Valve-in-Valve Transcatheter Aortic Valve Replacement Versus Redo Surgical Aortic Valve Replacement In Patients With Aortic Stenosis: A Systematic Review and Meta-analysis.

Aortic stenosis is a common and significant valve condition requiring bioprosthetic heart valves (BHV) with transcatheter aortic valve replacement (TAVR) being strongly recommended for high-risk patients or patients over 75. This meta-analysis aimed to pool existing data on post-procedural clinical as well as echocardiographic outcomes comparing ViV-TAVR to redo-SAVR to assess the short-term and medium-term outcomes for both treatment modalities. A systematic literature search on Cochrane Central, Scopus, and Medline (PubMed interface) electronic databases from inception to August 2023. We used odds ratios (OR) for dichotomous outcomes and mean differences (MD) for continuous outcomes. Twenty-four studies (25,216 patients) were pooled with a mean follow-up of 16.4 months. The analysis revealed that ViV-TAVR group showed a significant reduction in 30-day mortality (OR: 0.50 (95% CI: 0.43, 0.58), P < 0.00001), new-onset atrial fibrillation (OR: 0.34 (95% CI: 0.17, 0.67) P = 0.002), major bleeding event (OR: 0.28 (95% CI: 0.17, 0.45), P < 0.00001) and lower rate of device success (OR: 0.25 (95% CI: 0.12, 0.53), P = 0.0003). There were no significant differences between either group when assessing 1-year mortality, stroke, M.I, post-operative LVEF, and effective orifice area. ViV-TAVR cohort showed a significantly increased incidence of paravalvular leaks, aortic regurgitation, and increased mean aortic valve gradient. ViV-TAVR is a viable short-term option for elderly patients with high comorbidities and operative risks, reducing perioperative complications and improving 30-day mortality with no significant cardiovascular adverse events. However, both treatment modalities present similar results on short to medium-term complications assessment.

COVID-19 and myasthenia gravis: A review of neurological implications of the SARS-COV-2.

INTRODUCTION: This review highlights the potential mechanisms of neuromuscular manifestation of COVID-19, especially myasthenia gravis (MG). METHODS: An extensive literature search was conducted by two independent investigators using PubMed/MEDLINE and Google Scholar from its inception to December 2020. RESULTS: Exacerbations of clinical symptoms in patients of MG who were treated with some commonly used COVID-19 drugs has been reported, with updated recommendations of management of symptoms of neuromuscular disorders. Severe acute respiratory syndrome coronavirus 2 can induce the immune response to trigger autoimmune neurological disorders. CONCLUSIONS: Further clinical studies are warranted to indicate and rather confirm if MG in the setting of COVID-19 can pre-existent subclinically or develop as a new-onset disease.

Perception, Willingness, Barriers, and Hesitancy Towards COVID-19 Vaccine in Pakistan: Comparison Between Healthcare Workers and General Population.

Background Vaccine hesitancy has been a huge challenge in controlling preventable diseases. With the emergence of coronavirus disease 2019 (COVID-19) vaccines, it is vital to know their acceptance rates among the masses. No comparative data is available on the current subject from Pakistan yet. Therefore, this study aimed to evaluate the acceptance of a potential COVID-19 vaccine among the general population and healthcare workers (HCWs) of Pakistan, along with their perceptions and barriers to acceptance. Methods An online cross-sectional study was carried out in Pakistan from December 19, 2020, to January 10, 2021, using convenience sampling. A self-administered questionnaire consisting of 31 items was distributed after informed consent. Inclusion criteria consisted of HCWs and non-HCWs (general population) aged 18 years and above, residing in Pakistan. All analyses were done using Statistical Package for Social Sciences (SPSS) version 23.0 (IBM Corp., Armonk, NY, USA). Chi-square and T-test were used and a p-value of less than 0.05 was considered significant for all cases. Results Of the 404 respondents (n=196 general population and n=208 HCWs), 73.5% were willing to get a proven, safe, and effective COVID-19 vaccine if it was free of cost. This was reduced to only 64.3% if the vaccine was not free and had to be paid for. A total of 168 (41.6%) participants agreed to get vaccinated immediately, while 149 (36.9%) participants concurred to get it on a delayed basis. Eighty-seven (21.5%) participants refused to receive the COVID-19 vaccine, amongst which a significant majority (p<0.001) of the participants were from the general population. Doctors or scientists/scholarly journals were found to be the most trusted source of information (67.6%; n=273), while fear of unknown side effects (45.5%; n=184) was found to be the most common barrier towards COVID-19 vaccination. More than half (53.5%) participants believed that the vaccine is safe, effective, and has minimal side effects, amongst which a significantly large fraction (p<0.001) belonged to the HCWs. Conclusion The acceptance rate of a safe, effective, proven, and free COVID-19 vaccine was 73.5%. The fear of unknown side effects was the most common barrier to COVID-19 vaccine uptake. The general population demonstrated less knowledge, more false perceptions, and barriers to COVID-19 vaccine. Adequate measures should be taken to educate the masses about the COVID-19 vaccine, and its safety, and further studies are required.

