Remimazolam versus propofol for sedation in gastrointestinal endoscopy and colonoscopy within elderly patients: a meta-analysis of randomized controlled trials.

PURPOSE: Propofol has become the sedative of choice for endoscopy and colonoscopy. However, it has shown associations with various adverse effects, specifically in the geriatric population. In contrast, remimazolam is a novel benzodiazepine, demonstrating a superior clinical safety profile. Hence, this systematic review and meta-analysis aims to clarify the efficacy and safety of remimazolam versus propofol in elderly patients (≥ 60 years) undergoing gastrointestinal endoscopic and colonoscopy procedures. METHODS: Electronic databases including PubMed, Cochrane Library, ScienceDirect, and Google Scholar were explored from inception till January 7, 2024. The Cochrane Risk of Bias Tool for Randomized Controlled Trials (RoB-2) was utilized to evaluate the quality of each included study reported in this meta-analysis. RESULTS: Seven randomized control trials were included, resulting in the pooling of 1,466 patients (remimazolam: 731 patients; propofol: 735 patients). Propofol demonstrated a significantly lower time to loss of consciousness (P < 0.00001, 4 studies, 784 patients) and a greater sedation success after first dose (P = 0.05, 5 studies, 1,271 patients). Remimazolam reported a significantly lower risk of bradycardia (P = 0.02, 5 studies, 1,323 patients), hypoxemia (P < 0.00001, 6 studies, 1,389 patients), and pain on injection site (P < 0.00001, 5 studies, 1,184 patients). No statistically significant differences in sedation time, number of supplemental doses, procedural parameters, and other adverse outcomes were reported. CONCLUSION: As per the results of our analyses, propofol demonstrated comparatively superior efficacy, however, remimazolam demonstrated comparatively superior safety. The debatable evidence generated from this meta-analysis may not currently be powerful enough to advocate for the use of remimazolam in elderly patients undergoing gastrointestinal procedures; hence, further comprehensive studies are necessary in order to arrive at a robust conclusion.

Revisiting COVID-19 and Occupational Mental Health.

This cross-sectional study aimed to describe the frequency of psychological sequelae of COVID-19 in healthcare workers (HCWs) conducted at The Aga University Hospital, from May to July 2020. The data collection was done online using a demographics questionnaire, concern of COVID-19 scale, Generalised Anxiety Disorder, and Impact of event scale. A total of 560 responses were received. Nearly 25% of participants had moderate to severe anxiety or psychological distress due to COVID-19. Female responders reported more anxiety compared to males. (p= 0.001. The doctors and nurses reported significant psychological distress (p=0.046). The participants with moderate to severe anxiety and psychological distress reported statistically significant high levels of concern of the following: inadequate protective measures, contracting and spreading COVID-19, medical violence, and deteriorating quality of patient interaction due to COVID-19. The COVID-19 pandemic has highlighted areas of development for occupational healthcare policy development in Pakistan. Implementation of contextualised solutions, especially psychosocial determinants is necessary to mitigate the invisible mental health burden and its impact on HCWs in Pakistan. Key Words: Occupational mental health, Pakistan, Anxiety, Depression.

Caregiver Strain and its Associated Factors in Autism Spectrum Disorder in Karachi, Pakistan.

OBJECTIVE: To determine the frequency of caregiver strain and its associated factors in Autism Spectrum Disorder (ASD) at a tertiary care teaching hospital in Karachi, Pakistan. STUDY DESIGN: An analytical cross-sectional study. Place and Duration of the Study: Psychiatry inpatient and outpatient units at The Aga Khan University Hospital, Karachi, Pakistan, from December 2018 to December 2019. METHODOLOGY: The study participants were caregivers of ASD. Data were collected from the inpatient and outpatient departments using Caregiver Strain Questionnaire (CGSQ), and a demographic questionnare. Data were analysed using descriptive and inferential analysis. RESULTS: A total of 76 caregivers participated in the study. Among them, 61 (80.3%) were females and 15 (19.7%) were males, with mean age of 37.09±6.91 years. The overall caregiver strain (both subjective and objective) was reported to be severe by 11.8%, moderate by 47.4% and low by 40.8%. About 50% of the participants had a low objective strain on CGSQ whereas 59.2% of the participants subjectively felt the strain to be at moderate level. An association was found between the gender of the participants and subjective strain (p=0.016), and gender with internalised subjective strain (p =0.002). CONCLUSION:  Parenting of a child with ASD involves challenges and demands support. This study supports the recommendation that the caregivers need access to appropriate means to channelize their strain and manage their role productively. KEY WORDS: Autism, ASD, Stress, Burden, Caregiver, CGSQ, Pakistan.

Comparison of the Efficacy of Cisplatin/Paclitaxel Versus Carboplatin/Paclitaxel in Improving Survival and Quality of Life in the Advanced Ovarian Cancer Patient Population: A Systematic Review and Meta-Analysis of Randomized Control Trials.

