Global burden of the COVID-19 associated patient-related delay in emergency healthcare: a panel of systematic review and meta-analyses.

BACKGROUND: Apart from infecting a large number of people around the world and causing the death of many people, the COVID-19 pandemic seems to have changed the healthcare processes of other diseases by changing the allocation of health resources and changing people's access or intention to healthcare systems. OBJECTIVE: To compare the incidence of endpoints marking delayed healthcare seeking in medical emergencies, before and during the pandemic. METHODS: Based on a PICO model, medical emergency conditions that need timely intervention was selected to be evaluated as separate panels. In a systematic literature review, PubMed was quarried for each panel for studies comparing the incidence of various medical emergencies before and during the COVID-19 pandemic. Markers of failure/disruption of treatment due to delayed referral were included in the meta-analysis for each panel. RESULT: There was a statistically significant increased pooled median time of symptom onset to admission of the acute coronary syndrome (ACS) patients; an increased rate of vasospasm of aneurismal subarachnoid hemorrhage; and perforation rate in acute appendicitis; diabetic ketoacidosis presentation rate among Type 1 Diabetes Mellitus patients; and rate of orchiectomy among testicular torsion patients in comparison of pre-COVID-19 with COVID-19 cohorts; while there were no significant changes in the event rate of ruptured ectopic pregnancy and median time of symptom onset to admission in the cerebrovascular accident (CVA) patients. CONCLUSIONS: COVID-19 has largely disrupted the referral of patients for emergency medical care and patient-related delayed care should be addressed as a major health threat.

Prevalence of vitamin D deficiency in children presenting with supracondylar fractures of humerus.

OBJECTIVE: The purpose of the current analysis is to evaluate the predominance of vitamin D inadequacy in children with supracondylar fracture of the humerus. METHODS: This is a cross-sectional study conducted at Dr Ruth K. M. Pfau Civil, Hospital, Karachi, Pakistan, from December 2019 to July 2020. Patients aged 18 months-18 years presenting with supracondylar fractures were included in the study. Patients were divided into four groups based on their age as toddlers (18 months to 3 years), pre-school age (3-5 years), school-age (6 to 11 years) and adolescents (11-18 years). RESULTS: A total of 227 children presented with upper limb fractures of which 72 (31.7%) were supracondylar. The mean vitamin D level was found to be 32.5 ± 9.1 ng/mL. Of the study subjects, low vitamin D levels were found in 34.7% (n = 25), adequate in 59.7% (n = 43) and ideal in 5.5% (n = 4) of patients. The mean vitamin D levels for toddlers were 33.5 ng/mL, for preschool children was 27.66 ng/mL, for school-age children was 30.4 ng/mL and for adolescents was 37 ng/mL. CONCLUSION: Vitamin D deficiency is not only restricted to Pakistan but also other parts of the world, although the reasons may vary in each of those regions. However, vitamin D supplementation in all parts of the globe can prevent a significant number of fractures. This prevalence study showed vitamin D deficiency in 35% of children with supracondylar fractures, with the lowest mean values in the preschool age group.

Treatment of high-energy intra-articular fractures of tibia with Ilizarov external fixator in adults: A tertiary centre experience.

OBJECTIVE: To evaluate the clinical and radiological outcomes of the Ilizarov fixator in the proximal and distal fractures of the tibia. MATERIALS AND METHODOLOGY: This retrospective study reviewed 59 patients having high-energy intra-articular proximal and distal tibia fractures associated with severe soft-tissue injury, who were managed surgically with an Ilizarov fixator. The functional outcome was evaluated by using the American Orthopaedic Foot and Ankle Society scoring system (AOFAS) and the Association for the Study and Application of the Method of Ilizarov (ASAMI) Italy scoring system for tibial plateau and plafond fractures respectively. RESULTS: The most common mode of injury was road traffic accidents. According to the Gustilo open fracture classification, there were 16 patients with grade-I and nine with grade II open fractures. The remaining had closed fractures. According to the Schatzker classification of plateau fractures, 20 were graded as type V and 15 as type VI. According to the AO classification of plafond fractures, 12 fractures were graded as Type-43C1, 5 as Type-43C2, and 7 as Type-43C3. There was delayed union in 11 proximal and four distal fractures, all of which achieved union without additional bone grafting. In proximal fractures, according to AOFAS, out of 35, 26 had an acceptable while nine had a fair result. In distal fractures, according to ASAMI, out of 24, 16 had an acceptable while five had fair results. There were 192/448 wires in 58 patients with pin site infection; all were superficial and settled. Posttraumatic joint arthrosis was noted in nineteen. CONCLUSIONS: The postoperative clinical and radiological outcome indicated that primary Ilizarov external fixator is a reliable minimal invasive surgery and definitive fixation method for high-energy intra-articular proximal and distal tibial fractures with compromised soft-tissue. It also offers early stabilisation and painless joint motion without a high rate of complications.

