RESUMEN
This systematic review and meta-analysis aimed to assess the association of neutrophil-to-lymphocyte ratio (NLR) with an elevated risk of vascular access failure in end-stage renal disease (ESRD) patients undergoing hemodialysis. A comprehensive database search of MEDLINE (via PubMed), Scopus, and Cochrane Central was performed. Studies reporting the values of NLR in both functional and non-functional AVF groups in ESRD patients were selected. Quality assessment was performed using the Modified Newcastle-Ottawa scale for observational studies. Meta-analysis was performed using an inverse variance random effects model. Seven observational studies met the inclusion criteria, including 1313 participants with 554 cases and 759 controls. Pooled results showed significantly high NLR levels in patients with non-functional arteriovenous fistula (AVF) compared to functional AVF (SMD = 1.19, 95% CI = 0.74-1.65, p < 0.001). Subgroup analysis confirmed the consistency of the association between NLR and AVF failure across study design (SMD = 1.76, 95% CI = 0.78-2.73, p = 0.0004 in prospective vs SMD = 0.87, 95% CI = 0.42-1.32, p = 0.0001 in retrospective studies), etiology (SMD = 1.63, 95% CI = 0.75-2.52, p = 0.0003 in stenosis or thrombosis; and SMD = 0.80, 95% CI = 0.27-1.34, p = 0.003 in failure to mature of AVF), and NLR measurement timing (SMD = 0.98, 95% CI = 0.42-1.54, p = 0.0006 in preoperative vs SMD = 1.58, 95% CI = 0.47-2.69, p = 0.005 in postoperative NLR). The pooled odds ratio revealed high NLR values as a significant predictor of AVF failure in ESRD patients (OR = 3.91, 95% CI = 1.91-7.98, p = 0.0002). The pooled sensitivity and specificity were 89.72% (95% CI = 77.51%-95.67%) and 72.95% (95% CI = 63.82%-80.47%), respectively. The high NLR is a useful and predictive marker for AVF failure in hemodialysis patients. Future studies should prioritize larger cohort studies to validate and reinforce these observations.
RESUMEN
OBJECTIVE: To determine the frequency and pattern of different aetiologies of leg pain among patients visiting vascular surgery clinics. STUDY DESIGN: Cross-sectional study. Place and Duration of the Study: Vascular Surgery Clinics of the Aga Khan University Hospital, Karachi, Pakistan, between February 2021 and June 2023. METHODOLOGY: This study examined patients presenting with leg pain for the first time at vascular surgery clinics. The socio-demographic and clinical data including the clinical symptoms, physical examination findings, and management of leg pain were noted using a specially designed proforma. RESULTS: In a total of 142 patients (200 limbs), 82 (57.7%) were females and 60 (42.3%) were males, with a mean age of 46.8 ± 15.1 years. The patients' mean body mass index (BMI) was 30.2 ± 7.9 kg/m2. Ninety-one (64.1%) patients had a predominantly standing job compared to 51 (35.9%) patients who had a predominantly sitting job. The most common aetiology of leg pain was chronic venous insufficiency (CVI), diagnosed in 107 (53.5%) patients, followed by neurogenic pain [41 (20.5%)], musculoskeletal pain including knee osteoarthritis [30 (15.0%)], and arterial insufficiency [22 (11.0%)]. Conclusion: CVI followed by neuropathic pain was the leading cause of leg pain in vascular surgery clinics at a tertiary care hospital. KEY WORDS: Chronic venous insufficiency, Arterial insufficiency, Vascular surgery, Leg pain, Musculoskeletal pain, Neuralgia.
Asunto(s)
Pierna , Humanos , Femenino , Masculino , Persona de Mediana Edad , Estudios Transversales , Pakistán/epidemiología , Adulto , Pierna/irrigación sanguínea , Procedimientos Quirúrgicos Vasculares , Dolor/etiología , Dolor/epidemiología , Neuralgia/etiología , Neuralgia/epidemiología , Anciano , Dolor Musculoesquelético/epidemiología , Dolor Musculoesquelético/etiologíaRESUMEN
This study focuses on the current applications, potential, and challenges to Artificial Intelligence (AI) integration in vascular surgery with specific emphasis on its relevance in Pakistan. Despite the benefits of AI in vascular surgery, there is a substantial gap in its adoption in Pakistan compared to global standards. In our context with limited resources and a scarcity of vascular surgeons, AI can serve as a promising solution. It can enhance healthcare accessibility, improve diagnostic accuracy, and alleviate the workload on vascular surgeons. However, hurdles including the absence of a comprehensive vascular surgery database, a shortage of AI experts, and potential algorithmic biases pose significant challenges to AI implementation. Despite these obstacles, the study underscores the imperative for continued research, collaborative efforts, and investments to unlock the full potential of AI and elevate vascular healthcare standards in Pakistan.
