Endoscopic Therapy of Gastric Varices: Safety and Efficacy of N-Butyl-2-Cyanoacrylate Injection.

Background Upper gastrointestinal bleeding (UGIB) is a common medical emergency that results in significant morbidity, mortality, and socioeconomic burden. Both types of cardio-fundal varices, gastro-esophageal varix 2 (GOV2) and isolated gastric varices type 1 (IGV1), can cause massive bleeding and often are difficult to treat compared to the other types of gastric varices. Endoscopic variceal band ligation (EVBL) is a less effective treatment modality for gastric varices than esophageal varices and is associated with high re-bleeding rates. N-butyl-2-cyanoacrylate (Histoacryl) injection is an effective and potential treatment option for fundal varices. This study aims to evaluate the safety and efficacy of n-butyl-2-cyanoacrylate injection therapy in cardio-fundal varices. Objective To assess the efficacy and safety of n-butyl-2-cyanoacrylate injection therapy for fundal varices. Methods This retrospective observational cohort study was conducted at the Department of Gastroenterology, Allied Teaching Hospital, Gujranwala, over one year. All patients, irrespective of age and gender, presenting with UGIB and in whom fundal varices were diagnosed on gastroscopy followed by n-butyl 2-cyanoacrylate injection therapy were included in this study. The efficacy and safety of Histoacryl therapy were assessed by analyzing successful hemostasis, frequency of re-bleeding, obliteration, and regression of fundal varices on repeat endoscopy. Adverse events such as re-bleeding and mortality related to fundal variceal treatment were documented. Results A total of 60 patients were included in the study. Of these, 70% had IGV1, while the remaining 30% had GOV2. Hemostasis was achieved in 100% of patients following n-butyl-2-cyanoacrylate injection. Successful obliteration with regression of varices was observed in 91.3% of patients. Various adverse events were observed, with abdominal pain being the most common observed complication in 18.3% of participants. However, only 8.3% of participants developed re-bleeding due to ulcer formation at the injection site, and no death occurred directly due to fundal variceal treatment. Conclusion N-butyl-2-cyanoacrylate injection therapy is a lifesaving, effective, and safe intervention for controlling bleeding from cardio-fundal varices, leading to improved health status and a consequent decrease in episodes of recurrent bleeding. Its side effects are few and infrequent. However, larger-scale studies are needed to further evaluate the safety and effectiveness of n-butyl-2-cyanoacrylate injection therapy. These studies will be crucial in establishing comprehensive guidelines for the management of fundal varices.

Association of Metabolic Dysfunction-Associated Steatotic Liver Disease/Non-alcoholic Fatty Liver Disease With Type 2 Diabetes Mellitus: A Case-Control Study in a Tertiary Care Hospital in Pakistan.

Background Type 2 diabetes mellitus (T2DM) is a chronic metabolic disorder characterized by high blood sugar levels, insulin resistance, and relative insulin deficiency. Metabolic dysfunction-associated steatotic liver disease (MASLD) is the term used to describe fatty liver (steatosis) in individuals without a history of significant alcohol intake. MASLD is progressively known as the leading cause of chronic liver disease. Dietary factors, a significant risk factor for developing T2DM and cardiovascular disease, also contribute to MASLD development. The risk of developing MASLD increases with age, particularly in patients with diabetes mellitus. This risk is notably elevated among South Asians due to their higher incidence of insulin resistance and metabolic syndrome. Importantly, MASLD is acknowledged as a component of the metabolic syndrome, with insulin resistance playing a central role in its development. Objective To determine the association between MASLD and T2DM in patients presenting at a tertiary care hospital in Pakistan. Methodology This case-control study was conducted for one year in a tertiary care hospital in Gujranwala, Pakistan. A total of 380 patients were enrolled through convenient sampling and were analyzed according to two groups: those with diabetes (case) and those without diabetes (control). All participants were assessed for serum aspartate transaminase (AST) and alanine transaminase (ALT) levels and underwent abdominal ultrasound to determine hepatic fibrosis. A diagnosis of MASLD was made only in the presence of hepatic steatosis with AST and ALT values of more than 40 IU. The odds ratio (OR) was calculated, and stratified analysis was conducted according to gender, age, and BMI. A p-value of ≤0.05 was considered statistically significant. Results In our study, 55.53% of patients were male, while 44.47% were female. The average BMI (±SD) of the patients was 23.66±3.08 kg/m2. Among the cases group, the MASLD was noted in 91 (47.9%) patients, while among the controls group, the MASLD was noted in 64 (33.7%) patients with a statistically significant OR of 1.810 (1.19-2.74). Conclusion In conclusion, MASLD is significantly associated with T2DM, regardless of gender and BMI of patients. We recommend screening T2DM patients for the presence of MASLD at regular intervals to prevent hazardous consequences of MASLD in adult populations, particularly those with features of metabolic syndrome. Further larger-scale studies investigating the impact of T2DM on MASLD are required to reduce morbidity and decrease disease burden, especially in prevalent areas.

