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The present study aimed to calculate the estimated size and confidence interval for the effects of adding visual aid to counselling on anxiety, stress and fear of patients undergoing upper gastrointestinal endoscopy. The secondary aim was to calculate confidence interval for endoscopy-related variables that predict which patients are likely to benefit from visual aids. In a randomized, single-blind, two arm, parallel group, superiority trial, 232 consecutive patients who were scheduled to undergo either gastroscopy or colonoscopy were randomly divided into two intervention groups; counselling with video of endoscopic procedure and counselling with no-video (n = 116 in each group). Primary outcome was anxiety and secondary outcomes were stress and fear. One-way ANCOVA showed that there was significant between group differences of anxiety, stress and fear after controlling for the effect of covariates. Planned contrasts revealed that counselling along with visual aid of endoscopy procedure significantly decreased anxiety [Mean difference at post; −4.26 (−4.47, −4.05), p <.001, partial η2 = 0.88], stress [−5.35 (−5.63, −5.07), p <.001, partial η2 = 0.86] and fear [−2.82 (−2.97, −2.67), p <.001, partial η2 = 0.86] compared to counselling alone. Linear regression showed that gender, nature of complaints and concern over seniority of endoscopist were significant negative predictors, however, satisfaction on briefing of endoscopy procedure was significant positive predictor of outcome variables in visual aid condition. The increase in anxiety, acute stress and fear related to endoscopic procedures can be alleviated with psychological counselling coupled with visual aids before the procedure. Visual aid could lead to supplementary benefits in reducing anxiety scores. Number: NCT05241158. Registered 16/11/2022; Counselling along with visual aid of endoscopy procedure significantly decreased anxiety, stress and fear as compared to counselling alone. Male patients were less stressed after visual aid intervention as compared to female patients. Patients who had chronic GI symptoms were less stressed after visual aid intervention as compared to those who had acute GI symptoms. Patients who had concern over seniority of endoscopist were less stressed after visual aid intervention as compared to those who had no concerns over seniority. Satisfaction on briefing of endoscopy procedure was significant positive predictor of stress and fear. [ABSTRACT FROM AUTHOR]

Background: Data from many studies suggest that deficiency of vitamin D has got role in pathophysiology of cirrhosis. Though the vitamin D deficiency has strong assossiation with chronic liver diseases and cirrhosis, yet its relation with development of advanced liver fibrosis is still controversial. The objective of our research was to determine the correlation between deficiency of vitamin D (< 30 ng/ml) and severity of liver disease among cirrhotic patients. Methods: Levels of Vitamin D were evaluated in 125 patients suffering from Chronic Liver Disease. The participants were categorized in three groups on the basis of Child-Pugh scoring system: A, B and C. The association of vitamin D levels with Child-Pugh grade and additional variables in the research was calculated by the contingency coefficient and chi-square by means of p-values. Results: Amongst the patients, 65.6% had scarce or deficient levels of vitamin D, 23.2% had inadequate values of Vitamin D and remaining 11.2% had adequate stores of vitamin D (p > 0.05). Levels of vitamin D were remarkably associated with Child-Pugh class (p < 0.05). Conclusion: A decreased level of Vitamin D is markedly associated with severity of liver disease. Vitamin D levels must be regularly monitored in patients with advanced liver cirrhosis (Child-Pugh class B and C) and this deficiency should be corrected well in time for improvement of prognosis in patients having hepatic cirrhosis. [ABSTRACT FROM AUTHOR]

Background: COVID-19 has affected both adults and children with variable presentations and disease severity. Children can present with mild symptoms of fever, cough and shortness of breath, and rapidly progress to severe pneumonia, requiring mechanical ventilation. This population includes children who are younger than one year and older adolescents who have an underlying comorbidity-specifically immunosuppression or prior cardio-respiratory infections. In this review, we discuss the determinants of severe disease among the paediatric patients- primarily asthma, immune-status, obesity and multisystem inflammatory syndrome in children (MIS-C). Asthma and underlying lung pathologies can be a strong predictor (~20% prevalence) for development of severe COVID-19 infection, irrespective of age. However, as compared to asthma, a higher mortality rate was reported in immune-compromised patients. With a weakened immune system, immunosuppressed individuals were 1.55 times and immunocompromised patients 3.29 times more vulnerable to developing severer COVID-19 disease. Similarly, evidence suggests that a BMI of greater than 35 kg/m2 renders individuals more susceptible to developing COVID-19- related complications. This observation is based on the negative impacts obesity has on pulmonary functions and in downplaying the immune system. Furthermore, a possible association of COVID- 19 and MIS-C has been reported by multiple studies across the globe but it needs further studies to strengthen its stance due to the scarcity of data when compared with the other determinants discussed in this article. Authors recommend researchers directing attention on synthesizing the evolving evidence to fill the knowledge void in the paediatric population, which will better enable paediatricians to make informed decisions. [ABSTRACT FROM AUTHOR]

