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.

Long-Term Symptoms of COVID-19: One-Year Follow-Up Study.

INTRODUCTION:  Persistent and prolonged symptoms, termed as long COVID (coronavirus disease), have been reported in several patients who recovered from the acute phase at different intervals. However, there has been largely unclear data regarding the full range of long-term sequelae of coronavirus disease 2019 (COVID-19) patients. This study aims to evaluate the prevalence of long COVID syndrome. METHODS: A long-term research was conducted in the COVID-19 unit of a tertiary care hospital in Pakistan from July 2020 to December 2021 in which 2,000 patients who had recovered from COVID-19 and had been discharged were included in the study. Symptoms were noted at the time of discharge and at follow-up after 12 months. Data were analyzed using Statistical Package for the Social Sciences (SPSS) v. 22.0 (IBM Corporation, Armonk, New York, United States). RESULTS: The mean age of the participants was 43 ± 10 years, 801 (53.8%) males and 688 (46.2%) females. At the time of discharge, the most common symptom was fatigue (26.93%), followed by dyspnea (20.34%) and muscle pain (8.86%). The most common symptom on follow-up was fatigue (6.78%). CONCLUSION: We strongly emphasize discussing and exploring further knowledge on the post-infection syndrome, with an aim to bring healthcare professionals' attention to the importance of handling COVID patients, their counseling, warning for alarming signs, and a long-term follow-up with necessary investigations and treatment.

Risk Factors Associated With Clostridium difficile-Associated Diarrhea.

INTRODUCTION: Recent years have been alarming due to the sudden, dramatic rise in the incidence of Clostridium difficile infection (CDI). Identifying and addressing the risk factors associated with CDI will help in reducing the incidence of infection and associated complications. METHODS: This case-control study was conducted in a tertiary care hospital in Pakistan from June 2020 to March 2021, in which 200 patients diagnosed with Clostridium difficile-associated diarrhea (CDAD) were enrolled in the study. CDAD was diagnosed based on clinical symptoms and stool enzyme immunoassay. Another 200 participants without a diagnosis of CDAD were enrolled from the outpatient department as a control group. Participants were enrolled after seeking informed consent. RESULTS:  In patients older than 65, risk of CDI was higher compared to participants lower than 65 years old (15.5% vs. 8.0%; p value: 0.02). Hospitalization (25.5% vs. 6.0%; p value < 0.0001), the use of proton pump inhibitors in last 30 days (23.0% vs. 10.5%; p value: 0.001) , and use of antibiotics in the last 30 days (36.0% vs. 10.5%; p value < 0.0001) were significantly higher in participants with CDI. CONCLUSION: Hospitalization, the usage of proton pump inhibitors, and antibiotics in the last 30 days were significantly associated with CDI. A higher incidence of CDI was associated with risk factors like increased body mass index, diabetes, chronic kidney disease, and malignancy.

Comparison of Sexual Function Before and After COVID-19 Infection in Female Patients.

Introduction Ample data regarding the impact of coronavirus disease-2019 (COVID-19) on the pulmonary, nervous, and gastrointestinal systems are available. However, its impact on sexual performance is understudied. In this study, we will determine the impact of COVID-19 on the sexual performance of females.  Methods This longitudinal study was conducted in the COVID-19 unit of a tertiary care hospital in Pakistan from June 2020 to March 2021. We enrolled 300 female patients admitted to the hospital due to severe COVID-19. Patients' female sexual function index (FSFI) scale was assessed at the time of discharge. Participants were asked to answer the question based on their sexual performance before they contracted COVID-19. They were asked to return after 60 days, where FSFI was assessed again. Results The mean FSFI score for participants before COVID-19 was significantly higher compared to the score 60 days after discharge (28.16 ± 1.9 vs. 24.43 ± 2.5; p-value: <0.0001). Participants who had FSFI score more than 26 were significantly higher before COVID-19 (72.5% vs. 51.0%; p-value: <0.0001). Conclusion There is a significant decline in sexual function of females, who had contracted COVID-19 infection. COVID-19 survivors should be counseled properly about the impact on the sexual function when discussing long-term complications of COVID-19.

History of Pregnancy Loss as a Risk Factor for Myocardial Infarction.

