Factors Affecting 30-Day Outcomes in Patients Undergoing Nontraumatic Upper Extremity Amputation: A Retrospective Descriptive Longitudinal Study.

BACKGROUND: Current literature concerning upper extremity amputations (UEAs) is very sparse. In this study, we conducted the first multicenter retrospective analysis aiming to identify risk factors associated with unfavorable outcomes in patients undergoing nontraumatic UEAs. METHODS: A retrospective cohort study was conducted using the National Surgical Quality Improvement Program database. Adult patients who underwent nontraumatic UEAs between 2005 and 2021 were divided into two cohorts based on whether they experienced 30-day major morbidity (MM). Thereafter, multivariable binary logistic regression analysis was used to identify risk factors of MM. RESULTS: From a total of 2984 cases, MM was observed in 8.7% of patients. Factors associated with MM included American Society of Anesthesiologists classes 3 (odds ratio [OR], 2.974 [1.862 to 4.748]) and 4 (OR, 4.736 [2.857 to 7.848]), being underweight (OR, 2.370 [1.251 to 4.491]), and suffering from insulin-dependent diabetes (OR, 1.390 [1.018 to 1.898]). In addition, an infectious surgical indication was associated with an increased risk of MM compared with having a benign (OR, 0.648 [0.488 to 0.682]) or malignant (OR, 0.205 [0.091 to 0.462]) indication. Moreover, patients undergoing shoulder amputations were at an increased risk of MM compared with those undergoing amputations of the forearm/wrist (OR, 0.243 [0.072 to 0.819]) and hands/fingers (OR, 0.286 [0.095 to 0.861]). CONCLUSION: The risk factors identified for MM after nontraumatic UEAs should guide surgeons toward appropriately identifying high-risk patients and adequately counseling them preoperatively.

Tackling a deadly global phenomenon: sepsis induced coagulopathy: A narrative review.

Sepsis is a potentially fatal illness marked by organ failure and the two main causes of which are shock and disseminated intravascular coagulation. Multi-organ dysfunction in sepsis is mediated by the inflammatory cytokine storm, while sepsis induced coagulopathy is mediated and accelerated by activation of pro-coagulative mechanisms. Regardless of the severity of sepsis, disseminated intravascular coagulation is a potent predictor of mortality in septic patients. Additionally, oxidative stress in sepsis causes renal ischaemia and eventually acute kidney injury. The first and foremost goal is to initiate resuscitation immediately, with treatment mainly focussing on maintaining a balance of coagulants and anticoagulants. A simpler and more universal diagnostic criteria is likely to improve studies on the spectrum associated with sepsis.

Novel Journal Metrics in Cardiothoracic Surgery: How Different Are Contemporary Metrics From the Impact Factor?

OBJECTIVE: Despite shortcomings, impact factor (IF) remains the "gold standard" metric for journal quality. However, novel metrics including the h-index, g-index, and Altmetric Attention Score (AAS; mentions in mainstream/social media) are gaining traction. We assessed correlations between these metrics among cardiothoracic surgery journals. METHODS: For all cardiothoracic surgery journals with a 2021 Clarivate IF (N = 20), the 2-year IF (2019 to 2020) and 5-year IF (2016 to 2020), h-index, and g-index were obtained. Two-year journal-level AAS (2019 to 2020) was also calculated. Journal Twitter presence and activity was sourced from Twitter and the Twitter application programming interface. Correlations were assessed using Spearman correlation, and coefficients of determination were calculated. RESULTS: IF demonstrated a moderate-strong positive correlation with the h-index (rs = 0.48 to 0.77) and g-index (rs = 0.49 to 0.79) and a moderate correlation with AAS (rs = 0.53 to 0.58). The 2-year IF accounted for 25% to 49% of variability in the h-index, 27% to 55% of variability in the g-index, and 32% of variability in the AAS. Among journals with a Twitter account (N = 10), IF was strongly correlated with Twitter following (rs = 0.81 to 0.86), which was in turn strongly correlated with journal AAS (rs = 0.79). Article-level AAS was moderately correlated with citation count (rs = 0.47). CONCLUSIONS: IF accounted for only between 25% and 55% of variability in the h-index and g-index, indicating that these newer metrics measure unique dimensions of citation-based impact. Thus, the academic community must familiarize itself with these newer journal metrics. Social media attention may be associated with scholarly impact, although further work is needed to understand these relationships.

