Frequency of Subclinical Hypothyroidism in Patients With Chronic Kidney Disease.

INTRODUCTION:  Chronic kidney disease (CKD) is the progressive loss of function of the nephron over a long period of time. As the glomerular filtration rate falls, it leads to subclinical hypothyroidism (SCH). This cross-sectional study is carried out to measure the frequency of SCH in CKD patients in our population. METHODS: This case-control research was undertaken at the nephrology unit of the Peoples University of Medical and Health Sciences for Women in Pakistan from March 2021 to January 2022. The research included 200 volunteers with documented evidence of CKD between the ages of 18 and 60 years. A case group of 200 people without CKD was also enlisted, matched by age, gender, and comorbidities. Data were recorded in a self-structured questionnaire and analyzed using Statistical Package for the Social Sciences® software (IBM Corp., Armonk, NY). RESULTS:  Thyroid-stimulating hormone was significantly raised in participants with CKD (4.91 ± 1.10 mIU/L vs. 3.62 ± 0.72 mIU/L; p-value < 0.0001). A significant association between SCH and CKD was established (p-value < 0.00001). CONCLUSION:  Due to the positive correlation between SCH and CKD, multidisciplinary management, including a team of endocrinologists and nephrologists, is advised to keep a regular check on these patients.

Association Between Levels of Pre-operative Glycosylated Hemoglobin and Post-operative Surgical Site Infections After Elective Surgery in a Low-Income Country.

INTRODUCTION: Diabetic patients undergoing surgery are more susceptible to hospital-acquired infection, particularly surgical site infection (SSI). Good glycemic control in preoperative patients significantly decreases the risk of SSI. There is a scarcity of data from low-income countries studying the relation between perioperative glycated hemoglobin (HbA1c) levels and postoperative SSI. We aim to establish statistical relation between HbA1c and SSI which will help decrease post-operative infections and morbidity. METHODS: This study was conducted in the surgical unit of Jinnah Sindh Medical University, Karachi, Pakistan, from August 2020 to April 2022. Patients who underwent elective surgical procedures (n= 1024) were included in the study and divided into two groups based on their HbA1c levels. Patients with HbA1c levels higher than 6.5% were classified as group A and those with HbA1c less than 6.5% belonged to group B. For statistical analysis, IBM SPSS Statistics for Windows, Version 24.0 (Released 2016; IBM Corp., Armonk, New York, United States) was used. RESULTS: Group A comprised 579 (56.5%) patients. The presence of SSI in participants with HbA1c >6.5% was statistically significant (p-value: 0.011). Genderwise comparison with the presence of SSI was found to be insignificant (p-value: 0.28). Smoking was positively correlated with the absence of SSI. No significance in terms of presence or absence of SSI was found in the comparison of the type of wounds (p-value: 0.25). CONCLUSION:  There is a positive relationship between raised HbA1c levels and the development of SSI. Our study emphasizes the importance of the use of HbA1c levels as a more accurate predictor of glycemic control in pre-operative patients rather than blood glucose levels. It is imperative that surgeons must check HbA1c levels before selecting patients for elective surgeries, especially in low-income countries where the healthcare burden is already huge.

Long-Term Neurological Impact of COVID-19.

INTRODUCTION: Recent research has observed the ability of coronavirus disease 2019 (COVID-19) to spread in the brain from the respiratory system. The associated neurological disorder includes encephalopathies, inflammatory syndromes, stroke, peripheral neuropathies, and various other central nervous system disorders. This study aims to highlight the long-term neurological sequelae in patients with COVID-19 disease. METHODS: This long-term study was carried out in the COVID-19 unit of a tertiary care hospital in Pakistan from July 2020 to July 2021. After obtaining informed consent, we enrolled 1000 patients who recovered from COVID-19 and were discharged. The participants were followed up after 30 and 90 days. RESULTS: At the time of enrollment, there were 602 (60.2%) males and 398 (39.8%) females. The most common neurological symptom on 30-day follow-up was headache (8.8%), followed by insomnia. The most common neurological symptom on day 90 follow-up was insomnia (5.07%), followed by an altered sense of smell (3.3%). CONCLUSION: COVID-19 tends to produce a wide range of neurological symptoms, ranging from headache to anosmia to increased risk of stroke, that complicates clinical management. Potential neurologic effects and drug interactions have been reported secondary to the medications used to treat COVID-19. In light of the aforementioned facts, COVID-19 could potentially have a long-term effect on the brain. Therefore, it is important that the clinicians must be aware of the potential neurologic complications. Lastly, proper follow-up is recommended that would aid in timely recognition and management of the neurological disorder.