Asunto(s)
Inteligencia Artificial , Procedimientos Quirúrgicos Vasculares , Pakistán , Humanos , Procedimientos Quirúrgicos Vasculares/métodosRESUMEN
OBJECTIVE: To develop and content validate a questionnaire to assess the financial and functional impact of major lower limb amputation in patients with diabetes-related foot disease. DESIGN: Prospective observational study. SETTING: This study was conducted at a tertiary care centre in Pakistan. PARTICIPANTS: We conducted a thorough literature review and a group interview with 10 participants, resulting in domain identification and item generation. The group included seven patients with diabetes-related foot disease who underwent major lower limb amputation and three caregivers. Subsequently, a focused group discussion was held to assess overlap and duplication among the items, and two rounds of content validation were carried out by five content and five lay experts in both English and Urdu. Question items with a Content Validity Index (CVI) score of >0.79 were retained, items with a CVI score between 0.70 and 0.79 were revised and items with a CVI score of <0.70 were excluded. RESULTS: The initial literature review and group interview resulted in 61 items in the financial and functional domains. After the focused group discussion, the questionnaire was reduced to 37 items. Following two rounds of content validation, the English questionnaire achieved the Scale-Content Validity Index/Average (S-CVI/Ave) of 0.92 and 0.89 on relevance and clarity, respectively. Similarly, the Urdu questionnaire achieved the S-CVI-Ave of 0.92 and 0.95, respectively. CONCLUSION: A 37-item multidimensional questionnaire was developed and rigorously content-validated to assess the financial and functional impact of major lower limb amputation in patients with diabetes-related foot disease. The questionnaire used in this study has shown robust content validity specifically for our population.
Asunto(s)
Diabetes Mellitus , Enfermedades del Pie , Humanos , Extremidad Inferior/cirugía , Pakistán , Reproducibilidad de los Resultados , Encuestas y Cuestionarios , Estudios ProspectivosRESUMEN
OBJECTIVES: Simulation is used across surgical specialties for skill enhancement. The choice and assessment method of a simulator varies across literature. In the age of endovascular approach, trainees have limited exposure to open lower limb bypass procedures which needs attention. This review aims to assess the utility of simulation training in lower limb bypass surgery using Kirkpatrick's model. METHODS: Using PRISMA statement, we included all the studies done on simulators in lower limb bypass surgical procedures for this systematic review. The primary outcome was to assess the effectiveness of different types of simulation used for lower limb bypass surgery using the Kirkpatrick's model for training evaluation. RESULTS: An initial search identified 295 articles out of which 7 articles were found to be eligible for this systematic review. A variety of simulators were used including cadavers and synthetic models. Most studies (n=5) found the use of simulation as an effective tool in achieving technical competence. All the five studies we found at level 2 on Kirpatrick's model evaluation. CONCLUSION: Most of the existing studies are at level 2 of Kirkpatrick's model which reflects learning changes in trainees after simulation. Feedback mechanism needs to be evolved where the improvement after simulation training can be gauged by its replication in clinical practice and improved patient care practices corresponding to the highest level of Kirkpatrick's model.
