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BACKGROUND: Esophageal cancer ranks eighth among the most prevalent cancers globally and is the sixth leading cause of mortality from malignancy worldwide; it is the 7th most prevalent malignancy in males and the 6th most prevalent malignancy in females. In Pakistan, the incidence is 4.1 per 100 000 with the province of Baluchistan having the greatest incidence. OBJECTIVE: Report trends and characteristics of esophageal cancer in Pakistan over the past 10 years. DESIGN: Cross-sectional, retrospective review of medical records. SETTING: Tertiary care hospital. PATIENTS AND METHODS: The study included all patients admitted with a diagnosis of esophageal carcinoma with a mass lesion or luminal narrowing. The records were for the period from January 2011 to September 2020. MAIN OUTCOME MEASURES: Gender, histopathological types/differentiation along with clinical/laboratory findings. SAMPLE SIZE: 1009 with a mean (standard deviation) age of 49.3 (14.2) and a median (interquartile range of 50 (22) years (443 males and 566 females with age of 51.0 [20] years and 47.9 [23.8] years, respectively). The male-to-female ratio was 1:1.2. RESULTS: Most patients (82.7%) had squamous cell carcinomas with a male-to-female ratio of 1:2; the remainder had adenocarcinomas with a male-to-female ratio of 4:1 ( P P =.030), lesions were most likely to be ulcerated ( P =.910). Luminal narrowing was slightly more frequent in squamous cell carcinoma ( P =.215), thickening was more prominently circumferential in the adenocarcinomas. In squamous cell carcinoma, the most common variant was moderately differentiated while moderate to poorly differentiated variants were more common in adenocarcinoma. In the survival analysis, squamous cell carcinoma ( P =.014 vs adenocarcinoma), particularly the well-differentiated type ( P =.018 vs other variants), projected a better prognosis. CONCLUSION: Our study reports the most recent trends of esophageal carcinoma in this region. LIMITATIONS: Lack of metastatic workup, TNM staging, and mode of treatment, along with the overlapping pattern of histological variants. CONFLICT OF INTEREST: None.

Asymptomatic bacteriuria (ASB) is the isolation of bacteria in a urine sample from individuals who do not have any symptoms of a urinary tract infection (UTI). The outcomes of ASB in chronic kidney disease (CKD) patients are poorly understood in Pakistan. This study aimed to determine the characteristics of ASB and antibiotic susceptibility pattern among patients with CKD. A cross-sectional retrospective survey was administered to perform this study in a tertiary care hospital, to include all CKD patients. The study included all those patients with a diagnosis of CKD with no signs and symptoms of UTI present, and showing the growth of an organism in urine culture. A total of 175 urine cultures were observed retrospectively meeting the inclusion criteria through nonprobability consecutive sampling. Out of 175 urine cultures observed, mean age of 58.56 ± 16.81, 71% of them were females, 55% were diabetic, and 22% had a family history of CKD. Escherichia coli, Enterococcus, Klebsiella, Pseudomonas, Enterobacter, and streptococcal species were the most often isolated microbes. A total of 17 subjects got dual bacterial growth in their cultures which were having Enterococcus species as the most common organism. Twenty-three cultures were identified as pandrug resistant (13.14%), only sensitive to colomycin/polymyxin B. The susceptibilities of these organisms were contrasting to traditional antibiotics known to treat UTIs empirically, hence demanding further screening and treatment protocols to be defined for minimizing the irrational choice of antibiotics.

Background and Objectives: COVID-19 is a global pandemic. In our study, we aimed to utilize the hematological parameters in predicting the prognosis and mortality in COVID-19 patients. Materials and methods: A retrospective, observational study was conducted to include all the admitted patients (n = 191) having COVID-19 Polymerase chain reaction (PCR) positive, and evaluated those for prognosis and disease outcome by utilizing several biochemical and hematological markers. Results: Amongst the patients admitted in the ward versus in the intensive care unit (ICU), there were significant differences in mean hemoglobin (P = 0.003), total leukocyte count (P = 0.001), absolute neutrophil and lymphocyte counts (P