Comparison of Lipid Profile in Patients With and Without Subclinical Hypothyroidism.

INTRODUCTION: Thyroid hormone affects lipid metabolism. Various studies have shown a contradictory relationship between lipid profile (LP) and subclinical hypothyroidism (SCH). Currently, there is a scarcity of regional data on the relationship between LP and SCH. METHODS: This longitudinal study was conducted in the internal medicine and cardiology units of a tertiary care hospital in Pakistan from September 2019 to March 2021. A total of 900 participants, of either gender and between the ages of 40 to 70 years, were enrolled in the study. Blood samples were sent to the laboratory to determine lipid and thyroid parameters. Participants were divided into two groups based on the presence of SCH. RESULTS: In our study, 179 (19.8%) participants had SCH. Total cholesterol (TC) and low-density lipoprotein (LDL) was significantly higher in participants with SCH compared to participants without SCH (228.41 ± 35.21 mg/dL vs. 171.21 ± 30.21 mg/dL; p-value: <0.00001) and (131.65 ± 28.22 mg/dL vs. 89.26 ± 18.52 mg/dL; p-value: <0.0001), respectively. CONCLUSION: In conclusion, this study found an increased incidence of dyslipidemias in patients with SCH. It is associated with elevated TC and LDL levels, which are risk factors for cardiovascular disease and mortality.

Association Between Coronary Artery Disease and Plasma Omentin-1 Levels.

INTRODUCTION: Omentin-1 is secreted from visceral adipose tissue that contributes to chronic inflammatory diseases' pathogenesis, including cardiovascular events. In this case-control study, we will determine the association between plasma omentin and coronary artery disease (CAD). METHODS: This is a case-control study, conducted from June 2020 to April 2021 in the cardiology unit of a tertiary care hospital in Pakistan. Patients diagnosed with CAD (n = 300) within the last six months were included in the study. Another 300 participants without CAD and with similar demographic profiles were included in the control group. A blood sample of 5 ml was drawn from participants of both groups and sent to the laboratory to test for plasma omentin level. RESULTS: Plasma omentin level was significantly lower in patients with CAD compared to the patients without CAD (61.21 ± 10.21 ng/dL vs. 95.22 ± 12.21 ug/L; p-value: <0.0001). In both genders, the plasma omentin-1 was lower in patients with CAD compared to patients without CAD (p-value: <0.0001). CONCLUSION:  The present study revealed a negative association between omentin-1 and CAD. We speculate that low levels of omentin-1 might play a role in the pathogenesis of atherosclerosis. Therefore, plasma omentin-1 can be a potential biomarker to predict the development and progression of CAD.

Biochemical Risk Factors Associated With Hyperkalemia in Cirrhotic Patients.

INTRODUCTION: Patients with cirrhosis suffer from fluid and electrolyte imbalance. The usually reported electrolyte disorders include hyperkalemia, hyponatremia, and hypokalemia. The regional data about the prevalence and risk factors associated with hyperkalemia in cirrhotic patients are not sufficient enough. The purpose of this study is to determine various risk factors associated with hyperkalemia, which will assist in the early detection of cirrhotic patients at risk of hyperkalemia. METHODS: This cross-sectional study was conducted in the internal medicine and gastroenterology departments of a tertiary care hospital in Pakistan from March 2021 to June 2021. Sonographically documented liver cirrhosis patients (n=500), of either gender and between the ages of 18 and 70 years, were enrolled in the study. After enrollment, patients' demographics were noted in a self-structured questionnaire. Participant's Child-Pugh score was also noted in the questionnaire. After a detailed history, 5 mL of venous blood was drawn in two vials via phlebotomy and send to the laboratory to measure serum potassium, creatinine, albumin, and bilirubin levels. RESULT: Out of the total 500 participants, 101 (20.2%) participants had hyperkalemia. It was significantly more prevalent in participants with Child-Pugh C class and in those with a serum creatinine of more than 1.3 mg/dL. Similarly, it was more prevalent in participants with albumin levels less than 2.5 mg/dL. CONCLUSION: Hyperkalemia is associated with Child-Pugh class C. It has a direct relationship with serum creatinine levels which is an indicator of renal function, and an inverse relationship with serum albumin levels, an indicator of hepatic synthetic function.

Frequency of Ophthalmological Findings in Hospitalized COVID-19 Patients.

