Comparison of efficacy of daily and alternate day maintenance treatment of GERD with Vonoprazan 10-mg using Gastroesophageal Reflux Disease Symptom Assessment Scale.

Objectives: To compare efficacy of 10-mg of vonoprazan daily & on alternate days by Gastroesophageal Reflux Disease Symptom Assessment Scale (GSAS). Method: This prospective interventional cohort was done at Department of Medicine/Gastroenterology Dow Medical College, Karachi, Pakistan during the period August 2022 & January 2023. Potential participants fulfilling inclusion and exclusion criteria were asked to fill out GSAS questionnaires after their written consent. Patients were allocated in to two groups using random tables. Group-A was given Tab Vonoprazan 10-mg daily for two weeks. Group-B was given Tab Vonoprazan 10-mg on alternate day. GSAS was scored by totaling scores across symptoms and then they are divided by the total number of non-missing symptom scores. Both groups were assessed week-0 & week-2. Results: Only 90 proformas that were completely filled were included, Group-A had 30 males and 15 females while Group-B had 29 males and 16 females. No significant difference in score was found in GSAS score at week-0 except that in item 'gurgling' while at week two there was no significant difference between any of the items. Total GSAS score were significantly lower at Week-2 than at week-0 (p = <.001). Conclusions: Vonoprazan of 10-mg on alternate day is equally effective as 10-mg daily in maintenance of GERD patients at two weeks.

Medical Students' Perceptions at Dow University of Health Sciences using Dundee Ready Education Environment Measure Inventory.

Objectives: To assess medical students' perceptions regarding learning, teachers, academics, atmosphere at campus and social self-perceptions at Dow University of Health Sciences using Dundee Ready Education Environment Measure (DREEM) Inventory. Method: This cross-sectional observational study was conducted from March 1st, 2022 to September 30th, 2022. All medical students at Dow University of Health Sciences were offered to participate. All students were given the choice to respond to DREEM questionnaire via online Form or printed copy anonymously. The DREEM Inventory measures five domains of students' perceptions of a given institution. Comparison of responses between different years and institution was carried out by χ2 test. Means scores were compared by Student's t-test and ANOVA, p-value of ≤.05 was taken as significant. Results: Total of 1054 out of 1750 (60.23%) students submitted fully completed forms and were included, out of these 632 (60.0%) belonged to Dow Medical College & 422 (40.0%) belonged to Dow International Medical College. The mean ±SD of total score of DREEM by DMC students was 100.07 ±31.46 and that of DIMC was 100.52 ±32.73. According to DREEM Global scoring both colleges scores fell into category of "many problems". Analysis according to domains showed that maximum score was given to 2nd domain of their "perception regarding teachers" and minimum score was allocated to 5th domain regarding "social self-perceptions". Conclusion: Overall Students perceived environment at DUHS as "many problems" category. This needs to be investigated for betterment of Educational Environment (EE) at campus.

Correlation of HbA1c with Serum Iron & Transferrin Saturation in Non-Diabetic Patients with Iron Deficiency.

Objective: To determine correlation of HbA1c with serum iron and transferrin saturation in non-diabetic patients with iron deficiency. Methods: This cross-sectional comparative study was conducted at Dr Ruth KM Pfau Civil Hospital Karachi from 15th September 2021 to 14th March 2022, on non-diabetic patients based on fasting blood sugar (FBS) of <100 mg/dl. Patients were divided into two groups. Group one included patients having iron deficiency anemia (ID), whereas group two included same number of age and sex matched healthy subjects taken as controls, without ID. Blood sample was taken for HbA1c, CBC, serum iron and total iron binding capacity. Transferrin saturation (TSAT) was calculated. Comparison of quantitative variables with ID and non-ID group was done by Student's t-test. Correlation of HbA1c with iron &TSAT was done in both groups using Kendal tau-b test, as data was not normally distributed. Results: Out of 230 patients, 83 (36.1%) were males while 147(63.9%) were females. Mean age of patients was 43.7±13.28 years. Mean HbA1c level was significantly high in ID group (5.89±0.43) as compared to non-ID group (5.52±0.50) with a p-value <.001. The HbA1c levels correlated negatively with hemoglobin, serum iron levels and transferrin saturation with a p-value <.001. Conclusion: Low serum Iron and TSAT was related to elevation in HbA1c value. Iron deficiency needs to be corrected before HbA1c interpretation.

Liver and Renal Injury with Remdesivir Treatment in SARS-CoV-2 Patients.

