Flood Syndrome, Rare but Feared Complications

Madam, I am writing to bring attention to a medical condition known as Flood Syndrome, a life-threatening occurrence characterized by the sudden rush of fluid following the spontaneous rupture of an umbilical hernia in individuals with long-standing ascites and end-stage liver disease. While uncommon, this syndrome poses a serious threat to patients' well-being. The umbilical hernia typically ruptures due to increased intra-abdominal pressure resulting from coughing, vomiting, straining during defecation, or an increased ascitic fluid volume (1). This syndrome's history dates back to 1901, when Johnson first described it, while the term "Flood Syndrome" was coined by Frank B. Flood in 1961 (2). Ascites, a common complication of liver cirrhosis, affects nearly half of the population with this condition. Large-volume ascites significantly impairs the patients' ability to perform daily activities. Approximately 20% of cirrhotic patients with ascites also develop an umbilical hernia.  Flood Syndrome presents several potential complications, including cutaneous infections, skin necrosis or ulceration, peritonitis, hypotension, fluid imbalance, sepsis, and bowel incarceration (3). Despite its rarity, only a few case studies available on this topic, with the majority focusing on cases related to liver cirrhosis. An intriguing case presented by Murruste et al (5). highlights Flood Syndrome following right-sided heart failure, with no previous records of such a condition in connection with ascites primarily caused by right-sided heart failure. The optimal treatment for Flood Syndrome remains a matter of debate; however, research suggests that surgical intervention yields better outcomes compared to conservative treatment alone. Mortality rates can be as high as 60%-80% with conservative measures, while surgical hernia repair has a lower mortality rate of 6%-20% (4). Hence, raising awareness about Flood Syndrome and its associated risk factors is essential for improving patient outcomes and reducing the incidence of this life-threatening condition. Therefore, educate patients, particularly those with severe ascites due to liver cirrhosis to diligently follow up with their doctors and adhere to their prescribed medications to avoid such dreaded complications. Additionally, physicians should advise their patients to avoid heavy lifting, which can help prevent the formation of umbilical hernias. We can work towards more effective preventive measures and treatments.by fostering a better understanding of this syndrome among medical professionals and patients alike., Timely diagnosis and a multidisciplinary approach to treatment are vital in achieving the best possible outcomes in such cases. Together, we can make a significant impact in addressing this medical challenge.

Burnout in health care workers during the fourth wave of COVID-19: A cross sectional study from Pakistan

Objective

To assess the burnout among the healthcare workers during the fourth wave of COVID-19.

Methods

In this cross-sectional study, burn out was measured in health care professionals using the MBI scale inventory during the fourth wave of COVID-19. Age, gender, marital status, having children, hospital, job type, experience, and workload, as well as the severity of burnout in each subscale, were all measured. We used the chi-square test to detect the difference between the level of burnout and other demographic variables, and a multiple logistic regression test was used to define the predicted correlation between the high level of burnout and the risk factors. Odds ratios and corresponding 95% confidence intervals (CI) were reported. A p-value of less than 0.05 indicated a statistically significant outcome.

Results

Out of 776 healthcare workers who participated in our study, 468 (63.2%), 161 (21.7%) and 112 (15.1%) participants experienced low, moderate and high levels of emotional exhaustion, respectively. For the depersonalization subscale, 358 (48.3%), 188 (25.4%) and 195 (26.3%) people suffered from low, moderate, and high levels of depersonalization, respectively while 649 (87.6%), 40 (5.4%) and 52 (7.0%) respondents had low, moderate and high levels in the personal accomplishment subscale, respectively.

Conclusion

During the fourth wave of COVID-19, the healthcare workers reported increased level of burnout overall possibly due to the long term physical and mental impacts that the pandemic has had over the time. Moreover, healthcare workers in Pakistan were more prone to burnout as compared to other countries.

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Higher levels of burnout were observed in the fourth wave of COVID-19, possibly due to the long term physical and mental impacts that the pandemic has had over time.

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Healthcare workers in Pakistan were more prone to burnout as compared to other countries.

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This study yielded key findings that have important implications for preventing and reducing burnout in hospital settings.

Cardioprotective effects of Influenza Vaccination among Patients with Established Cardiovascular Disease or at High Cardiovascular Risk: A Systematic Review and Meta-analysis

BACKGROUND

The clinical impact of the influenza vaccination on cardiovascular outcomes in people with established cardiovascular disease (CVD) is still debated.

AIM

The aim of this meta-analysis was to estimate the effect of influenza vaccination on cardiovascular and cerebrovascular outcomes among patients with established CVD.

