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We are presenting a rare case of sino-nasal teratocarcinosarcoma. A 43-year-old male patient presented with repeated episodes of epistaxis and headache for 3 months. On examination, the ENT consultant noticed a mass in the right nasal cavity for which biopsy was performed and CT scan advised. Sinonasal teratocarcinosarcoma was diagnosed on biopsy and immunohistochemistry. CT Face followed by PET/CT showed a FDG-avid soft tissue density mass in the right nasal cavity extending locally with a standardised uptake value of 7.4 with no distant metastasis. Surgical debulking is the first line of treatment as per the literature; however, in this case, the multidisciplinary tumour board initiated induction chemotherapy of 02 cycles of CISP/DOC owing to marked local extension of the tumour. Subsequent CT scan of the face shows a good treatment response with shrinkage of the sinonasal mass. After successful chemotherapy, the patient is now scheduled for radiotherapy and subsequently follow-up to assess the response.

Objective: To report the effect of fibrosis on yield of Deoxyribonucleic Acid extraction from Formalin-Fixed Paraffin-Embedded tissue. Study Design: Cross sectional study. Place and Duration of Study: Department of Molecular Pathology, Armed Forces Institute of Pathology, Rawalpindi Pakistan, Jul to Dec 2021. Methodology: Fifty-four Formalin-Fixed Paraffin-Embedded tissues having size 2cm were excluded. Deoxyribonucleic Acid was extracted and quantified from Formalin-Fixed Paraffin-Embedded blocks. Results: Nine (17%) Formalin-Fixed Paraffin-Embedded tissues had no fibrosis, 28(51%) had Mild fibrosis, 9(17%) and 8(15%) had Moderate and Severe fibrosis. Measurement scale in 5 different stages for evaluation of our quantified results were used. For specimens with no fibrosis the DNA quantity fell on scale 1, 0(0%); on scale 2, 1(11%); on scale 3, 0(0%); on scale 4, 1(11%); and on scale 5, 7(78%). Deoxyribonucleic Acid yield in moderate fibrosis specimens fell on scale 1, 0(0%)’ on scale 2, 7(78%); on scale 3, 0(0%); on scale 4, 1(11%); and on scale 5, 1(11%). Among severe fibrosis the Deoxyribonucleic Acid quantity fall on scale 1, 5(62%); on scale 2, 3(38%); on scale 3, 0(0%); on scale 4, 0(0%); and on scale 5, 0(0%). Conclusion: Formalin-Fixed Paraffin-Embedded tissues having severe fibrosis resulted in significantly lower Deoxyribonucleic Acid yield as compared to Formalin-Fixed Paraffin-Embedded tissues having no fibrosis

Optimized management of type-2 diabetes mellitus (T2DM) remains a challenge not just because micro and microangiopathies’, chronic kidney disease, and infections related to poor cellular immunity. Methodology to manage T2DM remains in need for evolution to curb disease and help manage economy of diabetes care. Metformin remains the frontline soldier against T2DM. However, optimized and evidence-based use of metform for managing T2DM in clinics needs better molecular analytics to micro-precise medical management. We evaluated 353 manuscripts to finally shortlisted 45 reviews and RCTs using PRISMA guidelines from Google Scholar, PubMed and Cochrane Reviews. This systematic review attempted to identify the role of pharmacokinetic, pharmacogenomic, epigenetic and mitochondrial factors which can lead to sub-optimal diabetes management, metformin resistance and mutations which could lead to poor to no response to medicine. The most common mutations and polymorphisms in solute channels were observed to reduce the therapeutic efficacy/resistance

Objective: To determine the efficacy of short message service (SMS) for educating families of children with Type 1 Diabetes (T1D). Study Design: Single-masked randomized control trial (IRCT: 54713). Place and Duration of Study: Tertiary care hospitals of Rawalpindi and Islamabad Pakistan, from Mar to Jul 2021. Methodology: Twenty-nine T1D patients aged 1 to 18 years were randomly allotted to two groups: 15 to intervention or Group-A (receiving 5 SMS per week) and 14 to Control or Group-B (receiving disease education during hospital visits). Patients were followed up and their blood sugar levels (BSLs), HbA1c levels, journal maintenance, number of ER visits, number of Self-Monitored Blood Glucose (SMBG) levels, and hypoglycemic episodes compared at baseline and after intervention. Results: HbA1c had a mean decrease of 2.13±1.89% in Group-A and a mean increase of 0.18±0.84% in Group-B (p-value

Objective: To determine the utility of Anti-mullerian hormone (AMH) as a diagnostic marker of Polycystic ovarian syndrome (PCOS). Study Design: Comparative cross-sectional study Place and Duration of the Study: Department of Chemical Pathology and Endocrinology, Army Medical College Rawalpindi, Pakistan in collaboration with the Department of Gynaecology and Obstetrics, Pak-Emirates Military Hospital, Rawalpindi Pakistan from Jan 2019 to Jan 2020. Methodology: The study recruited 30 cases of PCOS and 30 age-matched Controls using Rotterdam criteria. Anti-mullerian hormone (AMH) and testosterone were measured for both the study groups. Results: Receiver operator curve (ROC) analysis confirmed the utility of anti-mullerian hormone in diagnosing patients with PCOS. The AUC was 0.754 with 95% CI (0.629-0.880). The optimal cut-off point was 3.22ng/mL (Sensitivity 80%, Specificity 66.7%). Conclusion: The AMH is appraised as an independent screening marker for PCOS patients. Using this single parameter can decrease the patient's inconvenience and financial burden on the health care system and the patient.

Objective: To compare and correlate the value of the Haller index calculated with chest x-ray with the values calculated with a Computed Tomography (CT) scan. Study Design: Cross-sectional study. Place and Duration of Study: Department of Radiology, Combined Military Hospital, Peshawar Pakistan, from Jan to Jun 2018. Methodology: A total of 50 male patients aged ≥16 years presenting with pectus excavatum were included. Haller index was calculated after CT scan and X-ray. Results: The mean age of the patients was 20.20±2.34 years. The mean Haller Index for CT scan was 2.35±0.39, and the mean Haller Index for X-ray was 2.01±0.45. A strong and positive correlation existed between the Haller index for CT scans and X-rays (r=0.83). Conclusion: X-rays can be used instead of CT scans to measure the Haller index and plan the surgical intervention with similar accuracy.

Objective: To evaluate the association of admission blood glucose levels with no-reflow or slow flow in patients with STElevation Myocardial Infarction (STEMI) undergoing Primary Percutaneous Coronary Intervention (PPCI). Study Design: Analytic Cross-sectional study. Place & Duration of Study: Armed Forces Institute of Cardiology/National Institute of Heart Diseases, Rawalpindi, Pakistan, from Jan 2023 till Jun 2023 Methodology: Total 141 STEMI patients (regardless of age and gender) presented in the emergency department with the time duration of 12 hours after onset of chest pain were included in the study by using non-probability Consecutive Sampling technique. Admission glucose levels were measured, and the occurrence of no-reflow or slow flow was assessed using the Thrombolysis in Myocardial Infarction (TIMI) flow score. Statistical analysis, including t-test and Chi-square tests were applied to evaluate the association between glucose levels and no-reflow or slow flow. Level of significance taken was ≤0.05. Results: Out of total 141 patients, mean age of the patients was 61.74+10.87 years and majority were males, 118(83.7%). 101(71.6%) were hypertensive and 69(48.9%) were diabetic. The average admission glucose level was 181.13+112.16mg/dl. Patients with no-reflow or slow flow had significantly higher admission glucose levels compared to those with normal flow (p=0.031). Additionally, a significantly higher number of patients developed no-reflow 4(9.3%) or slow flow 24(55.8%) in the group with admission glucose levels >200 mg/dl (p=0.01). Conclusion: Admission glucose levels may serve as a simple predictor of no-reflow or slow flow in STEMI patients undergoing PPCI, emphasizing the importance of adequate glucose management in these patients.