Coronavirus disease-2019 (COVID-19) is a global pandemic, also affecting Pakistan with its first case reported on February 26, 2020. Since then, it has been declared a pandemic by the World Health Organization. Our study aimed to evaluate the renal derangements associated with COVID-19 infection in our population. A retrospective, observational study was conducted to include all the admitted patients having COVID-19 positive, and evaluated those for derangements of renal function (n = 362). Out of the 362 patients, 229were admitted in the ward, 133 were in intensive care unit (ICU), 258 of them recovered, while 104 deaths reported. At admission, the renal profile was deranged in almost one-half of ICU admissions and mortalities which increased to two-third during the hospital stay, with around 80% of deaths reported with increased urea and creatinine levels. Among the deceased patients, around one-third of the mortalities developed renal profile derangements during the hospital stay although they were admitted with a normal renal profile. An estimated glomerular filtration rate showed a mean increase of 13.37 mL/min/1.73 m2 during the hospital stay of surviving patients, while a decline of 19.92 in nonsurviving patients. A hazard ratio of 3.293 (P

BACKGROUND: Viral hepatitis is a global phenomenon, with the disease burden varying on a daily basis. Amongst chronic infections, hepatitis B virus and hepatitis C virus (HCV) are egregiously linked to severe health-related complications, with a worldwide prevalence of 248 million and 71 million respectively. Amongst the developing world, a hand full of countries are exhibiting a gross decline in chronic viral infection prevalence, like Bangladesh. While countries such as India have a consistent prevalence, Pakistan bears one of the largest proportions of chronic viral hepatitis globally with increasing trends shown year-by-year. Various old literature texts have stated an approximate national prevalence rate around 2.6% and 5.3% of hepatitis B and C respectively. OBJECTIVE: The objective of this study was to determine the current seroprevalence rates of chronic viral hepatitis amongst the general population of rural Sindh using a screening program to determine the current disease burden. METHODS: An observational, cross-sectional survey based on a screening program was conducted in 5 districts with a combined population of over 6.5 million. The screening was carried out via the administration of various camps with the assistance of local social workers and welfare organizations. A total of 24,322 individuals met the inclusion criteria and were screened through (HBsAg/HCV) rapid test cassette (WC) Imu-Med one-step diagnostic test. RESULTS: Hepatitis B was found positive in 964 (3.96%) individuals including 421 (43.67%) males and 543 (56.32%) females, while hepatitis C was positive in 2872 (11.80%) individuals including 1474 (51.32%) males and 1398 (48.67%) females. The prevalence amongst the districts varied between 0.97% and 9.06% for hepatitis B, and 1.61% and 29.50% for hepatitis C, respectively. Umerkot was found to be the most prevalent district amongst rural Sindh, while Badin had the least number of seropositive people. The second most prevalent district of the study population was found to be Tando Allahyar followed by Mirpur Khas. The combined seroprevalence of 15.76% was calculated for hepatitis B and C together amongst the five studied districts of rural and peri-urban Sindh. CONCLUSION: The alarmingly high prevalence rates revealed in our study warrant the urgent need to generate multiple effective strategies in the region to enhance awareness amongst the general population regarding screening, prevention, and prompt treatment of the disease. RESUMO CONTEXTO: A hepatite viral é um fenômeno global, com a intensidade da doença variando diariamente. Entre as infecções crônicas, o vírus da hepatite B e o vírus da hepatite C (VHC) estão fortemente ligados a complicações graves relacionadas à saúde, com prevalência mundial de 248 milhões e 71 milhões, respectivamente. Entre o mundo em desenvolvimento, uma quantidade de países está exibindo um declínio bruto na prevalência de infecção viral crônica, tal como Bangladesh. Embora países como a Índia tenham uma prevalência consistente, o Paquistão tem uma das maiores proporções globais de hepatite viral crônica, com tendências crescentes mostradas ano a ano. Vários textos da menos recentes têm declarado uma taxa de prevalência nacional aproximada em torno de 2,6% e 5,3% da hepatite B e C, respectivamente. OBJETIVO: O objetivo deste estudo foi determinar as atuais taxas de soroprevalência da hepatite viral crônica entre a população geral do Sindh rural utilizando um programa de triagem para determinar a carga atual da doença. MÉTODOS: Foi realizada uma pesquisa observacional e transversal baseada em um programa de triagem combinada em cinco distritos com população de mais de 6,5 milhões. A triagem foi realizada por meio da administração de diversos acampamentos com o auxílio de assistentes sociais locais e organizações de assistência social. Um total de 24.322 indivíduos atenderam aos critérios de inclusão e foram examinados através do teste rápido (HBsAg/VHC) Imu-Med em uma etapa. RESULTADOS: Hepatite B positiva foi encontrada em 964 (3,96%) indivíduos incluindo 421 (43,67%) homens e 543 (56,32%) mulheres, enquanto hepatite C foi positiva em 2.872 (11,80%) indivíduos incluindo 1.474 (51,32%) homens e 1.398 (48,67%) mulheres. A prevalência entre os distritos variou entre 0,97% e 9,06% para hepatite B, e 1,61% e 29,50% para hepatite C, respectivamente. Umerkot foi encontrado como o distrito mais prevalente entre Sindh rural, enquanto Badin tinha o menor número de pessoas soropositivas. O segundo distrito mais prevalente da população de estudos foi encontrado como Tando Allahyar, seguido por Mirpur Khas. A soroprevalência combinada de 15,76% foi calculada para hepatite B e C em conjunto entre os cinco distritos estudados do Sindh rural e periurbano. CONCLUSÃO: As taxas de prevalência alarmantemente reveladas em nosso estudo justificam a necessidade urgente de gerar múltiplas estratégias efetivas na região para aumentar a conscientização da população em geral sobre rastreamento, prevenção e tratamento rápido da doença.