Role of Social Media in Psychiatry During Pandemic: A Potential Risk for Suicidal Ideation.

ABSTRACT: The COVID-19 pandemic brought with itself significant mental health challenges owing not only to the morbidity and mortality from the infection but also to mitigation strategies of social distancing and self-isolation. Indeed, in the absence of adequate pharmaceutical aids, quarantine and social distancing measures are taken to limit the spread of the SARS-CoV-2 virus. Thus, living in the world of social media, the average usage of social media could be expected to show a sharp rise as measures of social distancing and quarantine are adopted to contain the pandemic. In this context, social media could be thought of as an additional preventative resource aiding the containment of the pandemic by being a key network for communication during a crisis.Because social media usage cannot be brought down to null considering the fact that it does have some positive aspects to it in terms of disposition of useful information, we could alternatively modify the reporting to be more responsible.In conclusion, we could hypothesize that social media might surge responses for some adverse mental health conditions, increasing fear, anxiety, and panic responses, even spreading suicidal ideation and therefore impacting incidence of suicide in some way. Moreover, social media should be carefully handled, particularly during the pandemic, as social media engagement spiked. Indeed, suicide news, when not reported adequately, and most dangerous social media challenges could have devastating effects among youngest users.

Systemic lupus erythematosus with secondary thrombotic thrombocytopenic purpura and acute parkinsonism: A case report.

Systemic lupus erythematosus (SLE) is an autoimmune disease that has certain characteristic features but can also present with misleading signs and symptoms especially when it is of late-onset. Various case reports address its association with thrombotic thrombocytopenic purpura (TTP), however, its association with parkinsonism remains unclear. We present the case of a 58-year-old male who reported with acute-onset parkinsonism along with some gastrointestinal symptoms. Detailed laboratory investigations unmasked the underlying SLE with an overlapping picture of TTP. This unusual presentation in a resource-constrained setting created challenges and subsequent delays in the diagnosis and management of the patient. Despite urgent care, the patient's age, presence of overlapping conditions, and multi-organ involvement were some of the factors due to which the treatment failed and he could not survive. We report the association of SLE with secondary TTP and parkinsonism. More studies are needed to provide a greater understanding of these associations and various risk factors that drive them.

Antidiabetic drugs and non-alcoholic fatty liver disease: A systematic review, meta-analysis and evidence map.

