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Gastroenteritis is one of the most common diseases that affects children and remains a leading cause of morbidity and mortality around the world. There is conflicting evidence regarding the effect of rapid intravenous fluid regimen on the clinical outcome of patients with acute gastroenteritis. This study aimed to assess the current practice of intravenous hydration on the clinical outcomes of pediatric patients with acute gastroenteritis and determine the predictive factors for early discharge and emergency department (ED) revisit.A cohort study was carried out among children aged from 1 month to 14 years who presented to the ED in a tertiary care hospital between September 2015 and September 2017. Children diagnosed with acute gastroenteritis and moderate dehydration who require intravenous hydration were included in the study. The patients were followed up until discharge from ED, admission to the hospital or revisit to the ED. Collected variables were demographics, presenting symptoms, biochemical marker, amount of intravenous fluid (IVF) received and prescription of anti-emetics. Descriptive statistics were summarized as mean, standard deviation for continuous variables and proportions for categorical variables. Logistic regression was used to identify risk factors.Out of 284 patients, 148 (52%) were males, 20 (7%) were infants, 80 (28%) were toddlers, 90 (32%) were in preschool, 88 (31%) were in school and 6 (2.1%) were adolescents. No significant difference was observed in the admission rate, discharge within 12 h or less and ED revisits for those who received IVF ≥40 ml/kg as compared to those who received40 ml/kg. Patients with bicarbonate level closer to normal are more likely to be discharged after 4 h (odds ratio (OR) 1.2 and 95% CI 1.12-1.43). Patients presenting only with vomiting/diarrhoea were less likely to revisit ED (OR 0.33 (95% CI 0.143 - 0.776), while patients with an increase in COThis study did not show any additional benefits of receiving IVF ≥ 40 ml/kg over 4 h neither in early discharge nor in reducing the ED revisit. CO

Introduction The reuse of cardiac implantable electronic devices may help increase access to these therapies in low- and middle-income countries (LMICs). No published data exist regarding the views of patients and family members in LMICs regarding this practice. Methods and Results A paper questionnaire eliciting attitudes regarding pacemaker reuse was administered to ambulatory adult patients and patients’ family members at outpatient clinics at Centro Nacional Cardiologia in Managua, Nicaragua, Indus Hospital in Karachi, Pakistan, Hospital Carlos Andrade Marín and Hospital Eugenio Espejo in Quito, Ecuador, and American University of Beirut Medical Center in Beirut, Lebanon. There were 945 responses (Nicaragua – 100; Pakistan – 493; Ecuador – 252; Lebanon – 100). A majority of respondents agreed or strongly agreed that they would be willing to accept a reused pacemaker if risks were similar to a new device (707, 75%), if there were a higher risk of device failure compared to a new device (584, 70%), or if there were a higher risk of infection compared to a new device (458, 56%). A large majority would be willing to donate their own pacemaker at the time of their death (884, 96%) or the device of a family member (805, 93%). Respondents who were unable to afford a new device were more likely to be willing to accept a reused device (79% vs. 63%, P

Introduction There are limited studies on the burden of sepsis, from low to middle income countries (LMIC). We had carried out an analysis of the epidemiology of sepsis, in our hospital, a tertiary care university hospital in Pakistan, based on ICD-9 coding. Materials Retrospective data from electronic discharge records of all patients aged 17 or above, admitted with sepsis from January 2013–January 2014, at our hospital was taken. A validated method requiring a combination of two ICD-9 codes (international classification of diseases, ninth revision, clinical modification) representing infections and acute organ dysfunction, based on the Angus and Martin methodology, along with ICD-9 codes for sepsis, severe sepsis and septic shock, were used to abstract data. Results Overall, 8759 patients were identified to have sepsis or severe sepsis, out of total 31,111 admissions between 2013 and 14. Out of these cases, 61.25% (5365) had sepsis while 38.75% (3394) had severe sepsis or septic shock. Out of the total 8759 patients, 58.10% (5089) remained in the ward. 31.93% (2797) utilized the intermediate Care Unit while 9.97% (873) utilized the Intensive Care Unit (ICU). The overall mortality with sepsis, was found to be 9.8% and mortality from septic shock to be around 22.8%. The common comorbidities were diabetes (22.8%), renal disease (14.7%) and COPD (14.7%). The mean length of hospital stay was 3.7 days in mild disease, compared to 7.5 days, in severe sepsis and septic shock group. Conclusions The first ICD -9 coding-based study signifies a high burden of disease, along with high mortality from septic shock.

Incidence of colorectal cancer has surged in the past few decades, currently it accounts for approximately 10% cancer related mortality. Upfront curative surgery is the main stay of treatment for localized disease followed by adjuvant chemotherapy for high-risk disease; however, neo adjuvant chemoradiation followed by surgery and chemotherapy is a standard treatment for rectal cancer. Here, we present a case of a young male aged 33 years with eight months’ history of per rectal bleeding, associated with fever and weight loss who was later diagnosed as sigmoid colon adenocarcinoma. The patient managed to have only one cycle of neoadjuvant capecitabine, as his definitive surgery was delayed due to the rife in pandemic situation of Covid-19. Notably, follow up laparoscopic LAR specimen showed no residual disease, nevertheless, there was an eosinophilic abscess with a giant cell reaction and Ova of Ascaris lumbricoides, which seemingly contributed in achieving pathological complete response with minimal therapy.

Background: Systemic chemotherapy is the standard of care for patients with metastatic breast cancer, with an undecided role in surgery. Limited data is available for the role of surgery on the overall survival of stage 4 breast cancer regarding luminal subtypes of patients. This is a retrospective data analysis comparing overall survival benefit and disease-free survival in stage IV breast cancer after systemic treatment and systemic disease control concerning luminal classification in the last five years. Method: Patients who had surgery and no surgery after systemic treatment and disease control were compared for 5 years overall survival as the primary endpoint and disease-free survival as the secondary endpoint. The survival benefit was also compared regarding tumor biology (ER/PR, HER2 status). Results: Data included 421 patients, 237 in surgery and 184 in no surgery group. At one year survival for surgery performed and not performed was not significant. Five-year overall survival for surgery performed and not performed was 84.4% and 74.5%. A statistically significant difference in survival rates was observed (p

Background and objectives Anemia is a prevalent complication endured by patients with chronic renal disease. Renal anemia also leads to the development of cardio-vascular complications. Epoetin alpha and beta are recombinant human erythropoietin prioritized for managing anemia in hemodialysis patients. The current study aimed to compare the therapeutic efficacy of both erythropoietin alpha and erythropoietin beta in treating renal anemia. Materials and methods This prospective observational study was conducted in a Renal Dialysis Centre at a tertiary care Hospital of Karachi, Pakistan for a period of 3 months. The two erythropoietin products used were human recombinant erythropoietin alpha (Tropin®) and erythropoietin beta (Recormon®). Both groups were age-matched, BMI, eGFR, gender, and comorbidities like diabetes and hypertension were indifferent. The comparative analysis was performed after the completion of 3 months. Results A total of 94 participants were included in the analysis, 54 in group A and 40 in group B. Mean albumin, urea, creatinine, ferritin, iron, and transferrin saturation at inclusion were statistically insignificant, TIBC was higher in group A (p = 0.005) and CRP levels were slightly higher in group B (p = 0.050). There was significant improvement in Hb level (p = 0.025), PCV (p = 0.001), and RBC count (p = 0.007) in group B. While in group A, there was significantly increased MCV (p = 0.005) and MCHC (p = 0.002). In intention to treat analysis, 22.2% of subjects in group A and 40.0% in group B reached desired Hb levels of ≥11 g/l after 3 months. Conclusion In our assessment of hemodialysis patients, erythropoietin beta was found more effective than erythropoietin alpha.