Background and objective The term asymptomatic bacteriuria (ASB) refers to the isolation of bacteria in a urine specimen of individuals without any symptoms of urinary tract infection (UTI). Diabetes mellitus (DM) is a disease involving multiple organ systems, characterized by its chronicity and hence endless complications including ASB. This study aimed to determine the characteristics of ASB and antibiotic susceptibility patterns among patients with diabetes. Materials and methods This was a retrospective observational study conducted in a tertiary care hospital. The study included patients with a diagnosis of diabetes with no signs and symptoms of UTI but who still showed the growth of an organism in urine culture. A total of 222 urine cultures were analyzed retrospectively, ensuring that they met the inclusion criteria through non-probability consecutive sampling. Results The mean age of the study participants was 62.89 ± 13.77 years; 76% of them were females, and 61% had a family history of diabetes. The most frequent organisms isolated were Escherichia coli (E. coli), Enterococcus, Klebsiella pneumonia, Pseudomonas aeruginosa, and Enterobacter species. A total of 20 subjects had dual bacterial growth in their cultures, with Enterococcus species (n=17) being the most common organism. Gender, family history of diabetes, levels of hemoglobin A1c (HbA1c), and advanced age were all found significantly associated with ASB. Conclusion Our study is the first of its kind to analyze and examine the risk factors associated with ASB in DM patients, and to identify the pathogens involved, along with assessing their antibiotic resistance profiles.

Background and objectives Chronic liver disease (CLD) encompasses a variety of etiologies, and the infectious causes are mainly hepatitis B and hepatitis C virus. Chronic alcohol abuse and non-alcoholic fatty liver disease also have a major contribution to CLD. The Child-Pugh scoring system indicates the probable prognosis and mortality risk of a patient with cirrhosis. The primary objective of this research is to observe the mortality risks of CLD caused by a variety of etiologies mentioned above. The secondary objective is to determine the biochemical markers that are correlating with the severity of the study groups. Another aim was to determine the Model for End-Stage Liver Disease (MELD) scoring of each study group predicting the severity of disease among the Child-Pugh classification. Materials and methods We broadly classified the etiologies into two study groups: (1) hepatitis B, C associated CLD (hepatitis B, C--CLD) and (2) non-hepatitis B, C associated CLD (non-hepatitis B, C-CLD). This study was conducted as a descriptive, retrospective study involving patients admitted to the Gastroenterology Department at Dow University Hospital between July 2019 and December 2019. All patients who met the inclusion criteria were included in the study in order to document their levels of severity markers of CLD. A total of 167 individuals met the inclusion criteria, and the sampling was done through non-probability consecutive methods. All continuous variables were described as mean and standard deviations, which were then compared using an independent sample t-test. The comparison of categorical data was done either using the chi-square test or Fisher's exact test accordingly. A p-value of

