08 34 Proceedings S.Z.M.C. Vol: 37(2): pp. 34-38, 2023. PSZMC-894-37-2-2023 Mental Health Impact On Patients of ESRD On Renal Replacement Therapy: A Cross Sectional Survey Using Beck and Deck Inventory 1Rashid Ali, 1Sardar Sabeel, 2Danial Zahoor, 1Bushra Arif, 1Adnan Khan, 1Saqib Malik 1Department of Medicine, Ayub Teaching Hospital, Abbottabad. 2Deprtment of Surgery, JPMC, Karachi. ABSTRACT Introduction: Chronic kidney disease (CKD) affects approximately 8 to 16% of population worldwide. With increasing incidence of diabetes mellitus and an aging population, CKD is putting an enormous burden on health care resources. The prevalence of CKD in Pakistan has been estimated to vary between 5%-12.5%. Depression can be found in 25% to 42% of hemodialysis patients. There are no previous studies done in Pakistan to know the mental health impact in End- stage renal disease (ESRD)patients undergoing dialysis. Aims &Objectives: To assess the mental health impact on patients of ESRD on renal replacement therapy using Beck and Deck inventory in our population. Place and duration of study: Department of Medicine, Ayub Teaching Hospital, Abbottabad from February 2019 to July 2019. Material & Methods: 97 patients were enrolled using non-probability, consecutive sampling. Patients having CKD and on dialysis for 3 months from both genders from ages 15 to 60 years were included in the study. Patients were assessed using DSM-IV/BDI criteria for presence of depression. Data was entered and analyzed using SPSS version 20 Results: Of the 97 patients included in the study 57 (58.8%) were male and 40 (41.2%) were females. The mean age of patients was 45.00 ±14.82 years. The mean length of time since the patients were on dialysis was 20.47 ±22.81 months. Hypertension was the commonest cause of CKD (75.3%). The mean BDI score was 15.25 ±7.46. The number of patients who had no or minimal depression was 40 (41.2%). The number of patients having mild, moderate and severe depre ssion was 57 (58.8%) patients. Single patients were more likely to be normal (77.8%) compared to married individuals (37.5%). Of the patients who were on dialysis for more than 48 months, 75% were normal with no element of depression. Of the patients who were on dialysis for less than a year, 59.6% had depression. This was statistically significant. Conclusion: Depression is more prevalent in ESRD patients on hemodialysis. It is more prevalent than found in other major illnesses and in the general population. It should be recognized earlier so that these patients can be treated, and they can have a better quality of life. Keywords: Depression, ESRD, Dialysis, Chronic Kidney Failure. INTRODUCTION Chronic kidney disease (CKD) is rapidly becoming a global health concern. There has been a steep rise in the number of patients reaching End- stage renal disease (ESRD). CKD affects an approximately 8 to 16% of population worldwide1. CKD, as a cause of death, has climbed from 27thto 18th position in two decades2.This has translated to 82.3% rise in the number of deaths caused by CKD in the last twenty years. This is the third largest increase among the top 25 causes of deaths, paralleled only by AIDS and diabetes3.CKD is an alarming public health priority also because of the fact that the number of ESRD patients on renal replacement therapy is approximately 1.4 million and this number is increasing by 8% annually4. With increasing incidence of diabetes mellitus and an aging population, CKD is putting an enormous burden on health care resources5. In Western countries, the prevalence of CKD varies between 5.8% (Poland) to 14.8% (United States) in the adult population6. However, prevalence of CKD increases in diabetic people, in whom it varies between 34.7 and 45.4% according to different populations7. The prevalence of CKD in Pakistan has been studied very sparsely. It has been estimated to vary between 5% to 12.5% in a review published by Imtiaz S. et al.in 20188. Most of the ESRD patients undergo renal replacement therapy (hemodialysis) in a hospital setting. Although this has increased life expectancy in CKD patients, many studies suggest that these patients often suffer from poor quality of life9,10. 