Objective: To compare the GRACE score and SYNTAX score in predicting Coronary Artery Disease (CAD) severity and the variation of GRACE score with respect to SYNTAX score to assess severity of CAD. Study Design: Analytical, Cross-sectional study. Place and Duration of Study: Armed Forces Institute of Cardiology/National Institute of Heart Diseases, Rawalpindi Pakistan, from Jan 2023 to Jun 2023. Methodology: Data was gathered from n=139 participants by using consecutive sampling technique on a data collection tool.Study variables such as demographics, comorbids, clinical characteristics and SYNTAX and GRACE score were noted to asses their role in determining CAD severity. An experienced cardiologist was assigned to analyze the coronary angiogram findings, performed by using conventional techniques through radial artery, ulnar or femoral artery access. SPSS version-24.00 was used for data management and analysis. Chi square test and Pearson correlation was applied to find the association and correlation respectively. Results: Mean age of study participants was 62.09±9.74 years and males were more in number 114(82.0%). Ninety three (66.9%) patients had NSTEMI. Gender (p=0.011,0.007), was significantly associated with SYNTAX score as well as GRACE score respectively and diabetic status (p=0.003) with GRACE score. There was a strong and positive correlation between GRACE score and SYNTAX score (r=0.64; p

Objective: To assess CHADVASC score in predicting in-hospital mortality in patients presenting to the hospital with ST segment Elevation Myocardial Infarction undergoing primary PCI. Study Design: Analytical Cross-sectional study. Place and Duration of Study: Armed Forces Institute of Cardiology/National Institute of Heart Diseases, Rawalpindi, Pakistan, from Mar 2023 to Apr 2023. Methodology: A total of 198 patients were enrolled. Their CHADVASC scores were recorded and were divided into Group-A (score of 0-1), B (score 2-3) and C (score 4 and above). Sampling was done by using non-probability consecutive sampling. A brief clinical history including duration of symptoms, comorbid, duration of hospital stay and survivability status were recorded. Chi-square and Independent sample t-test were applied to find the association between In-hospital mortality and CHADVASC score, duration of hospital stay as well as comorbids. p-value

Objective: To determine impact of various forms of intra nasal packings and trans-septal suturing (without nasal packing) on cardiopulmonary and metabolic milieu of patients undergoing nasal and paranasal sinus operations. Study Design: Randomized controlled trial. ( Ltr no: IERB-01/3/23/Trg dated 8 March 2023) Place and Duration of Study: Department of Otorhinolaryngology (ENT), Combined Military Hospital, Jhelum Cantonment, Pakistan, from Aug 2022 to Aug 2023. Methodology: Clinical and laboratory markers of cardio-pulmonary and metabolic assessment of 140 subjects were evaluated, who had undergone some form of intranasal packing procedure or trans-septal suturing (without nasal packing) following nose or paranasal sinus operations. Results: Ventilated nasal packs and completely avoiding nasal packing by performing trans-septal suturing have a significant impact on clinical parameters like resting heart rate, respiration, blood pressure, arterial blood pH and arterial blood partial pressure of carbon dioxide (PaCO2) in patients undergoing surgical operations of the nose and paranasal sinuses. Conclusion: We strongly recommend adopting less invasive and technically more advanced operative methodology and refining surgical expertise regarding septal splinting during rhinologic operative procedures, mitigating discomfort and antecedent morbidity in patients undergoing these sino-nasal surgical operations.

ABSTRACT Introduction: Abnormal Implantation of the Placenta in uterine walls is the condition known as Morbidly Adherent Placenta. It includes Placenta accreta, increta and percreta. It is mostly reported after history of placental previa and C-section. The irreversible damages from Abnormal Placentation that includes morbidity and mortality in women can be prevented by a holistic approach of treatment. Objective: To determine the frequency of hysterectomy in morbidly adherent placenta in post-cesarean section patients. Methodology: A Hospital based descriptive cross-sectional study of 8 months, from September 2019 to April 2020 was carried out at the Obstetrics and Gynecology department. A total of 210 participants were selected for the study. Non probability consecutive sampling technique was used for data collection. Results: The Frequency of Hysterectomy in morbidly adherent placenta in post Cesarean section women was reported 166 (79.04%), out of the remaining 44 (20.96%) patients the Triple P was reported in 21 (10%) patients and B-Lynch done in 15 (7.14%) patients and 8 (3.8%) were reported with Balloon Tamponade. Conclusion: The frequency of hysterectomy in MAP is high. Attention is required to be given to conservative methods to protect fertility.

Objective: To investigate the degree of association between Reverse Transcription Polymerase Chain Reaction positivity and seroconversion after natural COVID-19 infection in Multan, City of Pakistan. Study Design: Cross-sectional study. Place and Duration of Study: Combined Military Hospital, Multan Pakistan from Apr 2021 to Sep 2021. Methodology: In this study, 219 Healthcare Workers with suspected SARS-CoV-2 infection were screened via Reverse Transcription Polymerase Chain Reaction for viral genome, followed by detection of corresponding antibody response in serum samples within ten weeks of their first exposure against spike protein via Chemiluminescence immunoassay. Results: There was a significant association between positive RT-PCR and detectable corresponding antibodies (p=0.001). However, we found no evidence of an association between age and RT-PCR positivity and between age and detectable antibodies (p=0.874 and 0.842, respectively). Furthermore, results indicated no association between gender and RT-PCR positivity and between gender and detectable antibodies (p=0.536 and 0.285, respectively). Conclusions: It is concluded that antibody detection against SARS-CoV-2 virus spike protein is a useful laboratory tool for screening for COVID-19 infection. Keywords: Antibody test, Asymptomatic cases, COVID-19, Healthcare workers, PCR, SARS-CoV-2.

Objective: To determine the diagnostic accuracy of a 16-slice contrast-enhanced CT scan (CECT) for the detection of malignancy in patients with complex adnexal masses on Ultrasonography (USG) (taking histopathology as the gold standard). Study Design: Cross-sectional study. Place and Duration of Study: Pakistan Naval Ship Shifa Hospital, Karachi Pakistan, from Jul to Dec 2020. Methodology: Seventy-five patients with adnexal masses were included. All patients had 16-slice contrast-enhanced CT scans. All the patients then had exploratory laparotomy, followed by histopathology as the gold standard. The diagnostic accuracy of CECT (contrast-enhanced computed tomography) was detected by determining sensitivity, specificity and diagnostic accuracy. Results: 16-slice contrast-enhanced computed tomography showed a sensitivity of 92.2%, specificity of 93.4%, and diagnostic accuracy of 93.1%.for correctly diagnosing adnexal malignancy. Conclusion: Due to its high sensitivity, specificity and diagnostic accuracy, 16 slice contrast-enhanced CT scan is a reliable test for diagnosing malignancy among patients with unexplained adnexal masses on USG.

Objective: To calculate the diagnostic accuracy of Ultrasonography versus Magnetic Resonance Imaging in detecting endometrial carcinoma with histopathology kept as a gold standard. Study Design: Cross-sectional study. Place and Duration of Study: Department of Diagnostic Radiology, Pakistan Institute of Medical Sciences Hospital, Islamabad Pakistan, from Apr 2019 to Apr 2020. Methodology: This study included patients of perimenopausal and post-menopausal age groups with abnormal uterine bleeding having a high index of suspicion for endometrial malignancy referred from the Gynecology department for an ultrasound examination. Patients having high suspicion for malignancy or inconclusive evidence on ultrasound were considered for Magnetic Resonance Imaging(MRI). All of them were followed for histopathological reports after surgical exploration. Clinical, sonological and Magnetic Resonance Imaging (MRI) findings, along with histopathological diagnosis, were documented. Results: Mean age of the patients was 56.58±10.28. Of these eight patients, 8(21.1%) did not have carcinoma upon histopathology. The most common type of carcinoma was poorly differentiated endometrial adenocarcinoma. The diagnostic accuracy of ultrasound was found to be 47.35%, while that for Magnetic Resonance Imaging (MRI) was 71.05%. Sensitivity and specificity for Ultrasound versus Magnetic Resonance Imaging (MRI) were 53.33% versus 66.67% and 75% versus 87.50%, respectively. The mean endometrial thickness on ultrasound was 15.97±5.64 mm, while on MRI was 15.42±6.9 mm. Conclusion: Magnetic Resonance Imaging (MRI) is a more accurate and sensitive modality in detecting endometrial carcinoma in patients with abnormal uterine bleeding.