Background and objectives Sleep disorders are prevalent in end-stage renal disease (ESRD) involving the majority of patients undergoing hemodialysis. The main objective of treating sleep disorders in patients of ESRD is to correct subjective and objective sleep quality, decrease fatigue and daytime sleepiness, and enhance daytime functioning. Irrespective of the adverse effects reported, benzodiazepines are widely utilized among patients with sleep disorders in end-stage renal disease. Melatonin is a newer agent being studied for use in hemodialysis patients for improvement of sleep quality. The aim of our observational study is to witness the effectiveness of both benzodiazepine and exogenous melatonin as a treatment of sleep disorders in patients undergoing hemodialysis. Materials and methods We conducted a comparative, observational study in ESRD patients who are on hemodialysis. These patients were selected from attendees of the hemodialysis unit, nephrology department of a tertiary care hospital, including those who were on regular hemodialysis, thrice-weekly in frequency for at least once per year, and taking regular sleep medications for at least three months with frequently reported drug dosages of alprazolam 0.5 mg once daily or melatonin 3 mg once daily (before bedtime). The subjective sleep assessment was done by utilizing four scales, including the Pittsburgh Sleep Quality Index (PSQI), Epworth Sleepiness Scale (ESS), Insomnia Severity Index (ISI), and Stanford Sleepiness Scale (SSS). Results A total of 117 hemodialysis-dependent patients met the inclusion criteria, among whom 79 patients were using alprazolam while 38 were using melatonin for their disturbed sleep. The mean age of the study participants was 49.12 ± 12.75, comprising 72 males (61.53%) and 45 females (38.46%). The duration of the diagnosis of chronic kidney disease (CKD), duration of onset of hemodialysis, and estimated glomerular filtration rate (eGFR) was comparable in both groups. Both groups had similar laboratory markers except for higher hemoglobin in the melatonin group (p=0.028) and high parathyroid hormone (PTH) levels in the alprazolam group (p=0.001). PSQI scores were 8.76 ± 3.09 in the alprazolam group and 7.32 ± 2.65 in the melatonin group (p=0.015). In the sub-scores, there were no differences in sleep latency (p=0.481) and daytime dysfunction (p=0.662) while sleep efficiency (p=0.167) and subjective sleep quality (p=0.132) were not statistically significant. The significant differences were lower scores of sleep duration (p=0.040) and sleep disturbance (p=0.003) in the melatonin group. The ESS scores revealed no significant difference in either group (p=0.074). With respect to the ISI and SSS, higher scores were obtained in the alprazolam group. Overall, 89 study participants had reported poor sleep quality, out of which 81% were using alprazolam, and 65% were using melatonin (p=0.071). A total of 50 study participants exhibited excessive daytime sleepiness with 45% of them were using alprazolam and 36% were using melatonin. About 54% of the alprazolam using hemodialysis patients had moderate insomnia while 50% of the melatonin using patients had sub-threshold insomnia (p=0.062). Conclusion As melatonin use has shown better sleep quality and less insomnia severity as compared to alprazolam use in our study, it is postulated that the sleep-wake cycle should be commonly targeted by pharmacological therapy in ESRD.

Background Abdominal trauma and intra-abdominal sepsis are associated with significant morbidity and mortality. Microcirculation in the gut is disrupted in hemorrhagic and septic shock leading to tissue hypoxia, and the damaged gut acts as a reservoir rich in inflammatory mediators and provides a continual source of inflammation to the systemic circulation leading to sepsis. Sepsis is defined as the presence (probable or documented) of infection together with a systemic inflammatory response to infection. Blood culture is commonly considered to be the preferred approach for diagnosing sepsis, although it is time-consuming, that is, reports are normally available only after 12-48 hours. Procalcitonin levels (PCT) have recently emerged as a promising biomarker in the diagnosis of sepsis. The aim of the present study is to determine the diagnostic accuracy of PCT levels in predicting sepsis in critically ill trauma patients. Methodology This was designed as a validation study conducted in the Indoor Department of General Surgery, Liaquat National Hospital, Karachi. The sample size was calculated by taking the estimated frequency of sepsis in suspected patients at 62.13%, expected sensitivity of PCT at 70.83%, and specificity at 84.21% and the desired precision level of 12% for sensitivity; the calculated sample size was 96. The non-probability consecutive sampling method was used to recruit participants who were diagnosed with sepsis on clinical assessment. Blood culture samples were sent for the enrolled patients and a final diagnosis was made on the blood culture report. PCT levels were measured in these suspected patients on the same day of sending blood culture. Diagnostic accuracy of PCT size was measured using the receiver operating characteristic (ROC) curve. ROC curve was formulated for PCT levels against culture-proven sepsis to determine the ideal cut-off value of PCT levels. Two different cut-offs were determined to obtain the highest sensitivity and highest specificity accordingly. Results A total of 97 individuals met the inclusion criteria with a mean age of 34.89 ± 10.52 years. Mean PCT levels were 0.96 ± 0.59, with a gender predilection towards females (p < 0.001). No age difference was documented among gender (p = 0.655). The mean duration of intensive care unit stay was 11.73 ± 3.56 days. Culture-proven sepsis was identified in 67.0% of the study participants with a higher PCT level (p < 0.001). Among the 52.6% males included in the study, half were reported to have culture-positive sepsis, but among the 47.4% females culture was positive in 87% (p < 0.001). ROC revealed PCT was predictive for culture-positive sepsis at a cut-off value 0.47 ng/mL (p < 0.001), with a sensitivity of 92.3%, specificity of 68.7%, positive predictive value (PPV) of 85.7%, and negative predictive value (NPV) of 81.5%. By increasing the cut-off value to 0.90 ng/mL at area under the curve of 0.816, the specificity increased to 81.3% and sensitivity became 66.2%, with a PPV of 87.8% and NPV of 54.2%. Conclusion Our study determined two cut-values for PCT to predict sepsis, one with the highest sensitivity and the other with better specificity. Other than that, higher PCT levels were significant in female trauma patients. We conclude that PCT is a reliable marker for culture-proven diagnosis of sepsis and may aid physicians/surgeons to promptly manage patients accordingly.

