AHSG rs4918 Polymorphism poses a weak predisposition to insulin resistance during pregnancy

Objective: To identify the association between Fetuin-A levels and genetic polymorphism with gestational diabetes mellitus among pregnant women visiting a tertiary care centre. Methods: This cross-sectional case-control study was conducted at Aga Khan University Hospital, Karachi, from December 2015 to September 2016, and comprised pregnant women in their second trimester. Those with gestational diabetes mellitus were considered the cases while the rest acted as controls. The enzyme-linked immunosorbent assay was used to quantify Fetuin-A levels while genotyping for alpha-2-Heremans-Schmidglycoprotein rs4918 was performed using restriction fragment length polymorphism technique. Blood samples were collected and serum and deoxyribonucleic acid were extracted and stored at -80°C. SPSS 21 was used to analyse the findings. Results: Of the 88 subjects, there were 44(50%) in each group. Serum Fetuin-A concentration was higher in cases compared to the controls (p\u3c0.01). The genotype data for the cases was 0.668 and for the controls 0.840 (p\u3e0.05). However, the G allele showed a weak risk or predisposition towards gestational diabetes mellitus (p=0.038). Conclusion: Increased Fetuin-A levels were found to be related to the occurrence of gestational diabetes mellitus, indicating that Fetuin-A possibly contributes towards insulin resistance

Comparison of figure of eight and traditional simple wire closure method to prevent dehiscence after sternal closure

Objective: To investigate significant differences, if any, between figure of-eight method and simple wire closure technique in reducing the incidence of infectious and non-infectious sternal dehiscence in patients undergoing sternal closure.Methods: The systematic review was conducted in the Cardiothoracic Surgery Department at Aga Khan University from 1st December 2015 to 13th December 2017. The review was registered with PROSPERO, the International Prospective Register of Systematic Reviews. Pubmed, Cochrane Library (Wiley) and Scopus databases were searched for articles published up to December 13, 2017. The search was limited to randomised control trials, clinical trials, retrospective cohort studies, journal analyses, systematic reviews and meta analyses. Cadaveric or animal studies and articles published in languages other than English were excluded.Results: Of the 286 articles retrieved, 265(92.6%) were excluded on the basis of study title and abstract. Another 15(5.2%) were excluded for being irrelevant to the topic n hand, and 6(2.1%) formed the final sample. Of them, 4(66.6%) studies showed no significant difference between the two techniques, while 2(33.3%) found figure-of-eight technique to be superior of the two.Conclusions: There was no significant difference between the figure-of eight method and the simple wire technique in reducing the risk of dehiscence in patients undergoing sternal closure

Rising trends in hospitalization costs in the United States: Analysis from the National Inpatient Sample

We assessed the contemporary temporal trends in hospitalization costs and the total number of hospitalizations in the US. A retrospective study was performed using annualized data of total hospitalizations and sociodemographics of patients using the National Inpatient Sample database. From 2012 to 2019, a total of 2.9 million hospitalizations and $3.5 trillion in hospitalization costs were recorded. The overall mean inflation-adjusted cost per hospitalization increased significantly from$11,585 in 2012 to $13,486 in 2019. Findings were consistent across males, females, and all pre-specified age groups, with a relative decline in crude hospitalization rates per 100,000 US population in females and all age groups during the study period. Further studies are warranted to study cause-specific hospitalizations that would explain these findings. Keywords: Costs; Expenditure; Hospitalization; National inpatient sample; Population

Trends in Sleep Apnea and Heart Failure Related Mortality in the United States from 1999 to 2019

