BACKGROUND: The CHA2DS2-VASc score guides anticoagulation therapy for stroke prevention in non-valvular atrial fibrillation (NVAF) patients. A previous meta-analysis showed a moderate discrimination ability of CHA2DS2-VASc score to detect stroke in patients with & without NVAF. In the presence of newly published data over the past three years, there is a need to recalibrate the existing statistical evidence. METHODS: A comprehensive literature search was conducted across PubMed, Embase, CENTRAL (the Cochrane Library), & Google Scholar from inception till May 2023. All studies evaluating the discrimination ability of the CHA2DS2-VASc score, as measured by the C statistic, for short (<2 years), intermediate (2-5 years), & long-term (>5 years) follow-ups in patients with & without NVAF were included. The generic inverse variance weighted random effects method was used to pool C-statistic & corresponding standard errors (SEs) from each study. RESULTS: A total of 28 studies with a population of 639450 patients were included. Seventeen studies (n=500555) reported the discrimination ability of CHA2DS2-VASc score for NVAF patients, & 11 studies (n=138895) for patients without NVAF. The summary C statistic for short-term follow up was 0.66 (0.62-0.70) for NVAF subgroup. For mid-term follow-up, the pooled C statistic was 0.65 (0.63-0.67), while being 0.63 (0.60-0.66) & 0.68 (0.66-0.70) for the subgroup with NVAF & without NVAF respectively. The CHA2DS2-VASC score showed moderate discrimination [0.66 (0.62-0.70)] at long-term follow up (NVAF [0.58 (0.55-0.61)]; without NVAF [0.67 (0.64-0.70]). CONCLUSION: CHA2DS2-VASc score has moderate & similar discrimination ability for detecting stroke in both NVAF & non-NVAF patients.
Anorectal malformations and jejunoileal atresias are common causes of intestinal obstruction in neonates. Both have their own set of associated anomalies but it is extremely rare for the two to co-occur in the same patient. In this case report, we detail and describe this unusual incidence in a three-day-old neonate who was provisionally diagnosed with a case of simple imperforate anus. Per-op findings showed a type 4 Ileal atresia and an ileostomy was then created. Our experience stresses the importance of timely antenatal diagnosis and the presence of a high index of suspicion when encountering such patients. Both factors are key and crucial in determining the outcome and post-op course of the patient.
Aims Among various factors that determine an individual's self-esteem, parenting styles play a very significant role in this regard. Certain parenting styles that are practiced around the globe include authoritarian, authoritative and permissive parenting. The study aimed to investigate the co-relation between parenting styles and self-esteem among medical students. Methods A cross-sectional study was conducted among the MBBS students of Rawalpindi Medical University, Rawalpindi from December 2020 to March 2021. 255 students took part in this study. An online survey was prepared by using Parental Authority Questionnaire-Short Version and Rosenberg Self-Esteem Scale and students were asked to fill it. Simple Random sampling technique was applied. SPSS version 26.0 was used to enter and analyze data. Pearson Correlation, Logistic regression and Hierarchal regression analysis were applied. Results Out of 230, 60% of the sample population experienced authoritative, 29% experienced authoritarian whereas 11% experienced permissive style of parenting. Authoritative (r = 0.283, p < 0.001) and authoritarian (r = -0.227, p < 0.001) parenting styles were significantly correlated with self-esteem. Authoritarian parenting style (AOR = 2.20, 95% CI: 1.17, 4.14) was significantly associated with self-esteem of the participants compared to authoritative parenting style. Conclusion Results indicated that authoritative parenting was only parenting style that correlates positively with self-esteem which suggest authoritative parenting is the optimum parenting style in Pakistani culture.