Background and objectives Stone in the biliary tract is one of the most common causes of hospitalization. However, it is difficult to determine the prevalence of gallstones in the general population because they are often asymptomatic. Thus, management lies in the proper clearance of the common bile duct (CBD) along with the removal of the gallbladder, for which it must be diagnosed on time with proper accuracy. Imaging modalities including magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), and endoscopic retrograde cholangiopancreatography (ERCP) provide true visualization of choledocholithiasis with comparable sensitivities. The gold standard ERCP is an invasive procedure and may cause complications, such as pancreatitis, perforation, and bleeding. EUS is a minimally invasive procedure to assess the biliary tract using high-frequency sound waves. Until now the EUS has not been addressed much in our local tertiary care setups and this study was conducted to evaluate its accuracy in the diagnosis of choledocholithiasis. The objective of our study is to determine the diagnostic accuracy (specificity and sensitivity) of EUS versus ERCP for the diagnosis of choledocholithiasis. Materials and methods This retrospective study was conducted on patients suspected of having choledocholithiasis undergoing both EUS and ERCP based on their history, clinical symptoms, and laboratory test results including upper abdominal pain, deranged liver function enzymes, and a dilated CBD on radiology. EUS was initially performed for the diagnosis of extrahepatic biliary obstruction followed by one or more of the confirmatory criterion standard tests (including ERCP). In order to reduce the chances of passage of stone resulting in negative analysis, only those patients were included in which both procedures were conducted temporally close together (24-72 hours in most instances). The main outcome measures were diagnostic accuracy with the help of sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) using a receiver operating characteristic curve. A total of 123 patients met the inclusion criteria via non-probability consecutive sampling methods. Results The mean age of our study population was 50.30 ± 13.91. We included 63 males (51.2%) and 60 females (48.8%). The most frequent indication for undergoing diagnostic procedures was deranged liver function tests (67.47%). The frequent comorbidities reported were hypertension (29.26%), diabetes (21.95%), chronic liver disease (16.26%), and ischemic heart disease (4.87%). Mean alkaline phosphatase and gamma-glutamyl transferase levels were markedly raised from the baseline in the study population. Post-ERCP complications were also reported in some of the study participants. About 85 patients (69.10%) were diagnosed with choledocholithiasis among the study participants. The diagnostic accuracy of EUS was compared with ERCP revealed an area under the curve (AUC) of 0.930, standard error of 0.031, 95% confidence interval of 0.868-0.991, the sensitivity of 89.5%, specificity of 96.5%, positive predictive value of 91.9%, and negative predictive value of 95.3%. Conclusion It is recommended that ERCP can be selectively conducted or excluded in patients with biliary obstruction in case of EUS negative, thus minimizing the complications and morbidity associated with an invasive procedure, with our results showing a comparative diagnostic accuracy of EUS.