RESUMEN
INTRODUCTION: Synovial sarcomas are rare tumors, and the incidence of axillary synovial sarcoma involving the brachial plexus has been reported as 2.9 % among all axillary soft tissue tumors. However, the recurrence of axillary synovial sarcomas has not been reported in literature. CASE PRESENTATION: A 36-years-old Afghan female presented in Karachi, Pakistan with a history of persistently increasing, recurrent, right axillary mass for 6 months. Initially diagnosed as a spindle-cell tumor on excision in Afghanistan, she had received ifosfamide and doxorubicin, but the lesion recurred. On examination, it was a 5 × 6 cm, hard mass palpable in right axilla. After radiological work-up and a multidisciplinary team discussion, she underwent complete excision of the tumor with successful preservation of brachial plexus. The final diagnosis was reported as monophasic synovial sarcoma FNCLCC Grade 3. DISCUSSION: Our patient presented with a recurrent right axillary synovial sarcoma that was involving the axillary neurovascular bundle and brachial plexus, which was initially diagnosed as a spindle cell sarcoma. Pre-operative core-needle biopsy was unable to provide a definitive diagnosis. MRI scan was useful in delineating the proximity of the neurovascular structures. Re-excision of the tumor was performed which is the mainstay of treatment for axillary synovial sarcomas, combined with radiotherapy depending on the disease grading, staging and patient factors. CONCLUSION: Axillary synovial sarcoma recurrence with involvement of the brachial plexus is an extremely rare presentation. Our patient was successfully managed through a multidisciplinary approach with complete surgical excision and preservation of the brachial plexus followed by adjuvant radiotherapy.
RESUMEN
INTRODUCTION: Innominate artery aneurysm (IAA) is an extremely rare fatal condition with an overall prevalence of less than 3 % of all supra-aortic artery aneurysms. These infrequent lesions usually present as an emergency and require challenging surgical procedures. CASE PRESENTATION: We report an interesting case of mycotic IAA in a 25 years old male patient. He was a known intravenous drug abuser having mycotic aneurysm arising from brachiocephalic artery with eccentric thrombus causing adjacent mass effect over the trachea. He underwent successful emergent surgical management of aneurysm with autologous vein graft using superficial femoral vein. Unfortunately, he died due to massive upper gastrointestinal bleeding leading to multi-organ failure after a prolonged post-operative course. CLINICAL DISCUSSION: Mycotic aneurysms of the IA are extremely rare with an overall incidence of 1-2.7 % cases of all IAA. Presentation of the IAA can be quite variable from asymptomatic to symptoms exhibiting mass effect over surrounding structures. Rupture of IAA can be fatal and can occur if not treated promptly. There are no current recommendations or guidelines for treatment and interventions in IAA. Surgical management involves complete excision of the aneurysm and then revascularization. CONCLUSION: Infected Innominate artery aneurysm is a rare surgical entity requiring early diagnosis, detailed investigation and prompt surgical management involving multidisciplinary team approach. Our case describes a relatively innovative approach to this scarce condition.
RESUMEN
Adequately created well functional haemodialysis access is an important part for the physical and mental wellbeing of renal failure patients. Every effort should be made to enhance the patency of these accesses. Recently, stem cell treatment modalities have opened new avenues in the better patency of arteriovenous fistula. Use of mesenchymal stromal cells (MSC) to prevent venous neointimal hyperplasia have been studied with good success rates. Adopting such costly treatment modalities in low middle income class country like Pakistan is associated with significant challenges. This short report discusses the current role of stem cells in arteriovenous access and how this exciting modality can be utilized in our country.
Asunto(s)
Derivación Arteriovenosa Quirúrgica , Humanos , Grado de Desobstrucción Vascular , Países en Desarrollo , Factores de Riesgo , Diálisis Renal , Células Madre , Resultado del Tratamiento , Estudios RetrospectivosRESUMEN
Within the last decade, social media has progressed from a form of mere entertainment to a medium for solution of complex issues in our daily lives. During the last few years, social media has gained value in medical education and the diversity in the use of digital media has given new dimensions to medical education while facing the Covid pandemic. Digital media helps in creating virtual communities which not only bring more harmony between teachers and students but has also shown to have reduced anxiety and stress among students. Common social media platforms such as Facebook and WhatsApp have recently gained popularity as platforms which are being actively used in various ways to enhance learning. Social media in medical education is also utilised to enhance communication skills, professionalism and better patient care, but this should be addressed with caution as violation of patient's privacy and confidentiality remains a threat.