Objective: To determine the impact of antenatal care on maternal morbidity. Study Design: Comparative cross-sectional study. Place and Duration of Study: Obstetric Departments of three military hospitals in Northern Punjab cities of Rawalpindi, Jehlum and Mangla, from Jan to Mar 2019. Methodology: Data of all mothers who gave live births in the selected military hospitals were collected. These mothers were classified as booked and unbooked on the basis of number of antenatal care visits. Maternal morbidities and complications of pregnancy were recorded. The data were analyzed using Statistical Packages for Social Science (SPSS) version 20. Results: In our study, 254 (8.8%) of mothers were unbooked, 2273 (78.8%) were partially booked and 358 (12.4%) were booked. 894 (31%) mothers did not have any co-morbidity while 1991 (69%) mother had co-morbidity. Out of 749 (27.5%) mothers had anaemia, 869 (30.1%) had hypertension, 141 (30.1%) had diabetes mellitus, 24 (0.8%) cardiac disease, 39 (1.4%) had tuberculosis, 9 (0.3%) had liver disease 13 (0.5%) had kidney disease, 69 (2.4%) had allergies while 33 (1.1%) had other diseases. These complications were significantly greater in unbooked patients as compared to booked patients (p

Objective: To determine the taboos and myths regarding breastfeeding practices in our pregnant population. Study Design: Cross-sectional study. Place and Duration of Study: Obstetrics and Gynecology Department, Fauji Foundation Hospital, Rawalpindi Pakistan, from May to Oct 2018. Methodology: A total of 100 pregnant women attending antenatal clinics were included in the study using non-probability purposive sampling technique. Taboos and myths regarding breast feeding practices were determined using self-administered questionnaire on 2-point Likert scale (1=agree & 2=disagree). Results: A total of 100 pregnant women participated in the study. Mean parity was 2.89 ± 1.75 and gravidity was 4.17 ± 2.04. Most of the mothers (90%) were house wives and received information regarding breast feeding from family members (81%). Mothers were aware of the nutritious value of breast milk as compared to formula milk. However, there were myths that were not evidence based. These include: breasts sag with breast feeding (48%), it is not necessary to breast feed the baby during night time (43%), breast milk alone was not sufficient to satisfy the child (51%), small size breast produce insufficient milk (27%). Conclusion: Participants of this study are aware of the importance of breast feeding. However, there are certain taboos and myths prevailing in our population which are not proven scientifically.

Objective: To study the serum sodium levels in patients of lower respiratory tract infections admitted in the paediatric intensive care unit with their prognosis. Study Design: Prospective observational study. Place and Duration of Study: Pak Emirates Military Hospital Rawalpindi, from Jan to Jun 2018. Methodology: Eighty patients suffering from lower respiratory tract infections who were admitted to the paediatric intensive care unit were selected at consecutive sampling. The outcome was recorded in the form of discharge or mortality. Serum sodium was done at the time of admission and then periodically after every 24-48 hours. The Association of patients’ serum sodium with their prognosis was studied using chi-square test and p-value was calculated. Results: A total of 80 patients were enrolled in our study out of which 50 (62.50%) were males and 30 (37.50%) were females. Out of the total, 48 patients suffered from hyponatremia. These 48 patients had a mean serum sodium concentration of 131.24 ± 3.31 mEq/L. The mean age of patients suffering from hyponatremia was 5.78 ± 3.4 years. Mortality occurred in 5 (80.12%) of patients suffering from severe hyponatremia. Conclusion: There was a significant association of hyponatremia with mortality in children admitted in paediatric intensive care settings with lower respiratory tract infections. Therefore, proper management hence correction of serum sodium levels can improve survival in, particularly children admitted in a pediatric intensive care setting.

Study Objective To assess postoperative management of pediatric patients with benign ovarian neoplasms, to develop recommendations for postoperative care. Design A retrospective cohort study. Setting Eight pediatric hospitals in the midwestern United States. Participants Patients up to 21 years of age who underwent surgery for a benign ovarian neoplasm between January 2010 and December 2016 were included. Interventions No prospective interventions were evaluated. Main Outcome Measures Main outcome measures included postoperative imaging findings, recurrence rates, reoperation rates, and the timing of the aforementioned results. Results A total of 427 patients met inclusion criteria. After the index surgery, 155 patients (36%) underwent a routine imaging study. Among those with routine imaging, abnormalities were noted in 48 patients (31%); 7 went on to have reoperation (5%), and no malignant pathologies or torsion were identified. Excluding the 7 patients who went on to have a reoperation as a result of routine imaging, 113 patients developed symptoms postoperatively and underwent imaging as a result (27%, 113/420). Abnormalities were noted in 44 (10%); 15 of these patients underwent reoperation (4%), among them 2 with malignancies and 3 with torsion. Of these 44 patients, 23 had initially undergone routine imaging and subsequently went on to have symptomatic imaging, with 17% (4/23) undergoing reoperation. Conclusions Routine imaging did not identify malignancy; most lesions identified on routine imaging were incidental findings. Although the study was not powered to appreciate a statistically significant difference, patients with malignancy or torsion were identified in the symptomatic group. This suggests no benefit from routine imaging, and supports symptomatic imaging postoperatively to minimize costs and patient/family burden.

There is a scarcity of data summarizing the clinical picture, laboratory, and imaging findings and outcome in children with malignancy and coronavirus disease 2019 (COVID-19) infection. This study characterizes a detailed comparison of pediatric oncology patients with and without COVID infection. A retrospective study was conducted at The Indus Hospital, Karachi, from March 2020 to June 2020. Clinical presentation, laboratory and imaging findings, disease severity, and outcome were compared between cohorts. The mean age of children with and without COVID was 8.0±4.9 and 7.4±4.1 years, respectively. Hematologic malignancy comprised the largest number of patients, followed by solid tumors. Lymphocytosis and low neutrophil-lymphocyte ratio was observed in the COVID positive group. Cardiac dysfunction (1.4% vs. 0%), acute respiratory distress syndrome (8% vs. 0%) and lower peripheral capillary oxygen saturation/fraction of inspired oxygen ratio (473 vs. 486) found to be associated with severe disease in COVID positive group (P

Background The objective of our study was to describe the workup, management, and outcomes of pediatric patients with breast masses undergoing operative intervention. Materials and methods A retrospective cohort study was conducted of girls 10-21 y of age who underwent surgery for a breast mass across 11 children's hospitals from 2011 to 2016. Demographic and clinical characteristics were summarized. Results Four hundred and fifty-three female patients with a median age of 16 y (IQR: 3) underwent surgery for a breast mass during the study period. The most common preoperative imaging was breast ultrasound (95%); 28% reported the Breast Imaging Reporting and Data System (BI-RADS) classification. Preoperative core biopsy was performed in 12%. All patients underwent lumpectomy, most commonly due to mass size (45%) or growth (29%). The median maximum dimension of a mass on preoperative ultrasound was 2.8 cm (IQR: 1.9). Most operations were performed by pediatric surgeons (65%) and breast surgeons (25%). The most frequent pathology was fibroadenoma (75%); 3% were phyllodes. BI-RADS scoring ≥4 on breast ultrasound had a sensitivity of 0% and a negative predictive value of 93% for identifying phyllodes tumors. Conclusions Most pediatric breast masses are self-identified and benign. BI-RADS classification based on ultrasound was not consistently assigned and had little clinical utility for identifying phyllodes.

