Aetiology, presentation and outcomes of patients presenting with acute pancreatitis in a tertiary care hospital.

Acute pancreatitis (AP) is a multi-causal disease with a high rate of hospita lisation. Only a few cl inical stud ies have i nvestig ated the aetiologic al backgroun d, sever it y, and outcome of AP in Pakistan. Hence, this study was carried out to determine the aforementioned factors and correlate them w ith outcomes in a tert iary care set ting. This was a cros s -sec tional, retrospective study conducted at the Department of Gast roe nterolo gy, Aga Khan University Hospita l, Karachi, from Januar y 1, 2022, to December 31, 2022. Data was analysed using statis tical s oftware SPSS version 25. Vomiting was th e predominant presenting complaint and was seen in 139 (78.5%) patients. Gallstones were the predominant cause in 68 (37%) patients, followed by idiop athic panc reatitis in 22 (12%) p atients. Thirteen (7.1 % ) pat ients expire d. Patients with syst emi c complications were lik ely to suffer fro m severe disease (p=0.0 2), whereas those with lo cal complications were at an increa sed ris k of mor tal it y (p=0.04). Due to lac k of diagnostic facilities, the aetiology of a large number of AP cases remains unknown.

Systemic lupus erythematosus presenting with pneumoperitoneum without evidence of pneumatosis cystoides intestinalis-when not to operate-a case report.

Pneumoperitoneum in patients with systemic lupus erythematosus is commonly recognized as a surgical emergency that requires exploration. However, it may not be associated with bowel perforation and may be a benign disease manifestation. We present a case of a young patient who developed spontaneous pneumoperitoneum after pulse steroid therapy for lupus enteritis and was successfully managed conservatively. Patients with connective tissue disease may present with pneumoperitoneum, with or without pneumatosis cystoides intestinalis. Therefore, a detailed clinical history, thorough clinical examination, and laboratory parameters should be evaluated before proceeding with surgical intervention. A conservative approach may be attempted in patients with spontaneous pneumoperitoneum, and surgery should only be considered if clinical deterioration occurs.

Short-term Outcomes of Elective Abdominal Aortic Aneurysm Repair.

OBJECTIVE: To evaluate the presentations, aetiologies, and outcomes (survival and morbidity) of patients who underwent abdominal aortic aneurysm (AAA) repair at a tertiary care centre in a low middle-income country (LMIC). STUDY DESIGN: Case-series study. Place and Duration of the Study: Section of Vascular Surgery, Department of Surgery, The Aga Khan University Hospital, Karachi, Pakistan, from January 2000 till April 2022. METHODOLOGY: All patients who underwent elective open repair for AAA were identified using ICD coding 10. Patients' demographics, presentations, treatment options, and outcomes were recorded on a specially designed proforma. Outcomes were measured in terms of 30-day survival and perioperative complications. RESULTS: Forty-two patients were included in the study. Thirty-nine (92.9%) of them were males. The mean age was 63.8 + 12.6 years. Thirty-four (81%) patients had an infrarenal aortic aneurysm. The average aneurysm diameter was 8.0 + 2.73 cm. The in-hospital survival rate was 95.2% whereas 2 (4.8%) patients had in-hospital mortality. Acute kidney injury (AKI) was the most common complication, seen in 5 (11.9%) patients. Adverse outcomes were seen more in diabetic patients whereas increased incidence of AKI was noted in operations with supra-renal clamping (p<0.05). CONCLUSION: Most patients presented with symptoms and large aneurysm size. Open AAA repair was performed safely with 4.8% in-hospital mortality and acceptable morbidity in the LMIC setting. KEY WORDS: Abdominal aortic aneurysm repair, Low middle-income country.

Managing Splenic Artery Pseudoaneurysms-An Experience from a Developing Country. A Retrospective Review.

Objectives: Splenic artery pseudoaneurysm is a rare but potentially fatal condition. Early diagnosis and intervention are the key steps in the management of this condition. We have reviewed our institution's 4-year data regarding the presentation and management of this condition. Methods: We conducted a prospective review of the records of 10 patients who presented to our institute from January 2018 to December 2021 with a splenic artery pseudoaneurysm. We found one patient with a true aneurysm, whom we excluded from the study. Results: This study included seven male and two female patients with a mean age of 47.7 years. Six patients presented to the emergency department with bleeding secondary to rupture aneurysm, which is the most common reason for admission. Pancreatitis was found to be the most common cause for splenic artery pseudoaneurysm (five patients). Computed tomography angiogram remained the modality of choice for diagnosing splenic artery pseudoaneurysm. All patients were successfully managed with endovascular intervention. Conclusion: Splenic artery pseudoaneurysm is usually a rare complication of pancreatitis, which is associated with high morbidity and mortality. Timely diagnosis and intervention are the keys to successful management. Endovascular embolization should be the first-line therapy in splenic artery pseudoaneurysm.

Concurrent Pacemaker Lead Perforation and Subacute Coronary Stent Thrombosis: A Case Report.

Stent thrombosis and lead perforation are important differentials for patients presenting with chest pain following recent coronary stent insertion and pacemaker insertion. In this report, we describe an unusual case of a 78-year-old male who presented with sharp chest pain one week after admission for posterior ST-elevation myocardial infarction (STEMI) and subsequent Mobitz type II block, for which he received primary percutaneous coronary intervention (PPCI) to the left circumflex artery (LCx) and dual chamber permanent pacemaker (PPM) insertion. Computed tomography (CT) chest and CT coronary angiogram (CTCA), respectively, showed he had concurrent lead perforation and stent thrombosis. On balance, the cause of chest pain was likely lead perforation. This diagnosis was reached by having a high index of suspicion for both of these important post-procedure complications and investigating appropriately.