Empathy levels among undergraduate medical students in Karachi, Pakistan: a cross-sectional study.

Empathy is a concept native to the field of medicine. However, over the course of medical school, empathy levels are expected to decline. The aim of this study was to assess the empathy levels among medical students in relation to their year of study and specialties of choice in the future. Materials and methods: A cross-sectional study was conducted to assess empathy levels among students from medical colleges in Karachi, Pakistan, using an online survey. The total duration of the study was 2 months. The authors analyzed the data using SPSS version 20. Results: A total of 463 undergraduate medical students participated in this survey. The overall mean empathy score was 101.9±16.3 with 104.6±14.1 for females, which was significantly higher than the male participants. The highest empathy levels were demonstrated in fourth-year medical students with a mean empathy score of 104.1±16.3, whereas, the lowest empathy levels were found in second-year medical students with a mean empathy score of 99.8±9.4. Study participants considering emergency medicine, neurology, obstetrics/gynecology, and oncology as their specialty of choice demonstrated the highest empathy levels followed by pediatrics and internal medicine. Conclusion: On average, there was a female preponderance in empathy levels among undergraduate medical students. Empathy levels among fourth-year students involved in clinical practice were greater as compared to students in their initial years of study. Further investigations are required to validate the findings of this study.

Association of Metabolic Syndrome with Stroke, Myocardial Infarction, and Other Postoperative Complications Following Carotid Endarterectomy: A Multicenter, Retrospective Cohort Study.

BACKGROUND: Metabolic syndrome (MetS) is a constellation of hypertension, insulin resistance, obesity, and dyslipidemia and is known to increase the risk of postoperative morbidity. This study aimed to assess the impact of MetS on stroke, myocardial infarction, mortality, and other complications following carotid endarterectomy (CEA). METHODS: We analyzed data from the National Surgical Quality Improvement Program. Patients undergoing elective CEA between 2011 and 2020 were included. Patients with American Society of Anesthesiologists status 5, preoperative length of stay (LOS) > 1 day, ventilator dependence, admission from nonhome location, and ipsilateral internal carotid artery stenosis of < 50% or 100% were excluded. A composite cardiovascular outcome for postoperative stroke, myocardial infarction, and mortality was generated. Multivariable binary logistic regression analyses were used to assess the association of MetS with the composite outcome and other perioperative complications. RESULTS: We included 25,226 patients (3,613, 14.3% with MetS). MetS was associated with postoperative stroke, unplanned readmission, and prolonged LOS on bivariate analysis. On multivariable analysis, MetS was significantly associated with the composite cardiovascular outcome (1.320 [1.061-1.642]), stroke (1.387 [1.039-1.852]), unplanned readmission (1.399 [1.210-1.619]), and prolonged LOS (1.378 [1.024-1.853]). Other clinico-demographic factors associated with the cardiovascular outcome included Black race, smoking status, anemia, leukocytosis, physiologic risk factors, symptomatic disease, preoperative beta-blocker use, and operative time ≥ 150 min. CONCLUSIONS: MetS is associated with cardiovascular complications, stroke, prolonged LOS, and unplanned readmissions following CEA. Surgeons should provide optimized care to this high-risk population and strive to reduce operative durations.

Knowledge, attitude, and perceptions about cancer genetic testing in clinical practice in Karachi, Pakistan.