BACKGROUND: The efficacy of antidiabetic agents for the treatment of non-alcoholic fatty liver disease (NAFLD) remains unclear. AIM: To conduct a meta-analysis to study the efficacy of pioglitazone and three novel anti-diabetic agents: glucagon-like peptide-1 (GLP-1) agonists, sodium-glucose co-transporter-2 (SGLT2) inhibitors, and dipeptidyl-peptidase-4 (DPP4) inhibitors in treating NAFLD. METHODS: Online databases were searched in May 2020 for randomized clinical trials. Results from random-effects meta-analysis are presented as weighted mean differences (WMDs) or standard mean differences (SMDs) and corresponding 95% confidence intervals (CIs). RESULTS: Twenty-six studies (n=946 NAFLD patients) were included. Reductions in ALT were seen with all four drugs: pioglitazone (MD -38.41, p<0.001), SGLT2 inhibitors (MD -16.17, p<0.001), GLP-1 agonists (MD -27.98, p=0.04) and DPP-4 inhibitors (MD -7.41, p<0.001). Pioglitazone (SMD -1.01; p<0.001) and GLP-1 agonists (SMD -2.53, p=0.03) also demonstrated significant improvements in liver steatosis. SGLT2 inhibitors (SMD -4.64, p=0.06) and DPP-4 (SMD -2.49, p=0.06) inhibitors trended towards reduced steatosis; however, these results were non-significant. CONCLUSION: Pioglitazone demonstrates significant improvements in transaminases and liver histology in both diabetic and non-diabetic NAFLD patients. Early evidence from diabetic NAFLD patients suggests that novel antidiabetics may lead to improvements in liver enzymes and hepatic steatosis, and this should encourage further research into possible utility of these drugs in treating NAFLD.

Brain abscess: A rare complication in a child with tetralogy of Fallot.

Brain abscess is a rarely occurring fatal complication accounting for 5%-18.7% of the population with cyanotic congenital heart diseases. Cyanotic heart diseases are associated with a right-to-left shunt that bypasses pulmonary circulation and results in tissue hypoxia and cyanosis. The most common cyanotic congenital anomaly seen is the tetralogy of Fallot. Herein, we discuss a case of uncorrected tetralogy of Fallot presenting as a parieto-occipital abscess in a 13-year-old boy. The patient was managed conservatively on intravenous antibiotics due to the small size of the abscess and then referred to cardiothoracic surgeons for the repair of the defect. The purpose of reporting this case is to highlight the importance of early detection and correction of cardiac defects to prevent serious complications resulting in childhood morbidity and mortality.

Effect of ertugliflozin on glycemic levels, blood pressure and body weight of patients with type 2 diabetes mellitus: a systematic review and meta-analysis.

PURPOSE: To conduct a meta-analysis to evaluate the effect of ertugliflozin on long-term hemoglobin A1c (HbA1c), body weight and blood pressure (BP). METHODS: Online databases available were searched from their inception to February 2020. Randomized controlled trials (RCTs) comparing ertugliflozin to either placebo or an active control drug were included. Data on four efficacy outcomes were extracted, namely: HbA1c, systolic blood pressure (SBP), diastolic blood pressure (DBP) and body weight. Continuous outcomes were pooled using a random-effects model and presented as weighted mean differences (WMDs) and corresponding 95% CIs. Additionally, a subgroup analysis was done to compare two doses of ertugliflozin (5 mg and 15 mg). A sensitivity analysis was also performed by eliminating studies using active drugs as controls. RESULTS: From a total of 123 search results, eight studies were included. Compared to the control group, ertugliflozin was associated with a significant decrease in SBP (WMD: -3.64 mmHg, 95% CI [-4.39,-2.90]; p < 0.001; I2 = 0%) and DBP (WMD: -1.13 mmHg, 95% CI [-1.67,-0.60], p < 0.001; I2 = 0%). Similarly, significant reductions in body weight (WMD: -2.35 kg, 95% CI [-2.94,-1.77]; p < 0.001; I2 = 0%) as well as HbA1c (WMD: -0.41%, 95% CI [-0.62,-0.20]; p < 0.001; I2 = 0%) were seen with ertugliflozin. Subgroup analysis demonstrated no significant difference in efficacy between the two doses in any of the four outcomes. CONCLUSION: Ertugliflozin results in significant reductions in HbA1c, body weight, SBP and DBP, when compared to control. Subgroup analyses suggest that these effects are not dose-dependent.

The impact of COVID-19 in diabetic kidney disease and chronic kidney disease: A population-based study.