Ovarian cancer, being one of the prevalent gynecological cancers, warrants a therapy that's both effective and well tolerated. After extensive drug testing, combination regimens with paclitaxel plus platinum-based agents such as cisplatin/carboplatin and taxanes, have shown promising results for advanced ovarian cancer. We conducted a systematic review and meta-analysis of randomized controlled trials (RCTs) to compare the efficacy of two treatment regimens for advanced ovarian cancer: cisplatin/paclitaxel and carboplatin/paclitaxel.  PubMed (Medline), Science Direct, and Cochrane Library were searched from inception to March 2023. The meta-analysis included patients with histologically verified International Federation of Gynaecology and Obstetrics (FIGO) stages IIB to IV ovarian carcinoma who received either carboplatin/paclitaxel or cisplatin/paclitaxel. The primary outcomes were progression-free survival (PFS), overall survival (OS), quality of life (QOL), complete response rate (CRR), and partial response rate (PRR). The revised Cochrane Risk of Bias Tool 2.0 was used to assess the quality of the RCTs The five RCTs chosen for this statistical analysis consisted of a total of 2239 participants, with 1109 receiving paclitaxel/cisplatin for treatment and the remaining 1130 receiving carboplatin/paclitaxel. Among all included outcomes, these reported significant findings: QoL (p-value=0.0002), thrombocytopenia (p=<0.00001), neurological toxicity (p-value=0.003), nausea/vomiting (p-value=<0.00001), myalgia/arthralgia (p-value=0.02), and febrile neutropenia (p-value=0.01). We concluded that the carboplatin/paclitaxel doublet endows a better quality of life (QOL) to patients along with significantly fewer gastrointestinal and neurological toxicities when compared with the cisplatin/paclitaxel combination. However, the myelosuppressive effects of carboplatin/paclitaxel remain a point of concern and may require clinical management.

Liaison psychiatry in low & middle income countries: Experiences at the Aga Khan University Hospital (AKUH), Karachi, Pakistan.

AIMS AND METHODS: Our study investigated the pattern of referrals made to psychiatric services from the general wards of Aga Khan University Hospital (AKUH). Data on all cases referred between years 2015 to 2016 was collected retrospectively from the medical records. Information included socio-demographic details, reason for referral, past psychiatric history, treatment, management suggested and outcome of referral. SPSS version 19.0 was used for data entry and analyzing. RESULTS: During the study period 1166 cases were referred for psychiatric consultations of which 995 were analyzed. The results show an almost equal distribution of females and males. Most referrals were from Internal Medicine. The most common reason for referral was behavioral problem and the most common psychiatric diagnosis made was delirium. CLINICAL IMPLICATIONS: Review of the service has identified areas that need improvement such as late referrals, problems with documentation, and issues in following through with the recommended management and will help us improve the existing services.

Perinatal mortality contributors in singleton gestation.

OBJECTIVE: To determine the feto-maternal factors contributing to perinatal mortality (PNM) in singleton gestation. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Gynae Unit-III, Civil Hospital, Karachi, from January to December 2002. METHODOLOGY: All obstetric patients with singleton pregnancy and gestation age greater than 24 weeks, regardless of age, parity and gravidity attending the gynae unit III in labor room and ward were recruited. Patients with gestational age less than 24 weeks or multiple pregnancy were excluded. Relevant data regarding history, risk factors in mother and baby were recorded on a pre-designed pro forma and later analyzed on SPSS 10 for descriptive statistics and comparison of proportions using chi-square statistics. Neonatal death was defined as live born infant who died before 28 days of age. Still birth encompassed any death of a fetus after 20 weeks of gestation or 500 gms, and perinatal mortality was considered as the sum of the still birth and neonatal death. RESULTS: In the 1505 studied mothers, the perinatal loss was 187(12.43%) including 140 still births and 47 neonatal deaths (3.12%). Perinatal mortality rate (PNMR) was 124/1000 total live births and neonatal death rate (NNDR) was 34/1000 live births. The commonest cause of still birth was antepartum hemorrhage (33.5%) and the commonest cause of NND was birth asphyxia (64%). PNM in relation to neonatal birth weight was highest in the 2.5 - 3.5 kg range i.e. 70 (50%, p=0.86). The proportion of primi/multi parity was 60 (45%) and 23 (49%) in still birth and neonatal deaths respectively (p=0.308). The leading causes of prematurity were antepartum hemorrhage, hypertensive disorders and chorioamnionitis. CONCLUSION: Perinatal mortality is markedly affected by fetal maturity. Parity and fetal weight have an insignificant effect on perinatal mortality.

Generalised tonic-clonic seizures on the subtherapeutic dose of olanzapine.

Olanzapine is a second-generation antipsychotic. Incidence of olanzapine-induced seizures (OIS) is low with monotherapy. Combination therapy with another antipsychotic, drug metabolism and old age are risk factors for OIS. Our patient was a 71-year-old man, admitted to the psychiatry unit. He was managed on the lines of bipolar affective disorder current episode depression and dementia. He was started on olanzapine 1.25 mg two times/day. The patient developed generalised tonic-clonic seizure that lasted for around two and a half minutes within 24 hours of olanzapine treatment. His electroencephalogram showed findings that were suggestive of mild slowing. Our case discusses the incidence of OIS on the subtherapeutic dose. This presentation involves multiple risk factors for OIS: a history of stroke, poststroke seizure, old age and cognitive impairment. Due to scarcity of evidence of OIS; mostly with recommended therapeutic dose range physicians may underestimate seizure risk at subtherapeutic doses.