Objective: To determine the effect of Remdesivir on liver enzymes and renal functions in SARS-CoV-2 patients. Methods: This prospective cohort study was conducted at Dr. Ruth KM Pfau, Civil Hospital Karachi between 1st December 2021 to 31st January, 2022. All patients of severe SARS-CoV-2 infection who received Inj. Remdesivir for five days as per protocol of SARS-CoV-2 management were included. Biodata of selected patients including age, gender, diabetic, hypertensive status was recorded. Patients Liver Function Tests and Serum Creatinine were performed on days 0, 3, 5, 7 and 14. Result: This study included 85 patients, out of which 55 (64.7%) were males and 30 (35.3%) were females. Out of 85 patients, Remdesivir was stopped in 3 (3.5%) patients. Among these three patients Remdesivir was stopped in one patient on day three because of decrease in CrCl to <30 ml/min. His CrCl improved after stopping Remdesivir. In the remaining two patients, Remdesivir was stopped due to increase in ALT to greater than 10 times from normal values on day three. Similarly, in these two patients the ALT improved after stopping Remdesivir. Conclusion: Only three patients developed adverse effects resulting in stopping of Remdesivir, however these were reversible on stopping the drug. Therefore, Remdesivir is a relatively safe drug and well tolerated in SARS-CoV-2 patients.

Validation and exploratory factor analysis of Urdu Version of Chronic Liver Disease Questionnaire.

Objective: To present and validate psychometric properties of Urdu version CLDQ, yet another objective was to do exploratory factorial analysis (EFA) of CLDQ Urdu version. Methods: This Cross-sectional Analytical Study was conducted at Dr. Ruth K.M. Pfau Civil Hospital Karachi during the period Nov. 15, 2021 to Jan. 30, 2022. CLDQ Urdu questionnaire was self-administered by the patients. The questionnaire consisted of 29 items and responses were recorded on 7-point Likert type scale. Reliability testing was done by Cronbach's α, test value of >0.7 is taken as reliable. Exploratory factor analysis (EFA) was conducted with principal component analysis with varimax rotation. Adequacies for conduction of EFA depended on Kaiser-Meyer-Olkin (KMO) value of ≥0.5 and Bartlett's Test of Sphericity (BTS) of ≤0.05. Mean CLDQ Urdu scores were also compared with Child Class using ANOVA and post-hoc analysis was done. Results: A total of 320 patients were selected after informed consent. All conditions for adequate EFA were met (Cronbach's α =.949; KMO = .846; BTS ≤.001). Mean CLDQ Urdu score was 156.74 in male and 133.27 in female (p<.001). Child Class-A had best quality of life with score of 186.63 ±6.91 and Child Class-C had the worst with scores of 109.78 ±21.33. EFA resulted in reduction of domains to 4 (Muscular Symptoms, Emotional Symptoms, Abdominal Symptoms & Somnolence) & reduced the number of items from 29 to 11. Conclusion: Urdu CLDQ version is validated in our settings. EFA resulted in reductions in number of domains and items. CLDQ Urdu showed that quality of life decreases significantly with Child Class.

Assessment of SARS-CoV-2 vaccination status in SARS-COV-2 infected patients admitted in Dr Ruth K.M. Pfau, Civil Hospital Karachi.

Objectives: To determine the frequency of vaccination status in patients with SARS-CoV-2 infection. Methods: This case-control study was conducted at Dr Ruth KM Pfau Civil Hospital Karachi, Pakistan between September 2021 to October 2021. All patients who had positive PCR on nasopharyngeal swab for SARS-CoV-2 infection were included. Information regarding vaccination status and brand of vaccination administered and duration between the last dose of vaccine and positive PCR was noted. The disease status of patients was classified on admission into severe and non-severe disease. Results: Study included 143 patients, out of which 58 (40.6%) were males and 85 (59.4%) were females. Majority of our patients (78.3%) were unvaccinated. Frequency of Severe SARS-CoV-2 Infection in fully vaccinated patients was less than in unvaccinated patients. The odds of developing severe COVID infection in unvaccinated patients versus vaccinated was 8.55 times higher (OR = 6.23, 95% CI 2.58-28.35). Proportion of vaccinated females was less as compared to males. Significant differences were found in severity between hypertension (p<.001), diabetes (<.001) and age (p<.001). Conclusion: The frequency of SARS-CoV-2 infection was greater in unvaccinated patients. The odds of developing severe COVID infection in unvaccinated patients versus vaccinated was 8.55 times higher.

Assessment of frailty in cirrhosis using bedside measures and its correlation with Child-Turcotte-Pugh, MELD & MELD-Na Scores.