BACKGROUND: The spectrum of pre-existing renal disease is known as a risk factor for severe COVID-19 outcomes. However, little is known about the impact of COVID-19 on patients with diabetic nephropathy in comparison to patients with chronic kidney disease. METHODS: We used the Mexican Open Registry of COVID-19 patients 11 to analyze anonymized records of those who had symptoms related to COVID-19 to analyze the rates of SARS-CoV-2 infection, development of COVID-19 pneumonia, admission, intubation, Intensive Care Unit admission and mortality. Robust Poisson regression was used to relate sex and age to each of the six outcomes and find adjusted prevalences and adjusted prevalence ratios. Also, binomial regression models were performed for those outcomes that had significant results to generate probability plots to perform a fine analysis of the results obtained along age as a continuous variable. RESULTS: The adjusted prevalence analysis revealed that that there was a a 87.9% excess probability of developing COVID-19 pneumonia in patients with diabetic nephropathy, a 5% excess probability of being admitted, a 101.7% excess probability of intubation and a 20.8% excess probability of a fatal outcome due to COVID-19 pneumonia in comparison to CKD patients (p<0.01).  Conclusions: Patients with diabetic nephropathy had nearly a twofold rate of COVID-19 pneumonia, a higher probability of admission, a twofold probability of intubation and a higher chance of death once admitted compared to patients with chronic kidney disease alone. Also, both diseases had higher COVID-19 pneumonia rates, intubation rates and case-fatality rates compared to the overall population.

Does the administration of sonothrombolysis along with tissue plasminogen activator improve outcomes in acute ischemic stroke? A systematic review and meta-analysis.

This meta-analysis was conducted to assess the safety and efficacy of sonothrombolysis along with intravenous recombinant tissue plasminogen activator, alteplase (IV rtPA), in the management of acute ischemic stroke. Electronic databases were searched under different meSH terms without the restriction of time and language. 1415 studies were analyzed and seven studies that matched the inclusion criteria were selected. Multiple safety and efficacy outcomes were extracted. Our pooled analysis demonstrated that there is no significant difference between sonothrombolysis group and control group in preventing mortality (RR 1.10 [0.81, 1.50]; p = 0.55; I2 = 0%) and intracranial hemorrhage (RR 1.11 [0.76, 1.63]; p = 0.59; i2 = 0%), however, among the efficacy outcomes; complete recanalization after 60-120 min was achieved more effectively in the sonothrombolysis group (RR 2.11 [1.48, 3.03]; p ≤ 0.0001; I2 = 0%). The rest of the efficacy outcomes like neurological improvement at 24 h (RR 1.20 [0.92, 1.57]; p = 0.18; I2 = 40%) and excellent functional outcome after 3 months (RR 1.19 [0.93, 1.52]; p = 0.17; I2 = 35%) showed no significant differences between the two groups. In subgroup analysis, we found that sonothrombolysis led to a better neurological improvement in patients who were less than 65 years of age (RR 1.20 [0.92, 1.57]; p = 0.05; I2 = 40%). Moreover, there were no significant differences in the following of the subgroups assessed: (a) microsphere or microbubble use, (b) Ultrasound frequency (2 MHz or < 2 MHz), (c) transcranial Doppler (TCD) duration (1 h or 2 h), (d) age (≤ 65 or > 65).

Corneal Collagen Cross-Linking Combined with an Artiflex Iris-Fixated Anterior Chamber Phakic Intraocular Lens Implantation in a Patient with Progressive Keratoconus.

We present here the case of a 24-year-old male who experienced progressive keratoconus and vision loss which adversely affected his ability to carry out everyday tasks. This landed him in the Hashmanis Hospital for consultation. He had a preoperative best corrected visual acuity of 6/12. He underwent multiple Oculus Pentacam examinations, which showed progressive keratoconus. Corneal collagen cross-linking (CXL) was performed to stabilize his cornea and, subsequently, an Artiflex anterior chamber iris-fixated phakic intraocular lens (ACIF-PIOL) was implanted to alleviate his refractive errors. The patient achieved a postoperative uncorrected visual acuity of 6/12. This report shows that CXL combined with ACIF-PIOL can be safe and effective in those with progressive keratoconus.

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.