Objectives: Guidelines recommend use of norepinephrine as the first-line treatment for fluid-refractory septic shock and if septic shock persists vasopressin may be initiated. Since there are limited data from low middle-income countries with high disease burden of sepsis, we aimed to compare the outcomes of using vasopressin adjunct to norepinephrine in comparison with norepinephrine alone. Design: Retrospective cohort study. Setting: Aga Khan University Hospital, Karachi, Pakistan. Patients: Six-hundred fifty-three patients diagnosed with septic shock from January 2019 to December 2019, with 498 given norepinephrine only and 155 given norepinephrine-vasopressin combination. Interventions: None. Measurements and Main Results: Primary outcome was in-hospital mortality. Secondary outcomes were duration of vasopressor used, length of hospital stay, length of ICU stay, and days on ventilatory support. After adjustment by multivariable logistic regression, it was found that mortality was not significantly associated with the norepinephrine-vasopressin combination (adjusted odds ratio, 0.633 [95% CI, 0.370–1.081]). However, Sequential Organ Failure Assessment score at admission (1.100 [1.014–1.193]), lactate at admission (1.167 [1.109–1.227]), duration of vasopressor used (1.481 [1.316–1.666]), and level of care (3.025 [1.682–5.441]) were found to be independently associated with the adjunct usage of norepinephrine and vasopressin. Conclusions: The use of norepinephrine-vasopressin combination has remained debatable in literature. Our study showed that although there was no difference in mortality between the two groups, admission Sequential Organ Failure Assessment scores and admission lactate levels were found to be significantly higher in the norepinephrine-vasopressin group. Hence, physicians from Pakistan used the norepinephrine-vasopressin combination in resistant septic shock patients who were sicker to begin with. Furthermore, duration of vasopressor therapy and ICU admission were also significantly higher in the combination group. Considering the recent hyperinflation of vasopressors costs and that most healthcare expenditure for patients in Pakistan is out-of-pocket, this can consequently lead to unwarranted financial burden for patients and their families.
AimsDepression is highly prevalent in children and adolescents in Pakistan, yet, factors affecting depression have not been widely studied. This study aims to assess the demographic and clinical characteristics of depression in children and adolescents and identify associations between parental marital status and confounding factors for depression.MethodA descriptive retrospective study was undertaken at the Aga Khan University Hospital in Karachi, Pakistan. Patient records of children and adolescents (aged under 18 years), presenting to the psychiatry clinic with depression from 2015-2019 were reviewed. The diagnosis of clinical depression was made based on clinical assessment according to international guidelines. Patients whose medical records had missing information were excluded. Data were analysed using IBM SPSS Statistics for Windows, version 23.0 (IBM Corp., Armonk, N.Y., USA). Continuous data are presented as mean +/- standard deviation, whereas categorical data are presented as percentages (%). Pearson Chi-square test of association has been used to assess the association between parental factors and confounding factors. In instances where Pearson's Chi-square test could not be applied, Fisher's exact test is used instead. Associations at p <0.05 (95% confidence limit) are considered statistically significant.ResultA total of 133 participants were included, of which 78 (58.6%) were female, and 55 (41.4%) were male, with a mean age of 15.5 +/- 2.4 (Range: Ages 4–18). The population had a 50.4% prevalence of suicidal ideation, 21.1% of self-harm, 15% of substance abuse and 14.3% of suicide attempts. Academic stress (54.9%), inter-parental conflict (30.1%) and child abuse (29.3%) were the most common confounding factors reported. Other confounding factors include a family history of depression (20.3%), experience of bullying (16.5%) witnessing domestic violence (16.5%), substance abuse (15.0%) and experiencing sexual abuse (6.0%). There is a statistically significant association between children having parents with non-intact marriages and experiencing sexual abuse (p < 0.001, Odds Ratio (OR) = 21.48), having a family history of depression (p < 0.001, OR = 7.04), child abuse (OR = 3.78). Children of non-traditional (not living with both parents) families were more likely to witness domestic violence (p < 0.001, OR = 4.28), have a family history of depression (p < 0.001, OR = 3.44), abuse substances (OR = 3.20) and experience child abuse (OR = 2.48).ConclusionThis study identifies factors that may put children at an increased risk of developing depression and performing high-risk behaviours. The findings can help develop better screening programs and counselling for children and adolescents, allowing prevention and ensuring early diagnosis and care.
We report the case of a 60‐year‐old woman, presenting with left vocal cord paralysis (VCP). Diagnostic evaluation revealed sarcoidosis to be the underlying pathology. Computed tomography (CT) scans exhibited enlarged subcarinal, pretracheal, and prevascular lymph nodes as the possible mechanism of left VCP through compression of the left recurrent laryngeal nerve. Initial treatment with oral prednisolone and azathioprine led to remission of symptoms; however, tapering of dosage led to relapse of cough without any signs of VCP. The dosage of prednisolone was further boosted, leading to complete remission. A review of literature reveals 20 cases have been reported to date, with all but one involving the left vocal cord. This is the first reported case, with a relapse of the disease without a relapse of VCP, indicating the rarity of sarcoidosis‐associated VCP.
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