Objective: To determine the frequency and compare serum calcium levels amongst extremely preterm and very preterm neonates. Study Design: Comparative cross sectional study. Place and Duration of Study: Combined Military Hospital, Multan Pakistan, from May to Oct 2018. Methodology: A total of 217 preterm neonates, born at Combined Military Hospital Multan up to the gestational age of 32 weeks completed from last menstrual period, were included in the study. They were divided in to two group’s i.e. very preterm and extremely preterm neonates. Those born between 28-32 weeks completed of gestation were categorized as severely preterm. Extremely preterm were those born between 24-28 weeks completed of gestation. Venous blood samples were acquired at approximately 36 hours after birth and total serum calcium levels were analyzed. Neonates having total serum calcium levels

Introduction: Shoulder joint is the third most-frequently involved structure in musculoskeletal conditions globally. More than 30 shoulder specific questionnaires have been generated in English in order to measure shoulder related quality of life and incidence of pain. Among all these questionnaires, Shoulder Pain and Disability Index (SPADI) is one of the most useful tools, therefore it has been translated, culturally adapted and validated to many languages. This study was carried out to translate and culturally adapt SPADI into Urdu language. Material & Methods: Study was conducted over a timeframe of three months, that’s March 2019 to May 2019 in Helping Hand Institute of Rehabilitation Sciences, Mansehra. Translation and cultural adaptation of Shoulder Pain and Disability Index (SPADI) was carried out according to internationally published six-step guidelines. In accordance with the provided directions a number of changes were made to the six-step guidelines. Through consensus of the expert panel, its final version was field in and tested on forty individuals with and without shoulder pathologies in an equal proportion. Results: Changes were required during each step of Beaton’s guidelines for cross-cultural adaptation. Translators during ‘forward and backward translations’ had faced a number of obstacles. Minor differences were found during reconciliation process and expert panel review. The pilot testing highlighted, misinterpretation among target population regarding item 3, 5, 7 and 8 of disability scale due to cultural differences. These items were adjusted according to cultural relevance and conceptual equivalence to the original version. Final version was found relevant and easily understood by the patients having shoulder pathology. Conclusion: SPADI-U has good face and content validity and it can be used to measure shoulder related quality of life in Urdu speaking population.

Background: Estimated glomerular filtration rate (eGFR) has always been considered a better and more accurate method to assess kidney function as compared to serum creatinine. Various equations such as the Cockroft-Gault equation corrected for surface area (CG-CRTD), the four-variable Modification of Diet in Renal Disease equation (MDRD) and 2009 Chronic Kidney Disease Epidemiology Collaboration equation (CKD-EPI) have been derived to estimate GFR. In the South Asian region, the CKD-EPI equation has not been validated or compared with other equations. This study compares eGFR in a Pakistani community cohort calculated by all three equations. Results: Serum creatinine was measured using Kinetic Colorimetric Assay in alkaline medium for 461 individuals age 15 and above. Less than half of the participants (47% by CG-CRTD, 40% by MDRD, 52% by CKD-EPI) had eGFR ³90 ml/min per 1.73 m2 and for participants with eGFR ³120 ml/min per 1.73 m2 , the percentages were even lower (15%, 12%, and 22% respectively). All the equations were linearly associated with each other, but the error estimation depicted that majority of the individual differences were ≥5 and ≤-5, and very few were within ±1 indicating less degree of agreement between the formulas. Age was significantly but negatively correlated with all the three formulas in their classification of patients as per eGFR Conclusion: Our study found that the values of estimated GFR are on lower side for Pakistanis as compared to the western population. The equations available for estimation of GFR even though associated linearly with each other have significant individual differences. Thirdly, using eGFR to classify CKD should have a better consideration of physiological age-related decline in GFR. All of these findings necessitate having an adequately funded randomized study measuring true GFR of this population and at the same time validating eGFR equations to find the normal GFR ranges of South Asians.

Objective: Diabetes have a central contribution with type I or type II towards the healthy lifestyles of sportspersons. Aerobic exercise and daily walking stay them fit and control their glucose levels in their bloodstream. The aim of this study was to find out the effects of aerobic exercises and walk on the sportspersons of type I and II diabetes. Methodology: The existing research has experimental design itself wherein pre-tests and post-tests were employed to make sure the novelty of results. The data was collected from the diabetic sportspersons dividing them equally into control group (N-20) and experimental group (N-20). Both groups had type I (N-20) and type II (N-20) diabetic individuals. Aerobic exercise and walk protocol was applied for six weeks on experimental group, whereas, control group continued their routine activities. Afterwards, the data was collected through pre and post treatments and edited into SPSS (v-26). The collected data was analyzed through descriptive statistics using frequencies and percentages, whereas, T-test was applied to make the differences of pre and post treatments. Results: The findings has shown that aerobic exercises and walk decrease the higher levels of glucose in blood and enable to stable glycemic balance, weight loss maintenance, decrease insulin resistance, blood pressure decrease, and blood glucose control. Conclusion: The prominent differences were observed between control and experimental groups either type I or type II. It was concluded that the sportspersons may reduce the excessive glucose engaging in aerobic exercises and walk on daily basis rather than using medications. They should spend their happy lives and get rid of medications and insulin through spending their spare time using light exercises and maintain their glucose levels in blood as well.

A prodrome is an early set of signs, symptoms or other findings that occur before the onset of typical symptoms of a disease. Prodromal phases are well recognized in several neurological and inflammatory diseases, but the possibility of a prodrome in multiple sclerosis (MS) has received relatively little attention until the past few years. In this Perspective, we summarize what is currently known about the MS prodrome, including its possible duration, clinical features and potential biomarkers. We also consider what insights and lessons can be learned from knowledge of and research into the prodromal phases of other diseases. A better understanding of the MS prodrome could have profound clinical implications as it could enable earlier recognition of MS and earlier initiation of treatments that reduce relapse rates and long-term disability. Knowledge of the MS prodrome could also affect research into the causes of MS, and putative risk factors must be re-evaluated in light of the MS prodrome. We conclude by outlining the major knowledge gaps and propose future initiatives.

Introduction Cytomegalovirus (CMV) predisposes to several clinical complications and is a major cause of morbidity and mortality in immunocompromised patients, including patients with hematological malignancies (HM). The present study was carried out to determine the distribution of CMV glycoprotein B, N, and O (gB, gN, and gO) genotypes and their potential effect on its viral load and on clinical outcomes in a cohort of Tunisian non-hematopoietic stem cell transplant (HSCT) patients with HM undergoing chemotherapy. Methods CMV viral load was evaluated by real-time quantitative PCR. The gB, gN, and gO genotypes of the CMV strains were analyzed by multiplex nested PCR and sequencing. Results This prospective study involved 60 clinical isolates obtained from 60 non-HSCT patients with HM undergoing chemotherapy. Mixed CMV gB, gN, and gO genotypes were the predominant glycoprotein genotypes in 31%, 41.4%, and 46.4% of patients, respectively. Mixed gB genotypes were associated with higher initial levels of CMV load (p = 0.001), increased rate of fever (0.025), and co-infection with other herpesviruses (HHVs) (p = 0.024) more frequently than in single gB genotype. Mixed gN genotypes were more associated with severe lymphopenia (ALC

Introduction: Hyperbilirubinemia is a common problem in the neonatal period. Phototherapy is the most important proposed treatments for hyperbilirubinemia, but several drugs along with phototherapy are used with recent advances. Aim: To see the effect of oral fenofibrate on serum bilirubin level in term neonates with unconjugated hyperbilirubinaemia. Methods: This prospective study was carried out in Combined Military Hospital Cumilla from July 2018 to June 2019. Total 60 term and normal birth weight neonates with neonatal jaundice were enrolled in this study. Jaundiced newborns presenting with infection, G6PD deficiency, conjugated bilirubin >2 mg/dl or >15% of total serum bilirubin (TSB) and congenital anomalies were excluded from this study. These neonates were randomly allocated to the Fenofibrate group (30 cases) and Control group (30 cases). Total serum bilirubin was measured every 24 hours till the end of phototherapy and at the time of discharge. Statistical analysis was done using SPSS 22.0 and p

Rheumatoid arthritis (RA) is one of the most common autoimmune diseases globally, and is an important public health concern, associating with early death and systemic complications. Although key development in RA treatment has already been made still RA affected individuals face comorbidity and disability. Therefore, there is a need to discover new risk factors in helping early diagnosis and treatment of RA. The present study is designed to assess the variations of Vitamin D receptor (VDR) and interleukin -6 (IL-6) in RA patients. Polymorphisms of said genes were calculated in 300 RA patients and 300 controls, using Tetra-ARMS polymerase chain reaction. Secondly, expression levels of selected genes were checked using the quantitative PCR (qPCR) and obtained results were evaluated using a different statistical test. Logistic regression analysis showed that frequency of mutant allele of VDR gene polymorphisms (rs11168268, OR = 4.84; 95% CI = 2.94–7.97; p = 0.0001; rs2248098, OR = 1.65; 95% CI = 1.07–2.54; p = 0.02) and IL-6 gene polymorphisms (rs184229712, OR = 2.47; 95% CI = 1.56–3.92, p = 0.0001; rs36215814, OR = 2.14; 95% CI = 1.30–3.53; p = 0.002) was observed significantly higher in RA patients vs controls. Expression analysis showed the significant upregulation of IL-6 (p