Objective: To determine the mean length of hospital stay of term and late preterm infants with transient tachypnea of the newborn treated with intravenous Furosemide compared to the Control Group. Study Design: Quasi-experimental study. Place and Duration of Study: Combined Military Hospital, Kharian, from Apr to Oct 2016. Methodology: All term and late preterm infants with transient tachypnea of new-borns were included in the study. One Group was given IV Furosemide, and the other was taken as control. Two doses of Furosemide were administered IV at 1 mg/kg 12 hours apart. The Control Group were given normal saline 01 ml/kg as a placebo 12 hours apart. Results: It was found that the duration of tachypnea in the Study-Group was less than that of the Control-Group (49.4±7.4 h vs 76.7±4.5h, p-value

Objective: To determine the diagnostic accuracy and agreement between ultrasound and magnetic resonance (MR) imaging in determining rotator cuff tears. Study Design: Cross-sectional study. Place and Duration of the Study: Armed Forces Institute of Radiology and Imaging, Pak Emirates Military Hospital,Rawalpindi Pakistan, from Jul 2018 to Jan 2019. Methodology: Patients of either gender with a traumatic shoulder injury duration of less than 15 days were consecutively included. Rotator cuff tear on ultrasonography was diagnosed on the presence of a hypoechoic discontinuity in the tendon and accentuation of cartilage shadow, giving a 'double cortex' view while on MRI, the hyper-intense signal area within the tendon on T2W, fat-suppressed and GRE sequences, corresponding to fluid signal seen. Results: Of 88 patients, the mean age was 54.022±5.19 years. Ultrasound diagnosed rotator cuff tears in 42(47.7%) patients, and MRI diagnosed rotator cuff tears in 44(50.0%) patients. Diagnostic accuracy of ultrasound taking MR imaging as the gold standard showed sensitivity as 81.82%, specificity as 77.27%, negative predicted value as 78.26%, positive predicted value as 80.95%, and overall diagnostic accuracy as 79.55%. A moderate agreement was found between ultrasound and MRI findings (p-value=0.591). Conclusion: The findings of the current study showed significant moderate agreement between ultrasound and MR imaging in the determination of rotator-cuff tears.

Objectives: To determine the diagnostic accuracy of the extended sick neonatal score (ESNS) in neonates admitted in a resource-limited neonatal intensive care unit (NICU) at Peshawar. Study Design: Cross-sectional analytical study Place and Duration of Study: Neonatal Intensive Care Unit, CMH Peshawar Pakistan, from Mar to May 2020. Methodology: Primary data was collected from 60 neonates admitted to NICU after taking consent from the parents. The receiver operating characteristic curve (ROC) was plotted to determine the clinical score (ESNS) cut-off value in predicting mortality. Result: The sensitivity and specificity of the Extended sick neonatal score to predict mortality among neonates was 93.3% and 97%, respectively, for a cut-off of 12.5. The area under the ROC curve was 0.990 (95% CI: 0.971–1.000). This was statistically significant with a p-value of

Objective: To establish the reference intervals in healthy pregnant females of Quetta, Baluchistan, for Glycosylated Hemoglobin (HbA1c) in all three trimesters of pregnancy. Study Design: Cross-sectional study. Place and Duration of Study: Pathology Department Combined Military Hospital, Quetta Pakistan, from Jun 2018 to Jun 2019. Methodology: Blood samples of healthy pregnant females were drawn for Glycosylated haemoglobin (HbA1c). Fasting plasma glucose and haemoglobin were also measured to rule out hyperglycemia and anaemia. Samples for Glycated haemoglobin(HbA1c) were analyzed by Turbidimetric Immuno-inhibition (TINIA) method. For all the trimesters, 5th and 95th percentiles were taken as reference intervals for Glycosylated haemoglobin (HbA1c) and compared for each trimester. Results: A total of 388 samples were taken, of which 136(35.05%) females were from the first trimester, 128(32.98%) and 124(31.97%) from the second and third trimesters, respectively. The mean age of the study population was 25.1±3.7 years in the first trimester, 26.7±4.5 years in the second-trimester while and the third trimester it was 26.8±4.8 years. In the first, second,and third trimesters, the reference intervals for Glycosylated haemoglobin (HbA1c) were 3.8-5.2%, 4.1-5.4%, and 4.2-5.7%,respectively. Conclusion: For the exact diagnosis of hyperglycemia in pregnancy, each laboratory should establish its reference intervals of Glycated haemoglobin (HbA1c) for each trimester as it varies from trimester to trimester.

Objective: To evaluate serum vitamin D levels in patients with vitiligo and compare them to the healthy controls. Study Design: Comparative cross-sectional study. Place and Duration of Study: Dermatology Outpatient Department, Fauji Foundation Hospital, Rawalpindi Pakistan, from Nov 2019 to Apr 2020. Methodology: The study included 75 patients with vitiligo (Group-1) and 75 healthy controls (Group-2). Complete blood count, urea and creatinine, liver function tests, TSH, fasting plasma glucose, vitamin B12 levels, serum calcium and vitamin D levels were performed. In addition, vitamin D levels were compared in both groups. Results: The mean age of Group-1 was 32.81±20.59 years, and Group- 2 was 40.13±16.09 years. In Group-1, deficient vitamin D levels were seen in 17(22.7%) of cases, insufficient in 25(33.3%) and 33(44.0%) had normal levels. In Group-2, 10(13.3%) had deficient levels, 10(13.3%) had insufficient levels and 55(77.3%) had normal levels. Patients with vitiligo had low serum 25(OH)D levels compared to controls, and this difference was statistically significant (p=0.001). Conclusion: Low serum vitamin D levels are seen in patients with vitiligo compared to controls.

Objective: To evaluate serum vitamin-D levels in patients with Alopecia areata compared to healthy controls. Study Design: Comparative cross-sectional study. Place and Duration of Study: Dermatology Outpatient Department, Fauji Foundation Hospital, Rawalpindi Pakistan, from Nov 2019 to Apr 2020. Methodology: The study included 70 patients with Alopecia areata (Group-1) and 70 healthy controls (Group-2). Complete blood count, TSH, urea and creatinine, fasting plasma glucose, liver function tests, serum Calcium and vitamin-D levels were performed. Results: The mean vitamin-D levels of Group-1 were 38.28±22.07ng/mL, and the mean vitamin-D levels of Group-2 were 39.61±18.36ng/mL. In Group-1, deficient vitamin-D levels were seen in 14(20.0%) of Group-1, and insufficient in 19(27.1%) and 37(52.9%) had normal levels. In Group-2, 10(14.3%) had deficient levels, 16(25.0%) had insufficient levels and 44(62.9%) had normal levels. No statistically significant difference seen between Group-1 and Group-2. Conclusion: There is no association between vitamin D level and Alopecia Areata.