Gut-brain axis dysfunction underlies FODMAP-induced symptom generation in irritable bowel syndrome.

BACKGROUND: FODMAPs produce similar small bowel water and colonic gas in patients with irritable bowel syndrome (IBS) and healthy controls (HCs), despite IBS patients reporting increased gastrointestinal (GI) symptoms. AIM: To unravel the mechanisms underlying FODMAP-induced symptom reporting, we investigated gut and brain responses to fructan administration in IBS patients and HC. METHODS: This randomised, double-blind, cross-over study consisted of three visits where fructans (40 g/500 mL saline), glucose (40 g/500 mL saline) or saline (500 mL) were infused intragastrically during 1 h MR brain scanning; abdominal MRI was performed before, 1 h, and 2 h post-infusion. Symptoms were rated using validated scales. RESULTS: In IBS (n = 13), fructans induced more cramps, pain, flatulence and nausea compared to glucose (P = 0.03, 0.001, 0.009 and <0.001 respectively), contrary to HC (n = 13) (all P > 0.14), with between-group differences for cramps and nausea (P = 0.004 and 0.023). Fructans increased small bowel motility and ascending colonic gas and volume equally in IBS and HC (between-group P > 0.25). The difference in colonic gas between fructans and saline covaried with differences in bloating and cramps in IBS (P = 0.008 and 0.035 respectively). Pain-related brain regions responded differentially to fructans in IBS compared to HC, including the cerebellum, supramarginal gyrus, anterior and midcingulate cortex, insula and thalamus (pFWE-corrected  < 0.05); these brain responses covaried with symptom responses in IBS. CONCLUSIONS: Fructans increase small bowel motility and colon gas and volume similarly in IBS patients and HC. Increased symptom responses to fructans in IBS covary with altered brain responses in pain-related regions, indicating that gut-brain axis dysregulation may drive FODMAP-induced symptom generation in IBS.

Behavioral and Cognitive Response to Selective Serotonin Reuptake Inhibitors in Frontotemporal Lobar Degeneration: A Systematic Review and Meta-analysis.

OBJECTIVE: This article systematically reviews current literature on the efficacy and efficiency of selective serotonin reuptake inhibitors (SSRIs) in the treatment of patients with frontotemporal lobar degeneration (FTLD), with a particular focus on behavior and cognitive functions. METHODS: A search was performed according to the Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines using CENTRAL, MEDLINE, and Cochrane Library databases. Eleven randomized controlled trials and open-label studies looking at the effects of SSRIs on FTLD patients were included. A random-effects meta-analysis was performed, consisting of 3 randomized and controlled studies that used the neuropsychiatric inventory to assess SSRI intervention. RESULTS: The meta-analysis shows a combined mean reduction of 10.17 points (95% confidence interval, 18.14-2.19; P = 0.01) on the neuropsychiatric inventory with SSRI treatment in FTLD patients. The I2 calculated for this study was 62% (P = 0.07), which represents moderate heterogeneity among the studies. The Egger regression test (P = 0.526) did not show a publication bias. Sensitivity analysis showed no significant change. CONCLUSIONS: The current meta-analysis supports SSRIs as an intervention for management of behavioral symptoms of FTLD. Marked improvements were seen in disinhibition, irritability, aggression, and aberrant motor activity across studies. However, apathy/loss of empathy did not show similarly promising results. A deteriorative effect on cognition was seen associated with SSRI use.

Clinical Characteristics, Management Strategies and Outcomes of Acute Myocardial Infarction Patients With Prior Coronary Artery Bypass Grafting.

OBJECTIVE: To investigate the management strategies, temporal trends, and clinical outcomes of patients with a history of coronary artery bypass graft (CABG) surgery and presenting with acute myocardial infarction (MI). PATIENTS AND METHODS: We undertook a retrospective cohort study using the National Inpatient Sample database from the United States (January 2004-September 2015), identified all inpatient MI admissions (7,250,768 records) and stratified according to history of CABG (group 1, CABG-naive [94%]; group 2, prior CABG [6%]). RESULTS: Patients in group 2 were older, less likely to be female, had more comorbidities, and were more likely to present with non-ST-elevation myocardial infarction compared with group 1. More patients underwent coronary angiography (68% vs 48%) and percutaneous coronary intervention (PCI) (44% vs 26%) in group 1 compared with group 2. Following multivariable logistic regression analyses, the adjusted odd ratio (OR) of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.98; 95% CI, 0.95 to 1.005; P=.11), all-cause mortality (OR, 1; 95% CI, 0.98 to 1.04; P=.6) and major bleeding (OR, 0.99; 95% CI, 0.94 to 1.03; P=.54) were similar to group 1. Lower adjusted odds of in-hospital major adverse cardiovascular and cerebrovascular events (OR, 0.64; 95% CI, 0.57 to 0.72; P<.001), all-cause mortality (OR, 0.45; 95% CI, 0.38 to 0.53; P<.001), and acute ischemic stroke (OR, 0.71; 95% CI, 0.59 to 0.86; P<.001) were observed in group 2 patients who underwent PCI compared with those managed medically without any increased risk of major bleeding (OR, 1.08; 95% CI, 0.94 to 1.23; P=.26). CONCLUSIONS: In this national cohort, MI patients with prior-CABG had a higher risk profile, but similar in-hospital adverse outcomes compared with CABG-naive patients. Prior-CABG patients who received PCI had better in-hospital clinical outcomes compared to those who received medical management.