Introduction There are few cardiovascular risk factors that are unique to females, such as after menopause, lipid profiles change unfavorably. Another risk factor that might be associated with an increased risk of cardiovascular diseases in women is the incidence of miscarriages and abortions. In this study, we will determine the association between the previous history of pregnancy loss and myocardial infarction (MI). Methods This case-control study was conducted from December 2019 to January 2021. We enrolled 600 female patients with a confirmed diagnosis of MI from the outpatient department (OPD) of the cardiology and internal medicine unit of a tertiary care hospital in Pakistan. Another 600 female participants without the diagnosis of MI were enrolled from the OPD as the control group. Participants were asked about the history of pregnancy, including the number of miscarriages, abortions, and stillbirths. Results Participants with myocardial infarction had experienced greater than one miscarriage compared to participants without MI (25.1% vs. 13.6%; p-value: <0.0001). Similarly, participants with MI had significantly more participants with stillbirth compared to participants without MI (12.0% vs. 6.66%; p-value: 0.0017). Conclusion Pregnancy loss is associated with MI in the future. Women with a history of pregnancy loss must undergo regular cardiovascular screening to protect themselves from cardiovascular events.

Impact of Asthma on the Quality of Sleep in Young People.

Introduction Asthma has a negative impact on the quality of life of patients and their families. One of the factors responsible for the low quality of life is poor sleep quality in asthmatic patients. Sleep disturbances, such as difficulty initiating and maintaining sleep, are common in asthma. In this study, we aim to determine the quality of sleep in young asthmatic patients in a local setting. Method This case-control study was conducted in the pulmonology and internal medicine unit of a tertiary care hospital, Pakistan from January 2021 to May 2021. After seeking informed consent, 200 patients with a previously confirmed diagnosis of asthma were enrolled in the study. The control group also included 200 participants. Pittsburgh Sleep Quality Index (PSQI) is an efficient measure of the quality and pattern of sleep. A global PSQI score of ≥5 signifies "poor sleep quality." Results The mean PSQI score was significantly higher in the asthmatic group compared to the control group (6.26 ± 2.01 vs. 3.41 ± 0.50; p-value: <0.0001). The percentage of participants with a PSQI score of ≥5 was significantly higher in the asthmatic group compared to the control group (54.5% vs. 17.0%; p-value: <0.0001). Conclusion Sleep disturbance is very common in young patients with asthma. Poor sleep may interfere with their daily performance, which may further have a negative impact on the quality of life in asthmatic patients. Management of asthma should also include improving sleep quality.

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.

Usefulness of Semisupervised Machine-Learning-Based Phenogrouping to Improve Risk Assessment for Patients Undergoing Transcatheter Aortic Valve Implantation.

Semisupervised machine-learning methods are able to learn from fewer labeled patient data. We illustrate the potential use of a semisupervised automated machine-learning (AutoML) pipeline for phenotyping patients who underwent transcatheter aortic valve implantation and identifying patient groups with similar clinical outcome. Using the Transcatheter Valve Therapy registry data, we divided 344 patients into 2 sequential cohorts (cohort 1, n = 211, cohort 2, n = 143). We investigated patient similarity analysis to identify unique phenogroups of patients in the first cohort. We subsequently applied the semisupervised AutoML to the second cohort for developing automatic phenogroup labels. The patient similarity network identified 5 patient phenogroups with substantial variations in clinical comorbidities and in-hospital and 30-day outcomes. Cumulative assessment of patients from both cohorts revealed lowest rates of procedural complications in Group 1. In comparison, Group 5 was associated with higher rates of in-hospital cardiovascular mortality (odds ratio [OR] 35, 95% confidence interval [CI] 4 to 309, p = 0.001), in-hospital all-cause mortality (OR 9, 95% CI 2 to 33, p = 0.002), 30-day cardiovascular mortality (OR 18, 95% CI 3 to 94, p <0.001), and 30-day all-cause mortality (OR 3, 95% CI 1.2 to 9, p = 0.02) . For 30-day cardiovascular mortality, using phenogroup data in conjunction with the Society of Thoracic Surgeon score improved the overall prediction of mortality versus using the Society of Thoracic Surgeon scores alone (AUC 0.96 vs AUC 0.8, p = 0.02). In conclusion, we illustrate that semisupervised AutoML platforms identifies unique patient phenogroups who have similar clinical characteristics and overall risk of adverse events post-transcatheter aortic valve implantation.

The Spectrum of Extra-intestinal Manifestation of Crohn's Disease.