Objective: To compare the efficacy of Probiotics with the yoghurt in the management of children with acute diarrhoea in terms of frequency and consistency of stools. Study Design: Quasi-experimental study. Place and Duration of Study: Department of Paediatric Medicine, Combined Military Hospital, Peshawar Pakistan, from Jun to Dec 2020. Methodology: Patients were allotted into three Groups A, B, or C. Group-A received a Probiotic (Bacillus Clausii), Group-B received plain yoghurt, and Group-C did not receive yoghurt or Probiotic. The outcome was an improvement in stool consistency at 72 hours. Stool consistency was assessed via Bristol stool chart along with frequency. Data were collected 72 hours after initiation of treatment. Result: The total number of patients enrolled was 159(53 in each Group). Among these, 85(53.5%) were males, and 74(46.5%) were females. There was a statistically significant association in terms of consistency (p=0.001) and term of frequency (p

Objective: To determine the mean change in central macular thickness after cataract surgery and to compare the mean change in central macular thickness after cataract surgery in non-diabetics and diabetics without diabetic retinopathy Study design: Case control Study settings and duration: A case control study was carried out at Ophthalmology department, POF hospital, Wah Cantt. Study duration was 6 months (April 2019-September 2019) Material and methods: A sample size of 60 patients was calculated by using Open Epi Software. We used non probability consecutive sampling. Patients were divided into two groups; Cases (Diabetic) and controls (non-Diabetic). All patients underwent phacoemulsification and observed after 4 weeks for macular thickness measurement using optical coherence tomography before and after surgery. Data analysis was done with SPSS version 20. Post stratification t test was applied. P value ≤0.05 was considered significant. Results: Total 60 patients were included. Mean age of patients was 65.31 ±7. 63SD.There were 35 (58.3%) males and 25 (41.7%) female patients in the study. We found a significant increase in central macular thickness in cases and controls [(223.100±15.86SD vs 227.2667±17.9SD, p=0.000) and (221.200±12.16SD vs 226.289±16.7861SD, p =0.001)] before and after phacoemulsification in cases and controls respectively. However, no significant difference was found between the groups (p=0.486). Conclusion: Central macular thickness was increased after uncomplicated phacoemulsification in both diabetics and non-diabetics without retinopathy for up to a follow-up period of 4 weeks but the thickness did not differ between the two groups.

Objective: To evaluate the level of anxiety and depression in children and adolescents with congenital heart disease in pre and post-surgical intervention period. Study Design: Quasi experimental study. Place and Duration of Study: Rawalpindi Institute of Cardiology, Rawalpindi Pakistan, from Jan to Dec 2019. Methodology: After written informed consent from parents and approval of hospital ethical committee 152 children and adolescents with congenital heart disease were included in the study. Demographic and clinical data was recorded on relevant proforma. In addition to clinical assessment the level of anxiety and depression were objectively measured with the help of Urdu version of Hospital Anxiety and Depression Scale by the mental health specialist a day before and 15 days after surgery. Results: The mean age of participants was 14.5 ± 3.3 years. Out of 152 participants, 80 (52.6%) were females, while 72 (47.4%) were males. Level of anxiety and depression was found higher in the preoperative period being 44 (28.9%) and 52 (34.2%) which dropped significantly in the postoperative period to 16 (10.5%) and 8 (5.3%) respectively. Majority of the patients had Tetralogy of Fallot i.e., 52 (34.2%) followed by Ventricular Septal Defect in 24 (15.7%) and Atrial Septal Defect in 18 (11.2%). Females were more likely to have depression than males (p-value=0.01). Conclusion: We found significant decrease in anxiety and depression in the postoperative period.

Objective: To determine the safety and efficacy of transcatheter closure of atrial septal defects and to evaluate the initial, midterm and long-term results of the treatment. Study Design: Cross sectional study. Place and Duration of Study: Department of Paediatric Cardiology, Rawalpindi Institute of Cardiology, Rawalpindi, from Jul 2017 to Jun 2018. Methodology: Sixty-four patients underwent transcatheter closure of atrial septal defect. Size of the defect was measured by Transoesophageal/Transthoracic. Follow up was carried out at twenty-four hours, one month, six months and at twelve months. Early, Midterm and late complications after device occlusion were analysed using SPSS-22 statistical software. Results: Minimum size of atrial septal defect on echocardiography was 7 mm and maximum size was 31 mm with mean of 18.3 ± 5.7 mm. The procedure was successful in 96.8% cases. There was only one device embolization (1.56%). Cobrahead” configuration malformation of the device occurred in one case (1.56%). Mitral valve regurgitation did not occur in any of the case. There was no residual shunt across the device in the present study. ECG abnormalities associated with transcatheter closure did not occur in any of the patient. In intermediate and long-term follow up, no complication like cardiac erosion was seen in all cases under study. Conclusion: Transcatheter occlusion of ASD with device was found effective and safe procedure with minimal complication rate, short hospital stay, good short, intermediate and long-term results.

Objective: To see the implementation of designed strategy for uninterrupted supply of HIV treatment at time of COVID-19 Pandemic along with the knowledge and preventive practices regarding COVID-19 among HIV positive patients to have baseline data for future interventions to control HIV-COVID-19 syndemic. Study Design: Cross sectional study. Place and Duration of Study: HIV Center at Benazir Bhutto Shaheed Hospital, Karachi Pakistan, from Mar to May 2020. Methodology: 100 patients who visited the center for medicines were interviewed. Participants were inquired about the availability of Antiretroviral Therapy (ART) during lockdown, discontinuity in treatment suffered during this pandemic, their preventive behaviour against COVID-19, most adopted prevention and source of information for this behavior. Results: Among all the participants 72% have achieved viral suppression. As far as multi month dispensing was concerned 10% received ART for one month, 64% for 2 months and 18% for 3 months as per the strategy devised by Pakistan AIDS control in collaboration with UNAIDS. Out of 11% developed symptoms but later on tested negative on PCR test. Most commonly adopted personal protection adopted was face mask among 68% participants followed by hand washing and social distancing. All the participants were of the opinion that they received sufficient information regarding COVID-19, its prevention and mode of spread. The source of information was TV 60%, HIV center 30% and both TV and HIV center 10%. Conclusion: It was found that all the patients got uninterrupted supply of anti-retroviral medicines. Despite sufficient knowledge regarding disease they couldn’t comply with........

Objective: To find out the association of type 2 diabetes mellitus with ABO and Rh blood groups. Study Design: Cross sectional study. Place and Duration of Study: Department of Haematology, Combined Military Hospital Lahore, from Jul to Dec 2020. Methodology: A total 179 patients with type 2 diabetes mellitus and 50 healthy individuals were inducted into the study. Five (5ml) blood from the patients was taken via clean aseptic venipuncture in a tube containing EDTA. HbA1C was generated through automated analyzer Cobas c501 and blood grouping was carried out using tube method by an experienced technician. Results: A total of 179 (77.8%) individuals with diabetes mellitus type 2 and 50 (21.7%) healthy cases were inducted into the study as a control group. A statistically significant difference was observed with blood group B being the most prevalent among them (p=0.001). There was a greater frequency of Rh-negative blood group in patients having diabetes mellitus type 2 as compared to the control group. Conclusion: There is a strong association found between ABO and Rh blood group with diabetes mellitus type 2. Blood group B negative was the most common among the patients having diabetes mellitus type 2. Blood group O positive showed the least association.

Objective: To evaluate different histopathological patterns and correlate them with indications, findings of Esophagogastroduodenoscopy Esophago-gastro-duodenal (EGD) and serological markers in patients presenting of unexplained anemia and chronic diarrhea. Study Design: Cross sectional study. Place and Duration of Study: Departments of Pathology and Gastroenterology, Combined Military Hospital Lahore Pakistan, from Jul to Dec 2020. Methodology: Histopathological patterns of endoscopic duodenal biopsies, submitted for evaluation of unexplained anemia and chronic diarrhea were studied. Hemoglobin and anti-tTG levels were recorded. Adults with history of unexplained diarrhea and anaemia were included. Biopsies with malignant diagnosis or unfit for evaluation were excluded. Histopathological patterns were correlated with indications and findings of Esophagogastroduodenoscopy and serological markers of celiac disease. Results: The most common indication for Esophagogastroduodenoscopy in 145 patients was chronic diarrhea. Upper gastrointestinal endoscopy in 2/3rd of patients revealed no pathology. Histopathological patterns of duodenal biopsies revealed only 15% cases suggestive of celiac disease. Only 12 patients were suggestive of celiac disease both on Esophagogastroduodenoscopy and histopathology combined. Half of patients with anti tTG level >100 u/ml, showed histopathological features of celiac disease on. There was no correlation between histopathological patterns, indications of Esophagogastroduodenoscopy, morphology of Esophagogastroduodenoscopy and serological markers of celiac disease. Conclusion: Indications for Esophagogastroduodenoscopy, Esophagogastroduodenoscopic findings and histopathological patterns cannot diagnose celiac disease alone.

