Diagnostic Accuracy of Aetiology Score for Predicting Variceal Bleed in Patients of Upper Gastrointestinal Bleeding

Objective: To assess the diagnostic accuracy of aetiology scoring system for diagnosing variceal bleeding in patients presenting with upper gastrointestinal bleeding using endoscopy as gold standard.Material and Methods: This cross sectional study was conducted at Department of Medicine Unit, Jinnah hospital Lahore (JHL) from 19th December 2015 to 20th May 2016. In total 230 subjects, fulfilling the inclusion criteria were selected by non-probability consecutive sampling technique and informed consent were obtained. Patients were evaluated for variceal bleeding on the basis of aetiology scoring system and then confirmed with endoscopy. Data was analyzed by using SPSS 21.0 and sensitivity, specificity, positive and negative predictive value of aetiology score was calculated taking endoscopy as gold standard.Results: Out of 230 patients presenting with upper gastrointestinal bleeding, males and females were 48.3% and 51.7% respectively. The mean age was 41.64 + 10.53 years, the mean Upper gastrointestinal bleeding Ateiology score system was 3.23+ 1.55. The sensitivity, specificity, positive predicted value and negative predicted value at a cutoff value of etiological score > 3.1 for variceal bleeding were 90.70%, 82.18%, 86.67% and 87.37% respectively. it was observed that there was statistically significant association between etiological score > 3.1 and endoscopy.Conclusion: The UGIB Aetiology Score, composed of 3 parameters, using a cut-off ≥ 3.1 accurately predicted variceal bleeding and may help to guide the choice of initial therapy for UGIB before endoscopy

Vitamin D Deficiency in HCV Antiviral Treatment Responders versus Non-Responders

Background: Hepatitis C virus (HCV) is a major cause of chronic liver disease (CLD). Pakistan has a high burden of infectious diseases, including HCV. Its prevalence varies according to geographic regions in the country from about 2·4% to 6·5%. The objective of the study was to compare the frequency of vitamin D deficiency in responders and non-responders of antiviral treatment for chronic hepatitis C.Material and Methods: This comparative cross-sectional study was conducted in Hepatitis Clinic, Jinnah hospital, Lahore from 20th May to 20th November 2013. After ethical approval, participants were selected by using purposive non-probability sampling, 52 responder patients i.e. who were labeled negative for HCV RNA by PCR after 12 weeks of antiviral treatment and 52 non-responder patients were included in this study. Data was collected by using pretested structured questionnaire. Vitamin D3 levels were measured by ELISA and a cut-off value of below 30ng/ml was labeled as Vitamin D deficiency. SPSS version 21 was used to analyze data with p value less than 0.05 taken as statistically significant.Results: Out of 104 patients (mean age 35±8.1 years), 61.5% were males and 38.5 % were females. There was a significant difference in frequency of vitamin D deficiency in treatment responder group when compared to non-responders (p = 0.016). Mean level of vitamin D was 21.8±10.8ng/ml in responders whereas it was 15.6±7.5 in non-responders with a statistically significant difference (p = 0.001).Conclusion: This study concludes that there is a significant vitamin D deficiency among treatment non-responders as compared to treatment responders in patients with chronic hepatitis C

Antimicrobial Susceptibility Pattern among Patients Presenting with Acute Exacerbation of COPD

Background: The irrational use of antibiotics in outpatient as well as indoor patients without studying the culture and sensitivity patterns may have led to resistance in common organisms causing acute exacerbation of chronic obstructive pulmonary disease. The objective of this study was to determine the culture and sensitivity patterns of bacteria in the sputum of patients presenting with acute exacerbation of chronic obstructive pulmonary disease (COPD) in our population.Material and Methods: This cross-sectional study was conducted in the Medicine Department, Jinnah Hospital Lahore from 1st January 2018 to 25th June 2018. A total of 215 patients with acute exacerbation of COPD were collected through non-probability consecutive sampling technique. COPD was diagnosed on the basis of history, examination, chest X-ray and spirometry. Acute exacerbation was taken as an acute rise in one or more of the following; sputum volume and/or purulence, frequency and severity of cough and dyspnea. Two sputum samples were collected from each patient. Antimicrobial susceptibility testing was done as per CLSI guidelines. Data was analyzed by SPSS version 21.0. with p-value ≤ 0.05 considered as statistically significant.Results: Among 215 selected cases, 118 (54.88%) were males and 97 (45.12%) were females. A total of 110 (51.16%) cultures were positive and 105 (48.84%) were negative for bacterial growth. Klebsiella pneumoniae (n=69; 62.72%) was the most frequent microorganism in patient’s sputum followed by Pseudomonas aeruginosa (n=21; 19.1%) and Staphylococcus aureus (n=20; 18.2%). Regarding sensitivity pattern, amikacin was found to be the most sensitive antibiotic against these organisms followed by gentamicin and ciprofloxacin.Conclusions: Klebsiella pneumoniae was the most common microorganism in the sputum of patients presenting with acute exacerbation of COPD, while amikacin was reported to be most sensitive antibiotic against the microorganism.Key words: Acute exacerbation, Antimicrobial susceptibility pattern, COP

