Multi Organ Failure (MOF) and a Promising Novel Device

Shahid Kamal

Acutely ill hospitalized patients are at risk of cascading failure of vital organs leading to prolonged stay in the hospital, persistent dysfunction of vital organs and higher probability of death. It is estimated that 50 to 75% of ICU patients have failure of one or more vital organs and as more organs are involved the risk of death increases [1, 2]. For example in Acute on Chronic Liver Failure (AOCLF) the 28 day probability of death increases from 20% with one vital organ failure to 90% or higher if 3 or more organs are involved. Dysfunction of brain, lungs, heart and kidneys are most commonly seen, kidney involvement is usually poor prognostic sign.


Association of Simple Febrile Seizure with Iron Deficiency Anemia in Children: A Case Control Study

Muhammad Saeed, Mohammad Hassan Hussain Al Sumaili, Badriah Gharamah Al Asmari, Mahnoor Saeed, Ali Mujtaba Tahir, Awad Salem Alrashdi, Saad Mufarrih Al Abdullah, Ali Maqbool, Abdul Qadir and Asma Imtiaz Hotiana

Abstract: Background: Febrile seizure is an established entity in Pediatrics which characterizes with absence of any intracranial infection or metabolic disorders. Simple febrile seizure carries a favorable prognosis without any sequelae. Still, it emerges as the most common etiology of seizure till the age of five years. Iron deficiency anemia is a commonly witnessed micro-nutrient deficiency with a worldwide distribution.

Objective: To establish relation of simple febrile seizure with iron deficiency anemia in paediatric population.

Materials and Methods: Case-control study, conducted in Pediatric Medicine Department, King Fahad Armed Forces Hospital Southern Region, Khamis Mushayat, Kingdom of Saudi Arabia, from1st January 2022 to 30th June 2023. The 102 children, having age six months to five years, with a diagnosis of first simple febrile seizure were assessed. Likewise, the control group included 102 febrile children without convulsion. The hematological parameters evaluated for diagnosis of iron deficiency anemia included hemoglobin, mean corpuscular volume, serum ferritin, serum iron, total iron binding capacity & red cell distribution width.

Results: The mean age for first simple febrile seizure was 23 months. Acute respiratory infection was the most common etiology (80%). Iron deficiency anemia was identified in 17% of cases of simple febrile seizure, in contrary to 6% of cases with febrile illness without seizure, with odds ratio of 3.2.

Conclusion: This study demonstrated that the children with iron deficiency anemia are at significantly higher risk of having febrile convulsions compare to control group with fever but without anemia.

Received: October 09, 2023
Revised: March 07, 2024
Accepted: March 08, 2024


Physician Burnout during Covid-19 Pandemic in Pediatric Emergency Rooms of Low-Middle Income Country, Pakistan

Zareen Qasmi, Irfan Habib, Huba Atiq, Sharmeen Nasir, Shah Ali Ahmed and Fehmina Arif

Abstract: Background: Burnout can adversely affect the mental health, quality of life and quality of work of healthcare workers.

Objective: We aimed to assess the burnout rate among physicians working in pediatric emergency rooms during COVID-19 pandemic, in public sector hospitals of Pakistan.

Materials and Methods: It is a descriptive study performed in March 2021. We included all physicians working in the pediatric emergency departments of 9 public sector hospitals of Sindh, Pakistan, excluding those who didn’t give consent. The participants were sent an online questionnaire based survey, comprising of Copenhagen Burnout Inventory (CBI) tool along with three added COVID-19 specific questions. It was disseminated electronically. Data was analyzed using SPSS ver22.

Results: A total of n=249 physicians filled the forms out of 320, giving a response rate of 77.8%. Majority 187 (75.1%) were females. Most of the physicians were females n=187 (75.1%) and worked primarily in emergency department n=186 (74.7%). The Copenhagen Burnout Inventory (CBI) score revealed that 88 (35.3%) of the physicians had burnout (Score > 50). The most common component was Personal burnout in 122 (48.9%). Physicians working in emergency department, full time shifts and at junior designations had higher rates of burnout (P value < 0.05).

