Incidence, implications and predictors of abdominal compartment syndrome in acute pancreatitis: A nationwide analysis.

BACKGROUND: Acute pancreatitis (AP) often presents with varying severity, with a small fraction evolving into severe AP, and is associated with high mortality. Complications such as intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS) are intricately associated with AP. OBJECTIVE: To assess the clinical implications and predictors of ACS in AP patients. METHODS: We conducted a retrospective study using the National Inpatient Sample (NIS) database on adult AP patients, further stratified by the presence of concurrent ACS. The data extraction included demographics, underlying comorbidities, and clinical outcomes. Multivariate linear and logistic regression analyses were performed using STATA (v.14.2). RESULTS: Of the 1,099,175 adult AP patients, only 1,090 (0.001%) exhibited ACS. AP patients with ACS had elevated inpatient mortality and all major complications, including septic shock, acute respiratory distress syndrome (ARDS), requirement for total parenteral nutrition (TPN), and intensive care unit (ICU) admission (P < 0.01). These patients also exhibited increased odds of requiring pancreatic drainage and necrosectomy (P < 0.01). Predictor analysis identified blood transfusion, obesity (BMI ≥30), and admission to large teaching hospitals as factors associated with the development of ACS in AP patients. Conversely, age, female gender, biliary etiology of AP, and smoking were found less frequently in patients with ACS. CONCLUSION: Our study highlights the significant morbidity, mortality, and healthcare resource utilization associated with the concurrence of ACS in AP patients. We identified potential factors associated with ACS in AP patients. Significantly worse outcomes in ACS necessitate the need for early diagnosis, meticulous monitoring, and targeted therapeutic interventions for AP patients at risk of developing ACS.

Nonvariceal upper gastrointestinal bleeding in COVID-19 patients: insights from the National Inpatient Sample.

BACKGROUND: This retrospective study, conducted using the U.S. National Inpatient Sample (NIS), examines the outcomes and management of nonvariceal upper gastrointestinal bleeding (NVUGIB) in COVID-19 patients and identifies predictive factors to enhance patient prognosis. METHODS: We analyzed the 2020 U.S. NIS data involving adult patients (≥18 years) admitted with NVUGIB and categorized them based on the presence of COVID-19. Primary and secondary outcomes, NVUGIB-related procedures, and predictive factors were evaluated. RESULTS: Of 184,885 adult patients admitted with NVUGIB, 1.6% (2990) had COVID-19. Patients with NVUGIB and COVID-19 showed higher inpatient mortality, acute kidney injury, need for intensive care, and resource utilization metrics. Notably, there was a lower rate of early esophagogastroduodenoscopy (EGD). Multivariate logistic regression revealed conditions like peptic ulcer disease, mechanical ventilation, and alcohol abuse as significant positive predictors for NVUGIB in COVID-19 patients, whereas female gender and smoking were negative predictors. CONCLUSION: Our findings suggest that COVID-19 significantly increases the risk of mortality and complications in NVUGIB patients. The observed decrease in early EGD interventions, potentially contributing to higher mortality rates, calls for a review of treatment strategies. Further multicenter, prospective studies are needed to validate these results and improve patient care strategies.

Predictive biomarkers for colorectal cancer: a state-of-the-art systematic review.

INTRODUCTION: Colorectal cancer (CRC) poses a substantial health burden, with early detection paramount for improved prognosis. This study aims to evaluate potential CRC biomarkers and detection techniques. MATERIALS AND METHODS: This systematic review, reported in adherence to PRISMA Statement 2020 guidelines, collates the latest research on potential biomarkers and detection/prognosis methods for CRC, spanning the last decade. RESULTS: Out of the 38 included studies, diverse biomarkers and detection methods emerged, with DNA methylation markers like SFRP2 and SDC2, microRNAs including miR-1290, miR-506, and miR-4316, and serum and plasma markers such as NTS levels and U2 snRNA fragments standing out. Methylated cfDNA and m5C methylation alteration in immune cells of the blood, along with circular RNA, showed promise as diagnostic markers. Meanwhile, techniques involving extracellular vesicles and lateral flow immunoassays exhibited potential for swift and effective CRC screening. DISCUSSION: Our state-of-the-art review identifies potential biomarkers, including SFRP2, SDC2, miR-1290, miR-506, miR-4316, and U2 snRNA fragments, with significant potential in enhancing CRC detection. However, comprehensive validation studies and a rigorous evaluation of clinical utility and cost-effectiveness remain necessary before integration into routine clinical practice. CONCLUSION: The findings emphasize the need for continued research into biomarkers and detection methods to improve patient outcomes.