National estimates of deaths related to both heart failure (HF) and sleep apnea (SA) are not known. We evaluated the trends in HF and SA related mortality using the CDC-WONDER database in adults aged ≥25 years in the US. All deaths related to HF and SA as contributing or underlying causes of death were queried. Between 1999 and 2019, there were a total of 6,484,486 deaths related to HF, 204,824 deaths related to SA, and 53,957 deaths related to both. There was a statistically significant increase in the age-adjusted mortality rate (AAMR) for both SA-related (average annual percent change [AAPC] 8.2%) and combined HF and SA- related (AAPC 10.1%) deaths. Men had consistently higher AAMRs compared with women, and both groups had a similar increasing trend in AAMR. Non-Hispanic (NH) Black individuals had the highest HF and SA-related AAMR, followed by NH White and Hispanic/Latino individuals. Adults aged \u3e75 years consistently had the highest AAMR with the steepest increase (AAPC 11.1%). In conclusion, HF and SA-related mortality has significantly risen over the past two decades with the elderly, men, and NH Black at disproportionately higher risk. Keywords: epidemiology; heart failure; mortality; sleep apnea; trends

Incidence of Lower Urinary Tract Symptoms in Middle Aged Patients Visiting the Gynaecology Out Patient Department of Shalamar Hospital, Lahore, Pakistan

Objective: To determine the incidence of Lower Urinary Tract Symptoms (LUTS) among patients visiting the gynaecology Outpatients Department (OPD) of Shalamar Hospital. Material & Methods: A cross sectional study was performed and 300 patients were recruited. Patients aged 40 to 60 years, visiting the Gynaecology OPD at Shalamar Hospital, Lahore were enrolled from 1st February 2018 to 30th September 2018. The participants were categorized in to two sets: Premenopausal (n=187) and Post-Menopausal (n=113). They were asked to fill the international Consultation and Incontinence Questionnaire-Short Form (ICIQ-UI Short Form). Results: Increased urinary frequency was found to be the most commonly reported symptoms (48%).Stress incontinence and urge incontinence were reported by 58% subjects amongst postmenopausal category and 42% in the premenopausal category. Presence of LUTS was observed to be directly proportional with age. Conclusion: A high incidence of LUTS was observed among patients visiting gynaecology OPD of Shalamar Hospital, Lahore. Risk factors of LUTS and incontinence, like obesity and multiparity were frequency reported. Further studies are required to understand the magnitude of this problem in general population of Pakistan

A case of native tricuspid valve Neisseria mucosa/sicca species infective endocarditis complicated by septic pulmonary emboli

We report a rare case of native tricuspid valve infective endocarditis caused by Neisseria mucosa/sicca, a gram-negative diplococcus which colonizes the upper respiratory tract. A female in her late 20 s with a history of injection drug use (IDU) who recently completed treatment for methicillin-sensitive Staphylococcus aureus (MSSA) native tricuspid valve infective endocarditis presented to the hospital with a 6-week history of increasing chest pain, shortness of breath and night sweats. Blood cultures grew Neisseria mucosa/sicca species in 3 of 3 sets. Transthoracic echocardiogram showed a large 3 cm × 2.2 cm vegetation on the tricuspid valve with severe regurgitation. The patient was initially treated with ceftriaxone and gentamicin. Her case was complicated by ongoing septic pulmonary emboli ultimately require pulmonary endarterectomy and repair of her tricuspid valve. We hope this case highlights a rare but known cause of infective endocarditis especially in patients with a history of IDU who may lick their needles, which predisposes those individuals to intravenous introduction of oral bacteria

A case of native tricuspid valve Neisseria mucosa/sicca species infective endocarditis complicated by septic pulmonary emboli

We report a rare case of native tricuspid valve infective endocarditis caused by Neisseria mucosa/sicca, a gram-negative diplococcus which colonizes the upper respiratory tract. A female in her late 20 s with a history of injection drug use (IDU) who recently completed treatment for methicillin-sensitive Staphylococcus aureus (MSSA) native tricuspid valve infective endocarditis presented to the hospital with a 6-week history of increasing chest pain, shortness of breath and night sweats. Blood cultures grew Neisseria mucosa/sicca species in 3 of 3 sets. Transthoracic echocardiogram showed a large 3 cm × 2.2 cm vegetation on the tricuspid valve with severe regurgitation. The patient was initially treated with ceftriaxone and gentamicin. Her case was complicated by ongoing septic pulmonary emboli ultimately require pulmonary endarterectomy and repair of her tricuspid valve. We hope this case highlights a rare but known cause of infective endocarditis especially in patients with a history of IDU who may lick their needles, which predisposes those individuals to intravenous introduction of oral bacteria. Keywords: Infective endocarditis; Intravenous drug use; Neisseria; Septic pulmonary emboli; Tricuspid valve