Prophylactic Antibiotics in Hip Fracture Surgery: A Randomized Prospective Study.

Introduction Hip fracture surgeries constitute a large portion of orthopedic surgeries, and infective complications are one of the most severe and devastating sequels following fixations or replacements. Preoperative antibiotic prophylaxis is an important means to control SSI. Thus, we set out to assess the impact of a single dose versus three doses of antibiotics on surgical site infections in patients undergoing hip surgery. Materials and methods A randomized controlled trial was conducted at the Department of Orthopaedics, The Indus Hospital, Karachi, Pakistan. All patients admitted for hip fracture surgery who met the inclusion criteria were enrolled and divided into two groups. One group (Group A) was given a single dose of antibiotics preoperatively, and the other (Group B) was given three doses, one preoperatively and two postoperatively. Patients were assessed for wound condition and signs of infection. Data were entered and analyzed using SPSS version 21.0. The chi-square test was applied to assess the significant association between both the groups and SSI. A significant statistical association was noted when the P value was found to be <0.05. Results The study included 62 patients, with the majority of them being females (n=33; 53.2%). The mean age of the patients was 60.5±15.1 years. Only three (4.8%) patients developed SSI. No statistically significant association was detected between surgical site infections and the two antibiotic regimens being administered after controlling for the confounders. Conclusion There was no statistical relationship between surgical site infections with a single dose versus three doses of antibiotics in patients undergoing hip surgery.

Prevalence of low back pain among medical doctors of the teaching hospitals in Karachi, Pakistan: A cross-sectional survey.

Objective: Our goal was to deduce the prevalence of low back pain among medical doctors in the teaching hospitals of Karachi, Pakistan, along with its associated variables and the functional disability accompanying it. Methods: This cross-sectional study was conducted among medical doctors from Creek General Hospital and United Hospital, affiliated with United Medical and Dental College, Karachi, Pakistan. A sample of 80 participants was included in this study, and a non-probability convenient sampling with randomization was utilized. Using a three-part questionnaire that included the Oswestry Disability Index, all participants were scrutinized for low back pain with its characteristics, associated risk factors, and functional disability. Results: Seventy percent of medical doctors included in this study suffered from the problem of low back pain, with 68% experiencing it over the last 3 months to 1 year. Furthermore, 89% and 11% suffered from minimal and moderate disability, respectively, affecting day-to-day and work life. Moreover, this study also found a significantly positive association (p value < 0.05*) of low back pain with age and work-related characteristics and was more common in those with work experience between 1 and 10 years, >8 working hours, >4 standing hours, and belonging to the surgery and medicine specialties. The association was significantly positive according to the chi-square/Fischer exact test. Conclusion: Our study addressed the evidence that low back pain is prevalent among medical doctors in teaching hospitals in Karachi, Pakistan, potentially affecting patient treatment and student education and accentuating the need for further intervention and research among doctors worldwide.

Caroli's Syndrome: A Case Report and Literature Review.

Synonymous with congenital non-obstructive saccular or fusiform intra-hepatic duct dilatation and congenital communicating cavernous ectasia of the intra-hepatic biliary tract, Caroli's syndrome (CS) is an extremely rare fibro-polycystic liver disorder characterized by ductal plate malformation and consequent peri-portal fibrosis due to segmental intra-hepatic duct dilatation. No more than 200 cases of the syndrome have been reported since 1958. CS may affect one or both lobes of the liver, but more commonly it affects the left hepatic lobe. We describe a rare case of CS localized to the right hepatic lobe in a 21-year-old male, who presented with complaints of upper gastrointestinal (GI) bleeding without any signs or stigmata of chronic liver disease. Personal as well as family history was non-significant except positive for consanguineous parental marriage. General physical examination was unremarkable except for pallor, and upper GI endoscopy revealed columns of bandable esophageal varices which led us to a line of investigations to identify the cause of portal hypertension. Blood tests were non-specific, though imaging studies chiefly abdominal ultrasound, CT abdomen and pelvis with contrast, and magnetic resonance cholangiopancreatography (MRCP) led us to confirmation of the diagnosis of CS in the right hepatic lobe with manifestations of portal hypertension as the predominant feature. Diagnosis was confirmed on liver biopsy which showed right-sided cystic dilations with congenital hepatic fibrosis.

Wound closure after total knee replacement: Comparison between staples and sutures.