Poor hospitalization outcomes in patients undergoing allogeneic hematopoietic stem cell transplant with hospital acquired influenza infection.

INTRODUCTION: Although hospital-acquired influenza infection (HAII) is a known complication among immunocompromised patients, the data in the setting of hospitalization for allogeneic hematopoietic stem cell transplant (allo-HSCT) are scarce. METHODS: A retrospective study using the National Inpatient sample database was done to determine the impact of HAII on hospitalization outcomes among patients admitted for allo-HSCT. RESULTS: The data for 77 103 allo-HSCT weighted hospitalizations were collected between 2002 and 2019. Among these, only 314 (0.4%) allo-HSCT cases were billed for HAII. Patients with influenza were more likely to have comorbid conditions like chronic obstructive lung disease, diabetes mellitus, hypertension, and myocardial infarction. Multivariate logistic regression revealed that patients with influenza had a higher risk of all-cause mortality: (odds ratio = 4.87, 95% confidence interval: 3.63-6.54; p < .01). Patients with influenza also had statistically higher odds of developing acute kidney injury, septic shock, and respiratory failure requiring mechanical ventilation. They also had a significantly longer length of stay (34 days versus 26 days) and adjusted cost for hospitalization ($195 345 versus $121 967). CONCLUSION: Our large analysis of real-world data reveals that patients undergoing allo-HSCT that develop HAII are at substantially higher risk of inpatient complications and death.

Clinical Research in Chronic Lymphocytic Leukemia in Pakistan; A Systematic Review.

Background: Significant advances have been made in the treatment of chronic lymphocytic leukemia (CLL) since the turn of the new millennium. However, most clinical trials were done in developed countries where minority ethnicities were underrepresented. Materials and Methods: To gauge the quality of research in CLL being done in Pakistan, we conducted a comprehensive literature search using PubMed, Clinicaltrials.gov, and Google Scholar on 14 January 2022 following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) recommendations. Results: A total of 16 studies met the inclusion criteria. The most common study design was cross-sectional. Eight studies evaluated the clinicohematological profile of CLL patients and the effect of various cytogenic abnormalities through fluorescence in situ hybridization (FISH) technique on disease progression and prognosis. Five studies discussed the prevalence of abnormalities such as autoimmune cytopenias and other serum chemistry derangements. Only two studies evaluated treatment outcomes, among which one study reported a 2-year overall survival of 65% among patients with 17p deletion. None of the studies had patients on novel targeted agents. No pharmaceutical sponsored or funded clinical trials were found. Conclusions: Our review suggests that although small clinical studies continue to be performed across the country, multiple financial and logistical barriers need to be addressed for larger, more impactful clinical trials to be conducted that will help answer demographic-specific questions and decrease reliance on foreign studies.

The Current Landscape of Clinical Trials for Immunotherapy in Pancreatic Cancer: A State-of-the-Art Review.

BACKGROUND: Pancreatic cancer remains a lethal malignancy with a 5-year survival rate below 6% and about 500,000 deaths annually worldwide. Pancreatic adenocarcinoma, the most prevalent form, is commonly associated with diabetes, chronic pancreatitis, obesity, and smoking, mainly affecting individuals aged 60 to 80 years. This systematic review aims to evaluate the efficacy of immunotherapeutic approaches in the treatment of pancreatic cancer. METHODS: A systematic search was conducted to identify clinical trials (Phases I-III) assessing immunotherapy in pancreatic cancer in PubMed/Medline, CINAHL, Scopus, and Web of Science, adhering to PRISMA Statement 2020 guidelines. The final search was completed on May 25, 2024. Ongoing trials were sourced from ClinicalTrials.gov and the World Health Organization's International Clinical Trials Registry Platform (ICTRP). Keywords such as "pancreatic," "immunotherapy," "cancer," and "clinical trial" were used across databases. Gray literature was excluded. RESULTS: Phase I trials, involving 337 patients, reported a median overall survival (OS) of 13.6 months (IQR: 5-62.5 months) and a median progression-free survival (PFS) of 5.1 months (IQR: 1.9-11.7 months). Phase II/III trials pooled in a total of 1463 participants had a median OS of 12.2 months (IQR: 2.5-35.55 months) and a median PFS of 8.8 months (IQR: 1.4-33.51 months). CONCLUSIONS: Immunotherapy shows potential for extending survival among pancreatic cancer patients, though results vary. The immunosuppressive nature of the tumor microenvironment and diverse patient responses underline the need for further research to optimize these therapeutic strategies.