Objectives: To assess frailty in cirrhotic by calculating Liver Frailty Index (LFI) using bedside clinical tests and correlate it with Child-Turcotte-Pugh (CTP), MELD, MELD Na, Fib- 4 and Transient Elastography (TE) scores. Methods: This cross-sectional observational comparative study was carried out in Dr Ruth KM Pfau Civil Hospital, Karachi from August 2020 to September 2021. Patients were subjected to three performance-based testing including dominant hand grip strength (HGS), Chair to Stand (CTS) Time & Three Position Balance (TPB). LFI was calculated using the online LFI calculator, available at http://liverfrailtyindex.ucsf.edu and classified as 'Robust' if LFI <3.2, 'Prefrail' LFI between 3.2 and 4.4, and 'Frail' as LFI ≥4.5. Correlation of frailty with MELD, MELD-Na and CTP Scores was done. Means of MELD & MELD-Na Scores and CTP scores were calculated in all 3 classes of frailty using one way ANOVA. A p-value of ≤.05 was taken as significant. Results: Out of 118 patients, 62 (52.5%) were males. Mean MELD score was 11.4 ±3.3, MELD-Na was 15.97 ±8.54, CTP 8.25 ±2.21, Fib-4 was 2.79 ±1.034 and TE score was 18.20 ±9.17. Mean LFI was 3.87 ±1.07; mean HGS was 18.12 ±4.68; mean of CTS was 9.62 ±3.55. LFI Class distribution in our cohort showed Robust were 36 (30.5%), Prefrail 34 (28.8%) and Frail were 48 (40.8%). Correlation of all these variables with LFI showed significant correlation with LFI, but highest correlation coefficient was seen with MELD-Na. Conclusion: Significant correlation between frailty score in cirrhotic with cirrhosis severity scores highlights the need for frequently assessing LFI in all cirrhotic at regular follow up visits.

Comparison of Vonoprazan and Amoxicillin Dual Therapy with Standard Triple Therapy with Proton Pump Inhibitor for Helicobacter Pylori eradication: A Randomized Control Trial.

Objectives: To compare the efficacy of Vonoprazan based dual treatment versus PPI based treatment for the eradication of Helicobacter pylori infection. Methods: A randomized controlled trial was conducted in Department of Medicine/Gastroenterology Ruth KM Pfau Civil Hospital, DMC during the period of 22 June to 21 September 2021. Sample size was calculated as 96 in each Group. All patients of age 18-75 years with Helicobacter Pylori Infection were inducted and randomly allocated to two groups. Group-A: were given Capsule Amoxicillin 1 gm; Tablet Clarithromycin 500 mg; Capsule Omeprazole 20 mg all medications were given twice daily for two weeks. Group-B were given Capsule Amoxicillin 1 gm; Tablet Vonoprazan 20 mg (Vonozon©, m/s Getz Pharma, Pakistan) twice daily for two weeks. Confirmation of Hp eradication was done by stool Hp antigen test four weeks after completion of treatment. Nine and four patients were lost to follow-up in Group-A & B respectively. Analysis was conducted on 87 patients in Group-A and 92 patients in Group-B. Results: Out of eighty-seven patients in Group-A and ninety-two patients in Group-B, 73 (83.9%) patients in Group-A and 86 (93.5%) patients in Group-B had negative H pylori result respectively after treatment (p = .042). Significantly higher frequencies of adverse events were observed in Group-A as compared to Group-B in nausea/vomiting (p = .035) and bloating (p = .045). Conclusion: VA-dual provides an acceptable eradication rate with fewer adverse events.

Are we missing varices by implementing Baveno-VI recommendation of not screening patients with Compensated Advanced Chronic Liver Disease?