METHODS

We systematically searched all electronic databases from inception until 15 April 2022. Primary clinical outcomes were all-cause mortality (ACM), and major adverse clinical events (MACE). Secondary endpoints were heart failure, myocardial infarction, CV mortality, and stroke.

RESULTS

Eighteen articles (five randomized trials and thirteen observational studies), with a total of 22,532,165 patients were included in the analysis. There were 217,072 participants included in the high cardiovascular risk or established CVD population (vaccinated n = 111,073 and unvaccinated n = 105,999). The mean age of the patients was 68 years old, without any difference between groups (69 vs 71) years. At mean follow-up of 1.5 years, vaccinated group was associated with lower risk for all-cause mortality [HR, 0.71(95%CI, 0.63-0.80), p < 0.001], MACE [HR, 0.83(95%CI:0.72-0.96), p = 0.01], CV mortality [HR, 0.78(95%CI:0.68-0.90), p < 0.001] and myocardial infarction [HR, 0.82(95%CI:0.74-0.92), p < 0.001] compared to unvaccinated group. While incidence of stroke [HR, 1.03 (95%CI, 0.92-1.06), p = 0.61] and heart failure [HR, 0.74 (95%CI, 0.51-1.08), p = 0.12] did not differ between the two groups.

CONCLUSION

Influenza vaccination reduced major adverse clinical events, all-cause mortality, CV mortality and myocardial infarction. These highlighted the importance of influenza vaccination in established CVD or high cardiovascular risk.

Safety and efficacy of percutaneous coronary intervention versus coronary artery bypass graft in patients with STEMI and unprotected left main stem disease: A systematic review & meta-analysis

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The advent of percutaneous coronary intervention (PCI) has caused much debate about the optimal revascularization method for LMCAD.

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Several studies have previously been conducted comparing PCI versus CABG for LMCAD, however most of these have only taken into account randomized controlled trials (RCTs), while ignoring observational studies.

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This study takes data from both RCTs and observational studies to obtain a better comparison of the two revascularization techniques.

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It is the first meta-analysis to report data for various adverse outcomes after 10 years of follow-up.

Introduction

Owing to its large area of supply, left main coronary artery disease (LMCAD) has the highest mortality rate among coronary artery lesions, resulting in debate about its optimal revascularization technique. This meta-analysis compares percutaneous coronary intervention (PCI) versus coronary artery bypass grafting (CABG) for the treatment of LMCAD.

Method

MEDLINE, TRIP, and Cochrane Central databases were queried from their inception until 25 April 2021, to determine MACCE (major adverse cardiac and cardiovascular events), all-cause mortality, repeat revascularization, myocardial infarction (MI) and stroke rates post-revascularization for different follow-ups. 7 RCTs and 50 observational studies having 56,701 patients were included. A random-effects model was used with effect sizes calculated as odds ratios (odds ratio, OR).

Results

In the short term (1 year), PCI had significantly higher repeat revascularizations (OR = 3.58, 95% CI 2.47–5.20; p < 0.00001), but lower strokes (OR = 0.55, 95% CI 0.38–0.81; p = 0.002). In the intermediate term (2–5 years), PCI had significantly higher rates of repeat revascularizations (OR = 3.47, 95% CI 2.72–4.44; p < 0.00001) and MI (OR = 1.39, 95% CI 1.17–1.64; p = 0.0002), but significantly lower strokes (OR = 0.54, 95% CI 0.42–0.70; p < 0.0001). PCI also had significantly higher repeat revascularizations (OR = 2.58, 95% CI 1.89–3.52; p < 0.00001) in the long term (≥5 years), while in the very long term (≥10 years), PCI had significantly lower all-cause mortalities (OR = 0.77, 95% CI 0.61–0.96; p = 0.02).

Conclusion

PCI was safer than CABG for patients with stroke for most follow-ups, while CABG was associated with lower repeat revascularizations. However, further research is required to determine PCI’s safety over CABG for reducing post-surgery MI.

From black to white: A roadmap to containing the rise of candidiasis amidst COVID-19 and mucormycosis in India

With numbers of active COVID-19 cases in India falling in recent weeks and the healthcare system finally showing signs of coping with the mucormycosis epidemic, several new reports of COVID-19 cases linked to "white fungus" have emerged. This has led to rising concern with the potential to stretch the capacity of an already burdened healthcare system. Moreover, the implications of this disease in the COVID-19 population and its consequences on the health and socio-economic structure of the country have not been vastly studied. This commentary explores the need for government efforts in the context of containing candidiasis during the pandemic and provides key recommendations on combating this imminent public health challenge.