Subcutaneous fibroblastoma resembling hemangioma: A case of benign tumor of the chest wall.

Key Clinical Message: Desmoplastic fibroma presents similar to other soft tissue tumors to such an extent that even a gold standard investigation can miss. Abstract: This is to report a mass in a 47-year-old male arising from the chest wall, which was first thought to be a hemangioma but was later diagnosed as a case of desmoplastic fibroblastoma with the help of a biopsy.

Electrocardiogram (EKG) knowledge and interpretation proficiency among healthcare professionals in Pakistan: a prospective cross-sectional study.

Background: Electrocardiogram (EKG) is a commonly used diagnostic tool for the evaluation of the electrical activity of the heart. The purpose of this study was to assess the knowledge and interpretation proficiency of EKG among healthcare professionals (HCPs) in Pakistan. Methods: This prospective cross-sectional study was conducted among HCPs working in different healthcare settings. A structured questionnaire was used to assess the participants' theoretical knowledge and ability to interpret EKG findings. The data were analyzed using descriptive statistics and χ2 tests. The study indicates that EKG knowledge and interpretation proficiency among HCPs in Pakistan is unsatisfactory. The inadequacy of training periods of EKG training sessions and insufficient participation of HCPs in offered training opportunities put forward the need for the formation and introduction of better structured and efficient EKG training programmes. Results: A total of 511 HCPs participated in the study, 28% of whom reportedly had received formal training for EKG interpretation. About 80% of the participants correctly identified theoretical questions pertaining to EKG, while 58% of the participants were able to accurately interpret EKG findings, and most HCPs (69.9%) read fewer than ten EKGs per week. Conclusion: This study demonstrates a lack of expertise and a poor understanding of EKG in HCPs of Pakistan. The low level of EKG knowledge and interpretation proficiency among HCPs may lead to diagnostic errors and poor patient outcomes. Therefore, efforts should be made to improve EKG education and training among HCPs in Pakistan.

Fournier's gangrene in a female: A case report.

Fournier's gangrene is characterized by an acute necrotic infection. The infection can occur in all parts of the body including the scrotum, penis, or perineum, and is a rare condition that is primarily reported in men and seldom in women. Existing literature suggests that it might be underreported, possibly leading to overlooked cases. Risk factors include diabetes, chronic illness, and trauma. This case involves a 52-year-old female with a 10-year medical history of diabetes mellitus, multiple healed skin lesions all over the body, and dermatitis. The presentation was a perianal swelling, which progressed into an extensive necrotizing soft tissue infection of the perineum, making a diagnosis of Fournier's gangrene. She underwent wide local debridement and was managed with antibiotics in a timely manner. The patient's clinical course and subsequent follow-up were uneventful. Uncontrolled diabetes and dermatitis significantly increase the risk of Fournier's gangrene; therefore, it should be suspected in women with such comorbid conditions. This case highlights the need for increased awareness and vigilance regarding this condition among women.

Introducing the Muzzammil classification for spoke wheel injuries in children to enhance injury assessment and treatment in developing countries.