Conclusion: Burnout is a significant problem in pediatric emergency departments, specifically during the COVID-19 pandemic. Timely training and provision of supplies along with safety, security and alleviation of fear are important strategies to overcome burnout.

Received: October 06, 2023
Revised: March 26, 2024
Accepted: April 01, 2024


The Non-Accessible Ureter: Can History, Gender, Age, BMI, Radiology and Stone Size Predict the Requirement of Pre-Stenting in Narrow Ureters

Anil Kumar Utraadi, Sharjeel Saulat, Syed Saeed-uddin Qadri, Ashba Mushtaque, Muhammad Osama and Umber Rasheed

Abstract: Background: The difficulty in access to the ureter during stone removal surgery enhances the chances of redo-surgery, DJ stenting, and associated complications, this failure leads to mistrust in the doctor-patient relationship.

Objective: This study aims to provide a comprehensive evaluation of the incidence & management of narrow ureters after failure to negotiate retrograde access of rigid or flexible Ureteroscope (6/7.5 Fr).

Materials and Methods: This is a Prospective, cross-sectional study, conducted at the urology department of Tabba Kidney Institute, from June 2022 to June 2023. The minimum required sample size was 250. Patients aged between > 18 to ≪ 60 diagnosed with Unilateral and bilateral ureteric stones and hydronephrosis without ureteric stone obstruction were included in the study. SPSS 22 was used to analyze the data, the chi-square test was applied, with p-value ≪ 0.05 as significant

Results: The overall mean age of the study population was estimated as 40.71 ± 12 years, while gender distribution indicated 138 (55.2%) male and 112 (44.8%) female patients. Group distribution identified 172 (68.8%) patients with negotiable ureter (Group A), while 78 (31.2%) with non-negotiable ureter (Group B).

Conclusion: We conclude that in our population there is a higher incidence of narrow ureters, as compared to other studies which are not accessible even using the same dilatation technique, so it is safe to counsel the patients pre-operatively about the possibility of the narrow ureter and need for pre-stenting. Tabba Ureter Accessibility (TUA) score can be used as a tool to predict the possibility of a narrow ureter.

Received: December 12, 2023
Revised: January 26, 2024
Accepted: January 26, 2024


Does the Time of Day have an Effect on the Success and Complications of ERCP?

Berk Bas, Omer Kucukdemirci, Muge Ustaoglu, Beytullah Yildirim

Abstract: Background: In ERCP, if modifiable risk factors can be minimized, indirectly, the rates of complications will also decrease.

Objective: In the present study, the aim is to investigate whether the timing of ERCP (morning versus afternoon) was associated with the success of cannulation and procedure-related complications in patients with bile duct stones undergoing ERCP.

Materials and Methods: This is a retrospective study of patients who underwent ERCP for common bile duct (CBD) stones. We compared the complication rate and the success of CBD cannulation between procedures conducted in the morning and those carried out in the afternoon during ERCP.

Results: A total of 402 patients were enrolled. The mean age of patients was 64.4 ± 19 years with a total bilirubin value of 7.5 ± 11.6 mg/dL, direct bilirubin value of 4.9 ± 8.6 mg/dL, and CBD of 11±2.4 mm. 201 (50%) of the patients underwent ERCP in the morning and 201 (50%) in the afternoon. The rates of post-ERCP pancreatitis, bleeding, and the success of cannulation were 5.5%, 10%, and 96.5% in the morning ERCP group and 5%, 13.4%, and 93% in the afternoon ERCP group, respectively. There were no statistically significant differences between groups in post-ERCP pancreatitis (p=0.606), bleeding (p=0.277), and the success of CBD cannulation (p=0.117).

Conclusion: Between morning and afternoon ERCP procedures, no statistically significant difference was detected.

Received: September 4, 2023
Revised: December 11, 2023
Accepted: December 18, 2023


Outcome of Delayed Distally Based Sural Flap for Distal Tibial and Foot Defects

Syed Mohammad Haider, Firdous Khan, Muhammad Shadman, Adeeba Ahmad, Waqas Hayat and Abida Binte Wali

Abstract: Background: Lower limb defects can be tricky to repair. We have limited options for reconstruction in the leg and foot region. Sural flap is considered as the workhorse for reconstruction of these defects. We present our case series of delayed reverse sural flap.

