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

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

Frequency of Subclinical Hypothyroidism in Women With Polycystic Ovary Syndrome.

INTRODUCTION: Polycystic ovary syndrome (PCOS) is a heterogeneous disorder characterized by hyperandrogenism and chronic anovulation. It may also influence thyroid hormones. Increasing evidence suggests that PCOS is linked with an increased prevalence of thyroid diseases such as nodular goiter, autoimmune thyroiditis, and subclinical hypothyroidism (SCH). Due to very limited global and regional data related to the prevalence of SCH in women with PCOS, we will determine the association between the two. METHODS: This case-control study was conducted in the endocrinology ward of a tertiary care hospital in Pakistan from March 2020 to April 2021. We enrolled 200 females between the ages of 18 and 30 years, with documented evidence of PCOS in the study. Further 200 females without PCOS were enrolled as the case group. After demographics were noted, blood was drawn from their cubital vein via phlebotomy and sent to the laboratory to assess for thyroid-stimulating hormone, free thyroxine, and free triiodothyronine. RESULTS: SCH was found to be more prevalent in participant with PCOS compared to participants without PCOS (43.5% vs. 20.5%; p-value: <0.00001). Increased weight (65.12 ± 5.62 kg vs. 60.02 ± 4.41 kg; p-value: <0.0001) and BMI (25.12 ± 2.51 kg/m2 vs. 22.51 ± 2.01 kg/m2; p-value: <0.0001) was significantly more in participants with PCOS compared to participants without PCOS. CONCLUSION: Based on our findings, this study demonstrated the strong association of SCH in women with PCOS as compared to their normal counterparts. Therefore, the clinical implication is to maintain a high index of suspicion for signs and symptoms of SCH, and awareness is needed for such women to enhance the reproductive and clinical pregnancy outcomes.

Long-Term Neurological Impact of COVID-19.

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

Comparison of 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.

Comparison of Sacubitril/Valsartan Versus Enalapril in the Management of Heart Failure.

Background and objective The recent emergence of new molecules like angiotensin receptor-neprilysin inhibitor (ARNI) has highlighted the need for an update in heart failure (HF) management, as they have proven to yield better patient outcomes compared to the traditional angiotensin-converting enzyme inhibitor/angiotensin II receptor blocker (ACEI/ARB) use. This study aimed to compare HF-related hospitalization and death in patients on either ACEI/ARBs or ARNI in a local setting. Methods This two-arm interventional study was conducted in the cardiology and internal medicine units of a tertiary care hospital in Pakistan from July 2018 to December 2020. After enrollment, participants were randomized into two groups as per 1:1 ratio using an online research randomizer software (https://www.randomizer.org). Group A received 24/26 or 49/51 mg sacubitril/valsartan twice daily for HF. Group B received 2.5 or 5 mg enalapril twice daily. Patients were followed up for 12 months or till the development of an event. Results The sacubitril/valsartan group had significantly fewer HF-related hospitalizations compared to the enalapril group (13.8% vs. 22.4%; p-value: 0.03), with a relative risk reduction (RRR) of 38.3%. The sacubitril/valsartan group had 52% RRR for HF-related deaths compared to the enalapril group. Conclusion Based on our findings, treatment with sacubitril/valsartan was superior to enalapril in reducing the risk of hospitalization and death related to HF. The magnitude of the beneficial effects of sacubitril/valsartan as compared to enalapril on cardiovascular mortality was at least as high as that of long-term treatment with enalapril.

Peripheral Artery Disease as a Risk Factor for Myocardial Infarction.

INTRODUCTION:  Atherosclerosis contributes to the underlying pathophysiology for peripheral arterial disease (PAD), coronary artery disease (CAD), and cerebrovascular disease. Several studies have been conducted to demonstrate PAD as a major risk factor for cardiovascular (CV) events, however, the regional data are limited. This study aims to highlight PAD as a major risk factor in CV events in a local setting. METHODS:  In this longitudinal study, 400 hypertensive patients with a confirmed diagnosis of PAD were enrolled from the outpatient department of the cardiology unit. Diagnosis of PAD was made using the ankle brachial index (ABI). ABI less than 0.9 was labeled as participants with PAD. Another group of 400 without PAD was also enrolled as the control group from the outpatient department of cardiology unit. Patients were followed up for 12 months or for the development of myocardial infarction (MI). RESULT:  Participants with PAD had a significant increased risk of total MI events with a relative risk (RR) of 1.67 (confidence interval, CI 95%: 1.05-2.66; p-value: 0.02). The RR for fatal MI was 2.62 (CI 95%: 0.94-7.29; p-value: 0.06) compared to the participants without PAD, however, it was not significant. CONCLUSION:  This study has focused on the risk factors of PAD and has suggested that the patients who have any of the mentioned risk factors should be treated with caution under strict instructions given by doctors. A variety of treatment options is available, but the initial changes should be made in the lifestyle of these patients, making sure the risk factors are being treated.