Motorbike spoke wheel injuries (SWIs) among children are a notable public health concern, especially in low and middle-income regions. The primary objective of this study is to comprehensively examine the patterns of motorbike spoke wheel injuries (SWIs) in children. Additionally, the study introduces a novel classification system for these injuries. The implementation of this classification system aims to streamline the management of SWIs, making it more efficient and facilitating the development of standardized treatment protocols. This prospective observational study was conducted in the Accident and Emergency Department from January 2019 to 2021. Children < 14 years of age of either gender with foot and ankle injury due to motorbike spoke wheels as passengers and presenting within 3 days were included. The motorbike SWI was assessed for its location and classified by a new classification as Class I, Soft tissue injury without skin loss; Class II, Skin loss of more than 1 cm without underlying tissue involvement; Class III, Skin loss with underlying tissue involvement, this class is further divided on basis of underlying soft-tissue involvement; Class IV: mangled foot/toe. Management plan and outcome were noted. In our study158 children suffering from SWI were registered with a mean age of 6.2 ± 5.4 years, 127 (80.37%) males and 31 (19.62%) females. Class I injury was seen in 18 (11.39%) patients, class II in 69 (43.67%), and class III in 68 (43.03%) patients. Class III injuries were further subcategorized as follows: IIIT (Tendon) injuries, which accounted for 32 cases (20.25%); IIIB (Bone) injuries, with 29 cases (18.35%); and IIINV (Neurovascular) injuries, identified in 7 cases (4.43%). Class IV injuries were observed in 3 (1.8%) children. The flap was needed in 33 (20.88%) patients. There were no complications like flap necrosis or graft rejection. In this current study, a new classification system specific for a motorbike SWI has been introduced along with its application on children presenting at tertiary care hospital's emergency department. The application of the proposed classification will enable universal management guidelines for SWIs, especially in the Ino-Pak region where SWIs are common.

Type B Aortic Dissection Management: A Narrative Review of Guidelines and Systematic Reviews.

BACKGROUND: Surgical or medical treatment for type B or descending aortic dissections with difficult presentation or stable hemodynamics is debatable. This study aimed to review the type B aortic dissection therapy to assess safety and effectiveness. MATERIALS AND METHODS: Online databases of PubMed, Science Direct, Web of Science, Cochrane, and Scopus were searched for relevant systematic reviews, guidelines, and meta-analysis studies on the management of type B aortic dissection, up to July 2023. The conclusions were qualitatively synthesized. RESULTS: Best medical therapy (BMT], thoracic aortic endovascular repair (TEVAR), and open surgeries (OS) were management approaches. Hemodynamics classify type B aortic dissection as complex or simple. Both examples reveal decreased in-hospital all-cause mortality with TAVR than OS. Guidelines recommend TEVAR for difficult situations and OS if it fails. Complication analyses favour TEVAR, however left subclavian artery coverage without revascularization increases stroke risk. Studies show Type B aortic dissection is simpler than TEVAR and BMT. Acute or subacute presentation did not affect reintervention rates between treatments. TEVAR had a greater early stroke risk than BMT but a decreased long-term aortic-related and all-cause mortality. The best data showed no differences in in-hospital mortality or early re-intervention between regimens. BMT reduced early stroke but increased late all-cause death. CONCLUSION: In conclusion, addressing Type B aortic dissection is complicated, depending on presentation and hemodynamics. TEVAR is best for difficult patients, however BMT and OS also work. TEVAR may reduce in-hospital mortality but increase early stroke risk.

Utilization of Continuous Positive Airway Pressure (CPAP) by Emergency Medical Services: Updated Systematic Review and Meta-analysis.

BACKGROUND: While new studies are being published on the prehospital continuous positive airway pressure (CPAP) application in patients with respiratory failure with conflicting results, previous meta-analyses are showing the benefits of CPAP in the prehospital transfer of patients with respiratory distress. Before the clinical application of high-level evidence, updated pooled estimates are needed based on the growing literature. This study aimed to compare prehospital CPAP with the usual standard oxygen therapy of respiratory failure patients. MATERIALS AND METHODS: PRISMA guidelines served as the framework for this updated review study. It is an extension of a prior systematic review. We conducted comprehensive searches across several databases, including PubMed, Web of Science, Embase, and Scopus, focusing on randomized trials that juxtaposed pre-hospital CPAP application against standard care. Our primary interest was to assess the in-hospital mortality risks, and we employed random effect models to aggregate risk ratios from the selected studies. RESULTS: Four articles were gathered based on the review of the updated literature (2013 to November 2022) in conjunction with the research incorporated in the preceding meta-analysis with a total number of 747 patients receiving prehospital CPAP with 101 events of in-hospital mortality. In the standard treatment control groups, there were 713 patients and 115 deaths occurred. Pooled mortality risk comparison between the group of prehospital CPAP and standard care patients had no statistically significant difference (P=0.16). There was no heterogenicity. A regression between the year of the studies and the effect size showed increased RR in new studies (P=0.017). CONCLUSION: Still more randomized trials are needed with higher sample sizes to conclude the lifesaving efficacy of the out-of-hospital CPAP.