Global, regional, and national sex-specific burden and control of the HIV epidemic, 1990-2019, for 204 countries and territories: the Global Burden of Diseases Study 2019

Background: The sustainable development goals (SDGs) aim to end HIV/AIDS as a public health threat by 2030. Understanding the current state of the HIV epidemic and its change over time is essential to this effort. This study assesses the current sex-specific HIV burden in 204 countries and territories and measures progress in the control of the epidemic. Methods: To estimate age-specific and sex-specific trends in 48 of 204 countries, we extended the Estimation and Projection Package Age-Sex Model to also implement the spectrum paediatric model. We used this model in cases where age and sex specific HIV-seroprevalence surveys and antenatal care-clinic sentinel surveillance data were available. For the remaining 156 of 204 locations, we developed a cohort-incidence bias adjustment to derive incidence as a function of cause-of-death data from vital registration systems. The incidence was input to a custom Spectrum model. To assess progress, we measured the percentage change in incident cases and deaths between 2010 and 2019 (threshold >75% decline), the ratio of incident cases to number of people living with HIV (incidence-to-prevalence ratio threshold <0·03), and the ratio of incident cases to deaths (incidence-to-mortality ratio threshold <1·0). Findings: In 2019, there were 36·8 million (95% uncertainty interval [UI] 35·1–38·9) people living with HIV worldwide. There were 0·84 males (95% UI 0·78–0·91) per female living with HIV in 2019, 0·99 male infections (0·91–1·10) for every female infection, and 1·02 male deaths (0·95–1·10) per female death. Global progress in incident cases and deaths between 2010 and 2019 was driven by sub-Saharan Africa (with a 28·52% decrease in incident cases, 95% UI 19·58–35·43, and a 39·66% decrease in deaths, 36·49–42·36). Elsewhere, the incidence remained stable or increased, whereas deaths generally decreased. In 2019, the global incidence-to-prevalence ratio was 0·05 (95% UI 0·05–0·06) and the global incidence-to-mortality ratio was 1·94 (1·76–2·12). No regions met suggested thresholds for progress. Interpretation: Sub-Saharan Africa had both the highest HIV burden and the greatest progress between 1990 and 2019. The number of incident cases and deaths in males and females approached parity in 2019, although there remained more females with HIV than males with HIV. Globally, the HIV epidemic is far from the UNAIDS benchmarks on progress metrics. Funding: The Bill & Melinda Gates Foundation, the National Institute of Mental Health of the US National Institutes of Health (NIH), and the National Institute on Aging of the NIH

Reducing the environmental impact of surgery on a global scale: systematic review and co-prioritization with healthcare workers in 132 countries

Abstract Background Healthcare cannot achieve net-zero carbon without addressing operating theatres. The aim of this study was to prioritize feasible interventions to reduce the environmental impact of operating theatres. Methods This study adopted a four-phase Delphi consensus co-prioritization methodology. In phase 1, a systematic review of published interventions and global consultation of perioperative healthcare professionals were used to longlist interventions. In phase 2, iterative thematic analysis consolidated comparable interventions into a shortlist. In phase 3, the shortlist was co-prioritized based on patient and clinician views on acceptability, feasibility, and safety. In phase 4, ranked lists of interventions were presented by their relevance to high-income countries and low–middle-income countries. Results In phase 1, 43 interventions were identified, which had low uptake in practice according to 3042 professionals globally. In phase 2, a shortlist of 15 intervention domains was generated. In phase 3, interventions were deemed acceptable for more than 90 per cent of patients except for reducing general anaesthesia (84 per cent) and re-sterilization of ‘single-use’ consumables (86 per cent). In phase 4, the top three shortlisted interventions for high-income countries were: introducing recycling; reducing use of anaesthetic gases; and appropriate clinical waste processing. In phase 4, the top three shortlisted interventions for low–middle-income countries were: introducing reusable surgical devices; reducing use of consumables; and reducing the use of general anaesthesia. Conclusion This is a step toward environmentally sustainable operating environments with actionable interventions applicable to both high– and low–middle–income countries