Objective: To determine the sexual dysfunction among the patients of rheumatoid arthritis and assess the relationship of various factors with presence of sexual dysfunction among the target population. Study Design: Cross sectional study. Place and Duration of Study: Rheumatology department, Pak Emirates Military Hospital Rawalpindi Pakistan, from Aug 2019 to Apr 2020. Methodology: The sample population comprised of 350 married female patients of rheumatoid arthritis between the age of 18 and 45 years, reporting for the routine follow-up at rheumatology department a tertiary care hospital. Sexual function was assessed using the female sexual function index (FSFI). Relationship of age, duration of rheumatoid arthritis, presence of comorbidities and polypharmacy was assessed with the sexual dysfunction among the target population. Results: Mean age of the study participants was 31.15 ± 4.22 years. Out of 350 women suffering from rheumatoid arthritis screened through female sexual function index, 172 (49.1%) had normal sexual function while 178 (50.9%) had sexual dysfunction. After applying the chi-square test, we found that polypharmacy and long duration of illness had significant association with the sexual dysfunction. Conclusion: High reporting of sexual dysfunction among the women suffering from rheumatoid arthritis indicates that this has been a neglected phenomenon by the physicians and researchers and may be added in routine screening. Women with long duration of illness and those managed with more than one drugs should be focused more while screening for sexual problems.

Background: The objective of this study is to create awareness about breast cancer among female students or other female population by evaluating their knowledge and perception towards the disease Methods: A Questionnaire bases study was conducted on 110 female students of University on Central Punjab, Lahore. Results: The results showed the insufficient knowledge of breast cancer among large number of female university students. About 53.6% students were well informed about meaning of breast self-examination (BSE) and only 39.1% female students were aware of steps involved in breast self-examination. Conclusion: Overall, the students had limited knowledge of risk factors and sign and symptoms of breast cancer

Background: Breast cancer (BC) is a heterogeneous disease, in which estrogen receptor (ER) expression plays an important role in the majority of breast tumors. A clinical dilemma may arise when a metastasis biopsy to determine the ER status cannot be performed safely or when ER heterogeneity is suspected between tumor lesions. Whole-body ER imaging, such as 16α-18F-fluoro-17β-estradiol (18F-FES) positron emission tomography (PET), may have added value in these situations. However, the role of this imaging technique in routine clinical practice remains to be further determined. Therefore, we assessed the value of 18F-FES-PET by evaluating if the physician's clinical dilemma that remained after standard workup was solved by the 18F-FES-PET scan. Methods: In this retrospective study, 18F-FES-PET scans, performed in patients with (suspected) ER+ metastatic BC with remaining clinical dilemma after standard workup, at the University Medical Center of Groningen between November 2009 and January 2019, were included. We investigated whether the physician's clinical dilemma was solved, defined as 1) 18F-FES-PET provided a solution for the clinical dilemma, and/or 2) a treatment decision was based directly on the 18F-FES-PET. In addition, category of clinical dilemma, and rate of 18F-FES positive or negative PET scans were reported, and related to frequency of solved dilemmas. Results: One hundred 18F-FES-PET scans were performed in 83 patients. Clinical dilemma categories were: 1) inability to determine extent of (suspected) metastatic disease with standard workup (n = 52), 2) unclear ER status of the tumor (n = 31), and 3) inability to determine which primary tumor caused metastases (n = 17). Dilemmas were solved by 18F-FES-PET in 87/100 cases (87%). In 81/87 cases a treatment decision was made based directly on the 18F-FES-PET (treatment change: n = 51 cases; continuance: n = 30 cases). The frequency of solved dilemmas was not related to the clinical dilemma category (P = 0.334). However, the frequency of solved dilemmas was related to whether scans were 18F-FES positive (n = 63) or negative (n = 37; p

BackgroundTopical treatment with sunflower seed oil (SSO) or Aquaphor® reduced sepsis and neonatal mortality in hospitalized preterm infants Methods497 infants were randomized to receive SSO, Aquaphor®, or neither through the neonatal period or hospital discharge. 159 infant survivors were enrolled in the longitudinal follow-up study using a validated Rapid Neurodevelopmental Assessment tool and the Bayley Scales of Infant Development II (BSID II) administered at three-monthly intervals for the first year and thereafter at six-monthly intervals. Lowess smoothing was used to display neurodevelopmental status across multiple domains by age and treatment group, and Generalized Estimating Equations (GEE) were used to compare treatment groups across age points.Results123 children completed at least one follow-up visit. Lowess graphs suggest that lower proportions of children who received massage with either SSO or Aquaphor® had neurodevelopmental delays than control infants in a composite outcome of disabilities. In GEE analysis, infants receiving SSO showed a significant protective effect on the development of fine motor skills [odds ratio (OR) 0.92, 95% confidence interval (CI) 0.86–0.98,p=0.006]. The Psychomotor Development Index (PDI) in the BSID II showed significantly lower disability rates in the Aquaphor group (23.6%) compared to the control (55.2%) (OR 0.21, 95% CI 0.06–0.72,p=0.004).ConclusionsEmollient massage of very preterm, hospitalized newborn infants improved some child neurodevelopmental outcomes over the first 2 years of follow-up. Findings warrant further confirmatory research.Trial registrationClinicalTrials.gov(98-04-21-03-2) under weblinkhttps://clinicaltrials.gov/ct2/show/NCT00162747

Objective: To find out the association between neonatal morbidity & mortality and the number of ante-natal visits of the mother of the newborn. Study Design: Comparative cross-sectional study. Place and Duration of Study: Neonatal Intensive Care Units (NICUs) of three military hospitals of the Punjab province, from Jan to Mar 2019.Methodology: Data of all newborns (total of 3065 neonates) delivered in selected Military Hospitals, and all newborns admitted to Neonatal Intensive care units, of Military Hospitals born in same hospital (in born) and born outside the Military Hospital (out born) during this period along with their mothers was collected. Neonatal morbidity and mortality in the selected hospitals was recorded. Mothers were classified as booked and unbooked according to the number of antenatal care visits. Data was analyzed by Statistical Packages for Social Science (SPSS) version 20. Results: Neonatal morbidity including prematurity, low birth weight, birth asphyxia, neonatal sepsis, pneumonia, diarrhoea, congenital malformation, and fits was significantly less (p-value

Background: Numerous diabetes susceptibility loci, include a region consisting vitamin D receptor gene found in chromo- some 12q, have been known using genome wide screens. Aim: The aim of present study is to probe the relationship between polymorphism of vitamin D receptor gene (single nu- cleotide polymorphisms) and type 2 diabetes mellitus (T2DM). Five hundred T2DM patients and 200 healthy subjects with normal HbA1c( ≤ 5.0 %), fasting blood sugar (≤ 120 mg/dL) and random blood sugar (≤ 140 mg/dL) were enrolled. Metholodgy: The genotypes were found by polymerase chain reaction restriction fragment length polymorphism and DNA sequencing. Results: revealed that no considerable differences in frequencies of genotype and allele of the Bsm I and Fok I polymor- phisms between healthy and patients in the North England (For Fok I: OR = 1.11, 95% CI: 0.72–1.12; for Bsm I: OR = 1.35, 95% CI: 0.79–1.98). Conclusion: It is recommended that both following polymorphisms of vitamin D receptor gene may not considerably add to the progression of T2DM in the North England. Keywords: T2DM; DNA Sequencing; Polymerase Chain Reaction-Restriction Fragment Length Polymorphism (PCR-RFLP); Single nucleotide Polymorphism (SNP);VDR.