Objective: To find out the post-obturation pain with Sealapex and AH26 Sealers on the first, third and seventh day. Study Design: Quasi-experimental study. Place and Duration of Study: Armed Forces Institute of Dentistry, Rawalpindi Pakistan, from May to Nov 2019. Methodology: Three hundred eighty-eight patients of either gender, ranging from age 20 to 45, presenting in the OPD for root canal treatment were selected. Teeth were opened, cleaned and shaped properly with rotary HyFlex EDM files. Obturation was done with Sealapex sealer in half cases, and the rest were obturated using AH26. Post-operative pain was recorded with VAS scoring on the days 1,3 and 7. Results: Of 388 patients reporting, 131(67.5%) were males, and 63(32.5%) were females. Comparative pain recording on the days 1, 3 and 7 showed post-operative pain for the AH Sealer-Group as 80(58%), 64(72.3%), 22(84.3%) and Sealapex SealerGroup as 58(42%), 24(27.7%) and 4(15.7%) respectively. The difference between post-obturation pain of both groups on all days was statistically significant, with an increased pain in the AH 26 Sealer-Group. There was a statistically significant relation between post-operative pain with gender distribution. Younger patients reported more pain as compared to older subjects. Conclusion: The post-obturation pain for AH26 is more than Sealapex sealer which gradually decreases with each passing day.

Objective: To establish the reference intervals of thyroid stimulating hormone and free Tetraiodothyronine in healthy pregnant women of Quetta, Baluchistan. Study Design: Cross-sectional study. Study Setting and Duration: Combined Military Hospital, Quetta Pakistan, at Jun 2018 to Jun 2019. Methodology: Consecutive blood samples of healthy pregnant women (in all three trimesters) were taken to analyse thyroid stimulating hormone and free Tetra-iodothyronine by electrochemiluminescence immunoassay. For all three trimesters, the 5th and 95th percentiles were taken as reference intervals of thyroid stimulating hormone and free Tetraiodothyronine. Results: A total of 388 blood samples were taken. Of these, 136 samples were from the first trimester. The mean age of the study population was 25.1±3.7 years in the first trimester, 26.7±4.5 years in the second trimester, and in the third trimester, it was 26.8±4.8 years. The reference interval for thyroid stimulating hormone in the first trimester was 0.6-3.3 uIU//ml, while it was 0.6-3.8uIU/ml and 0.6- 2.7uIU//ml during the second and third trimesters, respectively. Similarly, in the first-trimester reference interval for free Tetraiodothyronine was 9.8-18.0pmol/l. The values of free Tetraiodothyronine in the second and third trimesters were 10.4-20.1pmol/l and 11.0-20.9pmol/l, respectively. Conclusion: All laboratories should establish reference intervals for thyroid stimulating hormone (TSH) to avoid misdiagnosing thyroid disorders during pregnancy.

Objective: To determine the clinical course and outcome of hospitalized pregnant patients with laboratory confirmed SARS CoV-2 (COVID-19) infection Study Design: Prospective longitudinal study Place and Duration of Study: Obstetrics Units of Pak Emirates Military Hospital and Combined Military Hospital, Rawalpindi Pakistan, from May to Jun 2020. Methodology: All patients reporting for childbirth were tested for SARS-CoV-2, and those testing positive were included. The primary outcome was virus clearance time and categorization according to the severity of the disease into asymptomatic,mild, moderate, severe and critical. Furthermore, a comparison was made between the presence of comorbid conditions and symptoms in the category of COVID-19. In addition, neonatal sample evaluation for SARS-CoV-2 was done. Results: Out of the 881 women giving birth, 41(4.6%) tested positive for SARS Cov-2. Majority were asymptomatic 28(68.3%)followed by mild 8(19.5%), moderate 4(9.8%) and severe 1(2.4%) category. There was a significant association of the COVID categories with symptoms (p-value

Objective: To find out how common subclinical atherosclerosis is in psoriasis patients. Study Design: Descriptive cross-sectional study Place and Duration of Study: Dermatology unit of Fauji Foundation, Rawalpindi Pakistan, from Jan 2020 to Jun 2020. Methodology: After receiving informed consent, 314 cases that met the selection criteria were enrolled. Psoriasis was diagnosed depending on physical examination the family history of patients. Ultrasonography high-resolution B mode was opted to assess carotid atherosclerosis (Xario color Doppler probe frequency 5 to 7mHZ.). If the (IMT) was less than 0.9mm, it was regarded normal; values greater than 0.9mm were termed thickened intima, while digits greater than 1.5mm were considered atherosclerotic plaque. SPSS version 21.0 was used for data analysis. Results: Age of patients was from 18 to 70 years old, with a Mean±SD (44.00 ±12.12) years. Males made up 47(15%) of the population, while females made up 267(85%). There were 33(10.5%) smokers and 281(89.5%) non-smokers. The mean IMT was 0.84±0.61, with 0.1mm and 2.05mm as the minimum and maximum, respectively. Subclinical atherosclerosis was found in 96 patients (30.6%) (p

Objective: To determine the spectrum of Grown up Congenital Heart (GUCH) at Armed Forces Institute of Cardiology/National Institute of Heart Dieases. Study Design: Descriptive cross sectional study. Place and Duration of Study: Paediatric Cardiac Surgery and Obstetric department of Armed Force Institute of Cardiology/National Institute of Heart Diease, Rawalpindi Pakistan, from 2011 to 2021. Methodology: It was a descriptive cross sectional study conducted at Paediatric Cardiology, Paediatric Cardiac Surgery and Obstetric department of AFIC/NIHD. After taking informed consent, a total of 1344 patients fulfilling inclusion and exclusion criteria with non probability consecutive sampling were enrolled in study from 2011 to 2021. Diagnosis, transthoracic echocardiography findings, procedural details (cardiac catheterization/cardiac surgery/obstetrical intervention) and outcome of all patients were noted. Results: Out of 1344 patients, 700 patients had cardiac catheterization. Among patients who underwent cardiac cath, 304(43%)were males and 396(56.6%) were females. 279(39%) diagnostic and 421(61%) cardiac interventional procedures were done.Most common procedure done was ASD device closure in 227(32%) patients. Complications were seen in 29(4%) patients and mortality in 3(0.4%) patients. There were a total of 188 patients who underwent congenital cardiac surgery. Out of patients who underwent congenital cardiac surgery procedures, 96(51%) were male and 92(49%) were female patients. Major complications were observed in 51(25%) patients and the mortality was 11(5%).There were total of 456 patients in obstetrics department. Out of 456 patients, 54(11%) were with congenital cardiac lesions .The most common defect was VSD 27(6%)patients and dilated cardiomyopathy (DCM) 27(6%) patients followed by ASD and TOF. The maternal and fetal mortality was12(2.7%) and 22(5.5%) respectively. Conclusion:With immense advancement in diagnosis and management of congenital cardiac diseases, a significant number of patients remain undiagnosed and untreated till the time they present as GUCH. Most common presentation is ASD which is mostly manageable by transcatheter intervention, however late presentation carries a risk of complications like pulmonary hypertension.

The no reflow phenomenon is a feared complication in Percutaneous Coronary Intervention (PCI) procedures including elective as well as primary PCI (Percutaneous Coronary Intervention), and results in worse prognosis. A number of etiological factors are involved in pathogenesis of no reflow phenomenon. These include distal athero embolization, ischemic and reperfusion injury, microvascular spasm and endothelial dysfunction. The treatment of no reflow depends on underlying mechanism and includes pharmacological as well as non-pharmacological interventions. Pharmacological agents include vasodilators like adenosine, sodium nitroprusside, verapamil, in addition to adrenaline (intracoronary) and, GpIIa/IIIb inhibitors. Non pharmacological measures include mechanical thrombus aspiration. Among pharmacological agents, Verapamil is usually the least preferred agent because of its negative ionotropic effect. Here, we describe a case of refractory no reflow in a patient undergoing primary PCI to right coronary artery (RCA), which was treated with a no. of pharmacological agents as well as aspiration thrombectomy but without much success and finally responded to intracoronary verapamil.