Healthcare professionals (HCP) play an important role in the practical application of genetic screening tests but often feel inadequately prepared for cancer genetic testing (CGT) in clinical care. As the complexity of gene-related malignancies increases, it demands HCPs' preparedness to cater to patients' needs. Therefore, the aim of our study is to assess the knowledge, attitude, and practices of HCPs in Pakistan regarding the application of cancer genetics. Our cross-sectional survey was conducted from April 2022 to June 2022 amongst HCPs at a private and a governmental institution in Karachi, Pakistan. Non-probability random convenience sampling was used to select the population; however. non-clinical HCPs, as well as Interns, were excluded from our study. A total of 210 HCPs, 56.7% (119) bearing an experience of over 5 years of clinical experience, were included in this study. Most respondents from both hospitals deemed their knowledge inadequate, with only 2% (2) and 1.8% (2) being extremely knowledgeable, respectively. 68.6% (144) HCPs displayed a positive attitude towards CGT, with 55.2% (116) participants perceiving CGT in a positive light. As compared to the private sector, significantly more HCPs in the public sector dedicated ≥ 5 h/week for CME (P = 0.006), and were better prepared to counsel patients (P = 0.021) and interpret results concerning CGT (P = 0.020). Additionally, screening tests for specific cancer types were popularly considered a worthwhile avenue of investment to improve the current state of CGT in our healthcare system [47.6% (N = 100)]. Demonstrating a lack of knowledge among Pakistani doctors, our results call upon the need for additional training concerning CGT in both the public and private sectors alike. Understanding specific gaps in knowledge may further help enhance post-graduate training programs and eventually lead to effective incorporation of CGT into our healthcare setting.

Meta-Analysis Evaluating Risk of Hyperkalemia Stratified by Baseline MRA Usage in Patients with Heart Failure Receiving SGLT2 Inhibitors.

BACKGROUND: Both mineralocorticoid receptor antagonists (MRAs) and sodium-glucose co-transporter type 2 inhibitors (SGLT2is) have demonstrated beneficial reductions in cardiovascular outcomes. However, the risk of precipitating hyperkalemia with their concomitant usage remains unclear. METHODS: MEDLINE and Cochrane were searched from inception through March 2022. Randomized controlled trials on patients with heart failure (HF) evaluating the effect of SGLT2is on clinical outcomes between MRA users and non-users were considered for inclusion. Outcomes of interest were mild and moderate/severe hyperkalemia, for which hazard ratios (HR) were pooled using a random effects model. RESULTS: From the 972 articles retrieved from the initial search, three RCTs (n = 14,462 patients) were included in our meta-analysis. Pooled analysis demonstrated no significant difference in the incidence of mild hyperkalemia between MRA users (HR 0.82 [0.70-0.97]) and non-users (HR 0.95 [0.77-1.17]) (P-interaction = 0.28). The risk of severe hyperkalemia was significantly decreased in MRA users (HR 0.59 [0.44-0.78]; p = 0.0002; I2 = 0%) but not in non-users (HR 0.76 [0.56-1.02]; p = 0.07; I2 = 0%) (P-interaction = 0.22). Sensitivity analysis including patients with HF with reduced ejection fraction (HFrEF) revealed similar results across all subgroups, but no significant reduction in the incidence of mild hyperkalemia (HR 0.89 [0.76-1.04] was noted in MRA users with HFrEF. CONCLUSION: MRAs reduced the risk of mild or moderate/severe hyperkalemia, when added to SGLT2is. Future clinical trials should target scrupulous assessment of the risk of mild and moderate/severe hyperkalemia when used concomitantly with MRAs.

TRAIL mediated apoptosis ruling and anticancer trigger by fine-tuned nano spheres of Fagonia cretica methanolic extracts as novel cancer regime.

Fagonia cretica L. is a tropical plant of family Zygophyllaceae with wide range of medicinally important secondary metabolites. The low cellular uptake of the polar compounds in the extract of the plant limits its biological application. In present study efficacy of F. cretica modified bioactive nano-formulations for in vitro modulation of TRAIL mediated extrinsic apoptotic pathway as cancer therapy was investigated. F. cretica methanolic extracts were formulated at nano-scale for green synthesis of silver nanoparticles, albumin conjugation and liposomes encapsulation to enhance targeted bioactivity against cancer. Physical characterization of the synthesized nanoparticles was done by SEM, EDX and Zeta potential analyzer. In vitro cell viability assay MTT was done for MCF-7, Hep-2, HUH-7 and HCEC cell lines. Relative expression variation of the apoptotic pathway-associated genes was done by qRT-PCR. SEM revealed spherical shape of 56.62 ± 8.04, 143 ± 11.54 and 83.36 ± 38.73 nm size and zeta potential - 18.6, - 15.5 and - 18.3 mV for liposomes, silver and albumin nanoparticles. Silver nanoparticles showed highest anticancer activity in vitro than albumin and liposomes nanoparticles with IC50 0.101 ± 0.004, 0.177 ± 0.03 and 0.434 ± 0.022 mg/mL in MCF-7, Hep-2 and HUH-7 respectively. F. cretica albumin and silver nanoparticles upregulated the in vitro TRAIL, DR4, DR5 and FADD gene expression at statistically significant levels in Hep-2 cell lines. Nano-formulations of F. cretica proved therapeutically important biomolecules in vitro. The hypothesized modulation of extrinsic apoptosis pathway genes through the plant nanoparticles proved novel medicinal options for effective treatment of cancer and enhancing the bioavailability of the active plant metabolites.