Malnutrition Severity Predicts Clinical Outcomes in Alcoholic Hepatitis: Evidence from National Data.

OBJECTIVE: Alcoholic hepatitis (AH) represents a severe manifestation of alcoholic liver disease (ALD) associated with a wide severity spectrum. ALD is linked to nutritional deficiencies, with the gravity of malnutrition escalating as alcohol abuse and ALD progress. This study aims to delve into the impact of malnutrition on the clinical trajectory of AH. METHODS: We identified adult patients admitted with AH using the National Readmission Database (NRD) 2016-2020. We further classified AH patients based on the severity of malnutrition. We compared the outcomes of AH hospitalizations using a multivariate regression model. RESULTS: We included 82,367 AH patients, of whom 15,693 (19.00%) had malnutrition. 4,243 (5.15%) patients exhibited mild to moderate malnutrition, 5,862 (7.07%) patients had severe malnutrition, and 5,588 (6.78%) patients had unspecified severity of malnutrition. We found that adjusted in-hospital mortality due to AH was higher in patients with malnutrition, corresponding to the severity of malnutrition (adjusted odds ratio [aOR] 1.62 and 3.14 in mild-moderate malnutrition and severe malnutrition, respectively; p < .01). Additionally, patients with malnutrition had progressively elevated odds of septic shock, vasopressor requirement, mechanical ventilation, and intensive care unit (ICU) admission with escalating intensity of malnutrition. Liver-related complications, such as spontaneous bacterial peritonitis, coagulopathy, hepatorenal syndrome, and hepatic encephalopathy, were also found to have an increased likelihood in the presence of malnutrition. Furthermore, resource utilization showed a progressive increase with increasing severity of malnutrition. CONCLUSION: Our findings indicate that malnutrition is a common comorbidity in AH patients, with varying degrees of severity, which correlates with higher mortality rates, emphasizing the critical role of nutritional status in the prognosis of AH. These findings underscore the importance of addressing and managing malnutrition in patients with AH, not only for its potential contribution to mortality but also because of its association with a spectrum of complications and increased healthcare resource utilization.

Impact of interhospital transfer status on outcomes of variceal and nonvariceal upper gastrointestinal bleeding: insights from the National Inpatient Sample analysis, 2017 to 2020.

Background: Variceal and nonvariceal upper gastrointestinal bleeding (VUGIB and NVUGIB, respectively) require prompt intervention. Existing studies offer limited insight into the impact of interhospital transfers on patients with VUGIB and NVUGIB. Methods: We conducted a retrospective study using the US National Inpatient Sample database from 2017 to 2020. The outcomes included in-hospital mortality, incidence of complications, procedural performance, and resource utilization. Results: A total of 28,275 VUGIB and 781,370 NVUGIB adult patients were included. Transferred VUGIB and NVUGIB patients, when compared to nontransferred ones, demonstrated higher inpatient mortality (adjusted odds ratio [AOR] 1.49 and 1.86, P < 0.05). Patients with VUGIB and NVUGIB had a higher likelihood of acute kidney injury requiring dialysis (AOR 3.79 and 1.76, respectively, P = 0.01), vasopressor requirement (AOR 2.13 and 2.37, respectively, P < 0.01), need for mechanical ventilation (AOR 1.73 and 2.02, respectively, P < 0.01), and intensive care unit admission (AOR 1.76 and 2.01, respectively, P < 0.01). Compared to their nontransferred counterparts, transferred VUGIB patients had a higher rate of undergoing transjugular intrahepatic portosystemic shunt (AOR 3.26, 95% CI 1.92-5.54, P < 0.01), while transferred NVUGIB patients had a higher rate of interventional radiology-guided embolization (AOR 2.01, 95% CI 1.73-2.34, P < 0.01) and endoscopic hemostasis (AOR 1.10, 95% CI 1.05-1.15, P < 0.01). Conclusion: Interhospital transfer is associated with worse clinical outcomes and higher resource utilization for VUGIB and NVUGIB patients.