Background and Objective: Total Knee Arthroplasty is a commonly performed procedure for arthritic knees. Preventing complications is of utmost importance for good functional outcomes and preventing morbidity. Wound closure after the procedure is as important as the replacement aspect of surgery.The objective of this study was to provide subjective and objective evidence of better closure technique and material; we conducted the study so that the outcome of TKA can be further improved. Methods: We conducted a randomized trial at The Indus Hospital, Karachi, from December 2018 to June 2020. All patients from age 40 to 70 years who underwent total knee arthroplasty were included in the study. The wound of one knee was closed with Polypropylene (Prolene) sutures, and the other with staples. The wound was assessed independently by two assessors using Hollander's score; lower score means a worse outcome. All data was entered and analyzed using STATA version 16. Results: Thirty patients who underwent bilateral total knee replacement were included in the analysis, among which 71.8% were female. The average age of participants was 57.3 (± 7.5) years. The mean incision length on the right knee was 17.6 ± 1.1 cm, while on the left the incision length was 18.3 ± 1.2 cm. Overall, the mean Hollander score was significantly different among participants in the sutures and staples group in both the right (p-value=0.001) and left knees (p-value=0.001). The score was significantly higher in knees closed with sutures as compared to staples. Also, the mean Hollander score is significantly higher in females than males in both the right knee (B=0.56, p-value=0.049) and the left knee (B=0.38, p-value=0.044). Conclusion: The study has shown that Hollander's score was significantly higher in knees closed with sutures as compared to the patients in whom staples were used for wound closure.

Serum Vitamin D Levels in Patients With Distal Radius Fractures Presenting to a Tertiary Care Hospital.

Objective To compare the frequency of serum vitamin D levels in patients with and without distal radius fracture. Introduction Hypovitaminosis D is a common problem worldwide. Deficiency of vitamin D is not only associated with musculoskeletal problems, but also with chronic diseases like diabetes mellitus, cardiovascular disease and cancer. Vitamin D deficiency results in bone pain, aggravating osteoporosis and fragility fractures. Distal radius fractures are common upper limb fractures, mostly in the elderly population. Low serum levels of vitamin D have been reported to result in increased risk of distal radius fracture. Methodology This study was conducted at The Indus Hospital Karachi, from 1st March 2020 to 31st August 2020. Consecutive non-probability sampling was done. Patients aged between 20 to 80 years with and without distal radius fractures were enrolled and serum vitamin D levels were compared. Results A total of 130 patients were enrolled in this study, out of which 70 (53.8%) were males. The median (IQR) vitamin D, calcium, alkaline phosphate level, and albumin was 14.8 (9.5-23) ng/ml, 9.2 (8.9-9.5) ng/ml, 91 (77.3-111) U/L, and 4.2 (4-4.5) g/dl, respectively. No significant association between distal radius fracture and vitamin D levels was found in males, whereas a significantly higher proportion of females with no fracture had a mild-moderate deficiency in comparison to females with fracture. Conclusion No significant association was noted between patients with and without distal radius fracture and vitamin D levels, however, we recommend more studies on this topic so that more comprehensive results can be obtained.

Frequency of Vertebral Fractures in Patients presenting with Hip Fractures.

OBJECTIVE: To determine the frequency of vertebral fractures in patients presenting with hip fractures. METHODS: This prospective study was conducted at The Indus Hospital, Karachi, from May 2018 to November 2018. All patients above 40 years presenting with hip fractures were enrolled and a dorsal lumbar lateral view radiograph was obtained to investigate for vertebral fractures. Data was entered and analyzed using SPSS. Post-stratification, Chi-square/Fisher exact test was applied as appropriate to assess the significant association. P value of ≤0.05 was considered significant. RESULTS: Three hundred thirty five patients were enrolled. Of these, 189 (56.4%) were females and 165 (49.3%) presented with neck of femur fractures. Out of 335 hip fractures patients, 77 (23%) were found to have concomitant vertebral fractures, with 73 (96.1%) having a compression fracture. T12 was the most common vertebra involved and 68.8% of patients were asymptomatic. Co-morbid conditions were statistically significantly associated with vertebral fractures. CONCLUSION: There is a high prevalence of asymptomatic vertebral fractures in our population, but low compared to studies from western countries. There is a need to evaluate these fractures separately for the prevention of morbidity and mortality.

Burnout among gynaecological residents in Lahore, Pakistan: A cross-sectional survey.

OBJECTIVE: To determine the prevalence of burnout among gynaecological residents and factors associated with it. METHODS: This cross-sectional study was performed at the University Medical and Dental College, Faisalabad, Pakistan, from March to April 2016, and comprised female medical students. Participants were divided into groups on the basis of their ABO blood groups and on body mass index criteria. Blood groups were determined by simple conventional slide method. Blood pressure was estimated by manual auscultatory technique with a mercury sphygmomanometer. Data was analysed usingSPSS20. RESULTS: Of the 102 participants, 57(55.9%) were satisfied after choosing gynaecology as career. It was found that emotional exhaustion and depersonalisation were significantly higher among residents working in government institutions than private institutions (p<0.05). Those having more than 2 years of post-graduate experience had significantly higher depersonalisation than those with lesser experience (p=0.016). Also, working for 50-60 hours/week and feeling dissatisfied with the specialty were associated with significantly higher emotional exhaustion and depersonalisation (p<0.05). CONCLUSIONS: Burnout was highly prevalent among gynaecological residents.

