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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 determine the efficacy of therapeutic plasma exchange in patients suffering from COVID-19 requiring admission in the critical care setting. Study Design: Comparative cross-sectional study. Setting and Duration of Study: Critical Care Unit, Pak Emirates Military Hospital Rawalpindi, from Apr 2020 to Jun 2020. Methodology: The study was carried out on 160 patients managed at the Critical Care setting of our hospital in three months. Data were extracted from the record regarding the patients who underwent therapeutic plasma exchange and others who were only given supportive management. Overall mortality, duration of hospital stay, duration of Intensive Care Unit stay and duration of oxygen supplementation was compared in both the groups. Results: A total of 160 patients met the inclusion/exclusion criteria. Of these, 100 (62.5%) underwent therapeutic plasma exchange, while 60 (37.5%) did not undergo this procedure. The mean age of participants was 62.19 ± 5.192 years. Out of 15 (15%) patients died who underwent therapeutic plasma exchange, while 51 (85%) patients died who did not undergo plasma exchange (p-value

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 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.

Objective: To share our experience of tracheostomy in COVID-19 positive patients. Study Design: Prospective observational study. Place and Duration of Study: Pak-Emirates Military Hospital, Rawalpindi Pakistan, from Apr to Jul 2020. Methodology: A total of 94 COVID-19 positive cases admitted to the Intensive Care Unit of this hospital, placed on ventilatory support and who ultimately underwent tracheostomy (whether percutaneous or surgical) were included in the study. Patients were included irrespective of any age group or gender. Results: Out of 94 patients placed on ventilator, tracheostomy was performed only in 17 patients. Male predominance was 13 (76%), with mean age of patients as 55.59 ± 12.93 in 12 patients, surgical tracheostomy was performed (70.58%) whereas in 5 (29.4%) cases percutaneous tracheostomy was done. On post-operative follow-up 8 out of 17 (47%) patients recovered and were successfully decannulated whereas 9 (52.9%) patients could not survive. Tracheostomy was successfully performed as early as 8th day of mechanical ventilator support. Health Care Workers (HCWs) involved were subjected to RT-PCR and remained negative for SARS-CoV-2. There was statistically significant association between the type and indication of tracheostomy, p=0.002. Conclusion: Tracheostomy, in COVID-19 positive patients, being aerosol-generating procedure remains a medical hazard for the HCWs. By following strict safety protocols according to the medical resources available and training of the HCWs, it can be performed with complete safety. It can be done as early as 8th day of ventilator support. © 2021, Army Medical College. All rights reserved.

Objective: To compare the effectiveness of intraarticular injections of hyaluronic acid and corticosteroids in the treatment of patients with knee osteoarthritis symptoms.Study Design: Prospective comparative study.Place and Duration of Study: Rheumatology/General Medicine department, Pak Emirates Military Hospital Rawalpindi, from May 2019 to Jun 2020.Methodology: Patient of knee osteoarthritis with active symptoms of pain and stiffness who fulfilled American college of rheumatology criteria of 1997 were included in the study. They were randomly divided into two groups with group A receiving intraarticular hyaluronic acid. Western Ontario and McMaster Universities Osteoarthritis Index (WOMAC) was administered before and three months after the management to assess the efficacy of treatment in both the groups. Student ttest was applied to ascertain that the difference in the WOMAC scores before and after the management has been statistically significantly different in both groups. Results: A total of 150 patients of osteoarthritis of knee joint were included in the study. Mean age of the study participants was 58.439 ± 7.35. 85 (56.7%) patients were female while 65 (43.3%) were male. 81 (54%) received the intraarticular hyaluronic Acid while 69 (46%) received the intraarticular steroids. Mean difference before and after the management in WOMAC score in corticosteroids group was 9.295 ± 1.24 while in hyaluronic Acid group was 5.41 ± 4.556 (p-value

Objective: To determine the frequency of acute pancreatitis among the patients diagnosed with diabetic ketoacidosis at our tertiary care hospital. Study Design: Co-relational study. Place and Duration of Study: Medicine department, Pak Emirates Military Hospital Rawalpindi, from Jun to Dec 2019. Methodology: A total of 40 cases presenting with diabetic ketoacidosis were included in our study. Diabetic ketoacidosis was diagnosed by consultant medical specialist. All patients underwent baseline investigations including serum amylase, lipid profile and CT scan abdomen in order to diagnose acute pancreatitis. Relationship of age, gender, duration of diabetes mellitus and triglyceride levels was assessed with the presence of acute pancreatitis among the patients of diabetic ketoacidosis. Results: A total of forty patients were managed as diabetic ketoacidosis in our hospital during the study period. Out of them 8 (20%) had acute pancreatitis while 32 (80%) were not diagnosed with acute pancreatitis. Confusion (55%) was the commonest presenting complaint followed by abdominal pain (25%). With binary logistic regression analysis, we found that female gender and raised triglyceride levels had a statistically significant relationship with presence of acute pancreatitis among the patients of diabetic ketoacidosis included in this study. Conclusion: Considerable number of patients were diagnosed with acute pancreatitis who presented with diabetic ketoacidosis. Special attention should be paid towards female patients and those with raised triglyceride levels to look for the sign and symptoms of acute pancreatitis in order to diagnose and manage this condition.

PurposeTo evaluate the outcome of patients with COVID-19 triggered CRS treated with Therapeutic Plasma Exchange (TPE) as compared to propensity score matched (PSM)-controls not receiving TPE.Material and methodsUsing PS 1:1 matching, 90 patients were assigned 2 groups (45 receiving TPE and 45 controls). Forced matching and covariate matching was done to overcome bias between two groups.ResultsMedian age was 60 years (range 32-73 in TPE and 37-75 in non-TPE group), p= 0.325. Median duration of symptoms 7 days (range 3-22 days in TPE and 3-20 days in non-TPE), p=0.266. Disease severity in both groups was 6.6% moderate, 44.4% severe and 49% critical. Twenty-eight-day survival was significantly superior in TPE group (91.1%) as compared to PS-matched controls (61.5%), HR 0.21, 95% CI for HR 0.09-0.53, log rank 0.002. Median duration of hospitalization was significantly reduced in TPE treated group as compared to non-TPE controls 10 days and 15 days respectively (p< 0.01). CRS resolution time was also significantly reduced in TPE treated group (6 days vs. 12 days) (p< 0.001).ConclusionUse of TPE is associated with superior overall survival, early resolution of CRS and time to discharge as compared to standard therapy for COVID-19 triggered CRS.Highlights□Cytokine release syndrome (CRS) plays a pivotal role in pathophysiology and progression to severe and critical disease in patients with COVID-19.□Beyond supportive care, there are currently no proven effective treatment options (including Tocilizumab) for coronavirus disease (COVID-19)□Therapeutic plasma exchange (TPE) may dampen CRS of COVID-19 by removing circulating cytokines and toxins□TPE is the cheapest of all novel treatments available so far to treat severe to critical COVID-19□By intervening early with TPE, mortality and morbidity associated with COVID-19 triggered CRS can be reduced