Global Perspective on COVID-19 Therapies, Cardiovascular Outcomes, and Implications for Long COVID: A State-of-the-Art Review.

The COVID-19 pandemic has resulted in many therapies, of which many are repurposed and used for other diseases in the last decade such in Influenza and Ebola. We intend to provide a robust foundation for cardiovascular outcomes of the therapies to better understand the rationale for the clinical trials that were conducted during the COVID-19 pandemic, and to gain more clarity on the steps moving forward should the repurposing provide clinical benefit in pandemic situations. With this state-of-the-art review, we aim to improve the understanding of the cardiovascular involvement of the therapies prior to, during, and after the COVID-19 pandemic to provide meaningful findings to the cardiovascular specialists and clinical trials for therapies, moving on from the period of pandemic urgency.

Impact of Concomitant Thrombotic Thrombocytopenic Purpura on COVID-19 Mortality and Morbidity: A Nationwide Inpatient Sample Analysis.

Utilizing the comprehensive Nationwide Inpatient Sample (NIS) database, we examined the impact of thrombotic thrombocytopenic purpura (TTP) on the outcomes of patients with coronavirus disease-19 (COVID-19), emphasizing the potential role of the ADAMTS13 enzyme in disease pathogenesis and evolution. We analyzed extensive data from the NIS database using STATA v.14.2 and accounted for potential confounders using multivariate regression analysis to uphold the validity and reliability of the study. Among 1 050 045 adult patients hospitalized with COVID-19, only 300 (0.03%) developed TTP. These patients were younger (mean age 57.47 vs 64.74, P < .01) and exhibited a higher prevalence of preexisting conditions, such as congestive heart failure (13.33% vs 16.82%, P value not provided) and end-stage renal disease (3.33% vs 3.69%, P value not provided). On multivariate regression analysis, COVID-19 patients with concomitant TTP demonstrated a significant increase in mortality (adjusted odds ratio [AOR] 3.99, P < .01), venous thromboembolism (AOR 3.33, P < .01), acute kidney injury (AOR 7.36, P < .01), gastrointestinal bleeding (AOR 10.75, P < .01), intensive care unit admission (AOR 14.42, P < .01), length of hospital stay (17.42 days, P < .01), and total hospitalization charges ($298 476, P < .01). Thrombotic thrombocytopenic purpura in COVID-19 patients elevates the risk of mortality and complications, likely driven by the thrombotic nature of TTP. Our data underline the potential significance of ADAMTS13 in COVID-19 and TTP pathophysiology, suggesting its possible role as a therapeutic target.

Emerging from the shadows: A rare case of gastrointestinal AL amyloidosis presenting as hematemesis.

We document a unique presentation of light chain (AL) amyloidosis in a 62-year-old man exhibiting as acute hematemesis and chronic abdominal discomfort. Esophagogastroduodenoscopy disclosed marked thickening of gastric and duodenal folds, gastroduodenal nodularity, and friable ulcerations. Biopsy confirmed amyloidosis. Subsequent investigations ratified a diagnosis of systemic AL amyloidosis with cardiac involvement. Initiation of the cyclophosphamide, bortezomib, and dexamethasone (CyBorD) regimen, along with tafamidis and doxycycline for cardiac pathology, led to substantial improvement of abdominal symptoms. This case highlights the variability in amyloidosis presentations and the importance of early diagnosis.

Unveiling the Hazards: A Case Report on Kayexalate-induced Colonic Necrosis.

Sodium polystyrene sulphonate (SPS), employed in the management of severe hyperkalemia, is typically combined with sodium sorbitol to avert potential intestinal obstruction. Nonetheless, the administration of Kayexalate, even in the presence of minimal sorbitol, can lead to the grave complication of colonic necrosis. We present a case of Kayexalate-mediated colonic necrosis, highlighting the vital necessity of acknowledging the inherent risks associated with its usage in spite of its efficacy in potassium reduction. In light of these potential risks, it is incumbent upon physicians to exercise caution, and contemplate the use of alternative pharmacological agents that effectively eliminate excess potassium, whilst minimizing associated adverse effects.

Hemophagocytic Lymphohistiocytosis and Pancreatic Cancer: A Rare Association.

