Fahad Javaid Siddiqui

Systematic review of outcomes of liver resection for early hepatocellular carcinoma within the Milan criteria

Long‐term overall survival after liver resection in patients with hepatocellular carcinoma (HCC) within the Milan criteria has been reported to improve in recent years. This study systematically reviewed the outcomes of surgical resection for HCC in patients with good liver function and meeting the Milan criteria for early HCC, published in the past 10 years.

Cost‐effectiveness analysis of liver resection versus transplantation for early hepatocellular carcinoma within the Milan criteria

Both liver resection (LR) and cadaveric liver transplantation (CLT) are potentially curative treatments for patients with hepatocellular carcinoma (HCC) within the Milan criteria and with adequate liver function. Adopting either as a first‐line therapy carries major cost and resource implications. The objective of this study was to estimate the relative cost‐effectiveness of LR against CLT for patients with HCC within the Milan criteria using a decision analytic model. A Markov cohort model was developed to simulate a cohort of patients aged 55 years with HCC within the Milan criteria and Child‐Pugh A/B cirrhosis, undergoing LR or CLT, and followed up over their remaining life expectancy. Analysis was performed in different geographical cost settings: the USA, Switzerland and Singapore. Transition probabilities were obtained from systematic literature reviews, supplemented by databases from Singapore and the Organ Procurement and Transplantation Network (USA). Utility and cost data were obtained from open sources. LR produced 3.9 quality‐adjusted life years (QALYs) while CLT had an additional 1.4 QALYs. The incremental cost‐effectiveness ratio (ICER) of CLT versus LR ranged from

Frequency of isolation of various subtypes and antimicrobial resistance of Shigella from urban slums of Karachi, Pakistan

111,821/QALY in Singapore to

Efficacy and Safety of MLC601 (NeuroAiD®), a Traditional Chinese Medicine, in Poststroke Recovery: A Systematic Review

156,300/QALY in Switzerland, and was above thresholds for cost‐effectiveness in all three countries. Sensitivity analysis revealed that CLT‐related 5‐year cumulative survival, one‐time cost of CLT, and post‐LR 5‐year cumulative recurrence rates were the most sensitive parameters in all cost scenarios. ICERs were reduced below threshold when CLT‐related 5‐year cumulative survival exceeded 84.9% and 87.6% in Singapore and the USA, respectively. For Switzerland, the ICER remained above the cost‐effectiveness threshold regardless of the variations. Conclusion: In patients with HCC within the Milan criteria and Child‐Pugh A/B cirrhosis, LR is more cost‐effective than CLT across three different costing scenarios: the USA, Switzerland, Singapore. (Hepatology 2015;61:227–237)

A randomised controlled trial evaluating the impact of targeted vitamin D supplementation on endothelial function in type 2 diabetes mellitus: The DIMENSION trial

OBJECTIVES Shigellosis remains a major public health problem in developing countries. Antimicrobial resistance has complicated the empirical treatment. Knowledge of serotypes is crucial in vaccine development, as cross-protection between various serotypes is limited. Therefore we conducted a prospective study to determine the frequency of isolation of Shigella serotypes and antimicrobial resistance. METHODS Stool samples from 8155 individuals, collected through a surveillance study conducted in four slums of Karachi from January 2002 to March 2004, were cultured. RESULTS Shigella was isolated in 394 (4.8%) of 8155 patients presenting with diarrhea. Two hundred and forty-two (62%) isolates were Shigella flexneri, 72 (18%) were Shigella sonnei, 43 (11%) were Shigella boydii, and 37 (9%) were Shigella dysenteriae. Thirteen S. flexneri serotypes were identified, of which the most frequent were 2a (38), 6 (37), and 1b (25), followed by 2b (23). Only 22 (5.6%) Shigella isolates were found to be pan-susceptible. Large proportions of isolates were resistant to co-trimoxazole (89% S. flexneri, 81% S. dysenteriae, 80% S. sonnei, and 56% S. boydii) and ampicillin (87% S. flexneri, 68% S. dysenteriae, 35% S. boydii, and 4% S. sonnei). CONCLUSIONS Concurrent circulation of multiple strains with high resistance is worrying and mandates surveillance at the national level to facilitate the control of shigellosis.