Association of Acne with Face Mask in Healthcare Workers Amidst the COVID-19 Outbreak in Karachi, Pakistan

Background

In the wake of coronavirus (COVID-19) global alert, people have begun to practice safety measures in order to reduce the exposure to life-threatening disease. The largest at risk population is undoubtedly the frontline healthcare workers (HCWs) who are using personal protective equipment (PPE), essentially face masks, to battle against this deadly virus. This study was conducted with the prime intention to reveal an association between face mask and acne and measure the prevalence of acne amongst HCWs amidst COVID-19 outbreak in Karachi. Furthermore, this study aimed to identify the type of mask generating acne, locate the common sites, assess the severity and establish an association of mask use with the skin type.

Methods

This cross-sectional study was carried out at Medicare Cardiac and General Hospital, Jinnah Medical College Hospital, Jinnah Postgraduate Medical Centre and Jamal Noor Hospital located in Karachi, Pakistan. A total of 348 HCWs were interviewed, of which only 193 met the inclusion criteria. All information was recorded on a predesigned proforma and analyzed using SPSS 25.0.

Results

Among 193 participants, acne was prevalent in 103 (53.4%) participants with maximum cases reported in female HCWs, and in doctors (p<0.05). Out of 73 HCWs using N-95 masks, 46 (44.7%) developed acne, with a p-value of 0.036. Skin type and past history of acne also yielded statistically significant results. Among all the skin types, HCWs with oily skin (64, 62.1%) were prone to face resurgence of acne or new-onset acne. The most common sites of eruption of acne were along the cheeks (45.1%) followed by the nose (40.9%). Majority of the population suffered from mild acne. Moderate and severe acne eruption was particularly observed in those wearing N-95 and surgical masks.

Conclusion

The use of face masks is associated with high rates of acne eruption. Disseminating the guidelines and indications of World Health Organization (WHO) regarding proper use of mask, encouraging awareness among HCWs and following proper doffing and donning protocol as endorsed by Centers for Disease Control and Prevention (CDC) will possibly minimize the adverse reactions.

The Promising Future of Low-Molecular-Weight Heparin in Pediatric Cerebral Venous Sinus Thrombosis Occurring as a Rare Complication of Ulcerative Colitis

Pediatric cerebral venous sinus thrombosis (CVST) is a rare complication of ulcerative colitis. Ulcerative colitis is a form of inflammatory bowel disease which accentuates hypercoagulation, thereby leading to thrombosis. Herein, we report a case of a 10-year-old girl who presented with chief complaints of headache, confusion, and new-onset seizure activity for one month as progressively worsening sequelae of ulcerative colitis. Her magnetic resonance venogram confirmed thrombosis in the right transverse, sigmoid, and superior sagittal sinus. The acute ulcerative colitis flare was managed with a short course of steroids and anti-inflammatory monoclonal antibody, and CVST got improved with low-molecular-weight heparin (LMWH). Our study emphasizes the emergence of fatal complications of ulcerative colitis in the pediatric population. It also endorses the pivotal role of thromboprophylaxis with LMWH in pediatric CVST patients. Nevertheless, further studies are required to standardize the use of LMWH in clinical practice.

Association of quality of life, anxiety, and depression with restless leg syndrome in the hemodialysis patients

OBJECTIVES

Restless Legs Syndrome (RLS) is commonly known to cause morbidity in patients on hemodialysis, making them prone to chronic mental health illnesses such as depression and anxiety, and also adversely impact quality of life. In this study, we examined the association of quality of life, anxiety, and depression with restless leg syndrome in the hemodialysis patients at Karachi Institute of Kidney Diseases.

RESULTS

About 26.7% of the participants reported RLS among the sample size Presence of RLS was not associated with quality of life, depression, and anxiety. However, p-values < 0.05 were significant for body-mass index (BMI), diabetes mellitus as a cause of end-stage renal disease, and serum albumin levels. Majority (82.5%) of the RLS-diagnosed patients had moderate to severe symptoms with 16 (40%) and 17 (42.5%) clients, respectively.

COVID-19 Infection and Myocarditis: A State-of-the-Art Systematic Review

BACKGROUND

COVID-19 was initially considered to be a respiratory illness, but current findings suggest that SARS-CoV-2 is increasingly expressed in cardiac myocytes as well. COVID-19 may lead to cardiovascular injuries, resulting in myocarditis, with inflammation of the heart muscle.

OBJECTIVE

This systematic review collates current evidence about demographics, symptomatology, diagnostic, and clinical outcomes of COVID-19 infected patients with myocarditis.

METHODS

In accordance with PRISMA 2020 guidelines, a systematic search was conducted using PubMed, Cochrane Central, Web of Science and Google Scholar until August, 2021. A combination of the following keywords was used: SARS-CoV-2, COVID-19, myocarditis. Cohorts and case reports that comprised of patients with confirmed myocarditis due to COVID-19 infection, aged >18 years were included. The findings were tabulated and subsequently synthesized.