Introduction: Hemophagocytic lymphohistiocytosis (HLH) or hemophagocytic syndrome (HPS) is a life-threatening and relatively rare condition that usually presents as a multisystem febrile illness. It is associated with excessive activation of the immune system and hypercytokinemia, leading to an unregulated aggregation of macrophages and lymphocytes. Here, we present the first likely case of HLH with metastatic pancreatic carcinoma being the underlying etiology. Case: A 44-year-old male with past medical history significant for heart transplant for which he was on tacrolimus, End-Stage Renal Disease (ESRD) on hemodialysis, recently treated CMV viremia, and necrotizing pancreatitis presented to the emergency with complaints of chills, decreased appetite, worsening non-bloody emesis, and dull left upper quadrant abdominal pain with radiation to the back for four days. No shortness of breath, fever, diarrhea, or blood in the stool was reported. Vitals on admission were blood pressure of 90/61 mmHg, a heart rate of 110 beats per minute, temperature of 98.1 °F, and respiratory rate of 18 per minute. Physical exam was significant for scleral icterus, decreased bibasilar breath sounds, moderate abdominal tenderness in the left flank and left upper abdominal quadrant without any palpable mass, and 1+ bilateral pedal edema. The remainder of the physical examination was benign. Electrocardiogram (EKG) showed sinus tachycardia without any ischemic changes, and chest x-ray showed mild pulmonary edema. Initial blood workup revealed WBC at 8.3 k/uL, hemoglobin of 10.2 g/dL, platelet count of 90 k/uL, and BUN/creatinine of 45/5.8 (baseline 40/5.0). Cardiac workup showed an elevated high sensitivity troponin level of 2479 pg/mL and brain natriuretic peptide (BNP) of 600 (0-100 pg/mL). The hepatobiliary profile showed an aspartate transaminase (AST) level of 2645 U/L, an alanine transaminase (ALT) of 2935 U/L, alkaline phosphatase (ALP) of 106 U/L, and lipase of 61 U/L, with total and conjugated bilirubin of 3.5 mg/dL and 2.1 mg/dL, respectively. Transthoracic echocardiogram (TTE) showed reduced left ventricular size with hyperdynamic systolic function. Computerized tomography (CT) scan of the abdomen (Fig. 1) revealed numerous new pulmonary nodules, ring-enhancing lesions within the liver, hyperenhancement of the pancreas with walled-off necrosis, and splenomegaly. Microbiological work-up was positive for cytomegalovirus (CMV) serologies (IgM and IgG) but absent viral load on Polymerase Chain Reaction (PCR). The initial diagnosis was systemic inflammatory respiratory syndrome (SIRS), likely septic versus distributive in the setting of pancreatitis, demand mediated non-ST segment elevation myocardial infarction (NSTEMI), and shock liver. Tacrolimus was held, and the patient was started on broad-spectrum antibiotics including vancomycin and cefepime for sepsis of unknown origin along with vasopressors for hypotension, requiring admission to the medical intensive care unit. Blood and urine cultures were collected on admission which remained negative throughout the course of hospital. CA19-9 levels were found elevated at 5587 U/mL. Liver biopsy was consistent with poorly differentiated adenocarcinoma of pancreatic origin. Both Infectious Disease and Hematology were consulted due to broad differential diagnoses. Due to the patient's continued hemodynamic instability and nonresponsiveness to the antibiotics, HLH was suspected with supporting labs as follows: ferritin 55,740 ng/mL (22-322 ng/mL), triglycerides 177 mg/dL (30-150 mg/dL), and fibrinogen 244 mg/dL (173-454 mg/dL), thus conferring 70-80% probability of HPS based on H-score. Soluble IL-2 R levels came out at 19,188 pg/mL (ref range 175-858 pg/mL). The patient couldn't be started on HLH treatment due to initial concerns of underlying infection and the delay in results of soluble IL-2 Receptor (IL-2 R) levels. The infection as a possible etiology was ruled out due to negative blood and urine cultures and HLH was attributed to pancreatic cancer. A marrow biopsy couldn't be pursued as the patient died within a week of hospitalization. An autopsy was not performed as per family's request. Conclusion: HLH can occur secondary to solid cell malignancies including those from the pancreas and should be kept high in the differential in critically ill cancer patients who are nonresponsive to antibiotics. H-score has been reported to be a more sensitive tool compared to the HLH protocol, especially if used earlier during the presentation. Further research is needed to compare diagnostic efficacy for HLH protocol verses H-score especially in critically ill patients as they might benefit from steroid trial.