Aseptic meningitis after 20 years of endoscopic transsphenoidal pituitary surgery: a rare complication.

A transsphenoidal surgical (TSS) approach is used for pituitary gland surgery involving pituitary adenomas, as well as for the biopsy of various neurosurgical tumors. TSS, although a relatively safe procedure, can lead to complications like hypopituitarism, visual impairment, nasal septal perforation, diabetes insipidus, carotid artery injury, and cerebrospinal fluid (CSF) leaks. Aseptic meningitis is also one of the complications of this procedure with an incidence of 1-2%, presenting with symptoms similar to bacterial meningitis, but with a low-grade fever of <102 F or even apyrexia. Here, we present a rare case of aseptic meningitis due to CSF leakage, presenting after 20 years of endoscopic surgery. A ventriculoperitoneal shunt was placed to stem the leak after two unsuccessful attempts of endonasal repair.

The height as an independent risk factor of atrial fibrillation: A review.

Atrial fibrillation (AF) is characterized by abnormal heart rhythm. Among other well-known associations, recent studies suggest an association of AF with height. Height is related to 50 diseases spanning different body systems, AF is one of them. Since AF, a heterogeneous disease process, is influenced by structural, neural, electrical, and hemodynamic factors, height alters this process through its contribution to increasing atrial and ventricular size, leading to altered conduction patterns, autonomic dysregulation, and development of AF. Multiple underlying mechanisms associate height with AF. Apart from these indirect mechanisms, genome-wide association studies suggest the involvement of the same genes in AF and growth pathways. Tall stature is independently associated with a higher risk of AF development in healthy individuals. Since adult height is achieved much earlier than the onset of AF, protective measures can be taken in individuals with increased height to monitor, manage, and prevent the progression of AF.

A rare case of idiopathic ileocolic intussusception in an adult.

Intussusception is an invagination of one segment of the bowel into its adjoining segment. In children, the cause is usually benign, while in adults it is secondary to a mass lesion. Here we present a case in which the preoperative diagnosis of intussusception secondary to colonic mass was made, but no definitive cause was identified by histopathology. A 30-year-old male presented with abdominal pain, altered bowel habits, weight loss, loose motions, bleeding per rectum, and vomiting. The abdomen was distended, firm, mildly tender, and guarded. A vague mass of 15 × 10 cm was palpated on the left upper quadrant. X-ray and ultrasound showed dilated small bowel. A computed tomography scan suggested ileoileal intussusception. Colonoscopy showed a growth at 15 cm of the anal verge. Exploratory laparotomy was performed, showing the presence of ileocolic intussusception with two large perforations. Subtotal colectomy with ileostomy was done. The histopathological examination showed signs of perforation.

Frequency of Subclinical Hypothyroidism in Old-age Population.

This study was conducted to determine the frequency of subclinical hypothyroidism (SCH) in the old age population (>60 years). A cross-sectional study was conducted from July 2019 to January 2020 at Jinnah Postgraduate Medical Centre, Karachi, Pakistan. Healthy subjects (having no active complaint) of either sex aged 60-80 years were included. Those already on thyroid replacement, preexisting thyroid diseases, prior radiation therapy, or having chronic kidney disease were excluded. A total of 133 participants, 79 males and 54 females, were selected with a mean age of 69.5 ± 6.4 years. There were 29 diabetics, 30 hypertensives, and 10 smokers. A total of 17 (12.8%) were found to have SCH. On stratification, gender, diabetes mellitus, and hypertension had a significant association with the presence of SCH. SCH is a modifiable risk factor, more in females, diabetics, hypertensives, and the old age population. These results highlight the need for screening for SCH in primary care settings, especially in old age. Key Words: Subclinical hypothyroidism, Old age, Gender, Diabetes, Hypertension.

