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The efficacy of antibiotics and other antimicrobial agents in combating bacterial infections faces a grave peril in the form of antimicrobial resistance (AMR), an exceedingly pressing global health issue. The emergence and dissemination of drug-resistant bacteria can be attributed to the rampant overuse and misuse of antibiotics, leading to dire consequences such as organ failure and sepsis. Beyond the realm of individual health, the pervasive specter of AMR casts its ominous shadow upon the economy and society at large, resulting in protracted hospital stays, elevated medical expenditures, and diminished productivity, with particularly dire consequences for vulnerable populations. It is abundantly clear that addressing this ominous threat necessitates a concerted international endeavor encompassing the optimization of antibiotic deployment, the pursuit of novel antimicrobial compounds and therapeutic strategies, the enhancement of surveillance and monitoring of resistant bacterial strains, and the assurance of universal access to efficacious treatments. In the ongoing struggle against this encroaching menace, phage-based therapies, strategically tailored to combat AMR, offer a formidable line of defense. Furthermore, an alluring pathway forward for the development of vaccines lies in the utilization of virus-like particles (VLPs), which have demonstrated their remarkable capacity to elicit a robust immune response against bacterial infections. VLP-based vaccinations, characterized by their absence of genetic material and non-infectious nature, present a markedly safer and more stable alternative to conventional immunization protocols. Encouragingly, preclinical investigations have yielded promising results in the development of VLP vaccines targeting pivotal bacteria implicated in the AMR crisis, including Salmonella, Escherichia coli, and Clostridium difficile. Notwithstanding the undeniable potential of VLP vaccines, formidable challenges persist, including the identification of suitable bacterial markers for vaccination and the formidable prospect of bacterial pathogens evolving mechanisms to thwart the immune response. Nonetheless, the prospect of VLP-based vaccines holds great promise in the relentless fight against AMR, underscoring the need for sustained research and development endeavors. In the quest to marshal more potent defenses against AMR and to pave the way for visionary innovations, cutting-edge techniques that incorporate RNA interference, nanomedicine, and the integration of artificial intelligence are currently under rigorous scrutiny. [ABSTRACT FROM AUTHOR]

Objectives: To compare the nebulized salbutamol alone with combination of nebulized salbutamol and ipratropium for acute exacerbation of chronic obstructive pulmonary disease in terms of mean length of stay. Study Design: Quasi-experimental study Place and Duration of Study: Department of Medicine, Military Hospital, Rawalpindi Pakistan. Study was carried out over a period of six months from May to Nov 2017. Methodology: A total of 300 patients of chronic obstructive pulmonary disease (150 in each group) were recruited in the study. Group A received nebulized salbutamol (5mg) alone and Group B received a combination of nebulized salbutamol (5mg) and ipratropium bromide (0.5mg). Results: Mean age of the patients was 66.4±6.4 years and 65.7±6.8 years in Group-A and B, respectively. In Group-A, there were 136(90.7%) and in Group-B 134(89.3%) were males while 14(9.3%) and 16(10.7%) were females in Group-A and B, respectively. Mean duration of disease in Group-A was 5.2±2.4 years and in group-B 6.0±1.6 years. Comparison of mean length of stay (days) revealed in hospital between nebulized Salbutamol alone 5.0±0.5 days with combination of nebulized Salbutamol and Ipratropium 4.3±0.6 days with p-value <0.001. Conclusion: In conclusion, the routine addition of nebulized ipratropium bromide to salbutamol appears to be of benefit in the treatment of acute exacerbations of chronic obstructive pulmonary disease and in terms of mean length of hospital stay. [ABSTRACT FROM AUTHOR]

