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Objective: To compare the outcome in COVID 19 patients on oxygen managed with 6mg and 12 mg Dexamethasone at Pak Emirates Military Hospital Rawalpindi. Study Design: Comparative cross-sectional study. Place and Duration of Study: Pak Emirates Military Hospital Rawalpindi Pakistan, from Aug 2020 to Aug 2021. Methodology: Patients diagnosed with COVID-19 on PCR and were oxygen-dependent but not mechanical ventilation dependent were included in the study. They were randomly divided into two groups. Group-I received 6mg Dexamethasone, while Group-II received 12 mg Dexamethasone for ten days. They were followed up for 30 days to look for the outcome (prolonged admission, high dependency unit admission, intensive care admission, death). The difference in outcome in both groups was studied using the Pearson chi-square test. Results: Out of 600 patients included in the study, 401 (66.8%) were male, while 199 (33.2%) were female. The mean age of the study participants was 47.81 ± 8.716 years. 306 (51%) were given 6mg of Dexamethasone for ten days, while 294 (49%) were given 12mg of Dexamethasone for a similar time. prolonged admission (p-value-0.178), high dependency unit admission (pvalue-0.409), intensive care admission (p-value-0.176) and mortality (p-value-0.588) were not statistically significantly different in both the groups. Conclusion: All the outcome variables, including mortality and admission to the critical care unit, were not statistically significant in groups taking 6mg or 12 mg of Dexamethasone, so it could be concluded that a high dose of this medication is not superior in terms of efficacy when compared to the low dose.

Objective: To study the histo-pathological findings in lung biopsies of critical COVID-19 cases. Study Design: Case series. Place and Duration of Study: Pakistan Emirates Military Hospital, Rawalpindi Pakistan, from Jul to Dec 2020. Methodology: Deceased patients who remained on ventilatory support with a confirmatory diagnosis of SARS-CoV-2 both by PCR and radiological evidence on HRCT and clinically established severity of disease as per CALL scoring were included in the study. Written informed consent for lung biopsy was taken from the deceased's next of kin Result: Mean age of the study group was 67.20 ± 6.01 years. The patients had a mean high resolution computed tomography score of 36.73 ± 1.59, and the mean CALL score was 12.73 ± 0.691 on admission. The average time after intensive care unit admission to intubation was 1.23 ± 0.50 days. Histopathological examination of the lung biopsy showed 27 (87.1%) patients had the exudative stage of adult respiratory distress syndrome while three (9.7%) patients had a proliferative stage of adult respiratory distress syndrome. Conclusion: Histopathological findings of an exudative stage of adult respiratory distress syndrome in the lung biopsies of critical COVID-19 showed no significant difference with typical adult respiratory distress syndrome and are correlated with very high mortality rates in critical COVID-19.

Objective: To identify antimicrobial susceptibility pattern of multidrug resistant bacteria causing secondary infections in COVID-19 patients in ICU’ sofa tertiary care hospital. Study Design: Cross–sectional study. Place and Duration of Study: Department of Microbiology, Pak Emirates Military Hospital, Rawalpindi, from Apr to Jul 2020. Methodology: This study included blood samples and endotracheal aspirates from 114 critically ill COVID-19 patients. Peripheral blood specimens were collected fromthe patients with secondary bacterial blood stream infections and endotracheal aspirates were collected from patients with ventilator associated pneumonia for culture and sensitivity. The results were interpreted according to Clinical & Laboratory Standard Institute (CLSI) 2020. Results: A total of 114 COVID-19 patients were admitted in ICU during that time period. Fourteen (12.28%) were female and 100 (87.71%) were male, age distribution was between 36-82 years. Sixty six paired blood samples were sent to the microbiology lab out of which 51 (77.2%) showed bacterial growth while 15 (22.7%) samples were negative. Out of 50 endotracheal aspirates, 42 showed bacterial growth (84%) and 8 samples did not show any significant bacterial growth (16%). Most of the endotracheal aspirates showed growth of >1 bacterial isolates. The most common gram-negative organisms were Acinetobacter baumannii (n=54) and Klebsiella pneumonia (n=26) and most common gram-positive organism isolated was Enterococcus faecium (n=9). All isolated organisms were multidrug resistant. Conclusion: Poor antimicrobial stewardship particularly in critical care units resulted in secondary bacterial infections in COVID-19 patients. The pathogens isolated were multidrug resistant including Acinetobacter baumannii, Klebsiella pneumonia and Enterococcus faecium.

Aim: To determine the effectiveness of supratarsal triamcinolone injection versus dexamethasone in recalcitrant vernal keratoconjunctivitis. Study Design: Prospective/randomized study Place and Duration of Study: Department of Ophthalmology, Lorallai Medical College, Loralai from 1st October 2020 to 31st March 2021. Methods: Fifty patients (100 eyes) of both genders and age between 12-40 years were enrolled. Detailed demographics of enrolled cases age, sex and body mass index were recorded after taking informed written consent. All patients had recalcitrant vernal keratoconjunctivitis. Patients were equally divided into 2-groups. Group I had 25 patients and received 20mg of supratarsal triamcinolone injection in both eyes and group II with 25 patients received 2mg of dexamethasone in their eyes. Postoperative effectiveness, complications and recurrence of disease was observed and compared among both groups. Results: There were 15 (60%) males and 10 (40%) females in group I with mean age 18.14±6.34 years while in group II, 15 (60%) males and 10 (40%) females with mean age was 17.68±4.54 years. Palprebral vernal keratoconjunctivitis was found in 36 eyes (10 patients of group I and 8 patients of group II) and Mixed vernal keratoconjunctivitis in 64 eyes (15 patients of group I and 17 patients of group II). Symptoms were itching,photophobia, lacrimation and pain. Conjunctival hyperemia, giant papillae and limbal infiltrate were the most common signs observed. Post operatively effectiveness among group I and II was (100% vs 92%) without any complication. Recurrence rate of vernal keratoconjunctivitis in group I was lower 4% as compared to group II 10%. Conclusion: The use of supratarsal triamcinolone injection in patients of recalcitrant vernal keratoconjunctivitis was effective and safest method as compared to dexamethasone in terms of less recurrence and high rate of efficacy. Keywords: Supratarsal triamcinolone, Dexamethasone, Vernal keratoconjunctivitis, Effectiveness, Recurrence