Efficacy and Safety of Recombinant Thrombomodulin for the Prophylaxis of Veno-Occlusive Complication in Allogeneiccit Hematopoietic Stem Cell Transplantation: A Systematic Review and Meta-Analysis.

BACKGROUND: Hepatic veno-occlusive disease (VOD), also termed as sinusoidal obstruction syndrome (SOS), is a lethal complication after hematopoietic stem cell transplantation (HSCT). Various factors put patients undergoing allogeneic HSCT at an increased risk for VOD. Thrombomodulin (TM) is an important factor which has a wide range of effects, including anticoagulant, anti-inflammatory, angiogenic, and protective effect, on endothelial cells. It plays a role in preventing excessive coagulation and thrombosis by binding with thrombin and inhibiting the coagulation cascade. There are a limited number of options for the prevention of this fatal complication. Recombinant thrombomodulin (rTM), an endothelial anticoagulant co-factor, as prophylactic therapy might be able to prevent veno-occlusive complications after stem cell transplantation. METHODS: A literature search was performed on PubMed, Embase, and Web of Science. We used the following Mesh terms and Emtree terms, "Hepatic Veno-Occlusive Diseases" OR "Sinusoidal Obstruction" OR "Stem Cell Transplantations " AND "Thrombomodulin" from the inception of data up to April 1, 2021. The PICO (Patient/Population, Intervention, Comparison and Outcomes) framework was used for the literature search. RESULTS: For the VOD incidence after HSCTstem cell transplantation, the result was in favor of rTM with a risk ratio (RR) of 0.53 (I2 = 0%, 95% confidence interval [CI] = 0.32-0.89). The incidence of transplant-associated thrombotic microangiopathy (TA-TMA) after HSCT was reduced in rTM group. The RR for incidence of TA-TMA was 0.48 (I2 = 62%, 95% CI = 0.20-1.17) favoring rTM. The RR for incidence of graft-versus-host disease (GvHD) was also lower in rTM group, 0.48 (I2 = 64%, 95% CI = 0.32-0.72). CONCLUSION: In our meta-analysis, we evaluate the efficacy and safety of rTM in the prevention of SOS after HSCT. According to our results, rTM use led to a significant reduction in SOS episodes, TA-TMA, and GvHD after HSCT.

Tricuspid Valve Endocarditis: A Disguise In Multifocal Septic Arthritis.

Infective endocarditis (IE) is a rare cause of multifocal septic arthritis. We report a patient who presented with oligo-articular septic arthritis as a complication of tricuspid valve endocarditis, a rare condition. A 69-year-old female presented to the emergency department with complaints of fever, myalgia, right shoulder, and right knee pain. Initial investigation elaborated on elevated C-reactive protein, erythrocyte sedimentation rate (ESR), and white blood cell. Imaging studies, including X-ray, were unrevealing. Blood cultures came out positive for Methicillin-sensitive Staphylococcus aureus (MSSA) bacteremia. Magnetic resonance imaging (MRI) of the right shoulder and right knee showed joint effusion with soft tissue swelling. Diagnostic arthroscopic washout of right shoulder and right knee showed neutrophilic pleocytosis, and the cultures were positive for MSSA. Despite adequate antibiotic coverage for MSSA bacteremia with oligo-articular/multifocal septic arthritis, the patient's fever did not resolve. Initial transthoracic echocardiography (TTE) was negative for any vegetation. Transesophageal echocardiography (TEE) showed vegetations on the tricuspid valve with tricuspid regurgitation and was diagnosed with acute bacterial IE. A multi-disciplinary approach was adopted. She underwent tricuspid valve repair with annuloplasty and was treated with nafcillin for six weeks. She successfully recovered from MSSA bacteremia, and follow-up TEE was negative for any vegetations.

A Twist in Crohn's Disease: A Rare Case of Gastric Volvulus.