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Preliminary aerodynamic investigation of box-wing configurations using low fidelity codes

This work outlines the different aerodynamic aspects of box-wing design i.e. an unconventional aircraft design configuration exhibiting the capability of reducing induced drag. Being a nonplanar concept, the basic aerodynamic features differ from conventional designs. To understand these features and their influence on box-wing aerodynamics, parameter variations have been conducted while Munk’s theorem is validated for stagger and sweep. In this process, several important aspects of box- wing are highlighted. An optimization algorithm has been implemented by considering all the design variables collectively to find the global maximum for the box-wing design. All these investigations laid down the important aerodynamic features of box-wing and also proved a method for estimating the reduction in induced drag. To conduct these investigations, vortex lattice methods (VLM) are used. Non planar systems have certain limitations for best operations which provide maximum induced drag reduction. These limitations are examined and applied in the form of constant and specified lift distributions in the analysis. Furthermore, it is concluded that vortex lattice methods do capture the reduction in induced drag correctly if the limitations of span loading are maintained during the analysis. Based on previous results obtained, Euler inviscid analysis for a selected box-wing and a reference wing are carried out. The results of Euler inviscid analysis show good agreement with the results achieved by vortex lattice method in drag reduction. Therefore, VLM methods are capable of analyzing box-wing (and multi planar systems) to a good accuracy. At the same time, transonic airfoil selection is identified as one of the key factors in designing a commercial box-wing aircraft. This study is closed up by discussing different potential advantages for the aviation industry and discusses if a box-wing commercial aircraft should be made reality. On the whole, this work looks into a possible way of investigating futuristic multi planar aircraft configurations by using low fidelity aerodynamic codes.Validerat; 20101217 (root

Incidence and risk factors for genitourinary infection in individuals with type 2 diabetes using SGLT2 inhibitors: A retrospective study

Aim: To assess the frequency and risk factors for genitourinary infections in people with type 2 diabetes who are using SGLT2 inhibitors. Study design: A retrospective study. Place and Duration: Jinnah Hospital Lahore from March 2021 to March 2022. Methodology: This study included 57 people with type 2 diabetes who were using SGLT2 inhibitors.The parameters linked to genitourinary infections were observed via the use of multiple logistic regression analyses. This study utilized patients' medical records for observation and analysis. At the beginning of SGLT2 inhibitor therapy, data on the patient's age, gender, height, weight, duration of diabetes, menopausal status, HbA1c, and creatinine levels were collected. Two independent teams of scientists looked through the results of the investigation before concluding the final hypothesis. Results: Genitourinary infection occurred at a rate of 2.37 percent in the first month and 21.78 percent in the second month of the therapy. Genitourinary infections are more likely in individuals with HbA1c values between 7.0 and 8.0% (OR=3.45, p=0.001), 8.0% to 9.0% (OR=8.56, p=0.0001), and 9.0% (OR=11.45, p=0.0001), as well as diabetes medications such as SUR (OR=4.13, p0.001) and insulin (OR=3.81, p0.001).&nbsp

Clinical outcomes comparison in diabetic and non-diabetic COVID-19 patients: A case-control study

Aim: To compare the clinical outcomes of a severe attack of COVID-19 in patients with diabetes and patients with no diabetes. Study design: A case-control study. Place and Duration: This study was conducted at Liaquat University of Medical and Health Sciences Jamshoro Pakistan from October 2020 to October 2021. Methodology: Out of 62 patients who visited the emergency department during the study period with shortness of breath, 55 participants tested positive for COVID-19. Those 55 were included in the present study. All the patients were admitted to ICU. A detailed demographic and clinical history was taken. All the patients were categorized as diabetic and non-diabetic based on their blood sugar levels. The clinical outcomes were assessed by monitoring blood pressure, rate of shock, renal function tests, and level of troponin. Result: Out of a total of 55 patients, 33 (60%) patients were detected with diabetes and the remaining 22 (40%) did not have diabetes. A total of 21 (63.64%) of the diabetic patients needed invasive ventilation and 9 (27.27%) needed non-invasive ventilation. A total of 20 (60.6%) diabetic patients had acute kidney injury and 29 (87.88%) had elevated levels of troponin.&nbsp