Asunto(s)
COVID-19 , Educación Médica , Medios de Comunicación Sociales , Educación Médica/métodos , Humanos , Internet , ProfesionalismoRESUMEN
Healthcare has always been a complex system phenomenon which needs accountability from the leading clinical and management roles. Adequate and competent leadership is recognized as a driving point for a successful healthcare division. Medical professionals taking charge for quality improvement are well placed yet the style to deliver their leadership qualities bears a massive significance. While exceptional clinical prowess is of tremendous importance, harmonious teamwork, inefficiency reduction and patient communication and safety lead to noteworthy health management outcomes. Explores not explains the importance of leadership, qualities and styles of a leader, various leadership theories, the impact of leadership in medical education and the current issues related to medical leadership.
RESUMEN
OBJECTIVE: To assess the types and effectiveness of simulators present for open varicose vein surgery. METHODS: The systematic review was conducted at The Aga Khan University Hospital Karachi and comprised studies published from 1st January 2000 to 30th June 2020 related to open varicose vein surgical procedures done on simulators. Databases searched were PubMed, Medline, Google Scholar, Cochrane and Scopus using appropriate key words. The primary outcome of the review was to assess the effectiveness of different types of simulators used for varicose vein surgery. RESULTS: Of the 286 articles found, 6(2%) were included. A variety of simulators ranging from animal models, homemade simulators and commercially designed models with high fidelity options had been used. Technical competence was the major domain assessed in most of the studies 5(83.3%), while 1(16.6%) study focussed on self-assessment. Blinding was done in 4(66.6%) studies for assessment purpose, and videorecording of the trainees' performance was done in 5(83.3%) studies. Most studies 4(66.6%) found the use of simulation to be an effective tool in achieving technical competence. CONCLUSION: The use of simulation in the training of surgical residents for open varicose vein surgery was found to be beneficial, but most studies were heterogeneous in terms of design, simulator types and study participants. This makes it difficult to establish the superiority of any one type of simulator over the rest. Further research is needed to develop and validate simulators in open varicose vein surgery procedures.
Asunto(s)
Entrenamiento Simulado , Várices , Procedimientos Quirúrgicos Vasculares , Animales , Competencia Clínica , Humanos , Pakistán , Várices/cirugía , Procedimientos Quirúrgicos Vasculares/educaciónRESUMEN
Research in surgery has led to significant advances over the last century in terms of how medicine is practised in and outside the operating rooms today. Surgical research in the developed countries is responsible for most of this advancement, but it is often inapplicable in resource-limited settings in the developing world. Lower- and middle-income countries are in a unique position to take this work further, but they are limited by certain barriers. These barriers could broadly be classified under social and cultural, infrastructure, financial, ethical, and personal categories. These barriers are often not fully realised, but can potentially be addressed with concerted efforts to continue the advancement of medicine for everyone.
Asunto(s)
Países en Desarrollo , Renta , Humanos , QuirófanosRESUMEN
Objective: To develop and validate a task-specific rating scale (TSRS) by comparing with the Global Rating Scale (GRS) for the evaluation of brachial artery embolectomy (BAE). Methods: Participants were divided into expert and novice groups who were oriented on the locally developed simulator model. The following day, an embolectomy procedure was performed independently by the participants and graded by two independent assessors using the GRS and TSRS. Validity was evaluated using Pearson's correlation coefficient (r), reliability by the interclass correlation coefficient (ICC), and agreement by Bland-Altman plots. A p-value <0.05 was considered significant. Results: Thirty-two participants were enrolled in this study. The overall TSRS was found to be a valid assessment tool (r=0.82; 95% confidence interval [CI]: 0.66, 0.91; p<0.001). Domain-specific analyses showed a moderate positive association between all domains (p<0.05), except for instrument handling (r=0.09; 95%CI: -0.27, 0.42; p=0.642). The ICC for overall scores showed excellent reliability for both instruments, GRS and TSRS, with values of 0.97 and 0.92, respectively. Conclusion: The TSRS was found to be a valid and reliable assessment tool for BAE; however, for some domains, such as instrument handling and time and motion, it has limited reliability.