Dear Editor, Poliomyelitis is an acute viral disease caused by a single-stranded RNA poliovirus. This virus belongs to the family Picornaviridae and to the Enterovirus genus, which is again classified into three serotypes (types 1, 2, and 3). The virus affects mainly children under the age of 5 years. This virus invades the central nervous system and leads to paralysis, even causing death. It is transmitted via the fecal-oral route, especially in contaminated water and food. Being an ancient disease, still, no treatment is available for this lethal virus. The only possibility is its prevention through vaccination1. The WHO Region of South East Asia was declared a polio-free zone in March 2014. This accomplishment has saved the lives of millions of children, as more than 80% of the world’s population now lives in polio-free regions1. However, some countries, namely Pakistan, Afghanistan, and Nigeria, fall on the darker side of the moon. Pakistan and Afghanistan together have predominately contributed 85% of the current world’s polio cases. Looking at the curves since the pandemic, it has been surging at its peak. Wild Poliovirus (WPV) cases were 84 and 135 cases of Circulating Vaccine derived Poliovirus (cVDPV2) during 2020, then dipped to only one WPV case and cVDPV2 to eight cases in 2021, and this year already 17 cases of WPV have been noted. These cases are solely reported from the Khyber Pakhtunkhwa Province of Pakistan, with WPV of 15 cases from North Waziristan and two cases from Lakki Marwat district2. Compared to previous years, where cases were more scattered in different provinces, including Punjab, Sindh, and Balochistan, to date, cases are only contained in Khyber Pakhtunkhwa2. Owing to this surge in cases, the Centers for Disease Control and Prevention has announced an alert level 2 for travelers hailing from Pakistan. A single lifetime booster dose of inactivated polio vaccine has been recommended for those who have received a routine polio vaccine and a full series of vaccinations for unvaccinated ones. Pakistan, a generally warm country, is plagued by poor socioeconomic and law and order situations. The abundance of slums and poor sanitation, even in rather developed parts of the city, is fertile soil for polio infection. The strain of WPV was even found in the water supply of Gaddap and other parts of Pakistan3. Significant environmental challenges, for example, the recent monsoon flooding of Southern Punjab, Central Sindh, parts of Balochistan, and insurgency in the tribal belt neighboring Afghanistan, have displaced the population in temporary overcrowded settlements recently, and in the past. A misconception that taking the vaccine makes the baby sick, and that it contains haram materials, such as pig by-products, has further halted its use3,4. This makes vaccination in areas outside the writ of the government highly difficult and insecure. Despite polio being a heavily funded program in the west, the grassroots infrastructure faces difficulties due to continuously changing political and law and order situations5. With the ongoing fourth wave of coronavirus disease-2019, more than 1.5 million people have been affected, and the resources and infrastructure are still lacking in many places6. The devastation has made the country fragile and futile, and any infectious outbreak could lead to a total health crisis. Adding polio to the list can prove to be the worst nightmare for Pakistan. Adding to this, the monkeypox outbreak has made fear among the people, and already south East Asian nations are lacking much preparedness7. To overcome this threat, health authorities must ensure universal access to proper sanitation and clean water. Misbelieves and misconceptions about polio vaccination among community members should be addressed by tailored propaganda specific to the needs of the local community; finding local public health officials for high-risk areas and providing them with epidemiological training is a pivotal strategy in aiding mass polio vaccination. Intervention of multiple stakeholders, both political and religious, is required at different levels of the health system. Morals of the polio workers should be kept high by consistent wages, promotion opportunities, and job and life security. Integration of polio activities with other preventive health services, especially child health, nutrition, and routine immunization, may address community resistance and increase program reach. Augmenting the healthcare system to replace oral polio vaccine completely with parental polio vaccine as in tropical countries like Pakistan and India, oral polio vaccine has decreased per dose efficacy8. Furthermore, the concept of immunizing 80–85% of the population with herd immunity seems practicable in this situation. Along with the rest of the world, Pakistan should also focus on strategies to eradicate this virus once and for all. Ethical approval Not required. Patient consent Not required. Sources of funding None. Author contribution A.B. Shrestha: conceptualization. All authors were involved in various aspects of writing and editing of the manuscript. Conflicts of interest disclosure The authors declare no conflict of interest. Research registration unique identifying number (UIN) Not required. Guarantor Pashupati Pokharel Data availability All data are presented within the manuscript. Provenance and peer review Not commissioned, externally peer-reviewed.