Objective: To determine the frequency and pattern of various congenital heart diseases in a tertiary care hospital neonatal unit. Study Design: Prospective longitudinal study. Place and Duration of Study: Neonatal Unit of Pak Emirates Military Hospital, Rawalpindi Pakistan from Jul 2015 to Jun 2018. Methodology: All neonates admitted to the Neonatal Unit of Pak Emirates Military Hospital, Rawalpindi Pakistan, suspected of having congenital heart disease were included in the study. Suspicion for CHD was based on the presence of murmur, cyanosis with or without feeding difficulty, signs of congestive heart failure, and variation in pre and post-ductal SpO2 reading. Echocardiography was performed on all neonates by a Paediatric cardiologist to determine diagnosis and type of lesion. Results: One hundred and thirty-one neonates were found to have congenital heart disease with male predominance, with 79(60.3%) males and 52(39.7%) females. Ventricular Septal Defect (VSD) was the most common lesion occurring in 44(33.6%) neonates, followed by PDA in 28(21.37%) neonates. CHD occurred more frequently in term neonates (62.0%) than preterm neonates (38.0%). Conclusion: Congenital heart disease is the most common congenital malformation, with Asia having the highest prevalence worldwide. Lack of specialized antenatal and neonatal health services and paucity of diagnostic facilities lead to delays in diagnosis, increasing morbidity and mortality of CHD cases. Therefore, drastic measures are required to improve neonatal health and transport facilities in our country to mitigate the impact of this disease.

Objective: To determine the association of mean platelet volume with diabetic retinopathy in our population. Study Design: Cross sectional study. Place and Duration of Study: Department of Hematology & Ophthalmology, Combined Military Hospital Lahore, from Jul to Dec 2020. Methodology: A total of 146 known patients with type 2 diabetes were enrolled in this study. They included 78 patients with diabetic retinopathy (group 1) and 68 without diabetic retinopathy (group 2). Five (5ml) of whole blood was extracted from patients through clean venipuncture in a tube containing EDTA and mean platelet volume was generated through automated haematological analyzer Sysmex KX-21 and HbA1c was generated through automated analyzer Cobas c501. Result: A total of 146 patients with type 2 diabetes were included in this study. The age of patients ranged from 25-70 years (Mean age: 53.3 ± 0.02 years). Out of 146 patients 66 (45.2%) were males and 80 (54.8%) were females. Among patients with type 2 diabetes 78 (53.4%) has retinopathy while 68 (46.6%) have no retinopathy. A statistically significant difference (p

Abstract Objective: To determine the sensitivity, specificity, positive and negative predictive values using secondary Ultrasound features of inflammation, in suspected patients of acute appendicitis Study Design: Cross sectional validation study. Place and Duration of Study: Radiology department, Combined Military Hospital Bahawalpur, from Apr 2016 to Mar 2017. Methodology: A total of 178 suspected patients of acute appendicitis having right lower quadrant pain were referred for ultrasound. Patient’s ages ranges from 5-55 years. Primary and secondary signs of inflammation of acute appendicitis were assessed on ultrasound. Patient having positive primary sign alone or at least two or more secondary signs were labeled as acute appendicitis and underwent surgery. Statistical data was analyzed using Medcalc 17.5.5. Results: When only Secondary sonographic signs of inflammation were considered in suspected cases of acute appendicitis, then Sensitivity was 88.2%, specificity 72.5%, positive predictive value 81.1%, accuracy 81.5% and negative predictive value was 82.2%. Sensitivity and accuracy were increased to 93.7% and 87.6% % respectively, when primary and secondary signs were considered collectively. Conclusion: Ultrasound examination should be the first imaging modality to be carried out in suspected cases of acute Appendicitis with particular emphasis on secondary ultrasound features, as primary features are not always present. Presence of both these signs confidently diagnose Acute Appendicitis.

Abstract Objective: To measure incidence of COVID-19 vaccine breakthrough infections among health care workers vaccinated with both doses of Sinopharm Vaccine. Study Design: Prospective cohort study. Place and Duration of Study: All Military Institutes of Pakistan, from Feb to Jun 2021. Methodology: Detailed surveillance mechanism was developed before the start of Health Care Workers vaccination in Pakistan Military to report any PCR positive COVID-19 infection post vaccination. Among 39512 health care workers vaccineted with both doses of COVID-19 vaccine; those who developed COVID-19 infection ≥14 days post 2nd dose were included in the study. Total 124 participants till 30 Jun 2021 fulfilled the criteria of COVID-19 vaccine breakthrough infection and were analyzed. Results: Mean age of the participants was 38.8 ± 11 years. Males were 69.4% while females were 30.6%. Median duration from 2nd dose to development of COVID-19 vaccine breakthrough infection was 36.5 days (IQR, 26-62). Asymptomatic/mild infections were reported among 94.4% and only 5.6% had moderate disease. No severe/critical disease requiring oxygen supplementation or ventilator support was observed. Recovery rate was 100% with no mortality. There was no significant statistical association of age, gender, job category with COVID-19 vaccine breakthrough infection (p>0.05). Conclusion: Vaccines remain an important weapon in the battle against COVID-19. No vaccine is 100% effective against all strains of COVID-19; however among the completely vaccinated health care workers less severe disease was observed. There was no mortality.

Objective: To assess morbidity and success of transabdominal (O’Conor) repair of vesicovaginal fistula with or without interposition of flap between vagina and urinary bladder. Study Design: Prospective comparative study. Place and Duration of Study: Armed Forces Institute of Urology, Rawalpindi, from Mar 2016 to Jan 2019. Methodology: Fifty five patients were randomized into group A & B by lottery method. An inclusion criterion was single fistulous opening of ≤3cm. Complex and recurrent fistulae were excluded. Patients in group A underwent O’Conor repair without interpositional flap while in group B vesicovaginal fistulae were repaired with flap interposition. Results: Twenty two patients were randomized in group A while 27 in group B. Mean age of patients was 41.65 ± 11.93 years. Gynecological and obstetrical surgery was the main cause of fistula. Mean duration of surgery was 162.7 ± 18.49 minutes. Per-operative ureteric catheterization was done in 9 (16.8%) patients. Seventeen (30.6%) patients had paralytic ileus. There was transient fever in 4 (7.6%) of cases and wound infection was seen in 3 (5.8%) of patients. Mean hospital stay was 3.4 ± 2.3 days. Cystogram was done in 35 (64.5%) of patients before the removal of per-urethral catheter. The overall success rate was 92.9%. Ten (18.2%) of patients developed denovo urgency which was managed conservatively. There was no statistical difference in both groups in terms of morbidity and success. Conclusion: In simple Vesico-vaginal fistulae repair, interposition of flap can be omitted and it does not affect the outcomes in terms of success and morbidity.

Objective: To compare lipid profile in patients with diabetic neuropathy and without neuropathy. Study Design: Cross-sectional comparative study. Place and Duration of Study: This study was carried out at Multidisciplinary Lab-1, Department of Biochemistry and Molecular Biology, Army Medical College, from Jan 2020 to Sep 2020 in collaboration with Pak-Emirates Military Hospital, Rawalpindi. Methodology: Eighty-four subjects were selected and divided into three groups, twenty-eight in each. Group I included diagnosed patients with type 2 diabetes mellitus with peripheral neuropathy, group II included diagnosed patients with type 2 diabetes mellitus without peripheral neuropathy and group III consisted of healthy individuals. Biochemical parameters including total cholesterol, triglycerides, high density lipoprotein cholesterol and low density lipoprotein cholesterol were measured. Data was analyzed by SPSS version 22.0. One way ANOVA test was used that followed by post-Hoc Tukey test for group comparison. Results: There was significant difference in triglycerides (p-value 0.001) and high density lipoprotein cholesterol (0.003) levels among group I and III. While, between group II and III significant difference of high density lipoprotein cholesterol was present. There was no significant difference between group I and II regarding all lipid profile parameters. Conclusion: There was significant increase of triglycerides levels and decrease of high density lipoprotein cholesterol in patients with diabetic peripheral neuropathy as compared to healthy controls. No significant difference was observed for all parameters of lipid profile between patients with diabetic peripheral neuropathy and without peripheral neuropathy.