8 Intraoperative Peritoneal Lavage in Peritonitis: Normal Saline vs Metronidazole 1Hira Aslam, 2Muhammad Khurram Jameel, 2Pir Muneeb, 1Aneeqa Nasir Qureshi, 2Fawad Hameed, 3Muhammad Ammar, 2Maham Qazi, 4Abrar ul Hassan Pirzada 1Department of Surgery, Mayo Hospital, KEMU, Lahore 2Department of Surgery, ANMC / Chaudhary Muhammad Akram Hospital, Lahore 3Department of Urology, Chaudhary Muhammad Akram Hospital, Lahore 4Department of Plastic Surgery, ANMC / Chaudhary Muhammad Akram Hospital, Lahore, Pakistan ABSTRACT Introduction: Globally, acute generalized peritonitis ranks among the top surgical emergencies. Different studies have been conducted to show the amplitude of peritonitis worldwide eliciting a huge impact on overall patient morbidity and mortality. Largely peritonitis is caused by a gastrointestinal perforation or anastomotic leak. In peritonitis, anaerobes & gram-negative organisms are mostly responsible for sepsis and morbidity due to the overactive inflammatory cascade by endotoxins which is amenable to timely intervention. Aims & Objectives: The study's aim was to evaluate whether using normal saline or metronidazole solution during intraoperative peritoneal lavage (IOPL), results in a lower rate of postoperative wound infection. Place and Duration of Study: This study was undertaken at the South Surgical Ward, Mayo Hospital Lahore for 6 months from February 2nd, 2021, to August 1st, 2021. Material & Methods: Consecutive sampling strategy followed by a randomized controlled trial were used to induct and provide intervention to 90 patients aged 15-65 years with peritonitis caused by hollow viscus perforation. The patients were subdivided into 2 groups A& B(n=45 each).Two liters of normal saline were used for peritoneal lavage in group A, while two liters of normal saline were combined with 200 mL of metronidazole solution and administered to group B. intraoperatively.Baseline physiological parameters such as age, sex, BMI , intra operative surgical parameters as duration of operation and post-operative course were recorded till discharge. On 10th POD, patients returned to OPD for further monitoring. An infection was diagnosed if the patient had post-operative symptoms such as a high temperature, increased TLC, wound discharge, redness, or pain. Data was entered and analyzed using SPSS version 23. Results: A majority (54.44%) of the patients were young adults. Mean age of 37.33 ± 10.53 years of patients in the metronidazole group was comparable to mean age 40.04 ± 11.96 years in the saline group, difference was not significant (p=0.067). Male/female ratio in Metronidazole and Saline groups were 17/25 and 10/18, respectively. Patients who received intraperitoneal lavage with normal saline were more likely to develop wound infections (17/45) (37.78%), while only 3/45) (6.67% of those who received metronidazole solution did so (p 0.0001). Conclusion: Based on the results of this experiment, using metronidazole solution for intraoperative peritoneal lavage instead of normal saline reduces the occurrence of postoperative wound infection. Keywords: peritonitis, postoperative wound infection, intraoperative peritoneal lavage INTRODUCTION Globally, acute generalized peritonitis ranks among the top surgical emergencies1. It is more common in Third World nations. The prevalence of perforation is low (0.6% - 4.9%) in developed nations but high (33% - 63%) in West Africa2. 554 persons were discovered to have peritonitis in a study that took place over three years in India3. Researchers in Pakistan have conducted studies with similar methods, with one study reporting 650 cases in a just 9 months4. Most cases of peritonitis are caused by a gastrointestinal perforation or anastomotic leak5. In the case of peritonitis, anaerobes and gram- negative organisms are mostly responsible for sepsis and morbidity due to the overactive inflammatory cascade brought on by the release of endotoxins5.Clinical evidence is used to identify peritonitis. Diagnosis can be achieved via upright plain x-ray of the abdomen, USG, or CT scan. This is often done through diagnostic laparoscopy nowadays6.Resuscitation, diagnosis, prompt exploration, treatment of the underlying cause, and extensive surgical peritoneal lavage have always been the cornerstones of peritonitis therapy regimens (IOPL)7,8. Regular IOPL is performed to lessen bacterial contamination and burden. Even though large volumes of normal saline are used in IOPL, the rates of sepsis, wound infection, and mortality remain alarmingly high. Another method 6 1Department of Public Health, Health Services Academy, Islamabad. 2Department of Management Sciences, Riphah Int University, Islamabad. 3Department of Medicine, IHITC, Islamabad. 4Department of Rheumatology, PIMS, Islamabad. 5Department of Medicine, Dow University of Health Sciences, Karachi. 