Publications by authors named "Ahsan Zil-E-Ali"

26 Publications

  • Page 1 of 1

Asymptomatic Preoperative Leukocytosis Before Carotid Endarterectomy is Associated With Increased Risk of Stroke: A Study From NSQIP Database.

Ann Vasc Surg 2021 Oct 10. Epub 2021 Oct 10.

Department of Surgery, The Pennsylvania State University, College of Medicine, Hershey, PA.

Background: Carotid endarterectomy (CEA) is the gold standard operation for treating carotid artery stenosis in patients with symptomatic carotid stenosis of more than 50% and asymptomatic carotid stenosis of more than 80%. Asymptomatic leukocytosis before CEA represents a clinical dilemma for surgeons about the management options. The objectives of this study are to identify the relationship between asymptomatic preoperative leukocytosis and postoperative complications in patients undergoing CEA and to assess the relationship between asymptomatic preoperative leukocytosis and postoperative complications in the cohort of patients with symptomatic carotid stenosis.

Methods: The American College of Surgeons National Surgical Quality Improvement Program database for the years 2011-2019 was utilized for this analysis. Patients with preoperative sepsis, septic shock, pneumonia, wound infections, disseminated cancer, renal failure, and history of chronic steroid use were excluded. The remaining patients were sub-grouped based on white blood cell (WBC) count: Normal WBC (<11k/µL) and High WBC (≥11k/µL). Bivariate analysis between the patient characteristics and preoperative WBC levels was performed following simple and multiple regression analysis. A P-value of <0.05 was set as significant.

Results: Of the 26,332 patients in the study cohort, 7.4% (n =1,946) had preoperative leukocytosis. Patients with preoperative leukocytosis were relatively younger (mean age: 41.5 +/- 9.7 vs 44.3 +/- 9.1; P< 0.001) and more likely to be females (43% vs. 38.5; P< 0.001) than patients with normal WBC count. Patients with preoperative leukocytosis were also more likely to have DM, COPD, a bleeding disorder, be smokers, and be functionally dependent. The analysis revealed that patients with preoperative leukocytosis had a significantly higher rate of stroke, length of stay (LOS)>1- week, acute occlusion or revision, acute renal failure, and return to OR when compared to patients with normal WBC count. Furthermore, patients with high WBC count also experienced higher occurrences of infectious complications, such as wound dehiscence, wound infections, pneumonia, and sepsis. However, there was no difference in the overall 30-day mortality. Multivariate regression analysis showed patients with preoperative leukocytosis had anincreased risk of stroke (AOR 1.5, CI: 1.1-1.9, P = 0.009), LOS>1 week (AOR 1.3, CI: 1.1-1.5, P = 0.003), and return to OR (AOR 1.3, CI: 1.0-1.8, P = 0.030). The increased LOS was especially more pronounced in symptomatic carotid stenosis patients with preoperative leukocytosis. The occurrence of LOS>1 week was 4.91% in asymptomatic stenosis patients with high WBC count compared to 21.5% in symptomatic stenosis patients with high WBC count (P< 0.001).

Conclusions: Patients with asymptomatic preoperative leukocytosis undergoing CEA have a significantly higher risk of stroke and infectious complications in the postoperative period. Furthermore, patients with symptomatic carotid disease are especially at an increased risk of prolonged LOS. A routine preoperative hematological evaluation may be recommended as a risk assessment tool for patients undergoing CEA, and postponing the elective operation in patients with asymptomatic CEA may be advised unless a thorough preoperative infectious workup is completed.
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http://dx.doi.org/10.1016/j.avsg.2021.07.011DOI Listing
October 2021

Big data analytics: A promising healthcare solution.

J Pak Med Assoc 2021 Aug;71(8):2108

Heart and Vascular Institute, Penn State University, United States.

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http://dx.doi.org/10.47391/JPMA.2255DOI Listing
August 2021

Preoperative Dependent Functional Status Is Associated With Poor Outcomes After Carotid Endarterectomy and Carotid Stenting in Both Symptomatic and Asymptomatic Patients.

Ann Vasc Surg 2021 Oct 15;76:114-127. Epub 2021 May 15.

Division of Vascular Surgery, Penn State Heart and Vascular Institute, Penn State University, Hershey, PA. Electronic address:

Background: Both Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are the most common procedures to treat patients with symptomatic, and asymptomatic high-grade carotid stenosis. Poor preoperative functional status (FS) is increasingly being recognized as predictor for postoperative outcomes. The purpose of this study is to determine the impact of preoperative functional status on the outcomes of patients who undergo CEA or CAS.