RESULTS

In total, 54 case reports and 5 cohorts were identified comprising 215 patients. Hypertension (51.7%), diabetes mellitus type 2 (46.4%), cardiac comorbidities (14.6%) were the 3 most reported comorbidities. Majority of the patients presented with cough (61.9%), fever (60.4%), shortness of breath (53.2%), and chest pain (43.9%). Inflammatory markers were raised in 97.8% patients, whereas cardiac markers were elevated in 94.8% of the included patients. On noting radiographic findings, cardiomegaly (32.5%) was the most common finding. Electrocardiography testing obtained ST segment elevation among 44.8% patients and T wave inversion in 7.3% of the sample. Cardiovascular magnetic resonance imaging yielded 83.3% patients with myocardial edema, with late gadolinium enhancement in 63.9% patients. In hospital management consisted of azithromycin (25.5%), methylprednisolone/steroids (8.5%), and other standard care treatments for COVID-19. The most common in-hospital complication included acute respiratory distress syndrome (66.4%) and cardiogenic shock (14%). On last follow up, 64.7% of the patients survived, whereas 31.8% patients did not survive, and 3.5% were in the critical care unit.

CONCLUSION

It is essential to demarcate COVID-19 infection and myocarditis presentations due to the heightened risk of death among patients contracting both myocardial inflammation and ARDS. With a multitude of diagnostic and treatment options available for COVID-19 and myocarditis, patients that are under high risk of suspicion for COVID-19 induced myocarditis must be appropriately diagnosed and treated to curb co-infections.

Erectile Dysfunction and Associated Anxiety and Depression in Male Hemodialysis Patients: A Cross-Sectional Study at Karachi Institute of Kidney Diseases

Objectives Chronic kidney disease (CKD) is one of the most prevailing diseases in the world and is associated with sequelae of depression, anxiety, and sexual dysfunction. The goal of our study is to measure the prevalence of erectile dysfunction, depression, and anxiety among patients suffering from CKD and to establish a correlation between them. Methodology The research was a single-centered, descriptive cross-sectional study. All male patients present at the time of the survey were interviewed, and then based on the inclusion and exclusion criteria, 84 were selected. The questionnaire comprised demographic variables, erectile function scoring using the International Index of Erectile Function (IIEF) scale, and Hospital Anxiety and Depression Scale (HADS) for depression and anxiety. All data were analyzed using SPSS Software 25.0 (IBM Corp., Armonk, USA). Results Out of 84 male patients, 47.6% had erectile dysfunction (ED). 10% of the affected individuals had depression and 3% reported having anxiety. No known external factors had any contribution to erectile malfunction, depression, and/or anxiety. Conclusion We found no correlation of depression and/or anxiety with ED in this population of male subjects undergoing hemodialysis.

Sexual Dysfunction and Associated Anxiety and Depression in Female Hemodialysis Patients: A Cross-Sectional Study at Karachi Institute of Kidney Diseases

Objectives

Hemodialysis patients have to combat certain negative effects such as sexual dysfunction, depression, and anxiety. This study aimed to measure the sexual function and identify the relationship between sexual dysfunction, depression, and anxiety in females undergoing hemodialysis.

Methods

The descriptive, cross-sectional study was conducted at a dialysis unit in November 2019. Forty-eight females were enrolled in the study. Participants were interviewed for sociodemographic, clinical, and biochemical parameters. Sexual function was assessed through the Female Sexual Function Index (FSFI) while depression and anxiety scores were calculated using the hospital anxiety and depression scale (HADS).

Results

In this study, the mean age of patients was 44.60 ± 10.27 years. Median sexual function scores were low across all domains. A maximum possible score of 3.4 was calculated for the satisfaction domain while the minimum score calculated was 0 for arousal, lubrication, and orgasm. 14.6% and 45.8% were suffering from borderline abnormal and abnormal depression, respectively. However, 33.3% and 31.3% had borderline abnormal and abnormal anxiety, respectively. Pearson’s correlation showed a significant negative correlation between age and desire domain (r = -0.343; p < 0.05) and demonstrated that arousal, lubrication, orgasm, satisfaction, and pain domains were associated with borderline abnormal depression. None of the sexual domains were correlated with anxiety.

Conclusions

Sexual dysfunction, depression, and anxiety are highly prevalent in hemodialysis patients. In this study, borderline abnormal depression was independently linked to sexual dysfunction excluding sexual desire. Therefore, healthcare teams should keep up with the progress of their patients and evaluate for psychosexual health so that they can be timely managed.