of hospital stay was 11±3.92 days (range: 4-22 days). Three major peripheral arteries injured were brachial 32(38.5%), popliteal 55(40.7%) and femoral 20(20.7%), with more than half with complete transection 75(55.6%). Vascular repairs done were primary anastomosis 45(33.3%), reverse saphenous vein graft 68(50.4%), embolectomy 4(3%) and amputation 18(13.3%). Limb salvage rate and mortality was 101(74.8%) and 6(4.4%), respectively. Complications occurred in 38(28.1%) cases, with 24(18%) wound infections and 9(6.7%) myonecrosis. Factors leading to poor outcome/complications were Glasgow Coma Scale score <12 (p=0.01), referred case (p=0.04), significant bleeding (p=0.004), haemoglobin <9 at presentation (p=0.001), bone fracture (p=0.01), involvement of lower limb (p=0.003) and late presentation (p=0.003). CONCLUSIONS: Late presentation in hospital was the major modifiable factor improvement of which could lead to better outcome, apart from the early and proper surgical intervention.

Ventricular Dyssynchrony based on echocardiographic variables and exercise tolerance After right ventricular pacing: Impact of alternative septal lead locations.

OBJECTIVE: We investigated the impact of alternative locations of right ventricular (RV) pacing on left ventricular function and its relation to exercise capacity. METHODS: Fifty patients who received a single lead pacemaker were divided according to RV pacing site into group 1 "high septum" (n = 15), group 2 "mid-septum" (n = 25), and group 3 "low septum" (n = 10) using a documented fluoroscopic method. Dyssynchrony parameters were obtained using different echocardiographic parameters. Their exercise tolerance was evaluated after 6 months of pacemaker implantation using 6 minutes walk test (6 MWT). RESULTS: We found a lesser degree of dyssynchrony in mid-location and high location compared with low location pacing (radial dyssynchrony: P < .001; maximum temporal difference: P < .01; inter-ventricular mechanical delay: P < .05, standard deviation of time-to-peak strain by tissue Doppler: P < .05). Sm was significantly increased 6 months following pacemaker implantation in group 1 and group 2 in contrast to group 3 patients (P < .05). Importantly, E/e' increased significantly (P < .001) in patients with low septal location pacing. Furthermore, 6 MWT distance was significantly improved (P < .001) in favor of groups 1 and 2. Importantly, the intra-ventricular dyssynchrony with speckle tracking was considerably less in group 1 and 2 patients. Tps-SL ≤ 120 ms was the optimal value to predict improvement in functional capacity following high to mid-septal pacing locations. CONCLUSION: There was significant improvement of functional capacity after RV pacing in high and mid-septal locations compared with low septal location. This was associated with a lesser degree of dyssynchrony in favor with mid- to high septal location.

Comparison of the outcome of mesh hernioplasty under local anaesthesia in patients with age less than 60 years VS more than 60 years in terms of wound complications and urinary retention.

OBJECTIVE: To compare the outcome of mesh hernioplasty performed under local anaesthesia in relatively young and older patients regarding wound complications and urinary retention. METHODS: This comparative study was conducted at Mayo Hospital, Lahore, Pakistan, from 17th Feb 2017 to 17th feb 2018, and comprised patients who underwent mesh hernioplasty. Demographic profile was noted and the patients were divided into <60 and >60 age groups. Surgical method used was Lichtenstein mesh repair under local anaesthesia. Outcome was documented in terms of urinary retention at 8 hours post-operation, wound seroma and haematoma at 24 hours and wound infection after 5 days of surgery. Data was analysed using SPSS 20. RESULTS: Of the 102 patients, there were 51(50%) in each of the two age groups. Among patients <60 years, urinary retention developed in 4(7.8%) compared to 6(11.8%) in the other group. Frequency of the wound complications, including wound haematoma, seroma and wound infection, were seen in 3(5.9%), 2(3.92%) and none respectively in the younger group compared to 2(3.92%), 2(3.92%) and none respectively in patients aged >60 years. CONCLUSIONS: The results in patients aged <60 years and >60 years were comparable in terms of urinary retention and wound complications.

FibroScan as a surveillance marker post-cavopulmonary anastomosis for single-ventricle physiology.