Evaluating the safety and efficacy of daprodustat for anemia of chronic kidney disease: a meta-analysis of randomized clinical trials.

PURPOSE: Anemia of chronic kidney disease (CKD) has traditionally been treated with recombinant human erythropoietin (rhEPO). Recently, daprodustat, a hypoxia-inducible factor prolyl-hydroxylase inhibitor, has also been shown to increase hematocrit. It remains unclear whether daprodustat or rhEPO should be the treatment of choice for anemia of CKD. We aimed to assess the efficacy and cardiovascular safety of daprodustat versus rhEPO in CKD patients. METHODS: Online databases were queried in April 2022 for articles comparing the efficacy and safety of daprodustat in DD-CKD and NDD-CKD subgroups. Results from trials were pooled using a random-effects model. RESULTS: Data on 8245 CKD patients from eight clinical trials were included. Our results show that in comparison to rhEPO, daprodustat maintained the same efficacy in increasing hemoglobin levels in both the DD-CKD (MD: 0.10; 95% CI [- 0.13,0.34]; p = 0.50) and NDD-CKD (MD: - 0.01; 95% CI [- 0.38,0.35]; p = 0.95) subgroups. Daprodustat significantly lowered hepcidin levels and significantly increased TIBC in both subgroups. Additionally, daprodustat significantly reduced the incidence of major adverse cardiovascular events (MACE) (RR: 0.89; 95% CI: 0.89-0.98; p = 0.02) and its myocardial infarction (MI) component (RR: 0.74; 95% CI: 0.59-0.92; p = 0.006) in the DD-CKD subgroup. CONCLUSION: Daprodustat has similar efficacy compared to rhEPO for the treatment of anemia of CKD. On treatment, the reduced experience of MACE was reported in DD-CKD patients as compared to rhEPO. Furthermore, effects on iron metabolism varied by parameter, with daprodustat being superior to rhEPO in some cases and inferior in others.

Evaluating the effect of multivalvular disease on mortality after transcatheter aortic valve replacement for aortic stenosis: a meta-analysis and systematic review.

Aims: To determine the prognosis of multivalvular disease in patients undergoing transcatheter aortic valve replacement (TAVR) for severe aortic stenosis. Methods: Patients undergoing TAVR for aortic stenosis with covariate-adjusted risk of mortality associated with concomitant valve disease (mitral regurgitation [MR], mitral stenosis [MS] or tricuspid regurgitation [TR]) were included. Results: Moderate-to-severe MR was associated with increased mortality at 30 days (hazard ratio [HR]: 1.60; 95% CI: 1.11-2.30; p = 0.01) and 1 year (HR: 1.87; 95% CI: 1.22-2.87; p = 0.004). The presence of all-grade MS did not impact 30-day or 1-year mortality (HR, 30 days: 1.60; 95% CI: 0.71-3.63; p = 0.26; and HR, 1 year: 1.90; 95% CI: 0.98-3.69; p = 0.06); however, an increased risk of 1-year mortality (HR: 1.67; 95% CI: 1.03-2.70; p = 0.04) was observed with severe MS compared with no MS. Moderate-to-severe TR had a higher risk of all-cause mortality at 1 year (HR: 1.49; 95% CI: 1.24-1.78; p < 0.001) compared with no or mild TR. Conclusion: Moderate-to-severe MR or TR, and severe MS, significantly increase mid-term mortality after TAVR.