Modifiable Factors Associated With Survival After Out-of-Hospital Cardiac Arrest in the Pan-Asian Resuscitation Outcomes Study

Background: Subsequent to a pooled analysis of 2 trials, several more studies have been published assessing the benefit of MLC601 in stroke patients. Hence, it is timely to conduct an updated meta-analysis to frame the interpretation of the results of an ongoing large multicenter, randomized, double-blind, placebo-controlled study. Therefore, we conducted a systematic review of the efficacy of MLC601 in improving the recovery of stroke patients. Methods: PubMed® and the Cochrane Library® databases were searched for trials evaluating MLC601 in stroke patients. Primary outcome was functional independence, assessed by the Barthel Index or the Diagnostic Therapeutic Effects of Apoplexy scoring system, item 8. Secondary outcomes were improvement in functional independence scores, motor recovery, reduction in visual field defect and increase in cerebral blood flow. Two authors performed the article selection, appraisal and data extraction while resolving differences through discussion or consulting a third author. Data were analyzed in RevMan5®. Meta-analysis was conducted using a random effects model. Results: This review included 6 studies with overall low risk of bias but some clinical heterogeneity. MLC601 increased the chances of achieving functional independence after stroke compared to control treatments (risk ratio, 2.35; 95% CI, 1.31-4.23). No deaths and 4 serious adverse events were reported in the MLC601 group, although detail was sparse with inconsistent reporting. Conclusions: There is evidence that MLC601 as an add-on to standard treatment could be effective in improving functional independence and motor recovery and is safe for patients with primarily nonacute stable stroke.

Uncontrolled diabetes mellitus: Prevalence and risk factors among people with type 2 diabetes mellitus in an Urban District of Karachi, Pakistan.

We sought to determine if vitamin D supplementation, to target 25(OH)D concentrations of 30–40 ng/mL, improves endothelial function in Singapore’s multi-ethnic type 2 diabetes mellitus population. We randomised 64 type 2 diabetes mellitus patients with hypovitaminosis D to cholecalciferol 4000 International Unit/matching placebo [baseline 25(OH)D < 20 ng/mL] or cholecalciferol 2000 International Unit/matching placebo [baseline 25(OH)D: 20–30 ng/mL] daily for 16 weeks with a down titration at 8 weeks if 25(OH)D > 30 ng/mL. Endothelial function was assessed by peripheral tonometry (reactive hyperaemia index–endothelial peripheral arterial tonometry) and vascular biomarkers: E-selectin, von-Willebrand factor and high-sensitivity C-reactive protein. We compared the change from baseline parameters in the two groups using Student’s t-test or Kruskal–Wallis test. A log-normal multivariate regression analysis was used to adjust for relevant baseline variables. The median reactive hyperaemia index in the vitamin D group increased from 0.65 (interquartile range: 0.42) to 0.73 (interquartile range: 0.36), whereas it decreased from 0.73 (interquartile range: 0.65) to 0.65 (interquartile range: 0.38) (p = 0.02) in the placebo group. After adjustment for baseline variables, the change was not statistically significant for reactive hyperaemia index (p = 0.07) and for other vascular biomarkers (p > 0.05). Targeted vitamin D supplementation for 16 weeks resulted in a small but non-significant improvement in endothelial function in a type 2 diabetes mellitus cohort.

Is urgent coronary artery bypass grafting a safe option in octogenarians? A developing country perspective.