Introduction: Cardiovascular(CV) disease is one of the leading cause of death in females in USA out of which 44% suffer. According to the latest CDC guidelines, 13.4 % are suffering from the infertility.It includes the most common conditions including endometriosis, poly cystic ovarian syndrome. Studies shows a mutlitude of factors including genetic abnormalities, hormonal imbalances like chronic anovulation or increased androgens predispose the women to subsequent health conditions.Literature review suggests that long term cv risks are less understood in the infertile women. Aim: The aim of the study is to identify the CV outcomes including coronary heart disease(CAD) , acute coronary syndrome(ACS), and heart failure in women with underlying infertility condition. Methods: The NIS 2020 was queried for the female adult population (age>18 years) with a primary or secondary diagnosis of infertility. Prevalence of CV risk factors were compared between females with and without infertility problem. The association of cardiac diagnoses including CAD, ACS and was analysed. Multivariate regression analysis was performed taking all-cause mortality as a primary outcome. Results: A total of 3870 adult patients with a primary or secondary diagnosis of infertility were identified and the mean age was 36 years.In adult population without infertility condition, patients with an underlying infertility were found to have an increased association with DM (48.16%vs 23.11%; P<0.001),HLD(56.14% vs 30.72%; P<0.001),hypothyroid(17.47% vs 10.47%; P<0.001),metabolic syndrome(0.23% vs 0.16%; P<0.001) while we found decreased association in tobacco abuse( 14.18% vs 17.12%; P<0.001),HTN(1.47% vs 37.95%; P<0.001). The prevalence of CAD(46.64% vs 12.59%; P<0.001), ACS(46.64% vs 12.59%; P<0.001) was also found to be significantly higher in women with infertility. In the female subpopulation with infertility, approximately 5.91% of patients died. However, the odds of mortality was significantly increased if patients had underlying ACS (OR- 2.77; C.I.-2.72 -2.87; P<0.001) or CAD (OR- 3.97; C.I.: -3.93-4.02; p<0.001). There was no statistically significant increased mortality with HF( OR:1). Conclusion: In our study, infertility in women was associated with higher prevalence of CAD and ACS. The odds of mortality also increased if women with infertility condition if they developed ACS or CAD. Further clinical research and studies are warranted to understand its CV outcomes.
To investigate the associations of alkaline phosphatase (ALP) variability measures with adverse cardiovascular outcomes in type 2 diabetes mellitus.
Method
This population-based cohort study included patients with type 2 diabetes mellitus who presented to ambulatory, outpatient and inpatient facilities managed by the public sector in Hong Kong between January 1st, 2009 to December 31st, 2009 with last follow-up of December 31st, 2019. Comprehensive clinical and medical data including demographics, past comorbidities, medications, and laboratory examinations of complete blood, lipid/glycemic profile and their variability were collected. ALP and its variability measures were extracted. Univariable and multivariable Cox regression was used to identify the associations of alkaline phosphatase variability with new onset heart failure, cardiovascular and all-cause mortality.
Results
The study cohort included 14289 patients (52.52% males, mean age: 74.55 years old [standard deviation (SD): 12.7]) with a mean follow up of 2513 days [interquartile range (IQR): 1151-4173]). Univariable Cox regression found that high ALP measured at baseline and ALP variability predicted new onset heart failure, cardiovascular and all-cause mortality (p<0.01). Amongst the measures of ALP variability, the hazard ratio (HR) of coefficient of variation (CV) was markedly raised (new onset heart failure: HR=2.73, 95% confidence interval [CI]= [1.71-4.37], p<0.0001; all-cause mortality: HR=5.83, 95% CI= [5.01-6.79], p<0.0001; cardiovascular mortality: HR=4.81, 95% CI= [3.36-6.88], p<0.0001).
Conclusions
Higher ALP level and ALP variability are associated with increased risks of new onset heart failure cardiovascular mortality and all-cause mortality in type 2 diabetes mellitus.
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