Transcatheter aortic valve replacement (TAVR) is a minimally invasive heart procedure to replace a thickened aortic valve (aortic stenosis). In the current era, the use of TAVR has increased in patients suffering from uncomfortable and potentially life-threatening symptoms of severe aortic stenosis who are at increased risk for undergoing a surgical procedure to replace their valves. However, accompanying valve diseases like mitral regurgitation (mitral valve cannot close tightly), mitral stenosis (a narrowed mitral valve) and tricuspid regurgitation (tricuspid valve cannot close tightly) are highly common in these patients. Therefore in this paper we assessed the effect of accompanying valvular disorders on the likelihood of death following TAVR in this patient population. Our findings suggest that accompanying moderate-to-severe mitral regurgitation and tricuspid regurgitation leads to an increase in deaths post-TAVR. Likewise, severe mitral stenosis also increased the risk of deaths after TAVR.

In Silico Validation, Fabrication and Evaluation of Nano-Liposomes of Bistorta amplexicaulis Extract for Improved Anticancer Activity Against Hepatoma Cell Line (HepG2).

BACKGROUND: Bistorta amplexicaulis of the genus Polygonum (Polygonaceae) has been reported for its antioxidant and anticancer activities. However, the low cellular uptake of the compounds in its extract limits its therapeutic application. OBJECTIVES: The present study aimed at developing a nanoliposomal carrier system for B. amplexicaulis extracts for improved cellular uptake, thus resulting in enhanced anticancer activity. METHODS: Ultra Pressure Liquid Chromatography (UPLC) was used to identify major compounds in the plant extract. Nanoliposomes (NLs) were prepared by employing a thin-film rehydration method using DPPC, PEG2000DSPE and cholesterol, followed by characterization through several parameters. In vitro screening was performed against breast cancer cell line (MCF-7) and Hepatocellular carcinoma cell line (HepG-2) using MTT-assay. Raw extract and nanoliposomes were tested on Human Umbilical Vein Endothelial Cells (HUVEC). Moreover, molecular docking was performed to validate the data obtained through wet lab. RESULTS: The UHPLC method identified gallic acid, caffeic acid, chlorogenic acid and catechin as the major compounds in the extract. The NLs with a size ranging between 140-155 nm, zeta potential -16.9 to -19.8 mV and good polydispersity index of < 0.1 were prepared, with a high encapsulation efficiency of 81%. The MTT assay showed significantly (p > 0.05) high uptake and cytotoxicity of NLs as compared to the plant extract. Moreover, reduced toxicity against HUVEC cells was observed as compared to the extract. Also, the docking of identified compounds suggested a favorable interaction with the SH2 domain of both STAT3 and STAT5. CONCLUSION: Overall, the results suggest NLs as a potential platform that could be developed for the improved intracellular delivery of plant extract, thus increasing the therapeutic outcomes.

Prevalence of newly detected diabetes in pregnancy in Qatar, using universal screening.

BACKGROUND: Diabetes first detected during pregnancy is currently divided into gestational diabetes mellitus (GDM) and diabetes mellitus (DM)- most of which are type 2 DM (T2DM). This study aims to define the prevalence and outcomes of diabetes first detected in pregnancy based on 75-gram oral glucose tolerance test (OGTT)using the recent WHO/IADPSG guidelines in a high-risk population. METHODS: This is a retrospective study that included all patients who underwent a 75 g (OGTT) between Jan 2016 and Apr 2016 and excluded patients with known pre-conception diabetes. RESULTS: The overall prevalence of newly detected diabetes in pregnancy among the 2000 patients who fulfilled the inclusion/exclusion criteria was 24.0% (95% CI 22.1-25.9) of which T2DM was 2.5% (95% CI 1.9-3.3), and GDM was 21.5% (95% CI 19.7-23.3). The prevalence of newly detected diabetes in pregnancy was similar among the different ethnic groups. The T2DM group was older (mean age in years was 34 ±5.7 vs 31.7±5.7 vs 29.7 ±5.7, p<0.001); and has a higher mean BMI (32.4±6.4 kg/m2 vs 31.7±6.2 kg/m2 vs 29.7± 6.2 kg/m2, p< 0.01) than the GDM and the non-DM groups, respectively. The frequency of pre-eclampsia, pre-term delivery, Caesarean-section, macrosomia, LGA and neonatal ICU admissions were significantly higher in the T2DM group compared to GDM and non-DM groups. CONCLUSION: Diabetes first detected in pregnancy is equally prevalent among the various ethnic groups residing in Qatar. Newly detected T2DM carries a higher risk of poor pregnancy outcomes; stressing the importance of proper classification of cases of newly detected diabetes in pregnancy.