Objective: To explore the prokinetic effect of Ranitidine, to compare it with the prokinetic effect of Neostigmine and to observe the potentiating prokinetic effect of Ranitidine and Neostigmine in combination. Study Design: Randomised controlled trial (experimental study). Place and Duration of Study: Multi disciplinary centre, Army Medical College, Rawalpindi, from Jan to Dec 2015. Methodology: Experiments were performed on three groups of rabbits (n=6) and Cumulative dose response curves were plotted using isolated duodenal tissue on power lab (USA). In the first two groups of experiments, cumulative concentrations of Neostigmine and Ranitidine were studied separately with neostigmine acting as a control and in the third group the potentiating effect of a fixed dose of ranitidine on neostigmine was evaluated. Results: Neostigmine’s response was taken as 100 percent and Ranitidine’s response when compared to it came out to be 197 percent. The dose response curve of Neostigmine was shifted to the left and upwards in the presence of Ranitidine. The percent response with Neostigmine alone was taken as 100 percent and increased to 212 percent when the tissue was pre-treated with Ranitidine. Conclusion: Our study has indicated that Ranitidine has marked prokinetic effect which is found to be greater than Neostigmine. It is also inferred that Ranitidine can potentiate the prokinetic effect of Neostigmine.

Objective: To find out the frequency of thrombocytopenia and prolonged bleeding time in dengue fever and its effect on clinical outcome of patients. Study Design: Cross-sectional study. Place and Duration of Study: The study was conducted, from August 2016 to February 2017 in the Haematology department, at Pakistan Naval Ship (PNS) Shifa, Karachi. Methodology: The study was conducted on serologically proven positive dengue IgM cases fulfilling inclusion and exclusion criteria. Platelet count was done on Beckman Coulter and Sysmex analyzers and then rechecked manually by peripheral blood smear. Bleeding time measured by the Duke method. The clinical outcome was evaluated on the day of discharge (based on survival of the patient and their lab values) or the patient expired and their lab values. Results: A total of 135 patients were evaluated in the study. The mean age of the patients was 29.12 ± 13 yrs (range: 2-63 years). The thrombocytopenia was observed in one hundred and eleven (82.2%) patients. Severe thrombocytopenia was observed in nine (6.7%) cases, moderate thrombocytopenia was found in thirty (22.2%) cases and mild thrombocytopenia was observed in seventy-two (53.3%) cases. Bleeding time more than nine minutes was observed only in one case. Out of 135 patients, two (1.48%) expired and one hundred and thirtythree (98.52%) survived and were discharged. Conclusion: We observed that platelet count can be a predictor of disease and its progression, but the absence of either cannot be used to exclude the progression of the disease. Dengue continues to be a significant health problem in Pakistan.

Objective: To evaluate the up gradation of obstetric patient care by using obstetrics-specific triage acuity tool. Study design: Comparative prospective study Place and duration of study: This study was conducted at obstetrics unit of combined military hospital Kharian from June 2018 to Dec 2018. Methodology: Pregnant patients were triaged and prioritized according to Maternal fetal triage index (MFTI) into five levels. Primary outcome was time to triage and management plan documentation. Patient and health care provider satisfaction was evaluated using Likert’s scale before and after implementation of MFTI. Data was collected and expressed in frequencies and percentage. Chi square test was applied for association between before and after triage intervention variables, and a P value of 0.05 was considered significant. Results: A total of 1000 pregnant patients referred to OPD were enrolled, 500 patients before and 500 after implementation of MFTI. Patients were prioritized using MFTI system,10(2%) patients category 1 while category 2,3,4,and 5 were 28(5.6%),68(13.6%),150(30%) and 244(48.8%) respectively. There was significant reduction in waiting time from 35.4±8.2 minutes to18.2±6.5 p=

Objective: To determine different treatment options in patients of Patent Ductus Arteriosus with pulmonary hypertension beyond neonatal period. Study Design: Descriptive cross sectional study. Place and Duration of Study: This study was carried out in Pediatric Cardiology department of Rawalpindi Institute of Cardiology, from Jan 2017 to Jan 2019. Methodology: Patients having PDA with pulmonary hypertension were included in the study. Treatment options were divided into percutaneous catheter device closure, surgical ligation of patent ductus arteriosus and palliative treatment. Any adverse event during the procedure was documented. Stratification was done in regard to gender and age group. Post stratification chi square test was applied and p-value less than or equal to 0.05 was considered as significant. Results: Total number of patients included in the study were 37. Mean age (years) of patients (Mean ± SD) was 19.21 ± 8.76. Mean ± SD pulmonary artery pressure was 56.43 ± 11.55 mmHg. Percutaneous catheter device closure was successful in 24 (64.9%) patients, in 7 (18.9%) patients primary surgical PDA ligation was done, 3 (8.1%) patients were advised palliative treatment and in 3 (8.1%) patients adverse events occurred during percutaneous device closure and were thus referred for surgical ligation. Patent ductus Arteriosus Occlutech device was used in 18 (48.6%) patients, Occlutech VSD device was used in 7 (18.5%) patients and in 1 (2.7%) patient AGA duct occluder was used. Conclusion: In patients with patent ductus arteriosus and pulmonary artery hypertension, percutaneous catheter device closure is a safe and effective procedure.

Objective: To determine the frequency of congenital cardiac lesions in pregnant women reporting for fetal echocardiogram and correlate with obstetrical risk factors. Study Design: Descriptive cross-sectional study. Place and Duration of Study: To be conducted at pediatric cardiology and obstetrical unit of AFIC/NIHD and CMH Rawalpindi, from Jan 2009 to Jan 2020. Methodology: Pregnant women referred for fetal echocardiogram from 19-49 years of age were enrolled. Echo was done between 20 to 36 weeks gestation. Primary outcome was the nature of cardiac lesion and gestation at diagnosis. Neonatal scan was done at follow up to confirm cardiac diagnosis. Secondary outcome was obstetrical risk factors which were the reason for referral. This included age consanguinity, family history, previous history of intrauterine death or early neonatal death, maternal and paternal diseases. Data was collected and analyzed n frequencies and percentage. Chi-square was applied for association between variable and p-valve 0.05 was considered significant. Results: A total of n=967 pregnant women referred to outpatient department for fetal echocardiogram. Congenital cardiac lesion were detected in n=83 patients. Majority of patients had CAVSD (1.2%) CCAVB (1.2%) followed by ASD (1.1%) VSD (0.9%) Abnormal heart rate (0.8%) Single ventricle (0.3%). Most significant maternal age group was between 21 to 30 and 30-40 years (43.7 and 46.2%). Only 3% below 20 years and 6.7% above 40 years of age. Most important maternal risk factor was previous off spring 0.5% past family history 0.3% and abnormal obstetrical ultrasound 0.3% Followed by maternal diabetes 0.1% and maternal hypertension 0.1%. The yield of detection of congenital cardiac lesions was 8.3%. Conclusions: Congenital cardiac diseases are the second most common congenital anomaly and huge burden n pediatric population. Timely diagnosis and referral can be lifesaving.