Introduction Extra-intestinal manifestations (EIM) play an important role in the mortality, morbidity, and quality of life in patients with Crohn's disease (CD). Understanding the prevalence and clinical course of these manifestations is important to understand and manage CD. Materials and methods The hospital records of 103 patients diagnosed with CD between July 2016 and December 2019 at a tertiary care hospital in Pakistan were reviewed retrospectively. Baseline demographic and clinical characteristics including sex, age, follow-up duration, CD phenotype at diagnosis, clinical features, and course of EIMs were noted. The diagnosis of CD was based on clinical features in combination with endoscopic and radiologic findings. CD phenotype at diagnosis was assessed using the Montreal Classification by the World Congress of Gastroenterology (WCOG). Results The mean age at diagnosis of CD was 31 ±8 years. The most common age group as per the Montreal classification at diagnosis was 17-40 years (68.93%). The most common localization of disease was ileocolonic (70.87%), and the most common disease behavior was non-stricturing and non-penetrating (82.52%). In this study, 41 (39.8%) patients had a minimum of one EIM. The most common EIM was anal skin tags (29.12%), while 24 (23.30%) patients had elevated liver function tests (LFTs), three (2.91%) had peripheral arthritis, and 12 (11.65%) had cutaneous manifestations, the most common being erythema nodosum (7.76%). The most common ophthalmological manifestation was anterior uveitis (3.88%). Conclusions EIMs are prevalent in CD patients in Pakistan, yet very little is known about them. Further large-scale studies are needed to assess the frequency and impact of EIMs on patients with CD.

Disseminated Hydatid Disease in a Child Involving Multiple Organ Systems: A Case Report.

Hydatid disease is a parasitic infestation by Echinococcus granulosus, which involves the liver and lungs primarily. The authors report a case of disseminated hydatid disease involving multiple organs simultaneously in a 7-year-old child from Kabul, Afghanistan. The patient under examination had been having a complaint of cough and low-grade fever for the last one year. Computed tomography (CT) and ultrasonography (USG) demonstrated cystic lesions in his liver, lungs, spleen, and suprarenal region. The literature review showed that it was very rare for hydatid disease to involve multiple organs simultaneously, even in endemic areas, and the management of disseminated disease was very challenging, especially in the pediatric population.

Risk Factors for Pre-eclampsia and Eclampsia Disorders in Tertiary Care Center in Sukkur, Pakistan.

Introduction Pakistan has the third-highest incidence of maternal, fetal, and child mortality, according to a recent systemic analysis of global mortality. Thirty-four percent of maternal deaths are attributed to eclampsia among those who are admitted into tertiary care hospitals in Pakistan for delivery. In this study, we determine the risk factors associated with pre-eclampsia and eclampsia in the rural city of Sukkur, Pakistan. Methods and materials In this prospective observational study, a semi-structured questionnaire was developed to record information about maternal age, education status, parity, the status of chronic hypertension, gestational diabetes, anemia, body mass index (BMI), and history of cardiac disease of all women attending the antenatal clinic. Women diagnosed with pre-eclampsia and eclampsia were placed in a group, and their characteristics were compared with women with any pre-eclampsia and eclampsia. Results The incidence of pre-eclampsia and eclampsia was 5.6% (n=112/2212). Identified risk factors for pre-eclampsia and eclampsia included hypertension (28.7%), gestational diabetes (25.9%), anemia (14.9%), maternal age > 35 years (9.3%), BMI greater than 30 kg/m2 (8.1%) and 35 kg/m2 (11.7%), nulliparity (6.5%), unbooked status (i.e., lack of antenatal care; 6.4%), and low education level (5.8%). Conclusion It is important to identify the markers for pre-eclampsia and eclampsia, as they will help physicians and caregivers to reduce maternal and fetal mortality and the complications associated with it.

Correction: Depression and Anxiety in Patients with Gastroesophageal Reflux Disorder With and Without Chest Pain.

[This corrects the article DOI: 10.7759/cureus.6103.].

Evaluation of Risk Factors Associated with Reinfarction: A Multicenter Observational Study.

INTRODUCTION: Reinfarction after incidence of myocardial infarction is a serious complication and is responsible for high mortality. Various factors are responsible for reinfarction including smoking, prior procedures or surgeries, and use of medications such as aspirin, ß-blocker, and angiotensin-converting enzyme Iihibitor or angiotensin receptor blockers. MATERIAL AND METHODS: This prospective study was conducted with 243 participants. Participants were divided into two groups: patients who had a reinfarction during hospital and patients who did not. RESULTS: There were 142 (58.4%) men and 101 (41.6%) women in the study. A total of 17 (6.9%) patients had reinfarction. Age (68.4±10.9 vs. 64.4±11.8; 0.001), diabetes (47.05% vs. 22.12%; 0.02), and history of myocardial infarction (29.5% vs. 11.4%; 0.02) were identified as risk factors for reinfarction Conclusion: Our study reports that certain parameters such as age, obesity, diabetes mellitus,, and history of myocardial infarction can be used to assess the risk of reinfarction among these patients.