INTRODUCTION: The symptoms of coronavirus disease-19 (COVID-19) may range from mild to severe. Patients usually present with fever, cough, and other respiratory tract symptoms, but may also be asymptomatic. Some studies have also indicated the ocular involvement by the virus. This study aims to look deeply into all ophthalmic findings seen in COVID-19 patients and their clinical characteristics. METHODS: This longitudinal study was conducted in the COVID-19 unit of a tertiary care hospital, Pakistan. Data of patients hospitalized with COVID-19 infection between July 2020 and March 2021 were included in the study. Ophthalmological examination was done at the time of admission and was repeated every alternate day to look for any ophthalmological manifestation. RESULTS: Out of 441 (n= 441), 61 (13.8%) participants had ophthalmological findings on examination. Patients with ophthalmological findings were significantly younger compared to patients without ophthalmological findings (42 ± 6 years vs. 44 ± 7; p-value, 0.03). C-reactive protein (CRP) was also significantly higher in patients with ophthalmological findings (122.2 ± 16.2 vs. 112.8 ± 19.8; p-value, 0.005). The most common ophthalmological finding was conjunctival irritation (50.8%), followed by diplopia (27.8%) and cotton wool spots (27.8%). CONCLUSION: Ophthalmological findings are prevalent in patients with COVID-19. In this study, patients with higher CRP levels were associated with ophthalmological findings. It is important to conduct ophthalmological examinations in patients with COVID-19, as they may give a clue about other complications associated with COVID-19.

Comparison of Effect of Nebivolol and Bisoprolol on Sexual Function of Hypertensive Female Patients.

Introduction Male and female sexual dysfunction is frequently found in patients with hypertension. Many studies indicate that this is found more frequently in patients treated with beta-blockers rather than due to hypertension itself; however, almost all studies have been done on male population. This study aims to study the effect of two commonly used beta-blockers on sexual function of a hypertensive female patient. Methods This two-arm open-label randomized prospective study was conducted from April 1, 2019 to March 30, 2020 in a tertiary care hospital at Pakistan. One hundred and fifty participants randomized to group A were given nebivolol 5 mg once daily in addition to their current hypertensive treatment. Another 150 participants randomized to group B were given bisoprolol 5 mg once daily in addition to their hypertensive therapy. Sexual function was assessed on day 0 and day 90 using female sexual function index (FSFI). Results The mean sexual score in the nebivolol group significantly improved after day 90 in comparison to day 0 (24.16 ± 2.1 vs. 26.91 ± 2.6; p-value < 0.0001), while no difference in sexual score in bisoprolol group after day 90 was observed (24.14 ± 2.1 vs. 24.12 ± 2.0; p-value = 0.91). Conclusion In this study, nebivolol group was associated with a significant improvement in sexual function. This can be due to additional vasodilation properties and a low risk of sexual side effects associated with nebivolol.

Comparison Between Angiotensin-Converting Enzyme Inhibitors and Angiotensin Receptor Blockers for Incidence of Lung Cancer: A Retrospective Study.

INTRODUCTION: Angiotensin-converting enzyme inhibitor (ACEI) and angiotensin II receptor blockers (ARBs) are taken as the first treatment option for hypertensive patients. The various global trials have suggested that ACEIs and ARBs may increase risk of lung cancer; however, the results are contradictory and there is no local study available. This study is conducted to compare the incidence of lung cancers in patients on ACEIs and ARBs. METHODS: This retrospective study, conducted in a major cardiology unit of a tertiary care hospital in Pakistan, included patients diagnosed with hypertension, between 2005 and 2010, who were prescribed either ACEIs or ARBs. During the period of 2005 to 2010, 47,823 naïve hypertensive patients were reported in the outpatient department of the cardiology unit. Of which, 22,241 were prescribed ACEI and 25,582 were prescribed ARBs. After sorting patient data based on our inclusion criteria, n = 14,891 participants were included in the ACEI group and n = 19,112 participants were included in the ARB group. RESULTS: The incidence of lung cancer in the ACEI and ARB group was n = 165 and n = 160, respectively. In this study, the overall incidence rates of lung cancer in the ACEI and ARB cohorts were 12.2 and 16.6 per 10,000 person-years, respectively. The hazard ratio was 1.32 (95% confidence interval: 1.06-1.64; p-value: 0.01). CONCLUSION: In this study, the incidence of lung cancer was relatively more among people using ACEIs than ARBs. Hence, patients undergoing long-term treatment with ACEIs need regular follow-up and proper scanning to avoid grave complications.