Aim: To determine the prevalence of dry eye in glaucoma patients using topical anti-glaucoma therapy. Study Design: Descriptive observational study Place and duration of study: Department of Ophthalmology, Shalimar Medical & Dental College Lahore from 1st November 2020 to 30th April 2021. Methodology: Ninety patients of both genders were enrolled. Detailed demographics of enrolled cases age, sex and body mass index were recorded after taking informed written consent. Patients using topical anti-glaucoma therapy for more than 8 months and having symptoms of stinging and burning sensations itching, watering, irritation, due to regular use of topical antiglaucoma drugs were presented. Basal Schrimer’s test and tear film break-up time test was used to measure the frequency of dry eye syndrome as mild, moderate and severe. Results: There were 60 (66.7%) females and 30 (33.3%) patients were males. Mean age of the patients were 45.61±7.66 years with mean BMI 26.24±8.71 kg/m2. We found that 40 (44.4%) patients had burning and stinging sensations, itching found in 21 (23.3%), dry eye sensations were found in 16 (17.8%) patients and watering and irritation found in 13 (14.4%) .According to tear film break-up time test 20 (22.2%) cases did not show dry eye syndrome and 19 (21.1%) patients were normal in Basal Schrimer’s test. Conclusion: Use of topical anti-glaucoma medication resulted in dry eye syndrome as well as a decrease in the tear film's stability. Keywords: Anti-glaucoma therapy, Basal Schrimer`s test, Tear film break-up time, Anti-glaucoma therapy, Dry eye syndrome

Background Cytokine release syndrome (CRS) plays a pivotal role in the pathophysiology and progression of Coronavirus disease-2019 (COVID-19). Therapeutic plasma exchange (TPE) by removing the pathogenic cytokines is hypothesized to dampen CRS. Objective To evaluate the outcomes of the patients with COVID-19 having CRS being treated with TPE compared to controls on the standard of care. Methodology Retrospective propensity score-matched analysis in a single centre from 1st April to 31st July 2020. We retrospectively analyzed data of 280 hospitalized patients developing CRS initially. PSM was used to minimize bias from non-randomized treatment assignment. Using PSM 1:1, 90 patients were selected and assigned to 2 equal groups. Forced matching was done for disease severity, routine standard care and advanced supportive care. Many other Co-variates were matched. Primary outcome was 28 days overall survival. Secondary outcomes were duration of hospitalization, CRS resolution time and timing of viral clearance on Polymerase chain reaction testing. Results After PS-matching, the selected cohort had a median age of 60 years (range 32–73 in TPE, 37–75 in controls), p = 0.325 and all were males. Median symptoms duration was 7 days (range 3–22 days’ TPE and 3–20 days controls), p = 0.266. Disease severity in both groups was 6 (6.6%) moderate, 40 (44.4%) severe and 44 (49%) critical. Overall, 28-day survival was significantly superior in the TPE group (91.1%), 95% CI 78.33–97.76; as compared to PS-matched controls (61.5%), 95% CI 51.29–78.76 (log rank 0.002), pth day (p = 0.0045). Conclusion An earlier use of TPE was associated with improved overall survival, early CRS resolution and time to discharge compared to SOC for COVID-19 triggered CRS in this selected cohort of PS-matched male patients from one major hospital in Pakistan.

OBJECTIVE To assess the safety of percutaneous tracheostomy when performed by physician intensivists. STUDY DESIGN Descriptive study. PLACE AND DURATION OF STUDY Adult Medical ICU in the Department of Critical Care Medicine, Military Hospital, Rawalpindi, Pakistan, from September 2013 to August 2016. METHODOLOGY Departmental record for percutaneous tracheostomies, performed by physician intensivifts, was evaluated. Variables studied were underlying primary diagnosis, details of the operating doctors, presence of immediate complications, departmental protocol for the procedure, pre-procedure safety checklist, written instructions on procedure steps, use of ultrasound and bronchoscopy. Portex Percutaneous Dilation Tracheostomy Kit with Single-Stage Dilator was used in all the patients. RESULTS Fifty-six percutaneous tracheostomy procedures were performed with a male to female ratio 3:1; more than 2/3rd (80%) had an underlying neurological illness. All doctors performing the procedures were physicians having minimum qualification of Fellowship with at least one year experience in intensive care and had observed at least five procedures. Departmental protocol for the procedure was followed in all the cases. Minor complications were observed in three patients (5.35%). These included para-tracheal misplacement, accidental de-cannulation, and endotracheal tube cuff puncture. None of the patient died due to direct complications of the procedure. CONCLUSION Percutaneous tracheostomy is safe in Medical ICUs of developing countries, when performed by experienced physician intensivists under defined protocols.