Disease Spectrum and Frequency of Illness in Pediatric Emergency: A Retrospective Analysis From Karachi, Pakistan.

Background: The National Institute of Child Health (NICH) is the largest tertiary care pediatric hospital operating in Karachi, Pakistan. Its emergency department (ED) is always occupied. However, the spectrum of illness in patients presenting to this ED has not been investigated in depth to identify the most common presentations and to develop effective management for treating patients. Methods: This retrospective study included all children visiting the pediatric ED of the NICH from January 2017 through December 2017. Newborns to children 14 years of age were included, for a total cohort of 188,803 patients. Sociodemographic data and clinical information were extracted from the medical record. Univariate analysis was performed to determine the frequency and percentage for all the variables. Results: The cohort consisted of 9% (n=16,952) neonates (0 to 1 month) and 91% (n=171,351) older children (>1 month to 14 years). Among the neonates, 36.6% presented as triage level 1. Sepsis was diagnosed in 23.8% of neonates, low birth weight/preterm in 18.4%, and respiratory distress/pneumonia in 15.2%. In infants and older children, diagnoses related to the respiratory system (37.3%), gastrointestinal system (16.4%), and multisystem involvement (15.9%) were the most common. During the evening shifts, 38.1% of patients were seen, and on weekends, 51.6% of patients were seen. Sunday was the busiest day in the ED. Conclusion: The tertiary care pediatric EDs in Pakistan have witnessed an increasing number of critical emergencies over time. Respiratory and gastrointestinal emergencies form the majority of the ED burden. A surge of patients is seen on the weekends and during the evening shifts. The spectrum of illnesses should be investigated via prospective, longitudinal studies in other pediatric EDs in Pakistan to understand the trends and to provide the foundation for developing nationwide recommendations for improving pediatric emergency care.

Case Report: Rare comorbidity of celiac disease and Evans syndrome: The rare correlation of Celiac and Evans syndrome.

Background: Celiac disease is an immune-mediated enteropathy due to permanent sensitivity to gluten in genetically predisposed individuals. Evans syndrome is an autoimmune disorder designated with simultaneous or successive development of autoimmune hemolytic anemia and immune thrombocytopenia and/or immune neutropenia in the absence of any cause. Case Report: We report a rare case of Celiac disease and Evans syndrome in a 20-year-old female who presented to us with generalized weakness and shortness of breath. Her examination finding included anemia, jaundice, and raised jugular venous pulse. Her abdominal exam revealed hepatosplenomegaly. Her laboratory values showed microcytic anemia, leukocytosis and thrombocytopenia. To rule out secondary causes of idiopathic thrombocytopenia purpura, we tested viral markers for Human immunodeficiency virus, Epstein bar virus, Cytomegalovirus and performed a Helicobacter pylori test, all of which were negative. We also ruled out idiopathic thrombocytopenia purpura associated with any thyroid disorder.  For celiac disease, we took anti-tissue transgulataminase titers of IgA and IgG which confirmed the diagnosis of celiac disease. For the diagnosis of Evans syndrome, despite a negative serum coombs test initially, her bone marrow sample showed a positive Coombs test along with immune mediated hemolytic anemia and immune mediated thrombocytopenia. The patient was treated with prednisone which was tapered off and counseling was provided regarding a gluten free diet. Conclusion: Although rare, tests for Evans syndrome (and other coexisting autoimmune problems) should be performed in patients with celiac disease.

Effect of Migraine Headache on Productivity of Patients According to Migraine Disability Assessment Score: A Cross-Sectional Study.