To examine the clinical presentation and longitudinal outcome of Pituitary Apoplexy (PA) after gonadotropin-releasing hormone agonist (GnRHa) in a series of patients and compare to prior reports. A retrospective chart review was performed on seven patients receiving GnRHa who developed PA. Prior reported cases were analyzed. Six men (median age 72 years) with prostate cancer and one woman (aged 22 years) undergoing oocyte donation presented with PA between 1990 and 2020. Most presented with within 24 h of the first dose, but two developed PA 1 to 5 months after GnRHa initiation. The main clinical manifestations were headache (100%), nausea and vomiting (86%). While no patients had a previously known pituitary tumor, all had imaging demonstrating sellar mass and/or hemorrhage at presentation. Among those surgically treated (5/7), 80% (4/5) of patients had pathologic specimens that stained positive for gonadotropins; the remaining patient’s pathologic specimen was necrotic. At the time of PA, the most common pituitary dysfunction was hypocortisolism. Central adrenal insufficiency and central hypothyroidism were reversible in a subset. Pituitary imaging remained stable. This is the first report of a case series with PA after GnRHa administration with longitudinal follow-up. Although infrequent, PA can be life-threatening and should be suspected among patients receiving GnRHa, with or without a known pituitary adenoma, who develop acute headache, nausea and/or vomiting. Since hypopituitarism was reversible in a subset, ongoing pituitary function testing may be indicated.

Background/aim Knee osteoarthritis (OA) is a common pathology characterized by degeneration of the articular cartilage. The aim of the research was to ask patients how they decided to make the injection, what treatments they received, their complaints prior to and after the injection and how they feel at the moment, and whether they are currently exercising or not. Thus, to demonstrate the patients? outcomes with their own expression. Material and methods A total of 92 knee OA patients completed semi-structured interviews, which included six open-ended questions. Results A total of 92 patients (66 female, 26 male) aged between 36-95 years (mean 65.5±11,14) were included. Before the injection, the majority of the OA patients had pain complaints when walking (72.8%) and stair climbing (70.7%). One to four years after intra-articular injection, 45.2% of patients felt a decrease in their complaints. The majority of patients did not consider diet and exercise as a treatment option. In addition, almost all patients declared that they decided on hyaluronic acid injection treatment with the physician?s recommendation. Conclusion Pain during walking and stair climbing before hyaluronic acid injection was common in knee OA patients. Overall the patients felt a decrease in the symptoms after injection. Patients did not consider diet and exercise as a treatment option despite the recommendation by a physician.

Objective: To study clinical outcome of early versus late caffeine therapy in preterm infants. Study Design: Prospective comparative study. Place and Duration of Study: Neonatal Intensive Care Unit, Pak Emirates Military Hospital, Rawalpindi, from Jan to Jul 2018. Methodology: A total of 40 preterm infants with gestational age

Summary Background There is a paucity of evidence to support safe and effective management of patients with acute severe ulcerative colitis during the COVID-19 pandemic. We sought to identify alterations to established conventional evidence-based management of acute severe ulcerative colitis during the early COVID-19 pandemic, the effect on outcomes, and any associations with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection and severe COVID-19 outcomes. Methods The PROTECT-ASUC study was a multicentre, observational, case-control study in 60 acute secondary care hospitals throughout the UK. We included adults (≥18 years) with either ulcerative colitis or inflammatory bowel disease unclassified, who presented with acute severe ulcerative colitis and fulfilled the Truelove and Witts criteria. Cases and controls were identified as either admitted or managed in emergency ambulatory care settings between March 1, 2020, and June 30, 2020 (COVID-19 pandemic period cohort), or between Jan 1, 2019, and June 30, 2019 (historical control cohort), respectively. The primary outcome was the proportion of patients with acute severe ulcerative colitis receiving rescue therapy (including primary induction) or colectomy. The study is registered with ClinicalTrials.gov , NCT04411784 . Findings We included 782 patients (398 in the pandemic period cohort and 384 in the historical control cohort) who met the Truelove and Witts criteria for acute severe ulcerative colitis. The proportion of patients receiving rescue therapy (including primary induction) or surgery was higher during the pandemic period than in the historical period (217 [55%] of 393 patients vs 159 [42%] of 380 patients; p=0·00024) and the time to rescue therapy was shorter in the pandemic cohort than in the historical cohort (p=0·0026). This difference was driven by a greater use of rescue and primary induction therapies with biologicals, ciclosporin, or tofacitinib in the COVID-19 pandemic period cohort than in the historical control period cohort (177 [46%] of 387 patients in the COVID-19 cohort vs 134 [36%] of 373 patients in the historical cohort; p=0·0064). During the pandemic, more patients received ambulatory (outpatient) intravenous steroids (51 [13%] of 385 patients vs 19 [5%] of 360 patients; p=0·00023). Fewer patients received thiopurines (29 [7%] of 398 patients vs 46 [12%] of 384; p=0·029) and 5-aminosalicylic acids (67 [17%] of 398 patients vs 98 [26%] of 384; p=0·0037) during the pandemic than in the historical control period. Colectomy rates were similar between the pandemic and historical control groups (64 [16%] of 389 vs 50 [13%] of 375; p=0·26); however, laparoscopic surgery was less frequently performed during the pandemic period (34 [53%] of 64] vs 38 [76%] of 50; p=0·018). Five (2%) of 253 patients tested positive for SARS-CoV-2 during hospital treatment. Two (2%) of 103 patients re-tested for SARS-CoV-2 during the 3-month follow-up were positive 5 days and 12 days, respectively, after discharge from index admission. Both recovered without serious outcomes. Interpretation The COVID-19 pandemic altered practice patterns of gastroenterologists and colorectal surgeons in the management of acute severe ulcerative colitis but was associated with similar outcomes to a historical cohort. Despite continued use of high-dose corticosteroids and biologicals, the incidence of COVID-19 within 3 months was low and not associated with adverse COVID-19 outcomes. Funding None.

Objectives: To determine the accuracy of contrast-enhanced MRI in the diagnosis and detection of breast lesions and their malignant potential by taking the gold standard of histopathology.Materials and Methods: This study was conducted at the Department of Diagnostic Radiology, Pakistan Institute of Medical Sciences (P.I.M.S.) Islamabad. It was undertaken in collaboration with the Department of General Surgery P.I.M.S, Department of Pathology P.I.M.S Islamabad, and HIT Hospital Taxila. The study design was a cross-sectional (Validation) study and the duration of the study was 6 months (from 01-Oct-2016 to 31-Mar-2017). Results: Sample size was calculated by using sensitivity and specificity calculator taking sensitivity 94%1 with a precision of 6%, specificity 85%1 with a precision of 10%, prevalence is 45.9%2, and confidence interval of 95% it comes out to be 92%. Sample collection was made by the technique of Consecutive non-probability sampling.Conclusion: Breast MRI imaging is a modern evolving modality. A gradual increase in diagnostic specificity is achieved with improved software and techniques. More such studies would help develop confidence in this advanced imaging modality for improving patient management and avoiding unnecessary biopsies.