Methods: Data was obtained from the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database from the years 2011-2018. All patients in the database who underwent CEA or CAS during this time period were identified. Patients were then further divided into 2 subgroups: FS-Independent and FS-dependent. Bivariate and multivariate analyses was performed for pre, intra and post-operative variables with functional status. Outcomes for treatment of symptomatic carotid disease were compared to those with asymptomatic disease among the cohort of functionally dependent patients.

Results: A total of 27,163 patients (61.2% Males, 38.8% Females) underwent CEA (n = 26,043) or CAS (n = 1,120) from 2011-2018. Overall, primary outcomes were as follows: mortality 0.77% (n = 210) and stroke 1.87% (n = 507).Risk adjusted multivariate analysis showed that FS-D patients undergoing CEA had higher mortality (AOR 3.06, CI 1.90-4.92, P < 0.001), longer operative times (AOR 1.36, CI 1.17-1.58, P< 0.001) higher incidence of unplanned reoperation (AOR 1.68, CI 1.19-2.37, P = 0.003), postoperative pneumonia (AOR 5.43, CI 1.62 - 18.11, P = 0.006) and ≥3 day LOS (AOR 3.05, CI 2.62-3.56, P < 0.001) as compared to FS-I patients. FS-D patients undergoing CAS had higher incidence of postoperative pneumonia (AOR 20.81, CI 1.66-261.54, P = 0.019) and higher incidence of LOS ≥3 days (AOR 2.18, CI 1.21-3.93, P < .01) as compared to FS-I patients. Survival analysis showed that the best 30-day survival was observed in FS-I patients undergoing CEA, followed by FS-I patients undergoing CAS, followed by FS-D patients undergoing CEA, followed by FS-D patients undergoing CAS. FS-D status increased mortality after CEA by 2.11%. When the outcomes of CAS and CEA were compared to each other for the cohort of FS-D patients, CAS was associated with higher incidence of stroke (AOR 3.46, CI 0.32-1.97, P= 0.046), shorter operative times (AOR 0.25, CI 0.12-0.52, P < 0.001) and higher incidence of pneumonia (AOR 11.29, CI 1.32-96.74, P = 0.027). Symptomatic patients undergoing CEA had higher LOS as compared to symptomatic patients undergoing CAS, and asymptomatic patients undergoing CEA or CAS.

Conclusions: FS-D patients, undergoing CEA have higher mortality as compared to FS-I patients undergoing CAS. FS-D patients undergoing CAS have higher incidence of postoperative pneumonia and longer LOS as compared to FS-I patients. For the cohort of FS-D patients undergoing either CEA or CAS, CAS was associated with higher risk of stroke and reduced operative times. Risk benefit ratio for any carotid intervention should be carefully assessed before offering it to FS-D patients. Preoperative Dependent Functional Status Is Associated with Poor Outcomes After Carotid Endarterectomy and Carotid Stenting in Both Symptomatic and Asymptomatic Patients.
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http://dx.doi.org/10.1016/j.avsg.2021.04.027DOI Listing
October 2021

Evaluation of Factors Associated with, and Outcomes for Patients with Nonhome Discharge Destinations Following Carotid Endarterectomy.

Ann Vasc Surg 2021 Aug 7;75:55-68. Epub 2021 Apr 7.

Department of Surgery, Pennsylvania State University, College of Medicine, Hershey, PA. Electronic address:

Introduction: Following a carotid endarterectomy (CEA) procedure, patients are discharged to their homes or other locations than home such as an acute care facility or skilled nursing facility based on their functional status and level of medical attention needed. Decision-making for discharge destination following a CEA to home or nonhome locations is important due to the differences in survival and postoperative complications. While primary outcomes such as mortality and occurrence of stroke following CEA have been extensively studied, there is a paucity of information characterizing outcomes of discharge destination and the factors associated. The purpose of this study was to explore the factors associated with discharge to nonhome destinations after CEA, and outcomes after discharge.

Methods: Using the American College of Surgeons National Surgical Quality Improvement Program (ACS-NSQIP) database, we identified patients who underwent CEA from 2011 to 2018. Patients were divided into two groups based on their discharge destination (home versus nonhome). Univariate and multivariate analysis were performed for preoperative and intraoperative factors associated with different discharge destinations. Postoperative complications associated with discharge to nonhome destinations were analyzed and mortality after discharge from hospital was compared between the 2 groups.