Objective: To compare the adequacy of preparation for colonoscopy using polyethylene glycol with lactulose. Study Design: Quasi experimental study. Place and Duration of Study: Department of Gastroenterology, Combined Military Hospital Lahore, from Jul 2019 to Dec 2019. Methodology: The enrolled patients were randomized into two equal groups. Group A received polyethylene glycol (PEG) formulation containing 13.125g x 24 sachets with 4 liters of water over 24 hours, group B received lactulose 600ml (66.7g/100ml) with 4 liters of water over 24 hours. Quality of bowel preparation was assessed using Ottawa scoring system (OBPS). A designed questionnaire was used for recording patients’ tolerability toward the preparation method. Questionnaire was filled pre and post-procedure for socio-demographic data and scores. Patients were also assessed for tolerability of procedure and palatability of the solutions by questionnaire. Results: The median age of patients in group A was 49 (26 IQR) years and in group B was 48 (18.5 IQR) years. Out of 100 patients 60% were males and 40% were females. The most common indication of colonoscopy was anemia (32%), followed by diarrhea (26%), bleeding per-rectum (24%) and constipation (18%). Polyethylene glycol showed better bowel cleansing score compared with lactulose (p

Objective: To compare serum ferritin levels in pregnant women with and without gestational diabetes mellitus. Study Design: Comparative cross sectional study. Place and Duration of Study: Physiology Department, Army Medical College in collaboration with Pak Emirates Military Hospital, Rawalpindi, from Mar to Nov 2019. Methodology: Pregnant females after twenty four weeks of gestation were subjected to oral glucose tolerance test. Thirty healthy pregnant females with normal glucose tolerance test and thirty patients of gestational diabetes mellitus were selected. The diagnosis of gestational diabetes mellitus was based on International Association for Diabetes and Pregnancy Study Group (IADPSG) criteria. Serum ferritin levels of all the subjects were evaluated using electrochemiluminescence immunoassay. Data were analyzed using statistical package for social sciences (SPSS) version 22. Quantitative variables were expressed as mean ± SD. The two groups were compared using independent samples t test. Pearson correlation coefficient was used to assess the association between different quantitative variables. A p-value of ≤0.05 was considered significant. Result: Mean serum ferritin levels were significantly higher in women with gestational diabetes mellitus (49.61 ± 42.43 ng/mL) compared with healthy controls (18.30 ± 15.7 ng/mL). Moreover, serum ferritin levels correlated positively with fasting plasma glucose, 1 hour and 2 hour post prandial plasma glucose as well as hemoglobin (p-value

Objective: To find the appropriate skills which a surgery resident should have acquired at the end of the first year of training. Study Design: Descriptive study. Place and Duration of Study: Department of Surgery Combined Military Hospital Rawalpindi (CMH), from Jan 2008 to Mar 2009. Methodology: The study was conducted at CMH Rawalpindi to find the important skills expected to be acquired by a general surgery trainee at the end of first year of training. Important attributes/traits expected to be present in a surgery trainee were chalked out (after consultation with surgical supervisors). A questionnaire was formulated for ranking of each trait. Importance of each skill was assessed on an arbitrary scale ranging from 1 to 10 where, 1 stood for „irrelevant‟ and 10 meant „absolutely essential‟. Each numerical rank of a quality was accompanied by a box to be ticked. It was sent by postal mail to 29 general surgery supervisors, all registered with CPSP, serving in Pakistan Army Medical Corps in all four provinces of Pakistan. Twenty two consultants (76%) responded to the questionnaire. The weightage/value assigned to each item was analyzed using statistical package for the social sciences software for Windows 16. Results: Skills rated as most important by the supervisors surveyed came from the domains of clinical and team work skills. The team work skill of „Seeks advice when beyond limit of competence/when in doubt‟ was rated the most important of all 77 skills; with 68.20% of supervisors claiming it was „absolutely essential‟. Conclusion: Assessment of surgical trainees during training needs to be done objectively. An effort has been made to objectively define the qualities/skills according to which a trainee can be assessed and may be use a template for formulating further research and assessment criteria.

Objective: To determine the changes in liver function tests if any in patients of COVID-19. Study Design: Cross sectional study. Place and Duration of Study: Combined Military Hospital Lahore, from Apr 2020 to Jun 2020. Methodology: A total of 209 confirmed cases of COVID-19 positive by RT-PCR patients presenting to Combined Military Hospital, Lahore were included in the study. Their demographic details were recorded. Patients were grouped into mild- moderate and severe disease groups according to the symptoms, complications and oxygen or ventilation requirements. Liver function tests of all these patients were advised. Results: Amongst confirmed COVID-19 patients, 187 (89.5%) had mild to moderate disease whereas 22 patients (10.5%) had severe disease. Liver test abnormalities were defined as the elevation of the following liver enzymes in serum: ALT >42 U/L, AST >45 U/L, GGT >49 U/L, ALP >300 U/L, albumin17.1. In LFTs, Bilirubin was increased in 20 (9.6%) patients), ALT in 32 (15.3%) patients, of which 8 had severe disease, 38 patients having high AST levels (>45) 28 had mild-moderate disease and 10 had severe disease. ALP was raised in 24 (11.5%) patients with 8 being in severe disease and rest in mild moderate disease. Albumin was low in 35 (16.7%) patients of which 12 had severe disease and 23 had mild-moderate disease. Conclusion: About 15-20% of the confirmed cases of COVID-19 have deranged liver function tests and it correlates with severity of the disease.

Objective: To validate if Neutrophil-to-Lymphocyte ratio (NLR), Platelet-to-Lymphocyte ratio (PLR) or CALL score (a novel scoring model) predict worse prognosis such as need for Intensive Care Unit (ICU) Admission and Mortality in COVID 19 patients. Study Design: Prospective observational cohort study. Place and Duration of Study: Combined Military Hospital Lahore, from Mar 2020 to May 2020. Methodology: Consecutive symptomatic patients with confirmed COVID-19 infection by RT-PCR were included. Patients’ age, gender, comorbids and labs data including complete blood counts and serum LDH was recorded. neutrophil-to-lymphocyte ratio, platelet-to-lymphocyte ratio and CALL Score were calculated. Main outcomes were need for Intensive Care Unit Admission/ventilator support and mortality. Results: A total of 125 patients were admitted with the diagnosis of COVID-19 infection. There were 35 (28%) Intensive Care Unit admissions, 17 (13.6%) required mechanical ventilation and 17 (13.6%) patients were deceased. Regression Analysis was done. For Intensive Care Unit Admission/ventilator support significant predictors were neutrophil-to-lymphocyte ratio (p=0.03), age greater than 50 (p=0.02), moderate CALL score (p=0.02) and high CALL Score (p=0.004). For hospital deaths, significant predictors included neutrophil-tolymphocyte ratio (p=0.001) and age more than 50 years (p=0.01), CALL Score was not significant (p=0.3 & 0.9). Platelet-to-lymphocyte ratio (p=0.9 and 0.8) and Diabetes (p=0.1 & 0.6) were not significant. Conclusion: Neutrophil-to-lymphocyte ratio and age more than 50 years are significant predictors for need for Intensive Care Unit Admission or Ventilatory support and in-hospital mortality. High CALL Score is a significant predictor of Intensive Care Unit Admission or ventilator support but not for in hospital mortality.

Objective: To determine the clinical course and outcome of hospitalized pregnant patients with laboratory confirmed SARS CoV-2 (COVID-19) infection. Study Design: Prospective observational study. Place and Duration of Study: Obstetrics Unit of Pak Emirates Military Hospital (PEMH) and Combined Military Hospital (CMH) Rawalpindi, from May 2020 to Jun 2020. Methodology: All patients reporting for childbirth were tested for SARS CoV-2 and those testing positive were included. Demographic and reproductive profile including age, parity, occupation, contact and travel history, period of gestation at diagnosis and mode of delivery where applicable noted. The primary outcome was Virus clearance time and categorization according to severity of disease into asymptomatic, mild, moderate, severe and critical. Comparison was done between presence of co-morbid conditions and symptoms to category of COVID19. Neonatal sample evaluation for SARS CoV-2 was done. Results: Out of the 881 women giving birth 41 (4.6%) tested positive for SARS Cov-2. Majority were asymptomatic 28 (68.3%) followed by mild 08 (19.5%), moderate 04 (9.8%) and severe 01 (2.4%) category. There was significant association of COVID category with presence of symptoms (p-value