70 1Department of Orthopedics, THQ, Khanewal 2Department of Orthopedics, LGH, Lahore 3Department of Orthopedics, THQ, Ferozwala 4Department of Orthopedics, CMH, Lahore 5Department of Hand & Upper Limb Surgery, CMH, Lahore 6Department of Orthopedics, Al-Rehmat Benevolent Trust 1 1Department of Anatomy, UCMD, University of Lahore, Lahore 2Department of Anatomy, Punjab Medical College, Faisalabad Medical University, Faisalabad 3Department of Medical Education, Pak Red Crescent Medical and Dental College, Lahore p 1Dr. Adnan, 1Saqib Malik 35 Mental Health Impact on Patients of ESRD on Renal Replacement Therapy:A Cross Sectional Survey….. Depression is frequently associated with hemodialysis in CKD patients11. According to the American Psychological Association's Diagnostic and Statistical Manual-V, depression is characterized by low mood, a decreased interest or pleasure in activity, and at least three of seven other co-occurring symptoms present for a period of more than two weeks12. Depression can be found in patients in 25% to 42% of hemodialysis patients13,14. Further, depression frequently goes unrecognized in CKD patients on dialysis and it significantly affects the quality of life in such patients15. There are no previous studies done in Pakistan to know the mental health impact in ESRD patients undergoing dialysis. Therefore, this study was planned to assess the problem in our population. MATERIAL AND METHODS This cross-sectional study was conducted in the Department of Medicine, Ayub Teaching Hospital, Abbottabad from February 2019 to July 2019. IRB Clearance was received vide letter number (884-1) Sample size was calculated to be 97 cases with 95% confidence level, 4% margin of error and taking expected frequency depression in CKD patients on dialysis as 7.8%16.Non-probability, consecutive sampling was used. All patients having ESRD who were on dialysis for 3 months from both genders from ages 15 to 60 years were included in the study. Patients having previous history of depressive illness or mood disorders, antidepressant or antipsychotic use, history of stroke, bed ridden patients or having any malignancy were excluded from the study. After taking consent, patients were assessed using DSM-IV/Beck and Deck Inventory (BDI) criteria for presence of depression. Demographic data was also collected on a proforma. Data was analysed by using SPSS-20. RESULTS A total of 97 patients were included in the study of which 57 (58.8%) were male and 40 (41.2%) were females. The mean age of the patient’s was 45.00 ±14.82 years and the age ranged between 11 years and 80 years. The mean length of time since the patients were on dialysis was 20.47 ± 20.0 months. The mean time since the patients were diagnosed as having ESRD was 24.20 ± 24.08 months. Hypertension was the commonest cause of CKD (75.3%). Most of the patients, 93 (96%), were on twice weekly dialysis. The average time the patients travelled to the hospital for dialysis was 2.35 ±1.91 hours. Only 2% of patients were either Hepatitis B or C positive before the initiation of dialysis. 44.3% patients contracted Hepatitis C after being put on dialysis. No patient contracted Hepatitis B after starting dialysis. 85.6% patients did not associate any adverse outcomes with previous dialysis. The mean BDI score was 15.25 ±7.46. The number of patients who had no or minimal depression was 40 (41.2%). The number of patients having mild, moderate and severe depression was 57 (58.8%) patients. (Table-1). Results show significant association between adverse outcome during previous dialysis and the level of depression. Patients who did not experience any adverse outcome in previous sessions of dialysis were more likely to be normal (30%) compared to those that had an adverse outcome (7%). Marital status was also associated with a significant difference in the level of depression. Single patients were more likely to be normal (77.8%) compared to married individuals (37.5%). Mean BDI scores were 9.5 in single individuals and 15.8 in married individuals. This association was statistically significant, indicating that married individuals were more likely to be depressed. There was no significant difference in mean BDI scores in educated and uneducated individuals. Results showed significant association between total duration the patient was on dialysis and the level of depression. Of the patients who were on dialysis for more than 48 months, 75% were normal with no element of depression. Of the patients who were on dialysis for less than a year, 59.6% had depression. BDI Categories Number of participants (%) Minimal Depression (0-13) 40 (41.2) Mild Depression (14-19) 29 (29.9) Moderate Depression (20-28) 23 (23.7) Severe Depression (29-63) 5 (5.2) Table-1: BDI Categories and Number of Participants DISCUSSION The most common psychiatric disorder in ESRD patients is depression17. It has been associated with an increased risk of cardiovascular events, hospitalization and death18. Psychological stress and disturbing physical symptoms lead to reduced Quality of Life (QoL) which shows the way to depression19. Many studies have shown a significant association between depression and mortality in ESRD patients on dialysis20. 