Occupational hazards, illness and injuries faced by child labourers.

OBJECTIVE: To assess hazards, injuries and illnesses faced by child labourers in their working environment. METHODS: The cross-sectional study was conducted in a squatter settlement in Sultanabad, Karachi, in January and February, 2011. A total of 190 children, aged 9-14 years were interviewed through structured pre-tested questionnaire at their workplaces. They were asked about their health, illness, working hours, frequency of work related illness, frequency and severity of injuries they received during work and various other associated factors. SPSS 17 was used for statistical analysis. RESULTS: The mean age of the children was 12.60 +/- 1.47 years. Of the total, 140 (78.4%) said they had got injured while working during preceding 3 months; 64 (33.7%) had high frequency of injuries; 13 (6.8%) had severe and 59 (30.6%) had moderate type of injuries; 114 (60.0%) said their illness was 'sometimes' work-related or due to the working environment; 159 (83.2%) were unaware of the occupational hazards they were facing; and 142 (74.7%) had no adult supervision at work. A significant association was found between the occupational related illnesses and the working environment of the participants (p = 0.03). CONCLUSION: Majority of the child labourers were found to be facing unsafe working conditions, and encountered frequent work-related injuries and illnesses.

Informed consent, privacy and confidentiality practised by doctors of a tertiary care hospital in a developing country.

BACKGROUND: This aim of this study was to assess the degree to which the doctors of a public sector hospital in Karachi adhere to medical ethics during their consultations. MATERIAL AND METHODS: A cross-sectional study was conducted in Civil Hospital, Karachi, Pakistan, during April-June 2010. 337 patients from Out Patients Departments (OPDs) and wards were recruited through consecutive sampling. A pre-tested structured questionnaire was administered to the participants and they were asked about their demographic profile, and their doctor's practices regarding obtaining informed consent, respecting privacy and confidentiality, and treatment modalities. Written informed consent was taken from all the participants. Data was analysed using SPSS version 16.0, and a p-value of < 0.05 was considered as statistically significant. RESULTS: The mean age of the study population was 38.4 ± 15.0 years. There was an equal ratio of males and females. Our study showed that informed consent was obtained from 66.4% of patients. 56.9% of patients responded that they were not informed about the side effects of the prescribed medicines. 74% females were satisfied with the privacy maintained during the consultation. 64.8% were assured of the confidentiality of their information. Regarding advertisement by doctors, 46.5% of patients said it should be done. CONCLUSION: There has been a marked improvement as compared with the previous practices of biomedical ethics by the doctors of this public sector hospital. However, awareness sessions should be conducted to update / improve the knowledge of ethics among doctors to help them translate their knowledge into practice.

Factors affecting outpatient cardiac rehabilitation attendance after acute myocardial infarction and coronary revascularization--a local experience.

OBJECTIVE: To determine factors affecting cardiac rehabilitation attendance after myocardial infarction and coronary revascularization. METHODS: A cross-sectional study was conducted on 416 patients admitted in Tabba Heart Institute, Karachi from December 2010 to May 2011. Patients admitted with diagnosis of acute myocardial infarction (AMI) or who underwent elective coronary artery bypass graft surgery (CABG) or percutaneous coronary intervention (PCI) procedures were offered cardiac rehabilitation (CR). Out of these, patients who enrolled in 6 weeks outpatient CR programme were followed for number of CR sessions and their socio-demographic and clinical data were collected. Data was analyzed by Statistical Package for Social Sciences (SPSS) software, version 15.0. Chi-square test was applied to test association between categorical variables and Student's t-test for continuous variables. RESULTS: Out of 416 patients identified, only 151 patients (36.2%) enrolled and attended the CR programme. Of the 151 attendees, 111 (73.4%) patients subsequently completed more than 6 weeks of outpatient CR programme. We found significant association between CR attendance and easy access to the programme, elective CABG procedure, employment status, presence of diabetes or hypertension and baseline level of exercise (all p < or = 0.01). No association was found between CR attendance and patient age, gender, body mass index or different economic groups. CONCLUSION: Attendance rates of patients attending outpatient CR programme after AMI or coronary revascularization procedures are suboptimal. Patients who underwent elective CABG surgery and had easy access to the CR programme had better attendance. Factors contributing to poor attendance rates at CR programmes in developing countries need to be explored and subsequently addressed.