SARS-CoV-2 can vary on a spectrum of an asymptomatic disease process, to a severe stage characterized by a "Cytokine Storm". This phenomenon is a pro-inflammatory state marked by an intricate interplay of a cocktail of chemokines and cytokines. An excessively raised serum levels of cytokines and chemokines can lead to the development of acute respiratory distress syndrome. This article highlights the pathophysiologic mechanisms responsible for creating this cytokine havoc and delves into potential therapeutic interventions. [ABSTRACT FROM AUTHOR]

Background: Prolonged low levels of calcium in blood is a common finding in patients having longstanding liver disease as breakdown, degradation and digestion of calcium is related to stores of Vitamin D in body. Among these patients long-standing low stores of calcium remains ignored because of absence of any symptoms. Objective: To assess the frequency of hypocalcaemia and QT prolongation among patients presenting with chronic liver disease in a tertiary care hospital Methods: It was an observational cross-sectional study. It was carried out in North Medical Ward, Department of Medicine Mayo Hospital Lahore from 15-08-2017 to 15-04-2018. 110 patients fulfilling the selection criteria were enrolled. Blood sample were drawn and examined in the hospital Laboratory for evaluation of calcium levels. If levels were <8.8mg/dL, then hypocalcaemia was labeled. ECG was done to assess QT interval. If QT>460ms, then QT prolongation was labeled. All data was noted on proforma. Data was analyzed using SPSS version 20. Results: The mean age of patients was 46.45±8.67years. There were 44(40%) males and 66(60%) females. The mean BMI of patients was 22.73±4.25kg/m2. The mean duration of CLD was 7.09±3.42years. The mean calcium level of patients was 7.70±1.48mg/dl. In this study, 73(66.4%) patients had hypocalcaemia while 29(26.4%) patients had prolonged QT. The hypocalcaemia causing QT prolongation was found in 24(21.8%) patients. Conclusion: As far as current study is concerned low serum calcium levels are reason for remarkable QT prolongation and this is a grave situation. Due to absence of any symptoms or adverse reactions this condition goes on without coming into notice. But as far as its consequences are concerned it can become a reason for ventricular arrhythmias and remarkably can play a role in increased death rate of affected individuals. So we should try our best to identify extraordinary low levels of calcium and QT prolongation, though presenting without symptoms, if successful in doing so low levels of calcium and prolonged QT interval could be corrected at initial stages and this will directly decrease both morbidity and mortality. [ABSTRACT FROM AUTHOR]

Background: Non-alcoholic fatty liver disease (NAFLD) is considered a risk factor for chronic kidney disease, endocrinopathies, cardiovascular disease (CVD), cerebrovascular disease and osteoporosis. Many prospective follow-up studies demonstrated cardiovascular mortality as an important cause of death in these patients. However, the exact relationship between ALT and CVD especially LVH is undetermined. Objective: The objective of this study was to determine the correlation between raised ALT levels and left ventricular mass (LVM) in NAFLD patients. Methods: In this cross sectional analytical study, 115 patients (both male and female) were selected through non-probability purposive sampling technique after meeting inclusion and exclusion criteria. These patients, aged 20-60 years, were diagnosed cases of NAFLD with transaminitis (ALT >40 unit/L). Venous samples were collected for ALT, viral serology and fasting lipid profile. All the patients underwent ultrasound abdomen and echocardiography for LVM. Results: Mean age of patients was 44.63±1.03 while gender distribution showed 55(47.8%) male and 60(52.2%) female patients with a mean body mass index (BMI) of 26.75±5.048. Mean ALT level was 56.68±9.08 and mean LVM was 190.60±14.23 grams. Correlation coefficient for ALT and LVM was 0.571 which showed moderate correlation between these two parameters. A positive moderate correlation existed between ALT and LVM after stratifying the data according to age, gender and BMI. Conclusion: Elevated ALT levels in NAFLD patients can serve as a screening tool for cardiovascular risk assessment. Whether there is a temporal relationship between transaminitis and an increased risk of cardiovascular events needs further statistical evidence. [ABSTRACT FROM AUTHOR]