Results: A total of 25,094 patients met the criteria for inclusion in the study, of which 39% were females and 61% were males; median age was 71 years. Twenty four thousand one hundred twenty-five patients (93.13%) were discharged to home (Group I) and 1,779 (6.87%) were discharged to nonhome destinations (Group II). Following preoperative and intraoperative factors were associated with discharge to nonhome locations: older age, diabetes mellitus, functional independent status, transfer from other hospitals, symptomatic status, need for preoperative blood transfusions, severe ipsilateral carotid stenosis, elective CEA, need for intraoperative shunt and general anesthesia (all P< 0.05). Following postoperative complications had statistically significant association with discharge to nonhome destinations: postoperative blood transfusion, pneumonia, unplanned intubation, longer than 48 hours on ventilator, development of stroke, myocardial infarction, deep vein thrombosis, and sepsis (all P< 0.05). Mortality after discharge from hospital was 0.39% (n = 100). Mortality among those who were discharged to home was 0.29% vs. 1.63% for those who were discharged to nonhome locations (P< 0.05).

Conclusions: Majority of the patients after CEA are discharged back to their homes. This study identifies the factors which predispose patients discharged to locations, other than home. Patients who are not discharged home have higher mortality as compared to those who are discharged to their homes.
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http://dx.doi.org/10.1016/j.avsg.2021.02.026DOI Listing
August 2021

Impact of impaired ambulatory capacity on the outcomes of peripheral vascular interventions among patients with chronic limb-threating ischemia.

J Vasc Surg 2021 08 4;74(2):489-498.e1. Epub 2021 Feb 4.

Division of Vascular and Endovascular Surgery, Department of Surgery, University of California San Diego, La Jolla, Calif. Electronic address:

Objective: Despite prior literature recommending against limb salvage in patients with poor functional status such as nonambulatory patients with chronic limb-threatening ischemia (CLTI), peripheral endovascular interventions continue to be carried out in this group of patients. Clinical outcomes following these interventions are, however, not well-characterized.

Methods: A retrospective review was conducted on all patients treated for CLTI in the Vascular Quality Initiative from September 2016 to December 2019. Logistic regression, Kaplan-Meier survival estimates, log-rank tests, and Cox regression analyses were used as appropriate to study outcomes. The primary outcomes were 30-day mortality and 1-year amputation-free survival. The secondary outcomes were in-hospital death, postoperative complications, 1-year freedom from major amputation, and 2-year survival.

Results: Of the 49,807 patients studied, 28,469 (57.2%) were ambulatory, 15,148 (31.0%) were ambulatory with assistance, 5395 (10.8%) were wheelchair bound, and 525 (1.1%) were bedridden. There was a 2-fold increase in the odds of 30-day death in patients who were ambulatory with assistance (odds ratio [OR], 2.03; 95% confidence interval [CI], 1.77-2.34; P < .001) and wheelchair-bound patients (OR, 2.09; 95% CI, 1.74-2.51; P < .001), and a more than 6-fold increase in bedridden patients (OR, 6.28; 95% CI, 4.55-8.65; P < .001) compared with ambulatory patients. There was a significantly higher odds of postoperative complications in patients who were ambulatory with assistance or bedridden, but no difference with wheelchair-bound patients. Among ambulatory patients, the risks of major amputation and death within 1 year were only 10% and 12%, respectively, whereas that of bedridden patients were as high as 30% and 38%, respectively. A stepwise decrease in amputation-free survival from 81% with full ambulatory capacity to less than 50% (47.7%) in bedridden patients was observed. The risk of major amputation or death within 1 year was 35% higher for ambulatory with assistance (hazard ratio [HR], 1.35; 95% CI, 1.26-1.44; P < .001), 65% higher for wheelchair-bound (HR, 1.65; 95% CI, 1.51-1.79; P < .001) and 2.6-fold higher for bedridden (HR, 2.64; 95% CI, 2.17-3.21; P < .001) compared with ambulatory. A similar association was seen for 1-year freedom from major amputation and 2-year survival.

Conclusions: Ambulatory impairment in patients with CLTI is associated with a significant increase in 30-day mortality and significant decrease in amputation-free survival after peripheral endovascular intervention. Bedridden patients had a 6-fold increase in the 30-day death rate, whereas their amputation-free survival dropped to less than 50% at 1 year. These risks should be considered during shared decision-making regarding management options for nonambulatory patients with CLTI.
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http://dx.doi.org/10.1016/j.jvs.2020.12.088DOI Listing
August 2021

Factors associated with disease severity and mortality among patients with COVID-19: A systematic review and meta-analysis.

PLoS One 2020 18;15(11):e0241541. Epub 2020 Nov 18.

Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins School of Medicine, Baltimore, Maryland, United States of America.

Background: Understanding the factors associated with disease severity and mortality in Coronavirus disease (COVID-19) is imperative to effectively triage patients. We performed a systematic review to determine the demographic, clinical, laboratory and radiological factors associated with severity and mortality in COVID-19.