OBJECTIVES: This study aimed to validate Baveno-VI recommendations for variceal screening in cACLD in our region and proposed our own cutoff values. METHODS: Prospective cross-sectional study was conducted on cACLD patients from August 2020 till April 2021. Patients segregated into Group-A, having Liver stiffness measurement (LSM) of ≥ 20 kPa and platelet of ≤ 150 × 109 cells/L; and Group-B having LSM of < 20 kPa and PLT of > 150 × 109 cells/L. Gastroscopic findings were segregated into three categories, VNT, Varices Not Needing Treatment (VNNT) and No Varix (NV). ROC plots were generated for LSM and Platelet for VNT for sensitivity, specificity, Negative and Positive Predictive Values were calculated. RESULTS: A total of 134 patients of cACLD were included. Group-A had 72 (53.7%) patients and Group-B had 62 (46.3%) patients. Group-A had 6 (8.3%) NV; 18 (25.0%) VNNT and 48 (66.7%) VNT. Group-B had 26 (41.9%) NV, 24 (38.7%) VNNT and 12 (19.4%) VNT. The sensitivity of 66.7%, specificity of 80.6% and NPV of 67.56% was obtained. Thus 19.4% VNT were missed on following Baveno VI recommendations. ROC in our study suggested cutoff value of 11.5 kPa with sensitivity of 100% and 1-sepcifity pf 78% (AUROC = 0.865; p < .001) of LSM below which screening gastroscopy could be avoided. The positive and negative predicted values for 84.85% and 100% respectively. Cut off value of platelet count for VNNT came out to be ≥ 97.5 × 109 cells/L with AUROC 0.891 (p < .001), having sensitivity of 100 % and 1-specificity of 83.3%. CONCLUSIONS: Substantial number of VNT in cACLD patients are missed by following Baveno-VI recommendations and these needs to be revised on regional basis.

Muscle weakness assessment in non-hypoxemic COPD out-patients at tertiary care hospitals.

OBJECTIVE: To determine frequency of Muscle Weakness in Non-Hypoxemic COPD out-patients and Comparison with age matched non-COPD Controls. METHODS: This cross-sectional study was conducted at OPD of Ojha Institute of Chest Diseases and Medicine, Dow University of Health Sciences, Karachi, Pakistan, during the period 8th September 2019 till 30th May 2020. Patients of both genders aged 25-70 years who were satisfying GOLD criteria for COPD and having SpO2 ≥ 94% were included. An age matched control group was added as control. Hand Grip Strength (HGS) and Chair to Stand time (CST) were recorded. RESULTS: Two hundred fifty-six patients were inducted with aged and BMI matched group of non-COPD Control patients in ratio of 1:2 (n = 128). Comparison of HGS between Control and COPD Groups showed significant weakness in COPD group. Significant weakness in lower limbs in COPD Group with longer timings to complete the task. Mean FEV1 had significant low values in COPD Group. Age correlated negatively with HGS & positively with CST. BMI correlated positively with FEV1 and CST but negatively with HGS. HGS correlated positively with FEV1 and no correlation was found with CST. No correlation was found of CST with FEV1. CONCLUSION: Muscle weakness in COPD patients was shown by simple validated bedside tools. The older COPD patients had less HGS and were slower in doing CST whereas those COPD ones who had higher FEV1 had more HGS.

Frequency of hyponatremia caused by sodium picosulfate solution when used as a bowel cleansing agent for colonoscopy.

OBJECTIVE: To determine the frequency of hyponatremia in patients taking Sodium Picosulfate Solution (SPS) solution for bowel preparation prior to colonoscopy and to compare serum sodium levels before and after SPS. METHODS: This interventional study was conducted at Dr. Ruth K. M. Pfau, Civil Hospital Karachi between June 2019 to November 2019. Patients undergoing colonoscopy were included in the study. All patients were given SPS. Two samples of blood for electrolytes were taken, one 30 minutes before taking SPS solution and another 30 minutes before colonoscopy. Paired sample t-test was used to determine the difference between serum sodium level before taking the colonoscopy solution and serum sodium level before colonoscopy. RESULTS: Fifty- four patients fulfilling inclusion criteria were included. Out of the 54 patients 28 (51.9%) were males and 26 (48.1%) were females. Mean sodium levels before taking colonoscopy solution was 139.7 ±3.5 mEq/L and mean sodium level before colonoscopy was 138.9 ±3.8 mEq/L. The difference between serum sodium level before taking SPS colonoscopy solution and before colonoscopy was found to be statistically insignificant (t (53) = 1.308; p = 0.196). CONCLUSION: No serious adverse effects were reported in any of our patients. There was no significant difference in the serum sodium level of patients undergoing colonoscopy before taking SPS bowel preparation solution and serum sodium level before colonoscopy.

Frequency of silent carotid artery stenosis in diabetics and its associated factors: An analysis in tertiary care hospital.