RESUMEN
INTRODUCTION: Tunneled cuffed catheters (TCC) are generally used as a temporary means to provide hemodialysis (HD) until permanent arteriovenous access is established. However, certain complications are associated with use of TCCs such as infections, catheter malfunction/malposition or venous stenosis. Limited data is available on outcomes and long term complications associated with TCCs in our country. The aim of this study was to study the outcomes of TCCs and associated long term complications during the course of its usage. METHODS: We retrospectively studied case records of patients who had TCCs placed for HD at our institution, from January 2016 to June 2018. RESULTS: A total of 116 TCCs were placed during the study period. The mean age of the population was 57.09 years; 58.6% were males. The right internal jugular vein (52.6%) was the most common site of TCC insertion followed by the left internal jugular vein (29.3%). Functioning TCCs were successfully removed in almost two-thirds of cases (65.7%) once their permanent access was mature. Development of catheter related blood stream infection (CRBSI) was seen in 22 patients (19.8%) requiring catheter removal in 14 (12.6%) patients. Mechanical complications leading to catheter removal were seen in seven patients (6.3%). The median catheter duration was 62.5 days ranging from 1 to 343 days. CONCLUSION: TCCs, though associated with complications particularly CRBSI, are a viable option for short- to intermediate-term use for HD till the maturation of permanent arteriovenous access in a limited-resource setting.
Asunto(s)
Cateterismo Venoso Central , Enfermedades Vasculares , Cateterismo Venoso Central/efectos adversos , Catéteres de Permanencia/efectos adversos , Humanos , Masculino , Persona de Mediana Edad , Pakistán , Diálisis Renal/efectos adversos , Estudios Retrospectivos , Centros de Atención Terciaria , Enfermedades Vasculares/etiologíaRESUMEN
INTRODUCTION: Paraganglioma are infrequent neuroendocrine tumors that are most commonly found in the carotid body, ganglia of the vagus, jugular and tympanic nerve. Very rarely they can involve other cranial nerves outside the cranial cavity, we present one such case of hypoglossal nerve paraganglioma in neck. CASE REPORT: A 48 years old male presented with 1-month history of right sided stroke and aphasia. Ultrasonography of neck revealed a highly vascular mass on the right side of the neck. CT angiogram confirmed a highly vascular mass arising above the carotid bifurcation. With the working diagnosis of Glomus tumor, he underwent right sided neck exploration, however, intra-operatively tumor was found to be arising from the hypoglossal nerve instead. Surgery was abandoned on basis of the available literature, with only 6 reported cases in the past 54 years. Patient had no immediate post op complications and was sent for cyber knife treatment. After completion of 5 cycles of cyber knife there was a total of 45% reduction in the size of the paraganglioma with the resolution of the patient's symptoms after a follow up of 6 months. CONCLUSION: Hypoglossal nerve paraganglioma is an uncommon tumor of the neck and can be misdiagnosed with the other tumors in this region especially chemodectoma and glomus tumor. The diagnostic criteria and appropriate treatment modalities have not been established due to the rare presentation hence hypoglossal paraganliomas should be kept in mind when Highly vascular neck mass is encountered.
RESUMEN
OBJECTIVE: To review the managing strategies of adult patients with liver trauma in a tertiary care hospital during a six years period. METHODS: The medical records of all patients admitted with a diagnosis of liver trauma from January 2012 to December 2017 in the Aga Khan University Hospital were retrospectively reviewed. The details of demographic, clinical, and outcome variables including morbidity and mortality rates were noted. RESULTS: A total of 182 patients were admitted at AKUH with liver trauma between January 2012 and December 2017. Twenty-two patients were excluded according to our study criteria. Of 160 patients, 139 were male and 21 were female. One hundred twenty seven (79.4%) patients were less than 45 years of age. Most patients (89.4%) had no comorbids and 48 (44%) arrived at the hospital within 4 hours of injury. Majority, 101 (63.1%) of the patients had blunt trauma and 142 (89%) met with road accidents. A total of 109 (68.1%) patients were stable at arrival and 77 (48.1%) had abdominal signs present on examination. FAST ultrasound was done on 75 (46.9%) patients and CT scan abdomen on 145 (90.6 %) patients. Liver injuries were associated with other abdominal or systemic injuries in 139 (86.6%) patients. Low grade (Grade I & II) liver injuries were found in only 41 (25.6%) patients, with the remainder being high grade (Grade III- 41 patients, Grade IV-42 patients and Grade V-2 patients). Conservative treatment was offered to 68 (41.9%) patients, of which 57 (85.1%) remained stable and were eventually discharged. Of these, 2 expired and 3 required intervention. There were a total of 92 (57.2%) interventions done of which 60 patients were cured, 14 expired and 18 readmitted. Interventions included perihepatic packing (n=18), hepatorraphy (n=3), angioembolization (n=12) and hepatectomy (n=1). There were 16(10%) deaths in which liver haemorrhage and sepsis were the most common cause of mortality. Mean hospital stay in our study population was 8.9 days. Second admission was observed in 28 (17.5%) patients (n=28). Morbidity rate in our patients was 17.5% (n=28). The most common complication noted was that of a liver abscess, developing in 2 (1.3%) patients. Other significant problems were intra-abdominal collections (n=2) and biliary complications (n=3). Unstable haemodynamic status at arrival and prolonged stay in high dependency unit were noted to be independent risk factors for mortality. CONCLUSIONS: Conservative treatment was found successful in most of our patients with an intervention rate of 57.5% and overall mortality rate of 10%. So, NOMLI can be safely offered to liver trauma patients, even in high grade injuries.