Objectives: Hiatus Hernia is one of the leading gastrointestinal problems in Pakistan. Despite the diagnostic challenges, obesity and increasing age are considered significant predictors of hiatus hernia. The study was conducted to establish the association between body mass index (BMI) and hiatus hernia and assess the predictive value of BMI in these patients. Methods: During this descriptive case series 372 patients, presenting with GERD, underwent endoscopy using Olympus CLV-260 series gastroscope and findings were observed for hiatus hernia, grades of gastroesophageal flap valve (GEFV) according to Hill classification and stages of esophagitis according to Savary-Miller classification. BMI was calculated. Chi square test of independence for association between BMI & GEFV and a series of logistic regression analyses for predictive value of BMI were carried out during data analysis. Results: The mean age of the patients was 48 years (SD=14.2). Normal BMI was most prevalent (36.3%) while grade II and III GEFV were the most common findings in 29.8% and 28.5% patients respectively. A chi square test of independence established that the association between BMI & GEFV was significant (p<.01) but no significant association was found between BMI and esophagitis (p=. 14). A series of logistic regression analyses showed that BMI was not a significant predictor of hiatus hernia though age and gender were significant predictors. Conclusion: BMI is not a significant predictor of hiatus hernia, grades of GEFV or esophagitis. However, further studies need to be conducted to establish stronger predictors for hiatus hernia and esophagitis. [ABSTRACT FROM AUTHOR]

Objective: To compare Rifaximin versus neomycin in chronic liver disease (CLD) patients presenting with hepatic Encephalopathy. Methodology: This Randomized controlled trial was conducted at North Medical Ward, King Edward Medical University/Mayo Hospital Lahore from June to December 2013. Total 100 patients of CLD with Hepatic Encephalopathy were included through non-probability, purposive sampling and were named group A & B by random division. In Group A, patients received conventional Antibiotic Neomycin 3000mg 6-hourly daily while in Group B; patients received Rifaximin 600mg 12-hourly daily orally for 21 days. Blood Ammonia levels of both groups after 21 days treatment were analyzed by the software SPSS version 16. Results: The mean age of patients was 54.23±13.70 years with54 (54%) male and 46 (46%) females. Out of 54 male patients, 28 (52%) were randomized to Rifaximin and 26 (48%) were randomized to Neomycin. Similarly, out of 46 female patients, 22 (48%) were randomized to Rifaximin and 24 (52%) were randomized to Neomycin. The serum Ammonia level after treatment with Rifaximin was 58.00 (14-117) g/dl whereas with Neomycin was 87.00(38-381) g/dl. Significant difference was found between both groups (pvalue< 0.0001). Conclusion: Rifaximin is a better treatment option in CLD patients with Hepatic Encephalopathy as compared to conventional Neomycin. [ABSTRACT FROM AUTHOR]

Introduction: Liver cirrhosis is the consequence of hepato-cellular injury that leads to both fibrosis and nodular regeneration in the liver. It is the most common cause of portal hypertension and its morbidity and mortality is higher in our country. Objective: To compare the efficacy of different doses of carvedilol and propranolol for treatment of portal hypertension in patients of liver cirrhosis. This randomized clinical trial was conducted in the North Medical Ward, King Edward Medical University, Mayo Hospital, Lahore for 6 months i.e. March 2013 to August 2013. Methods: After ethical approval of the study, 100 confirmed cases of liver cirrhosis with portal hypertension of ages 16 to 85 years with either gender were selected for this study by non-probability purposive sampling. These cases were randomly named as group A (I), A (II) & B (I), B (II). In group A (I) & (II) patients were given propanolol (20mg), Cavedilol (6.25mg) and group B (I) & (II) patients were given propranolol (40mg), carvedilol (12.5mg). Portal hypertension was labeled as portal flow velocity >12cm H O/sec on Doppler 2 ultrasonography. Portal flow velocity (PFV) was measured before and 90 minutes after administration of trial drugs and >20% decrease in portal flow velocity from baseline was considered as efficacy. Results: The mean age of the patients in group A was 48±14.4 years and in group B was 54 ±12.4 years. In group A (I), the mean portal flow velocity at baseline was 22.16±4.28 cm H O/sec and after treatment at 90 2 minutes mean portal velocity was 18.12±4.14 cm H O/sec. In group A (II), the mean portal flow velocity at 2 baseline was 25.16±4.2 and after treatment at 90 minute mean portal velocity was 13.16±2.42. In group B (I), the mean portal flow velocity at baseline was 25.56±3.54 and after treatment at 90 minutes it was 13.96±3.5.In group B (II), the mean portal flow velocity at baseline was 28.44±4.13 and In group B (I) after treatment at 90 minute mean portal velocity was 10.36±2.49. Conclusion: High dose carvedilol was more effective than propranolol as well as low dose of carvedilol in reduction of PFV. [ABSTRACT FROM AUTHOR]