Objective: To determine the outcome of Delayed Distally based sural flaps for distal tibial and foot defects.

Materials and Methods: Study was carried out at plastic and reconstructive unit HMC and MMC. Over a period of 10 years from January, 2009 to December, 2018. This is a cross sectional study, presenting with soft tissue defects of foot. Patients presented in the emergency, as an outpatient or as referrals from another center. All patients were admitted and operated as elective cases.

Results: In 24 patients, there were no complications. Two patients (6%) had partial flap loss and required revision surgeries. Two patients had marginal flap necrosis and were treated conservatively.

Conclusion: This study presents our experience with use of reverse sural flap. It provides a reliable option for foot and distal leg defects. It is relatively easy to do and easy to learn. It can be attempted in centers where expertise or facilities for microvascular surgery are not available and in patients who are not ideal candidates for a free flap.

Received: February 02, 2023
Revised: February 22, 2024
Accepted: February 23, 2024


Assessment of Knowledge about Referral Letters among Fresh Graduates and General Dentists of Karachi

Marium Iqbal, Rooha Sultan and Hana Parvez

Abstract: Background: Medical or dental referrals are a very significant part of a health professionals’ job. It is imperative that they are proficient in developing effective referral letters with relevant information and sequence.

Objective: To find out how much the dentists know about effective referral letter writing. To assess the knowledge of fresh dental graduates and general dentists in Karachi regarding referral letters.

Materials and Methods: It is a cross-sectional questionnaire-based study. A questionnaire was developed consisting of two parts; first part pertaining to demographic data while second part consisted of multiple-choice questions. Convenience sampling technique was adopted and a sample size of n=75 was collected. Our study setting was Jinnah Medical and Dental College for fresh graduates while general dentists were approached from all over Karachi. The fresh graduates who were absent on the day of data collection and anyone who did not give consent was excluded from the study. Participants were approached by one of the investigators to fill out the designated questionnaires. Study duration spanned from October 2022 to January 2023. Data was documented in SPSS version 25 and frequencies calculated. T-test was used for comparison.

Results: Knowledge of n=35 fresh graduates and n=40 general dentists regarding referral letters was assessed. 31.4% of fresh graduates and 25% of general dentists exhibited good knowledge on cut-off scores. No significant comparative difference in the level of knowledge of the two groups was determined regarding the components of a referral letter.

Conclusion: Participants were well informed and knowledgeable about the relevance and importance of a referral letter.

Received: July 07, 2023
Revised: December 02, 2023
Accepted: December 19, 2023


Depression, Anxiety, and Stress in Patients Undergoing Hemodialysis: Assessment of Contributing Factors

Khurram Danial, Naseha Mushtaq, Erum Alam, Maliha Mushtaq and Sana Tariq

Abstract: Background: The frequency of Chronic Kidney Disease (CKD) assessed worldwide is 13.4% (11.7-15.1%), and cases with ESKD demanding renal replacement therapy are calculated to be between 4.902 and 7.083 million. Several factors prompt anxiety and depression in hemodialysis cases. These include co-morbidities, frequent hospitalizations, habitual pain, sleep disturbances, chronic inflammation, increased fatigue, uremia, failure of family support, non-compliance to adjunctive therapeutics such as restrictions in diet and fluids, and dependence upon treatment and health professionals.

Objective: To assess the frequency and contributing factors for incidents of depression, stress, and anxiety in hemodialysis patients.

Materials and Methods: This is an observational, cross-sectional study conducted at the Karachi Institute of Kidney Diseases from February 2023 to March 2023, the obtained minimum sample size was 194. Data was collected with the help of DASS 10 questionnaire. The data was entered and analyzed by using Statistical Package of Social Sciences (SPSS) Version 22. Data significance was analyzed using Chi-Square test keeping P- value ≤0.05 as significant.