Comparison of Incidence of Myocardial Infarction in Patients With Rheumatoid Arthritis and Diabetes Mellitus.

Introduction Patients with rheumatoid arthritis (RA) have a higher risk of cardiovascular diseases (CVDs) when compared to the general population, with most deaths attributed to myocardial infarctions (MI). However, patients with RA do not get the same attention in terms of cardiovascular screening as compared to other diseases, like diabetes mellitus (DM). Therefore, this study aims to compare the risk of CVD among patients with RA and DM. Methods This prospective study was carried out in Pakistan's two tertiary care hospitals. A total of 750 participants were enrolled in three groups with a 1:1:1 ratio; patients with RA, type 2 DM, and the control group. Patients were observed for 12 months or until the development of a major adverse cardiovascular event (MACE), whichever occurred first. Results Both fatal (12.66% vs. 13.48%; p-value: 0.79) and non-fatal (3.93% vs. 4.35%; p-value: 0.82) MI was comparable between both RA and DM group. However, compared to the control group, non-fatal MI (12.66% vs. 5.58%; p-value: 0.01) was significantly higher in the RA group. Conclusion Our study shows that RA and DM have an equal risk of cardiovascular (CV) events. It is important that RA should be considered as a prominent risk factor for CV events. The management of these patients should be multidisciplinary, including cardiologists.

Association Between Long-Term Use of Non-steroidal Anti-inflammatory Drugs and Hyperkalemia in Diabetic Patients.

Introduction The association between continuous use of nonsteroidal anti-inflammatory drugs (NSAIDs) and hyperkalemia is not consistent in the literature and creates grounds for further large-scale trials, particularly in patients with a chronic disease that affects renal function, such as diabetes mellitus (DM). In this study, we will compare mean serum potassium level and the prevalence of hyperkalemia in diabetic and non-diabetic patients based on their use of NSAIDs. Methods This case-control study was conducted in the internal medicine unit of a tertiary care hospital from May 2019 to December 2020. After taking informed consent, 700 patients with a confirmed diagnosis of type 2 DM, of either gender, were enrolled in the study via consecutive convenient non-probability technique. Another set of 700 participants from the public were enrolled as the reference or control group. Continuous NSAID use was defined as NSAID used for a minimum of 20 days in the last 30 days. Blood was drawn via phlebotomy and sent to the laboratory to test for potassium level. Results Serum potassium level was significantly higher in diabetic patients with continuous NSAID use compared to the diabetic patients without continuous use (4.8 ± 0.8 mmol/L vs. 4.5 ± 0.7 mmol/L; p-value: 0.0001). Additionally, serum potassium level was significantly higher in non-diabetic patients with continuous NSAID use compared to non-diabetic patients without continuous use (4.3 ± 0.7 mmol/L vs. 3.9 ± 0.5 mmol/L; p-value: 0.0001)  Conclusion In this study, the patients with continuous use of NSAIDs had higher levels of serum potassium level compared to patients without continuous use of NSAIDs. This difference was even higher in diabetic patients.

Frequency of Cardiovascular Manifestation in Patients With Rheumatoid Arthritis.

Introduction Rheumatoid arthritis (RA) is a chronic, inflammatory, systemic autoimmune disease. The increased inflammatory burden in RA may result in atherosclerosis, myocardial infarction (MI), and subsequent mortality. In this study, we will determine the frequency of cardiovascular manifestation in RA patients through history, laboratory workup, and echocardiography. Methods This cross-sectional study was conducted in the rheumatology unit of a tertiary care hospital in Pakistan. Three hundred and twenty-two (n=322) participants with a previously confirmed diagnosis of RA were enrolled in this study via consecutive convenient non-probability sampling. Results Cardiovascular manifestations were present in 188 (58.3%) participants. More participants had positive rheumatoid factor (82.9% vs. 32.8%; p-value: < 0.0001) in RA patients with cardiovascular manifestation compared to RA patients without cardiovascular manifestation. Patients with cardiovascular manifestations have a significantly higher C-reactive protein (CRP; 10.21 ± 2.81 mg/L vs. 8.17± 2.01 mg/L; p value: < 0.0001) and erythrocyte sedimentation rate (ESR; 16.2 ± 3.14 mg/L vs. 15.1 ± 2.99 mg/L; p value: 0.0017). Conclusion In this study, patients with a cardiovascular manifestation had a higher frequency of patients with rheumatoid factor, higher mean values of CRP and ESR. The early diagnosis and management of cardiac manifestations would aid in controlling the severity of the disease and the overall mortality.