Background: Current study aim to describe epidemiological, clinical and demographic features in patients confirmed to have COVID-19 in Balochistan Methods: This descriptive cross sectional Study was conducted during months of March and April 2020 based on the secondary data available regarding COVID-19 positive patients from the health service records of Government of Balochistan quarantine centers and hospitals during this period. Data was analyzed by using Excel and SPSS version 23. Mean and standard deviations are used for continuous variables like age and duration of stay (of recovered patients), while frequencies and percentages were used to describe age categories, point of entry and current status. Age specific case fatality rate is calculated by keeping deaths in numerator and confirmed cases in denominator. Results: Mean age of respondents was 35.3±16.12 years , two third of the study population i.e,652(76.3%) were males,353 (40.6)% were in the age group 30-49 years and 417(48.9%) had history of contact with COVID-19 case. Overall case fatality rate was 1.87% and Age Specific Mortality Rate was found to be highest (30%) in age group 70 years and above Conclusion: The epidemiologic behavior of COVID-19 infection introduced in Pakistani population from neighboring country has responded differently in community spread among different ethnic groups represented in different provinces of Pakistan. The case fatality ratios among Baloch ethnic group were much lower than international COVID-19 case responses

Background Middle East Respiratory Syndrome Coronavirus (MERS-CoV) is associated with a high fatality rate (34%), which is higher in the presence of co-morbidities. The aim of the current study was to assess the clinical course and the outcome in hematological or oncological malignancy cases, diagnosed with MERS-CoV. Methods This is a case series of hematological /oncological cases, diagnosed with MERS-CoV, in a tertiary care setting in 2015. The cases were identified based on the World Health Organization (WHO) MERS-CoV case definition. The demographic, clinical, and outcome data were retrieved from the patients’ medical charts and electronic health records. Results In total, nine hematological or oncological cases were identified, diagnosed with MERS-CoV. The baseline malignant condition was hematological malignancy in seven patients, as well as colon cancer and osteosarcoma in one patient each. Six (67%) patients were male. The median age was 65 years (range 16–80 years). Co-morbidities included chronic kidney disease (n = 3.33%), diabetes mellitus (n = 3.33%), and hypertension (n = 2.22%). The presenting symptoms were shortness of breath (n = 6.66%), fever (n = 5.55%), cough (n = 2.22%), and diarrhea (n = 2.22%). Chest x-rays indicated bilateral infiltrates in 6 patients (66%). The PCR (polymerase chain reaction) test was repeated in six patients to confirm the diagnosis. The mortality rate was 100%, and the median time to death was 26 days (range 15–77 days). Conclusion MERS-CoV infection in this small cohort of hematology or oncology patients has a 100% mortality rate, regardless of the status of the underlying disease. The confirmation of the diagnosis may require repeated testing. Additional studies are required to verify the findings and to elucidate the disease pathogenesis in cancer patients.

Aim: To determine the differences in-between hematological and ultrasonography findings of acute cholecystitis (AC) among middle-aged versus elderly patients. Methodology: This retrospective study was carried out after ethical approval. Patients diagnosed as case of acute cholecystitis was included and patients without findings consistent with acute cholecystitis or with pancreatitic gall stones, co-existing hepato-biliary or intestinal malignancy or with autoimmune biliary disease were excluded. Patients were divided into two groups, one being patients between 30 to 59 years and other group 60 and above year olds. Results: From total of 153 patients included, 87 patients were between 30 and 59 years (middle aged) while 66 patients were 60 years and older (elderly). In both the groups, higher ratios of females persisted (p-0.03). A significant differences between the values were observed only in WBC count (p-0.005) and CRP levels (p

The study objective was to assess the correlation of time outdoors in sunlight hours with spherical equivalent refraction (SER) and other variables. This was a cross-sectional study carried out in the Fauji Foundation Hospital, Rawalpindi, between January and April 2019. A total of 110 Individuals were included via convenient sampling, with myopia defined as having at least -0.5 D (SER ≤ -0.5 D). Collection of Questionnaires with interviews regarding eye care behaviour along with auto-refraction was done, followed by calculation of spherical equivalent refraction. Those having high myopia of 6 D or more (SER ≤ - 6 D), hyperopia of 0.5 D or more (SER ≥ +0.5 D), and history significant for ocular trauma and surgeries, were excluded. After data cleaning and their entry, analyses were done using SPSS version 26. The mean age data, available for 105 individuals, was 15.4 ± 3.69 years. Spearman's correlation was used for right SER with time outdoors in summers (r= +0.25, p=0.008) and winters (r= +0.243, p=0.010), indicating an inverse relationship with myopia. Females had more myopic refraction than males, but the independent sample t-test was not significant. Logistic regression was used and a protective effect was found for both summer and winter time outdoors, while education level was associated with myopia. Key Words: Myopia, Spherical equivalent refraction (SER), Sunlight exposure.

Objective: To determine the clinical profile, selected antepartum and intrapartum risk factor for adverse shortterm outcomes of hypoxic ischemic encephalopathy in babies with birth asphyxia. Study Design: Cross sectional study. Place and Duration of Study: Neonatal Intensive Care Unit of Pak Emirates Military Hospital, Rawalpindi, fromJan to Dec 2018. Methodology: This study including all birth asphyxiated babies born who fulfilled the inclusion criteria.Following data was collected prospectively regarding gender, gestational age, birth weight and mode of delivery, maternal age, antenatal follow up, history of premature rupture of membranes and meconium stained liquor. Babies were categorized into different stages of hypoxic ischemic encephalopathy according to Sarnat and Sarnat staging. Selected antepartum and intrapartum risk factors leading to hypoxic insult at birth were studied and short-term outcome was recorded in the form of need of mechanical ventilation, mortality and discharge from the hospital.Results: The frequency of birth asphyxia turned out to be 122/5986 (2.03%) at our center. Thirty four (27.87%)required mechanical ventilation, mortality was recorded at 20/122 (16.39%). While 61 (50%) babies suffered from stage I hypoxic ischemic encephalopathy, 13/20 (65%) of newborn who expired were suffering from grade III hypoxic ischemic encephalopathy. Conclusion: The severity of hypoxic ischemic encephalopathy affects the outcome of newborns having birthasphyxia with hypoxic ischemic encephalopathy grade III associated with maximum mortality. Early identifycation of pregnancies at risk for asphyxia, with appropriate intervention in selected cases is the key to prevent birth asphyxia and its ensuing neonatal complications.

Introduction: Neo adjuvant chemotherapy is increasingly being employed in breast cancer to reduce tumour size & down stage axilla. To reduce false negative rates in axillary lymph nodes after down staging with chemotherapy and to improve axillary conservation ultrasound guided clips were placed in involved axillary lymph nodes prior to commencement of NACT. The study aimed at whether preoperative lymph node clipping had any benefit in identification of lymph node after NACT.Methods: This is a single centre study of 55 patients (Mean age 53 years) with invasive breast cancer with biopsy proven involved lymph nodes (T1-3 N1) who underwent ultrasound guided axillary marker clip insertion before start of NACT. If Post chemotherapy imaging showed normal lymph nodes patients underwent SLNB with additional Lymph Nodes sampled to achieve a total of 4 lymph nodes. All sampled nodes were x rayed at the time of surgery to identify marker clip.Results: We had no procedure related complications with insertion of marker clip in any patients. The median number of nodes was 4.0. Average lymph nodes retrieved was 4.9. SLNB was identified in 47/55 patients (85.5%). Median number of sentinel nodes was 3.0 (Range 1-7) Marker was identified in 41/55 patients (74.5%) 30 (54.5%) patients had marker in sentinel node and 11 (20%) patients had marker in non-sentinel node. Histologically clip was reported in 21 (51.2%) patients. Overall pathological complete response (pCr) in axilla was seen 31/55 (56.45%). Tumours with Her2 over expression showed pCr in axilla 83% n=19/23 while triple negative tumours showed pCr in axilla 64% n=9/14. Er+ Her2- tumours showed low pCr rate 16.7% n=3/18. Completion axillary clearance was performed in 14/24 patients and 10/24 received radiotherapy to axilla.Conclusions: Clips in axillary lymph nodes are safe & relatively easy to deploy without any increased morbidity. Our clip identification rate (74.5%) co relates with other well-known publications (Caudel et al 80%, Z1071-76%). Our study findings validate that clip placement improves the identification of involved lymph nodes and hence improve the accuracy of limited axillary dissection in staging axilla. Citation Format: Mohammad Bilal Elahi, Raouef Ahmed Bichoo, Kartikae Grover, Eiman Khalifa, Naila Bint Ihsan, Peter J Kneeshaw, Brendan Paul Wooler, Dorin Dumitru, Ronjabati Roychaudhury, Ayesha Rahman, Tapan Kumar Mahapatra. Clipping of involved axillary lymph nodes before Neo adjuvant chemotherapy may improve in identification rates & staging of axilla in breast cancer [abstract]. In: Proceedings of the 2020 San Antonio Breast Cancer Virtual Symposium; 2020 Dec 8-11; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2021;81(4 Suppl):Abstract nr PS1-55.