Purpose: Single-ventricle physiology encompasses a group of congenital cardiac malformations with only one functional ventricle. The Fontan procedure is the final palliation of this pathway and has its complications. One of these is Fontan-associated liver disease (FALD). It is known that all patients with Fontan will have FALD, due to the physiology of the Fontan circuit, and only the severity will vary. The pathophysiology of hepatic damage in FALD is unique and not easily detectable by routine non-invasive investigations. Therefore, this study is aimed to identify if FibroScan can be used as a surveillance marker to detect and assess the progression of FALD. Methods: Patients who attended the Cardiothoracic and Vascular Surgery Outpatient Department (OPD) for follow-up post-cavopulmonary anastomosis (bidirectional Glenn and Fontan) were enrolled in this study. They underwent routine examinations and tests, and in addition a FibroScan was performed. Results: FibroScan showed that the liver stiffness measurement (LSM) was increased in all patients who had undergone Fontan and a couple of patients who had undergone bidirectional (BD) Glenn. The LSM was 12.29 (± 3.59) kPa in patients post-Fontan and 6.64 (± 4.24) kPa in patients post-BD Glenn. This raised LSM was not associated with a parallel rise in liver enzymes or other laboratory markers associated with liver function. This emphasizes the suitability of FibroScan as an early and non-invasive surveillance tool for monitoring the progression of hepatic venous congestion and FALD. Conclusion: We have found that LSM via FibroScan can effectively be a surveillance or screening test for FALD. Serial FibroScans can be used to monitor the progress of liver disease. Raised LSM may also have a role in predicting the morbidity for completion of Fontan post-BD Glenn operation. Large-scale studies are needed to validate our findings.

Comparing the antioxidant properties and volatile compounds of carrot-orange juice blend processed through varied chemical, pasteurization and ultrasound conditions.

Ultrasound technique is one of the green technologies that is being utilized widely for varying food processes. Our aim in this study was to carry out ultrasonication, pasteurization and chemical preservation (Potassium metabisulfite) techniques on a carrot-orange juice blend. Additionally, the effect of these treatments on the storage period of about 21 days was also determined. The study displayed an array of results under the effect of different treatments. Throughout the storage period of 21 days' significant results were presented by the carrot juice blend subjected to the ultrasound technique (25 min) giving the highest values for total phenolic content (25.56 ± 1.29 mg GAE/100 mL), total antioxidant activity (573.48 ± 2.29 mg Trolox /100 mL), DPPH (32.32 ± 1.83 %) and reducing power (45.45 ± 1.92 mg AAE/100 mL) with least deterioration, followed by the blends treated with potassium metabisulfite (KMS) and pasteurization. The physicochemical analysis showed a non-significant effect of treatments on pH and total soluble solids (oBrix) of carrot-orange juice blends whereas, the changes in color parameters L*, a* and b* were noted to show changes in treated blends. Similarly, the results for the GC-MS quantification of volatile compounds displayed the highest concentrations in the ultrasonicated blends as compared to other techniques. The peak quantity was obtained for the hexanal (9903.43 ± 7.61 µg.kg-1) followed by 3-Methylbutanal (2638.7 ± 5.44 µg.kg-1), terpinolene (2337.16 ± 5.28 µg.kg-1), elemicin (2198.28 ± 5.28 µg.kg-1), myristicin (1936.62 ± 6.72 µg.kg-1). The use of sonication can effectively enhance the nutritional qualities of juice, as perceived by consumers.

Probing the physicochemical characteristics of carrot sauce during storage.

Globally, the prevalence of vit-A deficiency disorders i.e., xerophthalmia and nyctalopia is increasing especially in teenagers due to lifestyle shifts and undernutrition. This research was designed to develop carrot-supplemented tomato sauce to overcome vit-A deficiency and its related disorders. The carrot sauce was formulated with the addition of 50, 60, and 70% carrot pulp in tomato paste. The prepared sauce samples were tested for physical and biochemical changes in beta carotene (BC), lycopene, viscosity, pH, total soluble solids, titratable acidity, total plate count, and sensory parameters for 12 weeks. A non-significant effect of storage on BC, lycopene, and total soluble solids was observed. The total plate count, acidity, pH, and viscosity were influenced significantly. Sauce containing 60% of the carrot paste showed good sensory characteristics and 42.39 µg/g BC for the whole period of storage. It is concluded that carrot sauce can be used as tomato ketchup replacers to boost the overall quality of life by fighting against vit-A deficiency disorders.

Effect of dietary tryptophan supplementation on growth performance, immune response and anti-oxidant status of broiler chickens from 7 to 21 days.