Post hypoxic myoclonus: A tale of two minds

Post hypoxic myoclonus (PHM) is considered a poor prognostic sign and may influence decisions regarding withdrawal of treatment. PHM is generally categorized in literature as either acute or chronic (also commonly referred to as Lance-Adams Syndrome) based on the onset of myoclonus. However, it may be more accurate to differentiate between the various presentations of PHM based on the clinical characteristics and electroencephalogram (EEG) findings for prognostication. Here, we describe a case of a 33-year-old female who presented after a cardiopulmonary arrest. MRI of the brain and cervical spine on admission were unremarkable. Twelve hours later, she developed generalized, stimulus-sensitive myoclonus suggestive of acute PHM. Various medications were trialed, and her symptoms eventually improved on clonazepam. On day 14, she started having resting and intention myoclonus, and dysarthria, consistent with LAS. Several adjustments were again made to her regimen, and she was eventually switched from clonazepam to baclofen which improved her resting myoclonus. This case highlights that PHM can present differently and have a markedly different outcome. It is important to develop a better understanding of the various types of PHM so as to avoid premature withdrawal of care

The Association of Frailty With Long-Term Outcomes in Patients With Acute Respiratory Failure Treated With Noninvasive Ventilation

The objective of this study was to investigate the prevalence and impact of frailty on mortality in patients with acute respiratory failure (ARF) treated with noninvasive ventilation (NIV). This was a single-center, prospective study of patients who developed ARF (irrespective of etiology) and were treated with NIV support. Frailty was assessed using the Clinical Frailty Scale (CFS). We modeled the relationship of CFS with one-year mortality using Cox proportional hazards regression, adjusting for other clinical and demographic characteristics. Of the 166 patients enrolled, 48% had moderate to severe frailty. These patients were more likely to be female (67% versus 33%) and on oxygen therapy at home (46% versus 28%). The median CFS score was 5 (interquartile range (IQR): 5-6). Moderate to severe frailty was associated with a 60% higher risk of one-year mortality (hazard ratio (HR): 1.63, 95% confidence interval (CI): 1.15-2.31). Frailty assessment may identify patients in need of ventilatory support who are at increased risk of mortality and may be an important factor to consider when discussing goals of care in this vulnerable population. Keywords: acute respiratory failure; critical illness; frailty; mortality; noninvasive ventilation

Post hypoxic myoclonus: A tale of two minds

Post hypoxic myoclonus (PHM) is considered a poor prognostic sign and may influence decisions regarding withdrawal of treatment. PHM is generally categorized in literature as either acute or chronic (also commonly referred to as Lance-Adams Syndrome) based on the onset of myoclonus. However, it may be more accurate to differentiate between the various presentations of PHM based on the clinical characteristics and electroencephalogram (EEG) findings for prognostication. Here, we describe a case of a 33-year-old female who presented after a cardiopulmonary arrest. MRI of the brain and cervical spine on admission were unremarkable. Twelve hours later, she developed generalized, stimulus-sensitive myoclonus suggestive of acute PHM. Various medications were trialed, and her symptoms eventually improved on clonazepam. On day 14, she started having resting and intention myoclonus, and dysarthria, consistent with LAS. Several adjustments were again made to her regimen, and she was eventually switched from clonazepam to baclofen which improved her resting myoclonus. This case highlights that PHM can present differently and have a markedly different outcome. It is important to develop a better understanding of the various types of PHM so as to avoid premature withdrawal of care. Keywords: Lance-Adams syndrome; Myoclonus; Post hypoxic