An 80-year-old male with a past medical history of Crohn's disease presented to the emergency department with complaints of nausea and multiple episodes of coffee-ground emesis and was initially diagnosed with upper gastrointestinal bleed. On physical examination, the patient was noted to have a mildly tense and tender abdomen with hyperactive bowel sound. His CT abdomen showed a markedly distended stomach with mesenteroaxial (MA) rotation and localized fluid in the left upper quadrant with the caudal displacement of the spleen due to the left upward position of the stomach. The gastric outflow tract was pinched to the left of the midline superior to the esophagogastric junction, consistent with the gastric volvulus. Endoscopic detorsion was initially planned, but it was unsuccessful due to the twisting of the distal stomach in the antrum. The patient underwent laparoscopic detorsion and gastropexy. He was found to be asymptomatic after the procedure and was discharged with outpatient follow-up. Gastric volvulus is a rare yet potentially fatal condition due to its variable presentation, and it can have lethal consequences if not treated properly and in a timely manner.

Initial Sequencing and Characterization of the Gastrointestinal and Oral Microbiota in Urban Pakistani Adults.

We report the initial characterization of the gastrointestinal tract (gut) and oral microbiota (bacteria) in 32 urban Pakistani adults. Study participants were between ages 18 and 40, had body mass index between 18 and 25 Kg/m2, and were students or early-career professionals. These individuals donated a total of 61 samples (32 gut and 29 oral) that were subjected to 16S ribosomal RNA (rRNA) gene sequencing. Microbiome composition of Pakistani individuals was compared against the uBiome database of selected individuals who self-reported to be in excellent health. We observed strong gender-based differences in the gut microbiome of Pakistani individuals, a skewness toward Firmicutes, and unusually high levels of Proteobacteria in the Pakistani men. These observations may indicate microbiota dysbiosis, though 16S data alone can neither establish cause nor effect to human health. Albeit conducted on a smaller scale, our report provides a first snapshot about the composition and diversity of gut and oral microbiota communities in Pakistani individuals.

Correlation of Hemoglobin A1c With Wagner Classification in Patients With Diabetic Foot.

Introduction Diabetic foot is a common complication of diabetes mellitus (DM). The Wagner classification is mostly used to grade its severity. The correlation between the hemoglobin A1c (HbA1c) and the Wagner classification is still controversial. Therefore, the purpose of this study is to determine the correlation of HbA1c with Wagner classification in patients with diabetic foot. Materials and methods This cross-sectional study was conducted at a major hospital in Shaheed Benazirabad in which 88 patients aged 18-65 years, of either gender, with a known history of DM type I or type II, and diagnosed with diabetic foot were enrolled for six months. Blood samples were collected to check the HbA1c levels. Wagner classification grading was performed after the examination of diabetic foot ulcers. Demographics such as age, gender, duration of DM, and other risk factors of foot ulcers were also noted. The mean and standard deviation for continuous variables, such as age and HbA1c level, and the frequency and percentage for categorical variables, such as distribution of age, distribution of HbA1c, gender, duration of DM, grades of Wagner classification, and other risk factors of foot ulcers, were calculated. The correlation of HbA1c with Wagner classification was also calculated by applying the chi-square test and taking p ≤ 0.05 as significant. Results The mean age of the study population was 47.4 ± 10.6 years. Of the 88 patients, 15 (17.04%) were 25-35 years of age, 34 (38.63%) were 36-50 years of age, and 39 (44.31%) were 51-65 years of age; 45 (51.13%) patients were males and 43 (48.86%) patients were females. The mean HbA1c level of the study population was 9.07 ± 1.65%; 5 (5.68%) patients had 6.5-7.5%, 34 (38.63%) patients had 7.6-8.5%, 24 (27.27%) patients had 8.6-9.5%, and 25 (28.41%) patients had an HbA1c level of >9.5%. Twelve (13.63%) patients had ≤ 7 years, 18 (20.45%) had 8-15 years, and 58 (65.9%) had >15 years of duration of DM. Zero (0%) patients had grade 0, 1 (1.13%) patient had grade 1, 6 (6.81%) patients had grade 2, 29 (32.95%) patients had grade 3, 32 (36.36%) patients had grade 4, and 20 (22.72%) patients had grade 5 of Wagner classification. 23 (26.13%) patients had foot abnormalities, 19 (21.59%) patients had nephropathy, 13 (14.77%) patients had neuropathy, 14 (15.91%) patients had hypertension, 9 (10.22%) patients had retinopathy, 3 (3.41%) patients had foot ulcers/toe amputation, 2 (2.27%) patients had a cognitive deficit, and 5 (5.68%) patients had cardiovascular diseases. The correlation of HbA1c with Wagner classification was found statistically significant with p < 0.00001. Conclusions The older age, male gender, longer duration of DM, increased HbA1c, and previously existing foot abnormalities in diabetic patients are the risk factors of diabetic foot. The monitoring of HbA1c can help predict the diabetic foot in the aforesaid high-risk diabetics because the HbA1c linearly rises with the higher grades of Wagner classification of diabetic foot. Subsequently, the strict control of HbA1c as well as patient education about proper foot care can help prevent diabetic foot and its complications. However, more studies on larger scales are needed to establish the factual relationship between HbA1c and Wagner classification.