8 Intraoperative Peritoneal Lavage in Peritonitis: Normal Saline vs Metronidazole 1Hira Aslam, 2Muhammad Khurram Jameel, 2Pir Muneeb, 1Aneeqa Nasir Qureshi, 2Fawad Hameed, 3Muhammad Ammar, 2Maham Qazi, 4Abrar ul Hassan Pirzada 1Department of Surgery, Mayo Hospital, KEMU, Lahore 2Department of Surgery, ANMC / Chaudhary Muhammad Akram Hospital, Lahore 3Department of Urology, Chaudhary Muhammad Akram Hospital, Lahore 4Department of Plastic Surgery, ANMC / Chaudhary Muhammad Akram Hospital, Lahore, Pakistan ABSTRACT Introduction: Globally, acute generalized peritonitis ranks among the top surgical emergencies. Different studies have been conducted to show the amplitude of peritonitis worldwide eliciting a huge impact on overall patient morbidity and mortality. Largely peritonitis is caused by a gastrointestinal perforation or anastomotic leak. In peritonitis, anaerobes & gram-negative organisms are mostly responsible for sepsis and morbidity due to the overactive inflammatory cascade by endotoxins which is amenable to timely intervention. Aims & Objectives: The study's aim was to evaluate whether using normal saline or metronidazole solution during intraoperative peritoneal lavage (IOPL), results in a lower rate of postoperative wound infection. Place and Duration of Study: This study was undertaken at the South Surgical Ward, Mayo Hospital Lahore for 6 months from February 2nd, 2021, to August 1st, 2021. Material & Methods: Consecutive sampling strategy followed by a randomized controlled trial were used to induct and provide intervention to 90 patients aged 15-65 years with peritonitis caused by hollow viscus perforation. The patients were subdivided into 2 groups A& B(n=45 each).Two liters of normal saline were used for peritoneal lavage in group A, while two liters of normal saline were combined with 200 mL of metronidazole solution and administered to group B. intraoperatively.Baseline physiological parameters such as age, sex, BMI , intra operative surgical parameters as duration of operation and post-operative course were recorded till discharge. On 10th POD, patients returned to OPD for further monitoring. An infection was diagnosed if the patient had post-operative symptoms such as a high temperature, increased TLC, wound discharge, redness, or pain. Data was entered and analyzed using SPSS version 23. Results: A majority (54.44%) of the patients were young adults. Mean age of 37.33 ± 10.53 years of patients in the metronidazole group was comparable to mean age 40.04 ± 11.96 years in the saline group, difference was not significant (p=0.067). Male/female ratio in Metronidazole and Saline groups were 17/25 and 10/18, respectively. Patients who received intraperitoneal lavage with normal saline were more likely to develop wound infections (17/45) (37.78%), while only 3/45) (6.67% of those who received metronidazole solution did so (p 0.0001). Conclusion: Based on the results of this experiment, using metronidazole solution for intraoperative peritoneal lavage instead of normal saline reduces the occurrence of postoperative wound infection. Keywords: peritonitis, postoperative wound infection, intraoperative peritoneal lavage INTRODUCTION Globally, acute generalized peritonitis ranks among the top surgical emergencies1. It is more common in Third World nations. The prevalence of perforation is low (0.6% - 4.9%) in developed nations but high (33% - 63%) in West Africa2. 554 persons were discovered to have peritonitis in a study that took place over three years in India3. Researchers in Pakistan have conducted studies with similar methods, with one study reporting 650 cases in a just 9 months4. Most cases of peritonitis are caused by a gastrointestinal perforation or anastomotic leak5. In the case of peritonitis, anaerobes and gram- negative organisms are mostly responsible for sepsis and morbidity due to the overactive inflammatory cascade brought on by the release of endotoxins5.Clinical evidence is used to identify peritonitis. Diagnosis can be achieved via upright plain x-ray of the abdomen, USG, or CT scan. This is often done through diagnostic laparoscopy nowadays6.Resuscitation, diagnosis, prompt exploration, treatment of the underlying cause, and extensive surgical peritoneal lavage have always been the cornerstones of peritonitis therapy regimens (IOPL)7,8. Regular IOPL is performed to lessen bacterial contamination and burden. Even though large volumes of normal saline are used in IOPL, the rates of sepsis, wound infection, and mortality remain alarmingly high. Another method 6 1Department of Public Health, Health Services Academy, Islamabad. 