Objective: To assess the fluid responsiveness with end tidal carbon dioxide using a simplified leg-raising maneuver in noncardiac patients admitted in medical Intensive Care Unit (ICU). Study Design: Cross sectional analytical study. Place and Duration of Study: Intensive Care Unit, Pak Emirates Military Hospital Rawalpindi, form Jun to Nov 2019. Methodology: A total of 80 cases were included in this study who were admitted in medical ICU and were on ventilator support. A standard 5-minute leg-raising maneuver was applied on all the patients. An increase in cardiac index >15% after passive leg rise was taken as criteria for responders. All echocardiographic evaluations were performed by experienced sonographers. Results: Mean age of study participants was 47.4 ± 4.421 years, 65 (81.3%) were males while 15 (18.7%) were female patients. Sixty (75%) patients responded to the simplified leg raising maneuver while 20 (25%) did not respond. Mean arterial pressure of the respondents was 92.3 ± 3.26 mmHg while mean arterial pressure of the non-respondents was 83.2 ± 4.57 mmHg. High body mass index and low mean arterial pressure had statistically significant relationship with no response to the maneuver in our study. Conclusion: Simplified leg raising emerged as an effective maneuver to stabilize the non-cardiac patients hemodynamically inside the setting of critical care unit. Patients with low baseline mean arterial pressure or high body mass index may be considered as high risk for non-response to this maneuver. [ABSTRACT FROM AUTHOR]

Background: Coronavirus disease 2019 (COVID-19) is a multisystem disorder and haematological abnormalities are frequently documented in affected patients. Methods: This retrospective study included 549 patients hospitalized with COVID-19 from 1st June to 15th July 2020 at Pak Emirates hospital, Rawalpindi Pakistan. p<0.05 was considered statistically significant. Results: Median age was 60 years (range 12–94 years), males 442 (80.5%) and females 107 (19.5%). There was no patient with mild illness, 181 (32.9%) had moderate, 158 (28.7%) severe and 210 (38.2%) patients had critical disease. Patients with severe and critical disease had lower absolute lymphocyte count (ALC) and platelets (p<0.001 for both) while higher white blood cell count (WBC), neutrophil lymphocyte ratio (NLR), C-reactive protein (CRP), interleukin-6 (IL-6) and lactate dehydrogenase levels (LDH) levels (all p<0.001). Overall survival of study cohort was 83.2% (n=457). Median haemoglobin and platelet count were significantly lower (p<0.001) while WBC, ANC, NLR, prothrombin time (PT), activated partial thromboplastin time (APTT), ferritin, IL-6, LDH were significantly higher (p<0.001) for patients who died. On multivariate logistic regression analysis WBC count>10x109/l (odds ratio [OR] 2.19 [95% CI 1.3–4.2] p=0.01), NLR>9 (OR 3.4 [95% CI 0.87–6.8], p<0.001), platelets<150x109/l (OR 3.9 [95% CI 1.4–9.8] p<0.001), CRP >100; (OR 4.1[95% CI 0.78–10.9] p<0.001) and ferritin >1000 (OR 5.3 [95% CI 1.9– 13.5], p<0.001) were associated with increased risk of death in patients with COVID-19. Conclusion: Monitoring of haematological, coagulation and inflammatory parameters provide reliable, convenient, rapid and cost-effective method for predicting disease severity, complications and prognosis of COVID-19 patients. [ABSTRACT FROM AUTHOR]

Objective: To assess the patterns of drug resistance (DR) among patients previously treated for pulmonary tuberculosis (TB). Study Design: Cross-sectional study. Place and Duration of Study: Department of Medicine, Pak-Emirates Military Hospital, Rawalpindi Pakistan, from Jul 2020 to Mar 2021. Methodology: Patients with previously treated pulmonary TB were included, based on their clinical history and characteristic chest X-ray findings. Patients were evaluated through an examination of sputum and/or bronchoalveolar washings for acid-fast bacilli (AFB), Mycobacterium TB-GeneXpert/RIF (Rifampicin) assay, and mycobacterial culture with drug susceptibility testing (DST). Patients with resistance to any anti-TB drug were classified as cases of DR-TB, and a pattern of drug resistance was documented. Results: One hundred twenty patients were identified as having been previously treated for TB. DST demonstrated DR-TB among 38(31.7%) cases, while isoniazid (INH) resistance was the most commonly reported problem in 29(24.2%) cases. Up to 26(21.6%) relapsing cases were resistant to Rifampicin (RFM). Moreover, 15(12.5%) instances of resistance against second-line anti-TB drugs (fluoroquinolones and aminoglycosides) were documented. Multidrug-resistant TB (MDR-TB) was the most prevalent resistance pattern in 20(16.7%) cases, followed by mono-drug-resistant TB in 7(5.8%) and extensively resistant TB (XDR-TB) in 2(1.6%) cases. No definitive resistance pattern was evident among 9(7.5%) cases. Conclusion: MDR-TB constitutes a major barrier in the line of TB eradication in Pakistan. Strict compliance with anti-TB protocols, along with a universal application of DST, can minimize the overall prevalence of relapsing cases of TB. [ABSTRACT FROM AUTHOR]