Social Stigmatization of Drug Abusers in a Developing Country: A Cross-Sectional Study.

INTRODUCTION:  Stigma is a label that differentiates a person from others and associates them with unenviable attributes. There are various forms of stigma: enacted stigma, perceived stigma, and self-stigma manifesting as stereotyping and harboring negative thoughts about the stigmatized group. Stigmatization of the drug abuser leads to effects such as low self-esteem, depression, and personality changes in the stigmatized.  Objectives: The purpose of the study is to know the impact of stigma on patients receiving substance abuse treatment in the Psychiatry Department, Mayo Hospital Lahore, Pakistan. DESIGN: Cross-sectional study.  Place: Psychiatry Department, Mayo Hospital, Lahore, Pakistan Study Period: Six months (February 22, 2020, to July 18, 2020). SUBJECTS AND METHODS: A population-based cross-sectional study was conducted in a tertiary care hospital. A total of 100 patients were recruited in the study. The selection was made on laid down criterion after taking due consent. Interviews were conducted through a pretested questionnaire. Data were collected, compiled, and analyzed through SPSS version 20 (IBM Corp., Armonk, USA), and relevant frequency tables were drawn.  Results: On analyzing the data, various forms of stigma were observed: enacted stigma (81% as considered less capable), perceived stigma (99% as having difficulties in the job seeking and relationships), and self-stigma (94% in having devaluation thoughts). Self-esteem was maintained (73% were content). Social support was present (76% from family). Moderate depression was seen in 17% of participants. Over 83% of our study population is aged 21 to 40 years, 15% between ages 41 and 60 years, and only 2% ranging between ages 1 and 20. A total of 80% of the population belonged to a low socioeconomic status, and 55% of participants abused opium, heroin, or brown sugar, followed by white crystal use in 37% of the study population. The majority reported the drug abuse duration of 1-5 years (70%). CONCLUSION:  Stigma in its various forms affects the drug abuser undergoing treatment. It results in low self-esteem and mild depression. Individuals from the broader socioeconomic range can be added in future studies, and a larger population can be studied by collecting data from other tertiary care hospitals and mental healthcare facilities. They can be assessed for factors contributing to their addiction and the challenges they had to go through to get the help they needed.

Kawasaki Disease-Like Features in 10 Pediatric COVID-19 Cases: A Retrospective Study.

Children with coronavirus disease 2019 (COVID-19), which is caused by severe acute respiratory syndrome coronavirus type 2 (SARS-CoV-2), usually present with symptoms of mild upper respiratory tract infection without developing any significant complications. However, this observation has been rendered incautious by hundreds of clinical cases from around the world that have depicted a less benign multisystem inflammatory illness mimicking Kawasaki disease in COVID-positive pediatric patients. Our study aimed at retrospectively reviewing the different features of Kawasaki disease-like illness in children suffering from COVID-19, including the complications, laboratory investigations, treatment strategies used during their hospital stay, and outcomes. We searched the electronic database of the two pediatric units of Mayo Hospital, Lahore, Pakistan, for children who had been admitted to the ward between April 2020 and July 2020 and were diagnosed with COVID-19. A total of 10 such pediatric cases were found, whose clinical details were then reviewed and the obtained data were presented in the form of tables and percentages. The median age was between 4 months to 11 years (mean: 6 years). Of the 10 patients, 8 (80%) were boys. Criteria for Kawasaki disease were met in all of them (100%), with a complete presentation in five (50%). Fever (100%), conjunctival and oral cavity changes (90%), and rash (80%) were the most common features. Seven (70%) patients required admission to a critical care unit, but no mortality occurred. This article can assist in understanding and dealing with Kawasaki disease-like manifestation of pediatric COVID-19 infection, especially in critical care settings, and its possible complications. It will help in a timely and appropriate decision-making regarding treatment and management of such cases.