2Department of Management Sciences, Riphah Int University, Islamabad. 3Department of Medicine, IHITC, Islamabad. 4Department of Rheumatology, PIMS, Islamabad. 5Department of Medicine, Dow University of Health Sciences, Karachi. 70 1Department of Orthopedics, THQ, Khanewal 2Department of Orthopedics, LGH, Lahore 3Department of Orthopedics, THQ, Ferozwala 4Department of Orthopedics, CMH, Lahore 5Department of Hand & Upper Limb Surgery, CMH, Lahore 6Department of Orthopedics, Al-Rehmat Benevolent Trust 1 1Department of Anatomy, UCMD, University of Lahore, Lahore 2Department of Anatomy, Punjab Medical College, Faisalabad Medical University, Faisalabad 3Department of Medical Education, Pak Red Crescent Medical and Dental College, Lahore p 36 Mental Health Impact on Patients of ESRD on Renal Replacement Therapy:A Cross Sectional Survey….. A systemic review and meta-analysis which included 249 populations and 55,982 participants showed that prevalence of depression to be 39.3% in ESRD patients21. In a study done by Chi-Ken Chen et al, on 200 patients on hemodialysis, depression was present in 35.0% of patients22. However, the estimates of depression in ESRD on hemodialysis patients have varied between 5% to 58%23. The prevalence of depression in our study is 58.8%. This rate is higher than that reported in many western populations. However, it corresponds to the levels of depression in Indian sub-continent. A study done in Western Rajasthan, India showed the prevalence of depression in hemodialysis patients to be 61%24. Similarly, Kumar et al. showed a prevalence of depression to be 61.3% in CKD patients on hemodialysis25. In our study, married people were likely to be depressed that single individuals. This is in contrast to some other studies which found that married people were less likely to be depressed and had better QoL than widowed/divorced individuals26,27. However, Amjad Khan et al., found that married people were more likely to be depressed than single individuals. They found 85.6% of married people to be depressed28. In our study, 62.5% married individuals were depressed. The difference could be explained by the fact that the first two studies compared married to widowed/divorced individuals, whereas Amjad Khan et al. and our study compared married to single unmarried individuals. A study done in Pakistan by Anees M et al. also showed that married individuals are more likely to be depressed than single individuals29. In our social setup, a married individual is usually a guardian of 4-8 dependents. As the disease process affects their employment status, this leads to increased mental stress as there is no social support for the family. This could cause higher levels of depression. In our study, the duration of dialysis was associated with the level of depression in an individual. Of the patients who were on dialysis for less than a year, 59.6% were found to have depression, whereas patients who were on dialysis for more than 4 years, 75% of them had no element of depression. This corresponds to findings of some other studies which propose that the commencement of dialysis puts a significant emotional and social stress on an individual, and as the duration increases the patient gradually adapts to the burden of the disease30,31. Although treatment can be challenging, it is very important to identify depression early in ESRD patients. Pharmacological and Cognitive Behavioral Therapy (CBT) can lead to improved quality of life in these patients32,33. CONCLUSION Depression is more prevalent in ESRD patients on hemodialysis. It is more prevalent than found in other major illnesses and in the general population29,31. 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The Authors: Dr. Rashid Ali, Assistant Professor, Department of Medicine Ayub Teaching Hospital,Abbottabad Dr. Sardar Sabeel, Post Graduate Trainee, Department Of Medicine, Ayub Teaching Hospital, Abbottabad Dr. Danial Zahoor, Post Graduate Trainee, Department of Surgery, JPMC, Karachi 38 Mental Health Impact on Patients of ESRD on Renal Replacement Therapy:A Cross Sectional Survey….. Dr. Bushra Arif, Post Graduate Trainee, Pulmonology Unit, Ayub Teaching Hospital, Abbottabad Dr. Adnan Khan, Assistant Professor, Department of Medicine AyubTeaching Hospital, Abbottabad Dr. Saqib Malik, Professor, Department of Medicine Ayub Teaching Hospital,Abbottabad Corresponding Author: Dr. Adnan Khan, Assistant Professor, Department of Medicine, Ayub Medical College, Abbottabad Email:adnanjrmcw1983@gmail.com Dr. Adnan, Dr. Adnan,