Perioperative Anaesthetic Management for Laparoscopic Gastrectomy in a Patient with Coarctation of Aorta.

Coarctation of the aorta (CoA) is a congenital condition, usually diagnosed and corrected early in life. Long-term survival with untreated coarctation is uncommon and is associated with high mortality rates in the fifth decade. A patient with CoA may present with problems while undergoing cardiac or non-cardiac surgical procedures which could pose considerable challenges in their anaesthetic management. Hence, the choice of anaesthetic technique plays an important role in determining the perioperative course and postoperative outcome in patients with CoA. This report discusses a case of middle-age man, recently diagnosed with CoA while undergoing a preanaesthetic assessment prior to the surgery for gastric adenocarcinoma involving proximal gastro-oesophageal junction. It highlights the successful anaesthetic management of CoA scheduled for laparoscopic-assisted gastrectomy for gastric adenocarcinoma. Perioperative management goals of the patient included general anaesthesia, epidural analgesia to avoid pain-associated adverse effects and efficient control of blood pressure distal to coarctation to limit the risk of intraoperative morbidity. It also demonstrates a major impact on anaesthesiologists who serve the most important role in managing such patients undergoing surgery with 'red flag' features.

Infective Endocarditis Associated with Atrial Septal Defect in an Intravenous Drug Abuser: A Case Report.

Atrial septal defect (ASD) is a common congenital abnormality, which accounts for 20-40% of all the adult patients with congenital heart diseases. Due to the slow velocity of shunt flow, ASD has a negligible risk for infective endocarditis (IE). However, intravenous drug abuse (IVDA) is a potential cause for IE. IE remains a diagnostic and therapeutic challenge. Our case report demonstrates the atypical presentation of IE in an ASD patient. The diagnosis was made on the basis of modified Duke criteria, and blood cultures were found out to be positive for methicillin-resistant Staphylococcus aureus (MRSA). The treatment for IE was completed in six weeks with full recovery, and the patient underwent a surgery for ASD closure. This case highlights that IE should not be overlooked in ASD patients and that a high index of suspicion, in addition to proper antibiotic therapy, is lifesaving. Also, follow-up, along with rehabilitation measures, should be taken for patients with a history of drug abuse in order to prevent the risk of reinfection.

Knowledge and Attitude of Teenagers Towards Electronic Cigarettes in Karachi, Pakistan.

Introduction Studies have shown that electronic cigarettes have gained immense popularity and their use has increased dramatically all over the world. However, little is known about the knowledge and attitudes towards e-cigarettes in third world countries such as Pakistan. The aim of this study was to determine the perceptions of teenagers in Karachi regarding e-cigarettes and whether the differences in said perceptions were affected by gender and level of education. Methods We conducted a cross-sectional study in January 2017 using convenience sampling and interviewed 441 young individuals, aged 13 to 19 years, to determine their knowledge, attitudes, and practices regarding e-cigarettes. The participants were questioned about their knowledge and its source. Attitudes were judged using four and five-point Likert scales while questions regarding practices focused on single and current use. Chi-square and Mann-Whitney tests were applied to compare the knowledge, attitudes, and practices of teenagers with gender and level of schooling. Results The majority of participants knew what e-cigarettes were (n=277, 68.7%) but did not know about their contents (n=225, 55.8%) and had learned about them from either friends or the internet (n=245, 60.%). Almost half of them (n=190, 47.2%) believed that the reason for e-cigarette use was either peer pressure or to quit smoking conventional cigarettes. An overwhelming majority also stated that; it was either easy or very easy to obtain e-cigarettes (n=277, 68.7%), they would not try smoking e-cigarettes even if a good friend of theirs recommended them (n=287, 71.2%), they were not current e-cigarette smokers (n=370, 91.8%) and they would never promote e-cigarette use (n=371, 92.1%). Statistically significant differences were found with males knowing more about e-cigarettes (p=0.006) and being more common to either have smoked (p <0.001) or be current e-cigarette smokers (p <0.001). Furthermore, middle school students were more likely to have negative attitudes towards e-cigarettes believing they were more harmful (p=0.003) and more addictive (p <0.001) than conventional cigarettes. Conclusion Many people were aware of what electronic cigarettes are but still, it was evident that there was the lack of proper knowledge along with negative attitudes towards e-cigarette use among teenagers in Pakistan due to cultural and social stigmas and lack of advertising. Males and females had considerable differences in their opinions regarding e-cigarette use owing to such social practices being considered taboo by females and males having greater freedom due to patriarchal, familial and cultural systems.