Results: A total of 194 participants were recruited in the study, gender distribution recorded male dominance at 103 (53%) and females at 91 (46%). 139 (71.6%), the mean value of the length of dialysis was 15.4 ± 4.9 years while the mean days of dialysis were 2.7 ± 1.3. Moderate depression was reported in 101 (52%) of the study participants, while severe depression was reported in 25 (12.8%). Anxiety was reported as mild most frequently with 133 (68.5%) while stress was reported as mild in 48 (24.7%), moderate in 83 (42.7%), and severe in 63 (32.4%) with a p-value of 0.214. We identified a positive association of severe depression, anxiety, and stress with age ≤ 45 years in general, while participants from the upper middle class reported stress more frequently.

Conclusion: This study concluded that compromised socio-economic status, young age, and higher prognosis rates are contributing factors for depression, anxiety, and stress in hemodialysis patients.

Received: August 01, 2023
Revised: November 25, 2023
Accepted: December 01, 2023


Functional Outcomes of Subtrochanteric Femur Fracture Fixed with Dynamic Condylar Screw

Hidayatullah, Muhammad Inam, Muhammad Tariq and Muhammad Jamil

Abstract: Background: Orthopedic surgeons find it most difficult to manage subtrochanteric femur fractures because of its notorious location, where difficulties might arise. Various techniques, including intramedullary and extramedullary implant stabilization have been tried with varying level of success.

Objective: Our study aimed to assess the functional results of dynamic condylar screws in sub trochanteric femur fractures in order to aid the underprivileged masses in our area.

Materials and Methods: This prospective observational study was conducted in Akbar Medical Center Dabgari Garden Peshawar, Pakistan from September, 2018 to August, 2022. All patients of either gender having age above 20 years with proximal femoral fracture without concomitant fracture, with negative hepatitis profile and no diabetes were managed using a dynamic condylar screw. Functional outcome of the surgery was evaluated using Harris Hip Score.

Results: There were total 88 patients in the study with male to female ratio of 3:1 having mean age of 33.96±9.63. Postoperative functional outcome in terms of Harris hips score range from 64 to 94 with a mean of 83.87 ±7.27 SD. Excellent functional outcome were observed in 14.8% patients, good results in 64.8% patients, fair outcomes in 11.4% and poor outcome were observed in 9.1% patients.

Conclusion: DCS results are excellent and good functional outcome in majority of patients. Therefore, it can be used as a good alternative to other intra and extramedullary implants fixation.

Received: August 17, 2023
Revised: November 11, 2023
Accepted: November 13, 2023


Comparison of Mean Hospital Stay after Nebulization with 3% Hypertonic Saline vs Salbutamol in Treatment of Bronchiolitis

Rabia Nizam, Amna Khalid, Mehwish Shafique, Mehwish Imtiaz, Shadab Masood and Muhammad Khalid Masood

Abstract: Background: With an estimated prevalence of 33% in children age >2years and owing to 1 in 10th cause of hospitalization in children, Bronchiolitis is a major factor for morbidity and mortality. Varying nebulization doses have been shown to produce different clinical outcomes in patients with bronchiolitis.

Objective: To compare mean hospital stay after nebulization with 3% hypertonic saline compared to the salbutamol among patients of bronchiolitis

Materials and Methods: This was a randomized control study done at pediatric medicine ward, Services Hospital, Lahore. The study was done during 8th May 2018 to 8th November 2018. Data was collected from 68 children of age >3 months to < 2 years of both genders i.e. (34 in each group) fulfilling inclusion criteria. SPSS software was used for data entry and analysis. For quantitative variables age, mean and standard deviation were used whereas for qualitative variables like gender, frequency and percentages were used. Independent sample t-test was used for comparing mean hospital stay among the two groups taking p-value ≪ 0.05 as significant. Results: Average age in Salbutamol group was 1.06 ± 0.50 years and in Hypertonic solution mean age was 1.24 ± 0.55 years. There was significant difference in mean hospital stay with relatively lesser in hypertonic solution vs the Salbutamol group [3.18 ± 1.11 vs 4.44 ± 1.08 ; p-value ≪ 0.001]. Upon post-stratification analysis, the mean hospital stay was found to be significantly lower in the Hypertonic group vs. Salbutamol group with respect to age, gender and the duration of the disease (p-values < 0.05 for all).