Objectives: Carotid intima-media thickness (CIMT) is one of the subclinical markers for detection of cerebrovascular disease. CIMT can be measured through noninvasive carotid artery Doppler ultrasonography. It has been observed that average CIMT of Non-Alcoholic Fatty Liver Disease (NAFLD) patients are significantly high as compared to non-NAFLD patients which may lead to cerebrovascular complications in these patients. So, this study was conducted to compare CIMT in NAFLD with and without transaminitis. Methods: This was a comparative cross sectional study, conducted in Mayo Hospital. 236 NAFLD patients were included in the study in accordance with a pre-defined inclusion and exclusion criteria. All the patients underwent abdominal ultrasonography for diagnosis of NAFLD & carotid doppler to measure CIMT. Liver function tests were performed in all the patients and results of carotid intimal media thickness CIMT in NAFLD with and without deranged transaminases were compared. Results: Mean age of the patients was 46.56 ± 11.60 years with 117(50%) female and 119(50%) male patients. Except Alkaline phosphates (p-value = 0.008), all other parameters of liver function test {ALT (pvalue= 0.618), AST (p-value=0.551), Albumin (p-value=0.385) & Protein (p-value=0.823)} were statistically similar in patients whose CIMT was >0.8 and <0.8 mm. Among the patients whose CIMT was >0.8, 17(45.9%) patients had deranged liver function test. Similarly among those patients whose CIMT value was <0.8, 95(47.7%) patients had abnormal LFTs. Statistically speaking no significant association was seen between LFTs of patients and CIMT value (> 0.8 & <0.8) p-value= 0.841. Conclusion: It is concluded that there is no significant correlation between CIMT and transaminitis in NAFLD patients. [ABSTRACT FROM AUTHOR]

Objective: To determine knowledge about Ramadan-specific diabetes management among resident doctors (RDs) working on medical floor through pre-post lecture format and to assess effectiveness of targeted educational activity. Methods: This study was conducted in Department of Medicine, King Edward Medical University, Lahore during May 2016. 82 RDs including house officers (HOs) and postgraduate residents (PGRs) working on the medical floor participated in the study. A self-designed 30-item questionnaire based on American Diabetes Association guidelines for management of diabetes during Ramadan was self-administered before and after a lecture on the same topic. Pre and post-scores and improvement after session was calculated for each group of RDs. Mann-Whitney & Wilcoxin signed ranks tests were used to assess differences in pre and post scores and for improvement in knowledge. p-value <0.05 was considered significant. Results: A total of 82 RDs including 44(53.66%) HOs & 38 (46.34%) PGRs participated in the study. At baseline, mean scores were 54.1%(±14.53) for HOs & 69.12%(±12.01) for PGRs (p-value 0.000) with lowest subscores for alarming blood sugar level category for both groups. Significant increase (p-value <0.05) in level of knowledge was seen after the lecture in both groups. HOs showed slightly higher absolute improvement than PGRs (45.05% vs 37.39% respectively). However, the relative improvement was significantly higher for PGRs (46.92%) than for HOs (36.82%) with p-value 0.028. Conclusion: Baseline knowledge of resident doctors regarding management of fasting diabetic patients is suboptimal but can be enhanced through targeted sessions. PGRs are more receptive to educational programs than their junior colleagues. [ABSTRACT FROM AUTHOR]

Objectives: To determine the pulmonary functions of patients with type 1diabetes mellitus.To correlate the pulmonary functions with duration of type 1diabetes mellitus. Material and Methods: This Cross sectional study was conducted at department of medicine, Mayo hospitalLahore during the months of January to June, 2015. Sixty two patients fulfilling the criteria enrolled through non-probability purposive sampling technique. Informed consent taken and demographic detailsnoted. Pulmonary functions were performed by using a spirometer. Pulmonary functionsinclude FEV1, FVC andFEV1/FVC ratio were calculated. Data entered and analyzed through SPSS version 17. Mean and standard deviation were calculated for age, height, weight, BMI, duration of diabetes and FEV1/FVC ratio.The correlation between duration of diabetes and FEV1/FVC ratio was measured by Pearson coefficient. P value< 0.05 was considered as significant. Results: In this study, mean age of the patients was 28.27±6.07 years, male to female ratio was 1.2:1, mean duration of disease in patients was 9.35±3.05 years and mean value of FEV1/FVC ratio of the patients was 86.39±31.19. In this study there was negative correlation between duration of disease and FEV1/FVC ratio of the patients with disease duration less than 10 years i.e. r=-0.048. Conclusion: Our study concluded that no significant correlation between the pulmonary functions and the duration of type 1 diabetes mellitus but positive correlation in patients with disease duration >10 years. [ABSTRACT FROM AUTHOR]

Pakistan has experienced major turbulence in terms of drug pricing over the course of the past two years, with prices jumping as high as 260% of their original. A country with a large majority of population living in low socioeconomic settings, with an out-of-pocket health-care finance system, non-availability of statesponsored healthcare insurance, and this price hike meant that treatment was now a privilege, rather than an essential commodity. However, the government faces serious backlashes from pharmaceutical industrialists when it retorts to appeasing the general public. With a moderation and regulation in drug pricing comes an acute shortage of medicinal availability across the country. Could this be blackmail? Or a genuine need for a price hike to optimize profits from the sale of medicines made from imported chemicals? [ABSTRACT FROM AUTHOR]