Objective: To determine frequency of cardiac involvement in patients of COVID-19. Secondary objective was to determine association of cardiac involvement with prognosis. Study Design: Descriptive cross-sectional study. Place and Duration of Study: Pak-Emirates Military Hospital, Rawalpindi Pakistan, from Apr to Jul 2020. Methodology: We prospectively assessed the laboratory data, Electrocardiogram and transthoracic echocardiography of all the COVID-19 patients admitted to our institute. Outcomes of interest included length of hospital stay, admission to Intensive Care Unit and mortality. Acute myocardial injury was defined by a value of high-sensitivity troponin I (hs-TnI) above the thth percentile upper reference limit. Statistical Package for the Social Sciences (SPSS) version 23 was used for all the analysis. Results: Our study included 1015 patients, mean age 50.34 (SD 13.71) years, 887 (87.3%) males and 128 (12.6%) females. Three hundred and thirty (n=330, 32.5%) patients had evidence of acute cardiac injury as shown by raised cardiac troponins, but 50, 4.92% had left ventricle dysfunction. Raised cardiac enzymes were associated with marginally prolonged hospital stay (10.03 versus 9.32 days, p-value 0.07) and higher mortality (OR 2.634, confidence interval 1.252-5.543, p-value 0.01). Conclusion: Cardiac involvement is quite common among patients suffering from COVID-19 and predicts worse prognosis. [ABSTRACT FROM AUTHOR]

Objective: To examine the existence of pharmacological aspirin resistance and its association with age and gender in cardiovascular disease patients. Methodology: This cross sectional study was conducted from October 2015 to December 2016 at Pharmacology department Army Medical College, National University of Medical Sciences (NUMS), Rawalpindi in collaboration with Armed Forces Institute of Cardiology and National Institute of Heart Diseases (AFICNIHD) and Armed Forces Institute of Pathology (AFIP), Rawalpindi. Platelet function was analyzed by light transmission aggregometry (LTA) using arachidonic acid as an agonist. Data was analyzed by using SPSS version 23. Chi-square test and students t test was applied to evaluate the categorical and numerical variables respectively. Results:Total of 384 cardiovascular patients meeting the explicit inclusion criteria were enrolled There were 272 (70.8%) male and 112 (29.2%) female patients with the mean age of 48.22 ± 11.87 years. The statistical analysis revealed 13.8% (n=53) aspirin resistant cases in study population with 14.7 % (n=40) male and 11.6% (n=13) female (mean age 49.87±13.20 years) were found to be aspirin non responders. Conclusion: Our study suggests that phenomenon of aspirin resistance does exist in Pakistani population, and it is not modulated by age and gender of patients. [ABSTRACT FROM AUTHOR]

Objectives: To determine frequency of left ventricular thrombus (LVT) in acute ST elevation myocardial infarction (STEMI) and to find out the correlation of risk factors with development of left ventricular thrombus. Study Design: Hospital-based observational cross sectional study. Place and Duration of Study: AFIC/NIHD Rawalpindi, from Nov 2016 to Feb 2017. Material and Methods: One hundred and fifty consecutive patients presented with first episode of acute STEMI were included. Patients with previous history of myocardial infarction, valvular heart disease, dilated Cardiomyopathy and mural thrombus were excluded. 2-D echocardiography was performed after 24 hours, 48 hours and 72 hours of admission. Descriptive and inferential statistical analysis was performed using SPSS version 23.0. Results: Mean age of patients was 59.84 ± 11.16 years. Thrombus was seen in 35 (23.3%) patients out of which 21 (60%) were males and 14 (40%) were females. left ventricular thrombus occurred in 8 (22.8%) after 24 hours and 27 (77.2%) patients after 72 hours. LV thrombus was seen in 20 (57.1%) patients whose EF was less than 30% while it occurred in 10 (28.5%) patients having EF 30-45% and 5 (14.2%) patients with EF >45%. Among risk factor LV thrombus was seen in 17 (48.5%) diabetic patients, 4 (11.4%) patients had hypertension and 14 (40%) were those who had both diabetes and hypertension. Conclusion: LVT is important complication of acute myocardial infarction. If diagnosed and anticoagulated earlier, risk of complications and its potential to embolise can be minimized. [ABSTRACT FROM AUTHOR]