Methods: We searched PubMed, Embase and WHO database for English language articles from inception until May 8, 2020. We included Observational studies with direct comparison of clinical characteristics between a) patients who died and those who survived or b) patients with severe disease and those without severe disease. Data extraction and quality assessment were performed by two authors independently.

Results: Among 15680 articles from the literature search, 109 articles were included in the analysis. The risk of mortality was higher in patients with increasing age, male gender (RR 1.45, 95%CI 1.23-1.71), dyspnea (RR 2.55, 95%CI 1.88-2.46), diabetes (RR 1.59, 95%CI 1.41-1.78), hypertension (RR 1.90, 95%CI 1.69-2.15). Congestive heart failure (OR 4.76, 95%CI 1.34-16.97), hilar lymphadenopathy (OR 8.34, 95%CI 2.57-27.08), bilateral lung involvement (OR 4.86, 95%CI 3.19-7.39) and reticular pattern (OR 5.54, 95%CI 1.24-24.67) were associated with severe disease. Clinically relevant cut-offs for leukocytosis(>10.0 x109/L), lymphopenia(< 1.1 x109/L), elevated C-reactive protein(>100mg/L), LDH(>250U/L) and D-dimer(>1mg/L) had higher odds of severe disease and greater risk of mortality.

Conclusion: Knowledge of the factors associated of disease severity and mortality identified in our study may assist in clinical decision-making and critical-care resource allocation for patients with COVID-19.
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http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0241541PLOS
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7673562PMC
December 2020

Presentation of pleural effusion and dilated cardiomyopathy in a case of dystrophic epidermolysis bullosa.

J Pak Med Assoc 2020 Jun;70(6):1106-1109

Department of Anesthesia, Hamad General Hospital, Hamad Medical Corporation, Doha, Qatar.

Epidermolysis Bullosa (EB), a genetic disorder of the skin that presents with eruptive lesions accompanied by blistering has multiple types. We present a case of dystrophic and epidermolysis bullosa (DEB), a rare variant of the disease with the underlying pathophysiology involving a mutation of type VII collagen that serves as an anchoring protein for basement membrane to the dermis. The patient presented with palmoplantar hyperkeratosis with blistering extending on multiple sites of the body, bilateral pleural effusion and an ejection fraction of 23% with moderate mitral regurgitation. The patient was treated symptomatically with diuretics and inotropic medication for the dilated heart, along with draining of pleural spaces. No case of DEB with pleural effusion has been reported prior to this one. We believe this is the first case that presented with both pleural effusion and dilated cardiomyopathy.
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http://dx.doi.org/10.5455/JPMA.49858DOI Listing
June 2020

A Case of Waardenburg-Shah Syndrome Type 4 Presenting with Bilateral Homochromatic Blue Irises from Pakistan.

Cureus 2018 Aug 14;10(8):e3143. Epub 2018 Aug 14.

Internal Medicine, Rawalpindi Medical University, Rawalpindi, PAK.

Waardenburg syndrome (WS) is a rare genetic disorder. It is caused by multiple mutations affecting the melanocytes, leading to a multitude of skin, hair, and eye symptoms. It is an autosomal dominant disease with four subtypes, each presenting with varying degrees of sensorineural hearing loss along with a constellation of other symptoms. Hirschsprung disease is unique to Waardenburg-Shah syndrome subtype 4 and is not associated with any other subtype. We present a case of this subtype 4 that presented with a bilateral sensorineural hearing loss, mutism, delayed milestones, white forelock, Hirschsprung disease, and bilateral blue homochromatic irises, a finding which is not typical for this subtype. This is the first case of WS with homochromatic irises and the fourth case to be reported from Pakistan.
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http://dx.doi.org/10.7759/cureus.3143DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6188159PMC
August 2018

The Effect of Physical Activity in Parkinson's Disease: A Mini-Review.

Cureus 2018 Jul 18;10(7):e2995. Epub 2018 Jul 18.

Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA.

This article will discuss the effects of physical activity in patients with Parkinson's disease. Presently, the motor and non-motor symptoms are difficult to treat with the current treatment of Parkinson's; therefore, as an adjuvant to the current treatment physical activity, has been recommended. Physical activity has been known to improve many symptoms in patients with Parkinson's disease. Some of these symptoms include the physical capacities, physical and cognitive functional capacities. Physical activity also slows the disease process, decreases the pain associated with Parkinson`s disease, prolongs the independent mobility (gait, balance, strength) and improves sleep, mood, memory hence improving the overall quality of life. Furthermore, physical activity has the potential to improve the non-motor symptoms (depression, apathy, fatigue, constipation) and the secondary complications of immobility (cardiovascular, osteoporosis) in Parkinson's disease.
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http://dx.doi.org/10.7759/cureus.2995DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6143369PMC
July 2018

Diagnosing Necrotizing Fasciitis Using Procalcitonin and a Laboratory Risk Indicator: Brief Overview.