Depression and Anxiety as a Risk Factor for Myocardial Infarction.

INTRODUCTION:  Patients having a cardiovascular disease experience negative states of psychology. An increased incidence of coronary artery disease is attributed to both depression and anxiety. MATERIALS AND METHODS:  In this retrospective study, the Hospitalized Anxiety and Depression Scale (HADS) was used to determine anxiety and depression in stable patients of myocardial infarction (MI) at the time of their discharge. All responses were based on the patients' perceptions two weeks prior to acute MI event. SPSS version 21.0 was used for data entry and analysis. RESULTS: The mean age of the participants in our study was 49.09±5.61 years. About 52.83% (n=28) and 58.49% (n=31) participants suffered from anxiety and depression two weeks prior to their myocardial infarction. CONCLUSION: Depression and anxiety can be a risk factor for myocardial infarction in susceptible individuals. Attention should be given to mental well-being, and a multi-disciplinary management approach should be taken for these patients including psychiatry and psychology.

Depression and Anxiety in Patients with Gastroesophageal Reflux Disorder With and Without Chest Pain.

Introduction Gastroesophageal reflux disease (GERD) influences patients' general health, daily and social functioning, and physical and emotional activities. It strongly affects the health-related quality of life with frequent interruptions during sleep, work, and social activities. GERD is defined as a condition that develops when the reflux of stomach contents causes troublesome symptoms and/or complications. GERD symptoms are a major concern for many patients, as they cause a disturbance in physical, social and emotional health. In this study, we determine the prevalence of anxiety and depression in patients with GERD with and without chest pain. Methods In this cross-sectional study, a total of 258 consecutive patients with a diagnosis of GERD were included in this study. Of 258 participants, 112 had concerns about chest pain. Clinical presentations and comorbid disorders were evaluated by a previously validated gastroesophageal reflux symptom questionnaire. Depressive and anxious symptoms were assessed using a Hospital Anxiety/Depression Scale. Results A total of 107 (41.4%) participants had depression, 89 (34.4%) participants had anxiety, and 70 (27.13%) had both depression and anxiety. Depression and anxiety were significantly higher in patients with GERD and chest pain. Conclusion Anxiety and depression were significantly higher in patients with GERD, particularly those who also reported concerns of chest pain. Measures should be taken to reduce the stress and anxiety of GERD patients to cope with their daily life activities and improve their quality of life.

The Frequency of Cutaneous Manifestations in Hepatitis C: A Cross-sectional Study in a Tertiary Care Hospital in Pakistan.

Introduction Even though the liver is the main targeted organ in hepatitis C, the manifestations of the disease are not limited to hepatic involvement. Other tissue types are often involved as well. Hepatitis C has dermatological and mucocutaneous manifestations. Methods This study was conducted from May 2016 to April 2017 in the gastroenterology unit of Ghulam Muhammad Mahar Medical College, Sukkur, Sindh, Pakistan. All participants with a clinical diagnosis of hepatitis C with cutaneous manifestations were included in the study after securing informed consent. Demographic data and detailed cutaneous examination results with full morphological descriptions were recorded in patient-completed questionnaires. Results Of the 212 participants, 141 (66.6%) were males and 71 (33.4%) were females. The mean age was 32 (±9) years (range: 17-58 years). The most common cutaneous manifestation was pruritus (33.96%), followed by lichen planus (LP) (23.5%). Conclusion Physicians should try to recognize extrahepatic manifestations of a hepatitis C infection as it may help in early diagnosis efforts. While managing hepatitis C, we recommend a multidisciplinary approach to tackle cutaneous and other extrahepatic manifestations.

Clinical and Microbiological Profile of Urinary Tract Infections in Diabetic versus Non-Diabetic Individuals.

Introduction Diabetic patients have a higher tendency of developing all infections, especially infections of the genitourinary tract. In most cases, urinary tract infections (UTI) in diabetic patients are asymptomatic. The aim of this study to was to compare the incidence and clinical and microbiological features of UTI between diabetic and non-diabetic patients. Methods In this prospective, comparative study, the incidence and clinical and microbiological features of UTI were compared between diabetic and non-diabetic patients via consecutive non-probability sampling technique. For every diabetic patient, one non-diabetic control was included. All patients were screened for UTI through a midstream urinary sample. Their demographic characteristics, clinical profile, and urinary microscopy were compared. Data were entered and analyzed using SPSS version 22.0. Results In the diabetes group, 35/256 (13.67%) patients had culture-positive UTI as compared to 18/250 (7.2%) in the non-diabetic group. Diabetic group had twice the risk of UTI (p = 0.01; odds ratio [OR]: 2.04; confidence interval [CI]: 1.12, 3.71) and female gender in the diabetic group had a risk of almost five times (p = 0.01; OR: 4.93; CI: 1.12, 20.16) that of the non-diabetic group. In the diabetic group, 31.4% patients were asymptomatic as compared to 5.6% in the non-diabetic group (p = 0.03; OR: 7.79; CI: 0.92, 66.18). E. coli was the most commonly identified microorganism in both groups. Pseudomonas aeruginosa was identified in 14% of diabetic cases and none in the non-diabetic. Conclusions UTIs are more frequent among diabetics. Asymptomatic bacteriuria is a more common entity in diabetic patients and does not require any treatment.