Background Disparity exists between men and women physicians. We aimed to examine changes in gender disparity in the medical profession over the last two decades. The study reviewed publications on gender differences and the measures which have been implemented or suggested to rectify these disparities. Methods Pubmed, Embase, Scopus, and The Cochrane Library were searched in December 2019 using (“gender disparity” OR “gender gap” OR “pay gap” OR “gender discrimination”) from 1998-2019. The sources list of reviewed articles was also used to retrieve more relevant articles. Articles about physicians in the United States were included, and Critical Appraisal Skills Programme (CASP) was used to evaluate the quality of the articles. Results In this systematic review that includes 49 studies, there is still disparity and discrimination in research, leadership, and pay between male and female physicians. Women have less leadership roles and progress at a slower rate to associate and full professor. Women publish less articles and have a lower h-index than men. Men earn $20,000 more a year after salary adjustment. More women than men experience negative comments about their gender (36% vs 4%), experience gender discrimination (65% vs 10%) and sexual harassment (30% vs 6%). Conclusions Although substantial research exists on this topic, there remains significant room for improvement to achieve gender equality. Institutions and individuals should implement interventions to rectify this disparity .

Background: Estimation of JAK2V617F mutational load in Polycythemia Vera (PV) helps to determine the severity of the disease phenotype, the risk of thrombotic events, progression to post-PV myelofibrosis and survival. Amplification Refractory Mutation Screening (ARMS) PCR or Allele Specific (AS) PCR is a simple easy method with a reasonable sensitivity for screening of zygosity.The purpose of this study was to see the frequency of disease burden and phenotypic characteristics in Pakistani patients diagnosed with JAK2V617F mutation positive PV. Materials and Methods: A cross-sectional study using non probability consecutive sampling was conducted at Hematology Department, Liaquat National Hospital Karachi from October 2018 to July 2019.Adult newly diagnosed JAK2V617F positive PV patients of either gender were included. Patients’ demographics, clinical characteristics and baseline CBC were noted. JAK2V617F zygosity was qualitatively analyzed by ARMS-PCR technique. Age and gender were stratified to see to see the result of qualitative and quantitative effect modifiers on these patients using Chi Square and fisher exact test as appropriate while mean comparison was done by independent t-test and one way ANOVAtest. P value of ≤0.05 was considered as significant. Results: Fifty one patients were included in the study with an average age of 59.60±14.29years.90.2% of patients had hypertension.All patients tested positive for heterozygous state. Significant association of gender was found with smoking (p=0.001) while age was significantly linked with hypertension (p-0.033). Conclusion: JAK2V617F positive PV patients are mainly heterozygous males showing significant association with smoking and hypertension. ARMS-PCR is a robust technique to determine zygosity which can be used for screening purposes.

To systematically review clinical and health economic impacts of treat-to-target (TTT) strategies in patients with rheumatoid arthritis (RA) managed in specialist units, compared with routine care. Sixteen and seven electronic databases were searched for clinical RCTs and cost-effectiveness respectively. Study selection, data extraction and quality assessment (Cochrane Collaboration risk of bias criteria) were performed. Evidence was reported by (1) TTT vs. usual care; (2) comparison of different treatment protocols against each other; (3) comparison of different targets against each other. Narrative synthesis was undertaken and conclusions drawn on a trial by trial basis, due to study heterogeneity. Twenty-two RCTs were included. Sixteen were at high risk of bias, five unclear and one low risk. Three trials showed TTT to be more effective than usual care in terms of remissions, in some or all comparisons, whereas one other trial reported no significant difference. Two trials showed TTT to be more effective than usual care in terms of low disease activity (LDA), in some or all comparisons, whereas two trials reported little difference. Some evidence suggests that TTT strategies involving combination therapy can achieve more remissions than those involving monotherapy, but little impact of alternative treatment targets on remission or LDA. Overall, there is evidence that TTT increases remissions in early RA and mixed early and established RA populations, and increases LDA in established RA. Although results varied, typically TTT was estimated to be more cost-effective than usual care. No target appears more effective than others.

Acute flaccid myelitis (AFM) is a disabling, polio-like illness mainly affecting children. Outbreaks of AFM have occurred across multiple global regions since 2012, and the disease appears to be caused by non-polio enterovirus infection, posing a major public health challenge. The clinical presentation of flaccid and often profound muscle weakness (which can invoke respiratory failure and other critical complications) can mimic several other acute neurological illnesses. There is no single sensitive and specific test for AFM, and the diagnosis relies on identification of several important clinical, neuroimaging, and cerebrospinal fluid characteristics. Following the acute phase of AFM, patients typically have substantial residual disability and unique long-term rehabilitation needs. In this Review we describe the epidemiology, clinical features, course, and outcomes of AFM to help to guide diagnosis, management, and rehabilitation. Future research directions include further studies evaluating host and pathogen factors, including investigations into genetic, viral, and immunological features of affected patients, host-virus interactions, and investigations of targeted therapeutic approaches to improve the long-term outcomes in this population.

Background: Dengue is a common disease in this part of the world. It is one of the dreaded fevers for the paediatric age group. The disease has various presentations and features, but early diagnosis and management can decrease mortality rate significantly. Aims: To evaluate the clinical profile of dengue infection in children under the age of 14 in urban areas of Telangana. The study is done in the tertiary care centre in urban area. Materials and Methods: It is Hospital based descriptive, prospective observational study. All probable cases of dengue were admitted with provisional diagnosis of dengue fever to the department of paediatrics for a period of one year. Total 198 children of age less than 14 years participated in present study. Results: Out of 198 samples of clinically suspected dengue cases, 192 were found positive for Dengue NS1 antigen, 145 were found to be positive by IgG and 139 cases were positive for IgM. Majority of cases are males (62%) females were 38%. Most commonly affected age group is 6- 10 years of age 95 cases (47.9%) Most of the patients in study are hospitalized for a period of 3-6 days (51.5%). Fever (99.5%) was the most common symptom found in all the patients followed by vomiting (17.7%). Hypotension was found in 9% of the patients. Severe thrombocytopenia was observed in 3.5% of patients and moderate thrombocytopenia in 7% of patients. 46.5% of patients had normal platelet count. Leukopenia was seen in 29.8% of patients. Conclusions: Fever was the most common symptom found in all the patients. Majority of cases showed thrombocytopenia. Keywords: Dengue virus infection, Fever, Thrombocytopenia.

Objective: To examine the types of procedures and analyze the frequency of anesthesia-related complications during pediatric cardiac catheterization. Study Design: A prospective observational study. Place and Duration of Study: Pediatric Cardiac Catheterization Lab at AFIC/NIHD Rawalpindi, from July 2019 to Nov 2019. Methodology: Total 180 consecutive patients undergoing cardiac catheterization fulfilling inclusion criteria were studied. Demographic variables, diseases, type of procedure, variables and anesthesia-related complications were noted. All the data was analyzed using SPSS-23. Results: The study included180 patients where 96 (53.3%) were male and 84 (46.7%) were female. Most of the patients in our study were between ages 1 to 3 years (85). 99 (55.0%) patients had diagnostic cardiac catheterizetion (CC), while 81 (45%) patients underwent interventional procedures. The overall complication rate noted as 18.9%, including arrhythmia in 11.1% followed by hypotension 4.4%, laryngospasm 3.9% and inotropic support requirement 3.3%, Mortality was 0.6%. Most of the patients presenting to the pediatric cardiac catheterization lab were for PDA device closure (16.6%). Age of child was found to be significant risk factor for cardiac catheterizetion associated complications with a p-value of 0.022. Conclusion: Congenital and structural heart disease catheterization procedures are progressively increasing, especially due to the medical advances and complex interventional therapeutic procedures. A thorough preanesthesia assessment should be carried out to optimize before cardiac catheterization.