OBJECTIVE: To estimate frequency of silent carotid artery stenosis and its associated factors in diabetic patients attending a tertiary care hospital. METHODS: This cross-sectional study was conducted in tertiary care Civil Hospital, Karachi from March 2019 to September 2019,. A total of 166 patients with Diabetes Mellitus were included in this study. Brief history was taken for the duration of DM, treatment, and smoking habits. Carotid artery stenosis (CAS) wafrs measured by Doppler ultrasound of right and left common, internal, and external carotid arteries. RESULTS: Frequency of silent carotid artery stenosis (CAS) in diabetic patients was observed in 28.92% (48/166) cases. The mean age ±SD of the patients was 54.8 ±7.96 years. 27 (22.29%) patients were smoker and all were male. Out of 166 diabetic patients, 59 (35.54%) were treated with insulin and 107 (64.46%) were treated with oral hypoglycemic. CONCLUSION: Substantial number of diabetic patients with increasing age, increased duration of diabetes and smoking habits have significant silent Silent Carotid Artery Stenosis (CAS).

Effect of pre-endoscopy intake of simethicone solution on endoscopic mucosal visibility: A single blinded, placebo control, randomized trial.

OBJECTIVE: To determine effect of pre-endoscopy intake of simethicone solution on endoscopic mucosal visibility. METHODOLOGY: A randomized, single blinded placebo control trial was done in patients undergoing oesophago-gastro-duodenoscopy for any indication at DOTs Endoscopy Suite, CHK during the period of April to June 2019. Informed consent was taken. Patients were randomly allocated in two groups. Group-A received placebo while Group-B received Simethicone. Evaluation of mucosal visibility was assessed at 4 sites (oesophagus, fundus, antrum & duodenum) by previously validated scoring. Mean of visibility scores were compared in two groups. RESULTS: Two hundred and forty-eight patients were inducted and randomly allocate to two groups of 124 each. Mean of total sum of scores in Group-A was 8.14 ±2.44 and that of Group-B was 5.80 ±1.75 (p<0.001). Adequate visibility in Group-A was seen in 41.1% and that in Group-B was 78.2% (p<0.001). CONCLUSION: Use of Simethicone significantly improves mucosal visibility during OGD.

Impact of bowel preparation on caecal intubation time during colonoscopy.

OBJECTIVE: To determine the caecal intubation time depending on bowel preparation as per Boston Bowel Preparation Scale. METHODS: This cross-sectional study was conducted at Dr. Ruth K. M. Pfau, Civil Hospital Karachi between August 2018 to February 2019. A total of 201 patients were included in the study. Time was recorded from insertion of colonoscope to the time required to reach the cecum. Bowel preparation was graded during withdrawal of colonoscope by using Boston Bowel Preparation Scale. Pearson Correlation test was used to study correlation of BBPS scores with CIT, gender, BMI, adenoma and polyp detection. RESULTS: In this study 201 patients undergoing colonoscopy were included. Mean ±SD of age of patients was 36.9 ±15.8 years. Out of the 201 patients 112 (56%) were males and 89 (44%) were females. The results of our study showed that increased Boston Bowel Preparation Scale Scores were associated with decreased caecal intubation time. The mean CIT was 10.7 ±5.4 minutes and Pearson correlation was significant at 0.002. Significant correlations of BBPS were also found with BMI and adenoma detection. CONCLUSION: The diagnostic effectiveness of colonoscopy depends upon the quality of the preparation. Good bowel preparation improves the speed of colonoscopy and its completeness.

Why doctors are not satisfied with their job-current status in tertiary care hospitals.

OBJECTIVE: To determine level and factors of job satisfaction among doctors working in tertiary care hospitals in Pakistan. METHODS: This is a multi-center cross-sectional survey conducted among Post graduate trainees, medical officers, consultants and faculty doctors. Job satisfaction was measured using 35 specific questions about sources of work-related stress and sources of work-related satisfaction. Satisfaction was defined if mean score of a factor was≥3.0, where factors were rated using a 5-point Linkert scale ranging from 1 (completely dissatisfied) to 5 (completely satisfied). RESULTS: In this study 373 doctors participated, out of which 215(57.6%) were males. Over all mean satisfaction score was of 2.69 ±0.37. Departmental mean satisfaction scores were Internal medicine 2.71 ±0.35, Medical subspecialties 2.63 ±0.38, Surgical and allied 2.73 ±0.45. Designation means were Consultant 2.87 ±0.38, Faculty 2.78 ±0.44, Medical officer/ Registrar 2.50 ±0.32, Post graduate trainee 2.71 ±0.45. Public and private sector means satisfaction scores were 2.53 ±0.80 and 2.92 ±0.84 respectively. CONCLUSION: Job dissatisfaction was seen among doctors from all the tiers and departments. Public sector doctors were more dissatisfied than private sector doctors. Increasing age, duration of current posting and working experience, positively correlated with satisfaction level.