Cureus 2018 Jun 7;10(6):e2754. Epub 2018 Jun 7.

Medical Student-3, FMH College of Medicine & Dentistry, Lahore, PAK.

Necrotizing fasciitis is a progressive inflammatory disease that requires an early diagnosis to avoid limb salvage and other deadly manifestations. The current protocol is the microbiological and histopathological sampling of the tissue. Once the diagnosis is made, it should be managed with antimicrobial therapy, debridement, and surgical interventions. Such interventions can be invasive and increase the time to treat, which may increase morbidity. Our article discusses procalcitonin, C-reactive protein, and other markers, such as "pain out of proportion," lactate, creatinine, and creatine kinase, to make a quicker diagnosis before proceeding with invasive procedures. We discussed a similar non-invasive approach called the "Laboratory Risk Indicator for Necrotizing Fasciitis" scoring system that can aid in the early diagnosis of necrotizing fasciitis, which can prompt rapid empiric therapy, reducing the chances of morbidity. This scoring system comprises C-reactive protein, white blood cell count, hemoglobin level, creatinine, sodium, and glucose. Such non-invasive, bedside, and quick tests can help in reducing the time required to make the diagnosis and can affect the course of the disease, hence, improving patient outcomes.
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http://dx.doi.org/10.7759/cureus.2754DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6080743PMC
June 2018

Comparison of Knowledge and Attitudes of Medical and Dental Students towards HIV/AIDS in Pakistan.

Cureus 2018 Apr 4;10(4):e2426. Epub 2018 Apr 4.

Internal Medicine, The University of Texas MD Anderson Cancer Center, Houston, USA.

The number of new human immunodeficiency virus (HIV) cases is increasing in Pakistan while it has seen a decline globally. A survey conducted recently has found that 132,000 people in Pakistan suffer from HIV. This study aims to check the levels of knowledge and attitudes about HIV/acquired immunodeficiency syndrome (AIDS) among medical and dental students. This cross-sectional study was designed and conducted at Combined Military Hospital Lahore Medical College and the Institute of Dentistry (CMH LMC) in Lahore, Pakistan in 2016. Students enrolled in the courses of the MBBS and BDS were included in this study. The questionnaire consisted of three sections: demographics, knowledge and attitude. A total of 414 students completed the questionnaire and out of them, 286 were medical students while the rest were dental students. The mean ± standard deviation score for the students was 10.02 ± 4.37 out of 17 for knowledge related to HIV and AIDS. For acceptable attitude towards AIDS and patients afflicted with the disease, an outcome of 1.93 ± 0.75 out of 4 was observed. The results of this study indicate lack of knowledge about HIV, especially about the modes of transmission and prevention techniques. Therefore, regular interactive workshops and seminars, besides teaching sessions, focused lectures on HIV/AIDS, need to be conducted.
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http://dx.doi.org/10.7759/cureus.2426DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6067834PMC
April 2018

Impact of Clinical Information on the Turnaround Time in Surgical Histopathology: A Retrospective Study.

Cureus 2018 May 8;10(5):e2596. Epub 2018 May 8.

Department of Pathology, Fatima Memorial Hospital College of Medicine & Dentistry, Lahore, PAK.