Asunto(s)
Traumatismos Abdominales/terapia , Tratamiento Conservador , Hemorragia/terapia , Hígado/lesiones , Heridas no Penetrantes/terapia , Traumatismos Abdominales/complicaciones , Traumatismos Abdominales/mortalidad , Accidentes de Tránsito , Adolescente , Adulto , Causas de Muerte , Embolización Terapéutica , Femenino , Evaluación Enfocada con Ecografía para Trauma , Hemorragia/etiología , Hemorragia/mortalidad , Hepatectomía , Humanos , Tiempo de Internación , Absceso Hepático/etiología , Absceso Hepático/terapia , Hepatopatías/etiología , Hepatopatías/mortalidad , Hepatopatías/terapia , Masculino , Traumatismo Múltiple , Readmisión del Paciente , Modelos de Riesgos Proporcionales , Sepsis/mortalidad , Centros de Atención Terciaria , Tomografía Computarizada por Rayos X , Índices de Gravedad del Trauma , Heridas no Penetrantes/complicaciones , Heridas Penetrantes/complicaciones , Heridas Penetrantes/terapia , Adulto JovenRESUMEN
Trauma continues to be the major cause of disability and death globally and surgeons are often involved in immediate care. However there has been an exponential decrease in the number of the trained trauma surgeons. The purpose of the current review article is to summarize the published literature pertaining to trauma education in postgraduate surgical training programmes internationally and in a developing country as Pakistan. Several electronic databases like MEDLINE, PubMed, Google scholar and PakMediNet were searched using the keywords 'trauma education' or 'trauma training' AND 'postgraduate medical education', 'surgery residency training', 'surgery residents' and 'surgeons'. The current training in most surgical residency programmes, locally and globally, is suboptimal. Change in trauma management protocols, and decrease in volume of trauma cases results in variable and/ or inadequate exposure and hands-on experience of the surgical trainees in operative and non-operative management of trauma. This warrants collaborative measures for integration of innovative educational interventions at all levels of the surgical educational programmes.
Asunto(s)
Países en Desarrollo , Educación de Postgrado en Medicina/métodos , Cirugía General/educación , Traumatología/educación , Heridas y Lesiones/terapia , Atención de Apoyo Vital Avanzado en Trauma , Curriculum , Humanos , Pakistán , Admisión y Programación de Personal , Heridas y Lesiones/epidemiologíaRESUMEN
OBJECTIVE: To look into the factors responsible for delay in presentation of Iimb ischemia patients to a vascular surgeon. Methods: The prospective cohort study was conducted at the Aga Khan University Hospital, Karachi, from October 01, 2016, to August 10, 2018. Patients coming with delayed presentation of both acute and chronic limb ischemia were included. All the patients were assessed by qualified vascular surgeons. SPSS 23 was used for data analysis. Results: Of the 55 patients, 33(60%) had acute and 22(40%) had chronic limb ischaemia. Mean age of acute cases was 44±23.72 years and it was 60±12.49 years for chronic cases. Overall, the commonest reason behind delay was non-referral by primary physician which was the case with 11(33.3%) patients in the acute group, and 13(59%) in the chronic group. The limb loss in the acute group was 20(60%) and 8(36%) in the chronic group.. Conclusion: Delayed presentation of patients with limb ischaemia is mainly due to non-referral. A robust campaign needs to be launched to reduce the rate of limb loss.