Peripheral Artery Disease as a Predictor of Coronary Artery Disease in Patients Undergoing Coronary Angiography.

Background Peripheral artery disease (PAD) may be a useful tool to predict coronary artery disease (CAD) in patients undergoing coronary angiography. If proven that PAD can be a good predictor of CAD, it can help in early and cost-effective diagnosis of CAD. Methodology This observational study was conducted from January 2020 to February 2021 in the cardiology unit of a tertiary care hospital. Participants older than 40 years, with a history of uncontrolled hypertension and unstable angina, who warranted the need of angiography were enrolled in study. After enrollment and recording history, these cases were assessed for the presence of PAD based on ankle brachial index (ABI). ABI values less than 0.9 were labelled as participants with PAD. Then these cases underwent coronary angiography at the same institute, and the presence of greater than 50% stenosis of any coronary vessel on angiography was taken as positive CAD. Results In this study, PAD was identified in 152 (62.8%) participants. A total of 165 (68.1%) participants had greater than 50% stenosis on angiography. Out of 152 participants with ABI less than 0.9, 140 had greater than 50% stenosis on angiography. In total, 90 participants had ABI more than 0.9, of which 35 participants had greater than 50% stenosis. Sensitivity of PAD in predicting coronary artery stenosis was 80.0% (95% confidence interval [CI]: 73.30%-85.66%), specificity was 82.09% (95% CI: 70.80%-90.39%), and accuracy was 80.58% (95% CI: 75.02%-85.37%). Conclusions Our study demonstrated that the sensitivity, specificity, and accuracy of PAD in predicting coronary artery stenosis were significant. Hence, we conclude that PAD can be an excellent predictor of CAD by helping in early and cost-effective diagnosis of CAD.

Effect of Cigarette Smoking on Hearing Levels in Young and Middle-Aged Males.

INTRODUCTION: Smoking is a well-recognized risk factor for many health issues; however, its association with hearing loss has been a debate. Some studies have shown a positive association while others did not. In this study, we aim to identify the effect of cigarette smoking on hearing in our population. METHODS: This cross-sectional study was conducted in a tertiary care hospital in Pakistan from August 2020 to March 2021. Five hundred male smokers (n = 500), with a history of smoking for more than three years between the ages of 21 and 50, were enrolled in the study via consecutive convenient non-probability sampling after informed consent. Five hundred male non-smokers (n = 500) were enrolled as a reference group. Audiometry was performed in a soundproof room. RESULTS: The hearing levels in audiometry were significantly higher in smokers compared to non-smokers (22.8 ± 8.12 decibels vs 18.7 ± 6.12; p-value < 0.0001). Participants who had been smoking for more than 10 years had higher hearing levels in the audiometry test compared to the participants with less than 10 years of smoking history (24.21 ± 8.91 decibels vs. 21.1 ± 8.01 decibels: p-value < 0.0001). CONCLUSION: In this study, smokers were associated with greater loss in hearing compared to non-smokers. In addition to other adverse events associated with smoking, smokers should be counselled about hearing loss related to it.

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

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

Frequency of Psychiatric Disorders in Suicide Attempters: A Cross-Sectional Study from Low-Income Country.

INTRODUCTION: In Pakistan, due to legal and religious association, cases of attempted suicides are underreported in Pakistan, yet it is essential to have accurate data so that the causality leading to this national tragedy can be studied and minimized. Psychiatric disorders leading to suicide is largely neglected and under-researched in Pakistan. In this study, we aim to observe the frequency of psychiatric disorders among suicide attempters, which can help the doctors to counsel and treat the patients better and devise preventive strategies. METHOD: In this cross-sectional survey, patients brought to emergency with attempted suicide were enrolled in the study, after taking informed consent from the attendant. After initial treatment, the patient's clinical history was sought via a General Health Questionnaire-28. Once recognized, participants underwent detailed psychiatric evaluation and mental state examination. RESULTS: Three hundred and fifty-two (352) patients were brought to the emergency with attempted suicide, of which 249 (70.7%) patients were identified with psychiatric morbidity. The most common psychiatric disorders were mood disorder (32.1%), comorbid psychiatric disorder (20.4%), and anxiety disorders (18.4%). Our study also showed that the prevalence of comorbid psychiatric disorders was significantly higher in females as compared to males, whereas substance use disorder was more common in males. CONCLUSION: The suicide rate has increased globally due to associated psychiatric disorders. Patients inflicting self-harm or failing at suicidal attempt are inclined towards attempting suicide in future. However, the social stigma associated with psychiatric disorders has heavily affected the process of successfully identifying and treating such patients. Along with focused long-term treatment, follow-up, and enhanced surveillance programs, mass awareness campaigns should be conducted to improve the knowledge and outlook of the general population towards psychiatric disorders.