Introduction Clinical information (CI) is a key requisite to diagnose and report a specimen in histopathology. A timely dispatched report can help a clinician to confirm a diagnosis and initiate a prompt treatment plan while an unnecessary delay in reporting time can compromise patient's healthcare. The aim of this study was to ascertain the impact of the adequacy of CI provided by clinicians on the turnaround time (TAT) and to investigate factors pertinent to specimens, their handling, and diagnosis. Methods This retrospective study reviewed a total of 803 surgical specimens reported in a duration of four months (from December 2015 till March 2016) by the Department of Histopathology, FMH College of Medicine & Dentistry, Lahore, Pakistan. Frozen section and cytology specimens were excluded. CI was classified into three categories: short and focused, long and detailed, and deficient CI. Deficient CI was designated where the pathologist had to seek more information from the requesting clinicians. Total time taken by the histopathologist to complete a report was calculated after excluding weekends and holidays. Other factors like type of specimen, special staining, diagnosis of malignancy and source of referral were also studied. The data were entered and analyzed on SPSS 22.0 (IBM, Armonk, NY). Shapiro-Wilk test was used to measure the distribution. Results Most of the specimens (46.2%, n = 371) were reported within three days. Of these, most of the specimens (46.9%, n = 174) had a short and focused CI (p < 0.001). Majority of the specimens which were reported within four to five days (42.1%, n = 114) and after five days (62.1%, n = 100) were found to have a long and detailed CI in their requisition forms. Median TAT extended to six (4.00-7.00) days with the use of special stains (p < 0.001). One hundred and sixty-three (20.29%) of the total cases were diagnosed as malignant in which the median TAT significantly prolonged to five days (p < 0.001). Most of the specimens (80%, n = 60) received from the outside laboratories had a long and detailed CI in requisition forms. Endometrial tissue specimen was the predominant type received by the department (24.3%, n = 90). Conclusion Adequate CI is necessary for timely and error-free reporting of a specimen in surgical histopathology. A short, focused and concise CI is associated with a shorter TAT. Long and detailed CI is often seen with a complex surgical specimen that requires a longer time to report. Factors like specimen type, special staining, number of special stains and diagnosis of a malignancy also affect TAT.
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http://dx.doi.org/10.7759/cureus.2596DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC6037332PMC
May 2018

Case Of Iatrogenic Cushing's Syndrome By Topical Triamcinolone.

J Ayub Med Coll Abbottabad 2018 Jan-Mar;30(1):121-123

Rush University, Chicago, Illinois-USA.

Cushing's syndrome is a collection of signs and symptoms due to hypercortisolism. Prolong use of topical steroid may cause this syndrome and suppression of hypothalamic and pituitary function, however such events are more common with oral and parenteral route. There are very few cases of Cushing's syndrome with a topical application amongst which triamcinolone is the rarest drug. We report a case of 11-year-old boy is presented who developed Cushing's disease by topical application. The child had body rashes for which the caregiver consulted a local quack, a topical cream of triamcinolone was prescribed. After application for three months, the patient became obese and developed a moon-like face. A thorough biochemical workup and diagnostic test for Cushing's disease was done to confirm. The following case report a dramatic example of development of the syndrome from chronic topical application of the least potent corticosteroid.
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August 2018

Relationship Issues and High Divorce Rate among Surgeons.

J Coll Physicians Surg Pak 2017 Nov;27(11):739-740

Department of Psychiatry, Rush University, Illinois, US.

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November 2017

Procalcitonin: A Powerful Rescuer on Surgical Floors.

Cureus 2017 Jul 8;9(7):e1446. Epub 2017 Jul 8.

Fmh College of Medicine, FMH College of Medicine.

Necrotizing fasciitis (NF) is a rare but life-threatening medical and surgical emergency. It is characterized by necrosis of the soft tissue leaving the overlying tissue unaffected, which delays the diagnosis and treatment. Delay in recognition of the severity of necrotizing fasciitis might lead to serious morbidity and mortality. Diagnosis of NF relies on strong clinical judgment, predictable by severe pain, erythema, and a presence of air under the skin, but all of them are not always present. Management of NF is prompt surgical intervention and antimicrobial therapy. The effectiveness depends on the timely diagnosis of NF because it rapidly spreads and may cause irreversible damage. Various investigations for necrotizing fasciitis have been proposed. However, misdiagnosis is not infrequent and more work is needed to identify the different presentations across the spectrum. We consider changing it to discuss the role of procalcitonin in the diagnosis of necrotizing fasciitis.There is scarce literature about its clinical role in necrotizing fasciitis although it has evolved not only as a prognostic marker but also as a way of differentiating between cellulitis and necrotizing fasciitis. It can also predict the future consequences of septic shock.
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http://dx.doi.org/10.7759/cureus.1446DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5590767PMC
July 2017

Case Of Debakey Class I Aortic Dissection.

J Ayub Med Coll Abbottabad 2016 Jul-Sep;28(3):637

Fatima Memorial Hospital, Lahore, Pakistan.

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December 2017

Simultaneous Robot-assisted Laparoscopic Excision of Pre-pyloric Gastrointestinal Stromal Tumor and Cholecystectomy.

Cureus 2017 Jun 3;9(6):e1306. Epub 2017 Jun 3.

Department of General, Colorectal & Hepato Pancreatico Biliary Surgery, Appalachian Regional Healthcare, Hazard, Kentucky, Us.