Retrospective Analysis of Eosinophilic Esophagitis in Patients with Refractory Gastroesophageal Reflux Disease.

Introduction Eosinophilic esophagitis (EoE) is not a common differential diagnosis in patients with longstanding refractory gastroesophageal reflux disease (GERD). The aim of this retrospective analysis was to assess the prevalence of EoE in patients with refractory GERD. Methods This retrospective analysis was performed in the Gastroenterology Department of a tertiary care institute in Karachi, Pakistan. Records of esophagogastroduodenoscopy (EGD) with esophageal biopsy from January 2016 till December 2018 were included. Results There were 16 (7.7%) patients of refractory GERD diagnosed with EoE. There were more females than males (5:3). The median age was 58 years (range: 41-63 years). Dysphagia was the chief complaint leading to EGD followed by food impaction and heartburn. The median duration of symptoms was 46.5 months (range: 22-65 months). Erosive esophagitis, white plaques, and friability are common endoscopic findings; however, strictures are also not uncommon. Conclusion Eosinophilic esophagitis is not uncommon in patients with refractory GERD. It may present with dysphagia, heartburn, and food impaction. Old patients with longstanding GERD, positive for atopy, not responding to gastric acid inhibitors must be considered for EoE screening via EGD and esophageal biopsy.

Risk Factors of Diabetic Foot Amputation in Pakistani Type II Diabetes Individuals.

Introduction The major grave outcome of diabetic complications is the amputation of lower limb extremities. Recurrent foot infections, trauma, ischemia, and peripheral neuropathy play a crucial role in predicting foot amputation. The aim of this study is to identify the risk factors of diabetic foot amputations in Pakistani patients. Methods Patients admitted with diabetic foot-related complications were followed throughout their hospital stay. Their sociodemographic and disease-related characteristics were recorded. Patients who were advised foot amputation were taken as group A, and patients who were managed conservatively were termed as group B. Their characteristics were then compared. Results Out of 226 study participants, there were 51 (22.5%) patients in group A who were advised foot amputation. There were more men in group A as compared to group B (72.5% vs. 30.8%; p<0.00001). Group A also had a longer duration of diabetes (15.23 ± 8.52 years vs. 11.98 ± 9.69; p=0.03). Group B included more patients taking insulin therapy (44.5% vs. 37.3%; p=0.002). All three risk factors of atherosclerosis - smoking, hyperlipidemia, and hypertension - were significantly associated with group A (p≤0.05). This coexistence of diabetic nephropathy and retinopathy were more common in group A (p≤0.05). Conclusion The incidence of foot amputation in diabetic patients is high. Crucial risk factors include male gender, smoking, hyperlipidemia, hypertension, cardiac history, and the coexistence of diabetic nephropathy and retinopathy.

Adherence to Levothyroxine Tablet in Patients with Hypothyroidism.

Introduction Patients with hypothyroidism are managed with life-long levothyroxine (LT4) therapy. However, as with other chronic illnesses, drug adherence (DA) is a prominent issue in these patients. The aim of this study is to identify the extent of DA to LT4 in hypothyroidism patients and study the clinical factors contributing to DA in these patients. Methods This cross-sectional study assessed patient adherence to LT4 therapy by Modified Morisky Adherence Scale (MMAS). Factors predicting the pattern of medication adherence were also assessed in all patients. Data were entered and analyzed using SPSS v. 22.0. Results On MMAS, 79 (27.3%) participants indicated low adherence, 117 (40.48%) indicated medium adherence, and 93 (32.2%) participants indicated high adherence. Regular endocrinologist visits and knowledge about medication were highest in high adherent patients (p < 0.05). Need for assistance in taking medication, avoidance of medication with symptomatic relief and busy work schedule was highest in low adherent patients (p < 0.05). Conclusion Patients with hypothyroidism showed moderate adherence to their treatment.