Conclusion: This study concludes that the mean hospital stay was statistically lower in the hypertonic solution group vs the Salbutamol group. Moreover, the clinical efficacy of the hypertonic saline can be utilized in future to gain early recovery of Bronchiolitis and hence it can reduce the hospital stay and related cost.

Received: September 26, 2023
Revised: February 19, 2024
Accepted: February 20, 2024


Frequency and Resistance Pattern of Carbapenemases (Class A & B) in E. Coli and Klebsiella Species

Hina Faisal, Amber Yasmeen Alvi, Azra Idris, Maliha Yasmeen, Naseha Mushtaq and Hira Zafar Siddiqui

Abstract: Background: Carbapenems are potent and strong antibiotics that are usually reserved as last resort for bacteria possessing basic antibiotic resistance. These are broad spectrum drugs with more effective coverage against gram negative organisms. The antibiotic resistance pattern observed in bacteria possessing chromosomal group 2f β-lactamases is unique. It involves resistance to carbapenems while remaining sensitive to broadly attacking cephalosporins.

Objective: This study aims to provide assessment of frequency of class A & B carbapenamase in E.coli and Klebsiella species producers and establish the resistance pattern from clinical isolates, at a tertiary care hospital in Karachi.

Materials and Methods: This is a cross sectional, prospective study conducted at general hospital liyari, Karachi during Jan 2022- Jan 2023. Sample size was calculated as 400. Samples were divided into Urine samples of urinary tract infection patients (n=150), Pus sample from different sites (n=100), Respiratory tract, tracheal aspirates and sputum sample (n=100) and blood sample from suspected septicemia (n=50). SPSS-22 was used to enter and analyze the data. Chi-square test was used to analyze significance between two mean values, keeping ≤0.05 as significant p-value.

Results: Distribution of microorganisms were reported as 120 (41.1%), 80 (28.5%), 2 (0.69%), 24 (8.36%), 55 (19.1%) and 6 (2%) of E. coli, Klebsiella Pneumonia, K.Oxytoca, Gram positive. Gram negative and Yeast respectively. The confirmed presence of carbapenemase (CP) was identifies in urine sample as 4/6 (26.6%) E.coli and 2/6 (13.3%) Klebsiella, while pus samples identifies 3/4 (20%) E.coli and 1/4 (6.6%) Klebsiella. Similarly samples of respiratory tract identifies 2/5 (13%) of E.coli and 3/5 (20%) of Klebsiella. The calculated p-value was insignificant with 0.834 and 0.913 for E.coli and Klebsiella respectively.

Conclusion: This study concludes that E.coli is by far the most frequently reported microorganism from class B while class A organisms are in lower frequencies. CRE indicated higher resistance from non-β-lactam antibiotics, limiting treatment options.

Received: October 10, 2023
Revised: April 16, 2024
Accepted: April 17, 2024


Mental Health Challenges due to Health Care Discrimination among Transgender Youth: A Selective Review

Mehak Aqsa, Nida Shoaib, Sameera Ali Rizvi, Manisha Juriasinghani and Muhammad Ismail Khan

Abstract: Background: Transgender youth face various difficulties including mental health due to discrimination in healthcare settings because of their gender orientation. This review investigates the mental health of transgender youth and health care discrimination leading to inadequate health care.

Materials and Methods: The study complied with the latest publications using PRISMA reporting guidelines. For the selective review, 19 articles were selected over the last five years (between 2017 and 2022) which were primarily focused on mental health challenges and lack of health care due to health care discrimination among transgender youth. The study included publications at a global level, citing the global articles first, followed by Asia. The study only took into account biological and/or non-biological factors for the young transgender community, including both male and female factors.

Results:All 19 articles confirmed the positive significance of the Mental Health of the transgender youth community due to discrimination meanwhile, 08 articles mainly indicated about lack of healthcare or unfair healthcare in settings due to being transgender along with mental health concerns. This review identified the differences in mental health and discrimination that the transgender population faces.