Operating on more than a single procedure in a same surgical intervention saves time, anesthesia duration and can increase the overall quality of life by lowering the duration of hospital stay and minimizing patient anxiety. But such interventions require expertise, high surgical performance, and precision in anatomical manipulation. We present a case of an outstanding performance of a unique minimally invasive simultaneous approach of removing a pre-pyloric gastrointestinal stromal tumor (GIST) along with a cholecystectomy by a robot-assisted laparascopic surgical system. So far, only 33 cases of GIST have been reported in literature that were managed by robot-assistance, and this case is the first of its kind. This is the case of a 60-year-old overweight female who presented for a follow-up for chest discomfort, shortness of breath, chronic gastric reflux and classical features of cholecystitis along with diarrheal and constipation episodes. A gastroduodenoscopy showed a mass in the pre-pyloric area that extended in the luminal cavity. A robot-assisted laparascopic approach was planned, and with precision and surgical expertise the mass was removed along with a cholecystectomy. The surgical specimen were confirmed on histopathology.
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http://dx.doi.org/10.7759/cureus.1306DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5493468PMC
June 2017

Hysteroscopic Myomectomy can lead to intrauterine adhesions and infertility.

J Pak Med Assoc 2017 Jun;67(6):964-965

Department of Surgery, Fatima Memorial Hospital, Lahore.

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June 2017

Think Before Chopping a Diabetic Foot: Insight to Vascular Intervention.

Cureus 2017 Apr 25;9(4):e1194. Epub 2017 Apr 25.

Biochemistry, Fatima Memorial Hospital.

Diabetes mellitus is a most commonly occurring chronic disease around the world, resulting in damage to multiple organs. One of the consequences of poorly controlled diabetes is vascular damage resulting in peripheral artery disease, leading to inadequate perfusion of the foot and eventually gangrene and amputation. Research over the past decade or so has provided us with the statistics that vascular intervention has better clinical outcomes including patient mortality, morbidity, quality of life, and patient satisfaction. This editorial advocates the importance of pursuing a vascular plan prior to a limb salvaging procedure. We highlight some important aspects of saving a diabetic foot and encourage the importance of giving a vascular trial.
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http://dx.doi.org/10.7759/cureus.1194DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5444914PMC
April 2017

Cross-Sectional Survey of Healthcare Provisions for Female Tuberculosis Patients in Specialized Pulmonary Division from Low Socioeconomic Class in Lahore, Pakistan.

Cureus 2017 Apr 3;9(4):e1133. Epub 2017 Apr 3.

Department of Internal Medicine, Fatima Memorial Hospital.

Objectives: This study aimed to investigate various healthcare provisions for women affected with tuberculosis (TB) from low socioeconomic status and their health seeking behaviors, also whether or not patients feel stigmatized about their disease.

Introduction: Pulmonary tuberculosis has more prevalence in Pakistan as compared to western countries where it occurs predominantly in the immunocompromised individuals and immigrants of certain countries. It is a contagious disease and Pakistan stands at the fifth position with maximum reported cases each year.

Methods: A cross-sectional study was carried at Gulab Devi Hospital, a public sector hospital located in Lahore, through a questionnaire-based survey followed by interviewing all participants. Two hundred seventy-seven female patients, who were already diagnosed with pulmonary tuberculosis, were included in the study. The sample was drawn by non-probability, convenience sampling. Literacy, a major contributor to socioeconomic status, was taken primary criteria to select the sample for the study.

Results: The study shows that literacy of patients has no impact on whether they feel stigmatized due to their disease as 42% (45 out of 108) of the literate women felt stigmatized while 39% (65 out of 169) of illiterate women also presented with similar feelings. Furthermore, the research also showed that these patients have no effect on requiring permission for going to the health facility as the study revealed that 62% (67 out of 108) in the literate women required permission while 67% (113 out of 169) illiterate women required permission.

Conclusion: Pakistani population must be educated about TB and factors associated with the progression and consequences of the disease. It was noted that even educated people feel embarrassed when they develop symptoms of TB, thereby causing the unprecedented delay in effective disease management. To conclude, TB clinic should be opened in each community so that people have easy access to treatment of the disease.
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http://dx.doi.org/10.7759/cureus.1133DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5415379PMC
April 2017

A Survey of Handwashing Knowledge and Attitudes among the Healthcare Professionals in Lahore, Pakistan.

Cureus 2017 Mar 9;9(3):e1089. Epub 2017 Mar 9.

Medical Student-4, FMH College of Medicine.

Objective: To evaluate the knowledge and attitudes towards handwashing of clinical year medical and dental students and health-care professionals (HCPs) working in the departments of medicine, surgery, dentistry, nursing, and physiotherapy in Lahore, Pakistan.