Study objective The study aims to identify modifiable factors associated with improved out‐of‐hospital cardiac arrest survival among communities in the Pan‐Asian Resuscitation Outcomes Study (PAROS) Clinical Research Network: Japan, Singapore, South Korea, Malaysia, Taiwan, Thailand, and the United Arab Emirates (Dubai). Methods This was a prospective, international, multicenter cohort study of out‐of‐hospital cardiac arrest in the Asia‐Pacific. Arrests caused by trauma, patients who were not transported by emergency medical services (EMS), and pediatric out‐of‐hospital cardiac arrest cases (<18 years) were excluded from the analysis. Modifiable out‐of‐hospital factors (bystander cardiopulmonary resuscitation [CPR] and defibrillation, out‐of‐hospital defibrillation, advanced airway, and drug administration) were compared for all out‐of‐hospital cardiac arrest patients presenting to EMS and participating hospitals. The primary outcome measure was survival to hospital discharge or 30 days of hospitalization (if not discharged). We used multilevel mixed‐effects logistic regression models to identify factors independently associated with out‐of‐hospital cardiac arrest survival, accounting for clustering within each community. Results Of 66,780 out‐of‐hospital cardiac arrest cases reported between January 2009 and December 2012, we included 56,765 in the analysis. In the adjusted model, modifiable factors associated with improved out‐of‐hospital cardiac arrest outcomes included bystander CPR (odds ratio [OR] 1.43; 95% confidence interval [CI] 1.31 to 1.55), response time less than or equal to 8 minutes (OR 1.52; 95% CI 1.35 to 1.71), and out‐of‐hospital defibrillation (OR 2.31; 95% CI 1.96 to 2.72). Out‐of‐hospital advanced airway (OR 0.73; 95% CI 0.67 to 0.80) was negatively associated with out‐of‐hospital cardiac arrest survival. Conclusion In the PAROS cohort, bystander CPR, out‐of‐hospital defibrillation, and response time less than or equal to 8 minutes were positively associated with increased out‐of‐hospital cardiac arrest survival, whereas out‐of‐hospital advanced airway was associated with decreased out‐of‐hospital cardiac arrest survival. Developing EMS systems should focus on basic life support interventions in out‐of‐hospital cardiac arrest resuscitation.

Coronary artery bypass surgery in the elderly: experience of tertiary care hospital.

AIMS This study aimed to explore the prevalence of, and factors associated with, uncontrolled diabetes mellitus (UDM) in a community setting in Pakistan. METHODOLOGY A single-center, cross-sectional study, conducted in a community-based specialized care center (SCC) for diabetes in District Central Karachi, in 2003, registered 452 type 2 DM participants, tested for HbA1c and interviewed face-to-face for other information. Logistic regression analysis was conducted to identify factors associated with UDM. RESULTS Prevalence of UDM among diabetes patients was found to be 38.9% (95% CI: 34.4-43.4%). Multivariable logistic regression model analysis indicated that age <50 years (OR: 1.9; 95% CI: 1.2-2.9), being diagnosed in a hospital (vs. a clinic) (OR: 1.8; 95% CI: 1.1-2.8), diabetes information from a doctor or nurse only (vs. multiple sources) (OR: 1.8; 95% CI: 1.2-2.9), higher monthly treatment cost (OR: 1.3; 95% CI: 1.1-1.6; for every extra 500 PKR), and higher consumption of tea (OR: 1.5; 95% CI: 1.0-2.2; for every 2 extra cups) were independently associated with UDM. CONCLUSION The prevalence of UDM was approximately 39% among persons with type 2 diabetes visiting a community based SCC for diabetes. Modifiable risk factors such as sources of diabetes information and black tea consumption can be considered as potential targets of interventions in Karachi.

Effect of known history of heart disease on survival outcomes after out-of-hospital cardiac arrests

Life expectancy has increased during recent decades leading to a growing number of older population. The objective of this study was to evaluate the outcomes of coronary artery bypass grafting (CABG) in octogenarians and to compare the outcomes of the emergent CABG with elective surgery. Prospectively collected data from 31 consecutive octogenarian patients who underwent CABG between 1 January 2006 and 31 December 2008 were analyzed. Main outcomes of interest included mortality, length of ICU stay, length of hospital stay, priority of surgery, postoperative complications and functional status on follow-up. Fifteen patients were operated on an urgent basis. Patients operated on an urgent basis were in NYHA class III or IV preoperatively (P=0.0016). There were no significant differences in operative and postoperative variables. There were three in-hospital deaths and 23 patients (82%) were alive on follow-up and 19 were in functional class I or II. Quality of life assessment was performed using Seattle Angina Questionnaire and patients reported remarkable improvement in quality of life. Overall, 90% patients were not or slightly disabled in their daily activity. Satisfaction with their current quality of life was reported by 95% of patients. CABG may be performed in octogenarians with remarkable outcomes and improvement in quality of life.