Conclusion:As a reform, lower levels of depression and suicidality have been associated with social transition and having access to gender-affirming medical treatment. However, policies affecting this young transgender minority, who experience mental and social prejudice, must be changed. Multilevel intervention should also be advocated to address both of these severe issues.

Received: August 07, 2023
Revised: April 02, 2024
Accepted: April 02, 2024


Disseminated Salmonella Typhi Infection Presenting with Slurred Speech and Encephalopathy: An Unusual Presentation

Malik Saad, Quratulain Maha and Muhammad Talal

Abstract: Salmonella enterica serovar Typhi causes systemic infections and typhoid fever in humans, mainly affecting infants and children. It presents mostly with fever, malaise, anorexia, abdominal pain, constipation, and/or diarrhoea. Complications of the disease include intestinal perforation and haemorrhage. However, sometimes extra-intestinal complications are also reported, which rarely include encephalopathy. This report presents a case of a 28-year-old male who presented with somnolence and later developed slurred speech. A week before his current admission, he was admitted with abdominal pain and underwent a laparoscopic appendectomy, and was discharged uneventfully. Now after eight days he presented with somnolence. His neurological examination was otherwise unremarkable. Imaging studies helped to rule out ischaemic stroke. A detailed system-wise examination revealed mild right upper quadrant tenderness and hepatosplenomegaly on abdominal examination. Imaging revealed hepatosplenomegaly with gallbladder wall oedema and mesenteric lymphadenopathy. Blood culture was reviewed, revealing extensively drug-resistant (XDR) Salmonella Typhi. A diagnosis of XDR Salmonella bacteraemia leading to encephalopathy was made. The patient responded well to antibiotic therapy guided by the culture and sensitivity.

Received: July 25, 2023
Revised: February 26, 2024
Accepted: March 03, 2024


Application of Jean Watson Theory on Patient with Polytrauma

Shama Nazmeen, Tayyba Iqbal, Jamila Fatima and Bushra Sultan

Abstract: Nursing is emerging as a distinct health profession that has its own unique values, knowledge, and practice. Application of nursing theories into practice help the nurses to understand their unique contribution to health care settings. Watson’s theory is an example of theory based nursing practice that can enhance human health and healing in stressful life events, such as the moment when patient in this case realized his inability to mobilize. The purpose of this case study was to assess the application of Watson’s theory during the implementation of nursing care in patients with polytrauma. This case study presents the application of Watson’s Theory on patient with polytrauma. Watson’s theoretical concepts i.e. caring process and clinical caritas contributed effectively in providing care to the patients in stressful life situations.

Received: August 09, 2023
Revised: March 10, 2024
Accepted: March 11, 2024


Orbital and Ocular Myiasis

Hafiz Muhammad Jahan Zaib, Nida Armoghan and Fahmina Nazir

Abstract: Myiasis is the body’s infestation with maggots or eggs/larvae of certain flies. The infection is ether specific or non-specific. Although human Myiasis is rare, members of cyclorhabid, specifically the genus of Sarcophaga and Oestridae (Diptera), mainly produce myiasis [1]. Ocular and periocular myiasis are very rare and only few case reports have been published so far. Ophthalmomyiasis generally occurs in humans’ eyes, residing or working in close contact of livestock [2]. Older people, children, immunodeficient (people with orbital carcinomas, those with diabetes mellitus and with immunosuppressive drugs treatments) are affected usually [3]. However, there are few reports in which the infestation occurs in immuno-competent hosts. Compromised environmental sanitation and poor personal hygiene are often held as responsible factors. Infestation happens after fingers’ contamination after dealing with the infested livestock or by the fly itself. Under the skin, the larvae start the tissue penetrating and later they transform into large maggots. In the recent past ivermectin has largely been used with great success as non-invasive method of treating orbital myiasis [4]. The objective is to present a very rare case of ocular myiasis in a patient with infradiagnosed and careless squamous cell carcinoma of the upper eyelid.

Received: February 21, 2023
Revised: May 12, 2024
Accepted: May 13, 2024



NJHS Front Page v8.n2
2024 VOL 9 , Issue 2