Objective: This study was done to find out how angiographic findings including severity, site, type of lesion, calcification and based on these findings the Syntax Score were related to the level of cardiac Troponin-I (cTn-I) in patients of Non ST Elevation Myocardial Infarction. Study Design: Cross sectional study. Place and Duration of Study: Armed forces institute of Cardiology/National Institute of Health Sciences Rawalpindi Pakistan, from July 2016 to Dec 2016. Material and Methods: A total of 120 patients were studied over a period of 6 months. They were divided into two groups according to High sensitivity Trop I levels; high/Group A (Troponin-I level >0.78 ng/ml) and low Group B (Troponin-I 0.06–0.78 ng/ml). Thus 54 patients fell into Group A while 66 into Group B. The angiographic characteristics and Syntax Score of the two groups of patients were then compared. Results: A total of 120 patients were studied. There were 86 (71.6%) males and 34 (28.3%) females with age range 29-77 years. cTnI was markedly raised in 59 (49%) patients i.e. Group A and lower in 61 (51%) i.e. Group B. High levels of cnT-I were related to number of vessels involved p<0.001. Three vessel involvement was higher 34 (57%) of Group A in comparison with group B 4 (6.5%). While more patients had single vessel involvement in Group B vs Group A i.e. 38 (62%) and 5(8.4%). Type A lesions were more common in Group A than Group B; 44(72%) vs 11(18%). Thrombus burden was higher in Group A, Calcification frequency was more in Group A than B; 73% vs 11% p<0.001 and Syntax Score was >32 in 52% of Group A and in 3% of Group B p<0.05. Proximal lesions were more frequent in Group A 33(55%) than Group B 26(42%) but the correlation was insignificant p=0.48. Conclusion: Patients of Non-ST elevation Myocardial Infarction with raised serum Troponin-I had more severe coronary disease and higher Syntax Score than those with lower serum Troponin-I. [ABSTRACT FROM AUTHOR]

Objective: To determine the success rate of cardiac resynchronization therapy and defibrillator implantation in heart failure patients. Study Design: Descriptive cross sectional study. Place and Duration of Study: This study was conducted at AFIC-NIHD from 1st Jul 2014 to 31st Dec 2014. Material and Methods: A total of 45 patients were included in the study that underwent CRT-D implantation. The procedural success was noted in the catheterization laboratory (cath lab) and in wards, where patients were managed after CRT-D implantation. Procedural success was based on three criteria: 1) class improvement in NYHA class, 2) ≥ 5 % improvement in ejection fraction (EF) and 3) conversion of Left bundle branch block (LBBB) into normal QRS complexes. Results: Most of patients 15 (33.0%) were between 57-62 years of age. 34 (75.6%) were males and 11 (24.4%) females. the mean age of the patients was 53.6 ± 7.8 years (range 35 - 67 years). Pre-procedure mean EF was 24.71% and post procedure mean EF was 31.33%. Prior to procedure 33 (73.3%) patients were in NYHA Class III and 12 patients (26.7%) were in NYHA Class IV. 93.0% patients showed improvement in NYHA class. EF improved in 93.0% patients and 89.1% patients converted to normal QRS complexes after CRT-D implantation. The overall combined success rate was 93.0%. Conclusion: The procedural success rate of CRT-D was high and should be offered to the patients with heart failure who are non responder to medical treatment whenever the facility is available. [ABSTRACT FROM AUTHOR]

Cardiac disease is a leading cause of maternal mortality worldwide. Mitral stenosis is the most common form with increased pregnancy and delivery complications for both mother and neonate. During pregnancy physiological hemodynamic changes of the circulation are the main cause of mitral stenosis decompensation. Morbidly adherent placenta is a serious complication of pregnancy and is associated with massive intrapartum hemorrhage and high maternal morbidity and mortality. The case under discussion is of a recently diagnosed patient with severe mitral stenosis and placenta previa who was effectively managed in a tertiary care setting inspite of having both cardiac and obstetric life threatening situations with a outcome comparable to a normal patient. [ABSTRACT FROM AUTHOR]