Objective: To observe the effect of modified ultrafiltration on hemodynamics of pediatric patients. Study Design: A descriptive cross-sectional study. Place and Duration of Study: Pediatric Cardiac Surgery department, AFIC/NIHD Rawalpindi, from Jun 2019 to Dec 2019. Methodology: A total of 60 pediatric patients were included undergoing open-heart surgery with cardiopulmonary bypass, having age ≤6 years and weights ≤15kg. To assess hemodynamics parameters observed were pre modified ultrafiltration and post modified ultrafiltration measurements of haemoglobin level, systolic pressure, diastolic pressure, central venous pressure and the number of transfusions given after off-bypass. The data was entered and analyzed in SPSS-23. Results: The pre-operative mean Hb level of the 60 sampled patients was 12.08 ± 2.89 g/dl. The findings taken pre modified ultrafiltration and post modified ultrafiltration of haemoglobin level was (9.91 ± 0.91 g/dl and 13.09 ± 1.38 g/dl, p0.005) compared pre modified ultrafiltration and post modified ultrafiltration respectively. Conclusion: The study concluded that modified ultrafiltration has a significant impact on haemoglobin levels after bypass, decreases the allogenic transfusions and also improve the hemodynamics of the patient.

Background: Cystic fibrosis (CF) is a genetic disease that affects the transmembrane conductance regulator gene responsible for modulating chloride ion transportation in the cell membrane. Hypovitaminosis D is frequently observed among fibrocystic disease patients. Therefore, this study was aimed to evaluate the effect of vitamin D3 supplementation in patients with CF concerning their metabolic and deoxyribonucleic acid (DNA) methylation profiles. Methodology: A clinical trial involving 12 CF patients was carried out in Joao Pessoa. After assessment of hypovitaminosis D prevalence in the studied population, four patients with vitamin D3 insufficiency/deficiency were administered cholecalciferol megadose supplementation in addition to biochemical examinations and analysis of inflammatory and epigenetic indicators. The DNA methylation profile of the studied genes' promoter regions was determined through a qualitative methylation restriction enzyme technique. Data were analyzed using the Statistical Package for the Social Sciences 25.0 software for T-tests, Mann-Whitney, and Wilcoxon test calculations. Results: Hypovitaminosis D was observed in 58%, 33% of the studied individuals. Patients with hypovitaminosis D reported blood sugar, glutamic-pyruvic transaminase (ALT), and uric acid levels significantly higher (p = 0.02; p = 0.05; p = 0.02, respectively) compared to individuals with sufficient 25-hydroxyvitamin D (25(OH)D), as well as elevated inflammatory values. Supplementation did not influence epigenetic nor metabolic parameters significantly, although the mean 25(OH)D serum concentration value increased from 18.3 ng/dl to 34.1 ng/dl (p = 0.06). Conclusion: Cholecalciferol megadose elevated 25(OH)D serum levels, although it did not alter inflammatory, glycemic, or epigenetic parameters. This encourages future studies on the matter since significant differences were found in blood sugar, uric acid, and ALT serum levels for the vitamin D3 insufficiency/deficiency group despite this study�s small sample size.

Background: To assess the current knowledge related to hand washing and efficiency of intervention on hand washing techniques amongst school children. Methodology: A randomized control trial was conducted amongst class II students of a private school in Korangi, Karachi. Pre-intervention assessment including baseline knowledge and observed practices of hand washing in comparison with World Health Organization (WHO) standard hand washing techniques was done. This was followed by education and demonstration of proper hand washing steps by principal investigator utilizing visual aids. Participants were then randomized into two group: Group A (education only group) and Group B (education along with glow gel application group). First post-intervention assessment was conducted on same day where both groups were observed for the hand washing steps and scored for hand washing technique. In addition, participants of group B were shown germs under Ultraviolet (UV) light. School was revisited after 1 week later and participants were reassessed for their hand washing technique along with cleanliness grade after applying glow gel and observing under UV light. Data was entered and analyzed using SPSS version 21.0. Result: No significant differences were found in median hand washing scores pre-intervention between both the groups (Group A vs B: 4 vs 5, P value = 0.659), while significant improvement in median hand washing scores was seen post intervention in group B as compared to group A (7 vs 6, P value = 0.011). However, no significant differences were seen in median hand washing scores at follow-up between both the groups (Group A vs B: 9 vs 8.5, P value = 0.715) but a significant improvement was observed in both the groups in the hand washing practices from baseline (P-value = 0.000). On the contrary, no significant differences were found in median cleanliness grade between both the groups (Median for both the groups was 5, P value = 0.695). Conclusions: Hand washing education utilizing various aids is an effective method to improve children's hand washing capability. This short-term intervention was effective even in absence of glow gel, but no cleanliness of hands was observed in both the groups.

Background and Aim: “Self-medication” is the self-use of medicines for treatment of illnesses. Inappropriate use of medicines without prescription leads to unwanted adverse effects, harmful drug interactions, and antibiotic resistance which is an emerging concern in developing countries due to escalating burden of infectious diseases. This study aims at identifying the frequency and contributing factors of self-medication, nature of illness, and types of medicines used without doctor's prescription. Material and Methods: This cross sectional study was conducted at Indus Hospital Karachi between March 2017 and December 2018. Two hundred and forty people of any age visiting the outpatient clinics of the Indus hospital consenting to participate were included. Whereas all clinicians including medical officers, specialists and consultants were excluded from the study. Results: Three-fifth (n = 147; 61.3%) of the participants reported that they did self-medication either for themselves or for their children in the past one year. The most common symptoms for which self-medication was done were fever (n = 82, 55.8%), cough/cold (n = 38; 25.8%) or diarrhea (n = 22; 15.0%). Out of which, 122 (83%) did self-medication based on their previous experience, 18 (12.2%) used previous doctor's prescriptions, whereas 22 (15%) reported that other people advised them. Education, presence of unused medicines at home, and those who have heard of antibiotic were found to be the significant risk factors associated with self-medication. Conclusion: Among Pakistani population, the frequency of self-medication is very high, with most people practicing self-medication on the basis of their previous experiences. It puts them at risk of experiencing adverse reactions and most importantly antibiotic resistance.

OBJECTIVE To systematically review the published literature on the use of prophylactic mesh reinforcement of midline laparotomy closures for prevention of ventral incisional hernias (VIH) SUMMARY BACKGROUND DATA:: VIH are common complications of abdominal surgery. Prophylactic mesh has been proposed as an adjunct to prevent their occurrence. METHODS PubMed, Embase, Scopus and Cochrane were reviewed for randomized controlled trials (RCTs) that compared prophylactic mesh reinforcement versus conventional suture closure of midline abdominal surgery. Primary outcome was the incidence of VIH at post-operative follow-up ≥24 months. Secondary outcomes included surgical site infection (SSI) and surgical site occurrence (SSO). Pooled risk ratios were obtained through random effect meta-analyses and adjusted for publication bias. Network meta-analyses were performed to compare mesh types and locations. RESULTS Of 1969 screened articles, twelve RCTs were included. On meta-analysis there was a lower incidence of VIH with prophylactic mesh (11.1%vs21.3%, RR = 0.32; 95%CI = 0.19-0.55, P < 0.001) however publication bias was highly likely. When adjusted for this bias, prophylactic mesh had a more conservative effect (RR = 0.52; 95%CI = 0.39-0.70). There was no difference in risk of SSI (9.1%vs8.9%, RR = 1.08, 95%CI = 0.82-1.43; P = 0.118), however, prophylactic mesh increased the risk of SSO (14.2%vs8.9%, RR = 1.57, 95%CI = 1.19-2.05; P < 0.001). CONCLUSION Current RCTs suggest that in mid-term follow-up prophylactic mesh prevents VIH with increased risk for SSO. There is limited long-term data and substantial publication bias.