Methodology: This was a cross-sectional survey conducted during May and June 2016. After approval from the institutional review board, a modified form of the World Health Organization (WHO) Hand Hygiene Knowledge Questionnaire for Healthcare workers that included 18 items was sent to 400 clinical year students and HCPs from six medical colleges and affiliated hospitals of Lahore. The data obtained was entered and analyzed by using IBM SPSS version 20 (IBM, NY, USA). Chi-square was used as the test of significance. A p of <0.05 was considered statistically significant for all purposes.

Results: The response rate was 79%. Less than half of the respondents (149, 47.9%) were satisfied with their knowledge regarding hand hygiene. Statistically significant associations of various groups of HCPs were observed with their satisfaction regarding knowledge about hand hygiene (p-value = 0.022), their awareness of the proper technique required for handwashing proposed by the WHO (p-value = 0.001), and their awareness about other preventive techniques proposed by the WHO and Centers for Disease Control (CDC) (p-value = 0.021).

Conclusions: The majority of the clinical year students and HCPs were not satisfied with their knowledge regarding hand hygiene. HCPs working in different departments have varying knowledge and attitudes towards hand hygiene. Females were found to be more satisfied with their handwashing practices. Teaching proper technique of handwashing to medical students and starting refresher courses regarding hand hygiene for HCPs are dire needs. The WHO-recommended guidelines should not only be taught but also implemented in the medical field as poor hand hygiene techniques have led to the spread of many diseases around the globe.
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http://dx.doi.org/10.7759/cureus.1089DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5388362PMC
March 2017

A Non-invasive 24 Hours Stabilization of Duodenal Ulcer Perforation by a Combination Regimen.

Cureus 2016 Dec 1;8(12):e908. Epub 2016 Dec 1.

Department of Medicine, Shifa International Hospital, Islamabad, Pakistan.

Surgical repair of perforated gastroduodenal ulcer has been extensively practiced in emergency clinical situations. Non-invasive conservation treatment is regaining the attention towards management of such ulcers. We report the case of a 50-year-old male smoker who presented in the emergency unit with acute generalized abdominal pain and guarding in the epigastric and right upper quadrant region. He is a known regular user of over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDS) for more than 10 years for his osteoarthiritis and myalgias. A differential diagnosis of gastritis and duodenal perforation was made owing to the symptoms and long usage of NSAIDs. He was managed with an intravenous proton pump inhibitor and intravenous antibiotics. This therapy lead to stabilization of the clinical symptoms as well as laboratory and imaging studies.
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http://dx.doi.org/10.7759/cureus.908DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC5208553PMC
December 2016

EVLA: A modern approach for varicose veins.

Authors:
Ahsan Zil-E-Ali

J Pak Med Assoc 2016 Aug;66(8):1046

Department of Surgery, Fatima Memorial Hospital, Lahore.

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August 2016

Presentation of parathyroid adenoma with genu valgum and thoracic deformities.

J Pak Med Assoc 2016 Jan;66(1):101-3

Department of Pathology, Fatima Memorial Hospital, Shadman, Lahore.

Parathyroid adenoma is the main cause of primary hyperparathyroidism. It is usually asymptomatic and occurs more commonly in adults. It presents with raised parathormone (PTH) and Ca+ levels in serum. Its presentation in adolescence is rare. We report one such incidence of a 14 years old girl who presented with bone pains short stature, and generalized muscle wasting. She was found to have genu valgum at the knee joint, pectus carniatum, scoliosis and cystic changes in pelvis and calvarium. Biochemical investigations and parathyroid Tc-99mMIBI scan confirmed the diagnosis of a parathyroid adenoma. The gland was removed by parathyroidectomy. Till date 12 such cases are reported and none had thoracic, vertebral or calvarium involvement.
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January 2016

Cancer illustrations and warning labels on cigarette packs: perceptions of teenagers from high socioeconomic status in Lahore.

J Pak Med Assoc 2015 Jun;65(6):688-91

Department of Community Medicine, FMH College of Medicine & Dentistry, Lahore.

Smoking is linked with adverse health outcomes and multi-organ diseases with six million deaths every year. The smoking population includes both genders and the habit is seen in minors as well. The cross-sectional study was conducted in Lahore among teenagers belonging to high socioeconomic class. A sample of 191 students was recruited by convenience sampling. The teenagers were questioned on their perceptions relating to prohibition labels, factors that led them to smoke, and ideas to make health warnings more effective. Overall, 66(34.55%) teenagers were smokers, and of them, 50(75.75%) were boys and 16(24.24%) were girls. Besides, 25(37.9%) smokers were of the view that smoking is a bad habit; 40(60.6%) said prohibition labels would not change the mindset of the smoker; 35(53%)believed that a smoker is completely uninfluenced by prohibition labels. Results suggest that the warning labels on cigarette packs should be made more comprehensible and alarming for smokers.
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June 2015
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