INTRODUCTION: Migraine, a primary headache disorder, is usually recurrent with moderate to severe intensity. Migraine is the third most common cause of disability under the age of 50. There are various scoring systems for assessing this disability, one of which is MIDAS; the Migraine Disability Assessment Score. The objective of our study was to determine the extent of disability among migraine patients, patterns of prophylaxis, and their healthcare-seeking behaviors. METHODS: This survey was done in 50 migraine patients at Jinnah postgraduate medical Centre from April to May 2018. The questionnaire inquired about the demographic information, management of migraine, and effect of this condition on their sleep, and the last part had assessment to know about their functional disability. RESULTS: The majority of the patients were females with a mean age of 31 ± 10 years. Acetaminophen was the most common medication used during a migraine attack, followed by nonsteroidal anti-inflammatory drugs. Only 54% of subjects admitted using prophylaxis, out of which 94% had stopped taking it after some time, with the most common reason being their side effects. ß-blockers were the most common prophylaxis used. Only 32% had a regular follow-up visit with their doctors. Patients were graded according to the MIDAS score as: little or no disability, 22%; mild disability, 14%; moderate disability, 24%; and severe disability, 40%. CONCLUSIONS: The majority of migraine patients were found to have severe disability, which affected their daily work and social activities. Despite an increase in disability rate due to migraine, people do not seek regular medical care for this type of headache in Pakistan.

Complete blood picture with skeletal and visceral changes in patients with thalassemia major.

OBJECTIVE: The objective of this to find the prevalence of skeletal and visceral changes in thalassemics and its relationship with variation in blood components. METHODOLOGY: This is a cross-sectional study conducted in tertiary care hospital in Karachi among patients diagnosed with thalassemia major who require regular blood transfusions. RESULT: Among 200 individuals, 95 were females, whereas 105 were males. 96.5% of the study sample showed normocytic normochromic blood picture. Mean pre-transfusion hemoglobin (Hb) for 200 patients was 8.91 g/dl, while the mean post-transfusion Hb was 12.07 g/dl. Among all the variables, some strong predictors of change were age and HbA which were found associated with the development of cardiac change in transfusion-dependent thalassemia patients. Hepatomegaly was observed in 66.5% of the patients while normal liver span was observed in 33.5%. 6% of patients showed evidence of skeletal changes on X-ray. Splenomegaly was observed in 26.5%, while in 4.5% of the patients, spleen was not visualized due to splenectomy. Cardiac involvement was observed in 8% of the patients on T2*magnetic resonance imaging. CONCLUSION: Visceral changes particularly hepatomegaly is very common among transfusion-dependent thalassemia patients. Blood studies for Hb and ferritin levels help to detect these changes when conventional investigations are not possible.

Wernicke Encephalopathy Due to Hyperemesis Gravidarum in Pregnancy: A Case Report.

Wernicke's encephalopathy (WE) is a life-threatening acute or sub-acute neurological emergency characterized by ataxia, confusion, nystagmus, and ophthalmoparesis caused by thiamine deficiency. It was first described in 1881 by Carl Wernicke with alcohol being the most common cause. We present a rare case of a 35-year-old pregnant female who presented to our emergency department with a history of vomiting and loose motions for two weeks. She later developed fever, confusion, slurred speech and blurring of vision. Magnetic resonance imaging (MRI) of the brain revealed typical lesions of WE. She was immediately treated with thiamine and her symptoms improved in a few days.

The Clinicopathological Profile of Eosinophilic Myocarditis.

Eosinophilic myocarditis (EM) is a rare form of myocarditis. As there is extreme diversity in its manifestations, the true incidence is difficult to assess and no proper epidemiological criteria are present. It generally presents with a wide array of clinical manifestations. Clinical presentation tends to differ in cases and not all the patients show the same signs and symptoms. The etiology of EM often remains obscure but potential causes have been identified which may include hypersensitivity to drugs, exposure to certain viruses and parasites, and hyper-eosinophilic syndromes. Endomyocardial biopsy is considered to be a gold standard for the diagnosis of EM. Echocardiography, cardiac magnetic resonance, and bio markers particularly serum eosinophilic cationic protein concentrations are also known to aid in diagnosis. EM may lead to progressive, irreversible, and fatal myocardial damage if prompt diagnosis is not made and therapy is not initiated. The current treatment regimens include corticosteroids, cytotoxic agents, and immunosuppressive therapy. However, a proper treatment criterion is yet to be established.