BACKGROUND: This study was conducted to investigate the optimum dietary level of tryptophan (Trp) supplementation at which broiler chickens have better growth with efficient immune system and anti-oxidant status. METHOD: One hundred and twenty (n = 120) 1-day-old broiler chicks were fed a common commercial diet from days 1 to 7. On day 7, the chicks were randomly divided in three treatment groups, that is, Trp 0.2 [national research council (NRC) recommended level of tryptophan], Trp 0.3 (tryptophan supplemented at 0.3%) and Trp 0.5 (tryptophan supplemented at 0.5%). All the experimental diets were iso-caloric (ME; 3,000 kcal/kg) and iso-proteic (CP; 18.5%). Weekly data on feed intake and body weight gain (BWG) were recorded to calculate feed conversion ratio (FCR). On day 19, avian tuberculin was injected to note the cellular immunity. On day 21, two birds per replicate were killed to determine carcass and visceral organ weights. Blood serum samples were collected for analysis of humoral immune response against sheep red blood cells, total oxidant and anti-oxidants by spectrophotometric method. RESULTS: Feed intake, carcass and visceral organ weights remained unaffected by dietary treatments while BWG and FCR tended to improve (p < .05) in broiler chicks fed the Trp 0.3 and the Trp 0.5 diets. Total oxidant status was also improved (p < .05) in broiler chicks fed the Trp 0.5 diet. Likewise, broiler chicks fed the Trp 0.3 and the Trp 0.5 diets tended to have better (p < .05) total anti-oxidant status, catalase, glutathione peroxidase, glutathione reductase and arylesterase (ARE). The overall antibodies response and IgG improved (p < .05) by the Trp 0.3 and Trp 0.5 diets compared to control. However, IgM level remained similar across the treatment. The cellular immunity against avian tuberculin improved at 24 hr post-injection but its effect disappeared at 48 hr. CONCLUSION: The results of present study revealed that Trp above the NRC recommended level may give better growth, immune response and anti-oxidant status in broiler chickens.

Neurosurgical Procedures and Safety During the COVID-19 Pandemic: A Case-Control Multicenter Study.

OBJECTIVE: Quantitative documentation of the effects of outbreaks, including the coronavirus disease 2019 (COVID-19) pandemic, is limited in neurosurgery. Our study aimed to evaluate the effects of the COVID-19 pandemic on neurosurgical practice and to determine whether surgical procedures are associated with increased morbidity and mortality. METHODS: A multicenter case-control study was conducted, involving patients who underwent neurosurgical intervention in the Kingdom of Saudi Arabia during 2 periods: pre-COVID-19 and during the COVID-19 pandemic. The surgical intervention data evaluated included diagnostic category, case priority, complications, length of hospital stay, and 30-day mortality. RESULTS: A total of 850 procedures were included, 36% during COVID-19. The median number of procedures per day was significantly lower during the COVID-19 period (5.5 cases) than during the pre-COVID-19 period (12 cases; P < 0.0001). Complications, length of hospital stay, and 30-day mortality did not differ during the pandemic. In a multivariate analysis comparing both periods, case priority levels 1 (immediate) (odds ratio [OR], 1.82; 95% confidence interval [CI], 1.24-2.67), 1 (1-24 h) (OR, 1.63; 95% CI, 1.10-2.41), and 4 (OR, 0.28; 95% CI, 0.19-0.42) showed significant differences. CONCLUSIONS: During the early phase of the COVID-19 pandemic, the overall number of neurosurgical procedures declined, but the load of emergency procedures remained the same, thus highlighting the need to allocate sufficient resources for emergencies. More importantly, performing neurosurgical procedures during the pandemic in regions with limited effects of the outbreak on the health care system was safe. Our findings may aid in developing guidelines for acute and long-term care during pandemics in surgical subspecialties.

The longitudinal impact of COVID-19 pandemic on neurosurgical practice.

OBJECTIVE: This observational cross-sectional multicenter study aimed to evaluate the longitudinal impact of the coronavirus disease 2019 (COVID-19) pandemic on neurosurgical practice. METHODS: We included 29 participating neurosurgeons in centers from all geographical regions in the Kingdom of Saudi Arabia. The study period, which was between March 5, 2020 and May 20, 2020, was divided into three equal periods to determine the longitudinal effect of COVID-19 measures on neurosurgical practice over time. RESULTS: During the 11-week study period, 474 neurosurgical interventions were performed. The median number of neurosurgical procedures per day was 5.5 (interquartile range [IQR]: 3.5-8). The number of cases declined from 72 in the first week and plateaued at the 30's range in subsequent weeks. The most and least number of performed procedures were oncology (129 [27.2 %]) and functional procedures (6 [1.3 %]), respectively. Emergency (Priority 1) cases were more frequent than non-urgent (Priority 4) cases (178 [37.6 %] vs. 74 [15.6 %], respectively). In our series, there were three positive COVID-19 cases. There was a significant among-period difference in the length of hospital stay, which dropped from a median stay of 7 days (IQR: 4-18) to 6 (IQR: 3-13) to 5 days (IQR: 2-8). There was no significant among-period difference with respect to institution type, complications, or mortality. CONCLUSION: Our study demonstrated that the COVID-19 pandemic decreased the number of procedures performed in neurosurgery practice. The load of emergency neurosurgery procedures did not change throughout the three periods, which reflects the need to designate ample resources to cover emergencies. Notably, with strict screening for COVID -19 infections, neurosurgical procedures could be safely performed during the early pandemic phase. We recommend to restart performing neurosurgical procedures once the pandemic gets stabilized to avoid possible post pandemic health-care system intolerable overload.