Background and objectives In surgical patients, coronary disease is the main cause of perioperative mortality. The incidence of serious cardiovascular complications is reported as 5% with a probability of 1-2% of death from the cardiac cause in major non-cardiac surgery. B-type natriuretic peptide (BNP) is a sensitive and specific predictor of left ventricular systolic dysfunction and predicts first cardiovascular event and death in the general population. The recent guidelines recommended the use of pro-BNP for independent perioperative prognosis in cardiac patients undergoing non-cardiac surgery. The aim of this study is to assess the predictive value of raised pro-BNP levels in patients who underwent major abdominal surgery and evaluate its relationship with cardiovascular complications and mortality occurring up to 30 days after surgery. Materials and methods We reviewed the medical records of patients undergone surgical procedures in the abdominal region lasting more than two hours, requiring postoperative high dependence or intensive care and an expected hospital stay of at least three days. All types of open or laparoscopic-assisted abdominal or pelvic surgeries that were evaluated for preoperative pro-BNP levels were included in the study. During the postoperative period, all patients were followed for cardiac complications and mortality for 30 days after surgery. Postoperative adverse cardiac events were predefined as angina pectoris, myocardial infarction, cardiogenic dyspnea, acute arrhythmias (atrial fibrillation/flutter, ventricular fibrillation/tachycardia), acute hypertensive event (hypertensive emergency or urgency), congestive heart failure, acute pulmonary edema, or primary cardiac death. While non-cardiac complications were also documented as either pulmonary, septic, postsurgical site infection, and other systemic complications. Subsequently, a survival analysis was done for the discretion of cardiovascular complications and mortality. Results The mean age of the study population was found to be 50.22 ± 14.28 years, mean pro-BNP levels were 909.29 ± 3950.04, and mean days of hospital stay were 7.43 ± 4.49 days. The 30-day postoperative all-cause mortality was found to be 9.8%. Hypertension and diabetes were frequent comorbidities amongst the study population. The mean preoperative pro-BNP levels were found higher in the male gender (p=0.071), also found higher in those with cardiovascular complications (p=0.006) and mortality (p=0.057). Receiver operating characteristic (ROC) analysis showed cardiovascular outcomes with a cut-off value of pro-BNP at 143 pg/ml, AUC of 0.891, at a sensitivity of 91%, positive predictive value (PPV) of 96%, a specificity of 75%, and negative predictive value (NPV) of 58%, while the same for mortality at a cut-off value of 164 pg/ml was found with AUC of 0.815, at a sensitivity of 84%, a specificity of 66%, PPV of 97%, and NPV of 21%. The unadjusted odds ratio for cardiovascular complications was found to be 17.857 (95% CI: 6.56-48.60) while that for mortality was 10.863 (95% Cl: 2.29-51.37). The Kaplan-Meier survival curves showing elevated pro-BNP levels were significantly associated with cardiovascular events, with 30 days mortality at a cut-off value of 164 pg/ml. Conclusion Pro-BNP is a useful marker in postoperative patients for not only predicting cardiovascular outcomes as cited by many previous studies but also mortality.

Pulmonary lung involvement in adult-onset Still’s disease (AOSD) can be classified into two categories: with or without acute respiratory distress syndrome. Interstitial fibrosis in AOSD is rare, occurring in less than 5% of cases. Here, the authors present a case of a 40-year-old male of Asian descent with a past history of hyperthyroidism who presented with fever, shortness of breath associated with cough, sore throat, diffuse arthralgias, pink-coloured rash, and hepatomegaly. Laboratory investigations revealed leukocytosis, abnormal liver function tests, negative antinuclear antibodies, and negative rheumatoid factor. Chest X-ray showed bilateral basal infiltrates, while high-resolution CT chest scan confirmed the diagnosis of interstitial lung disease in association with ASOD. This case suggested a direct association of AOSD and interstitial lung disease, but autoimmune pathogenesis is the only link synchronising both diseases and the exact mechanism of direct involvement is ambiguous.

Background and objectives Chronic kidney disease (CKD) share a common pathophysiology with non-alcoholic fatty liver disease (NAFLD). This study aims to identify the lipid derangements in patients of CKD and to associate them with radiological evidence of NAFLD. Material and methods A cross-sectional observational study was performed in a tertiary care hospital, to include all chronic kidney disease patients (n=238) through non-probability consecutive sampling. The criteria for inclusion were baseline estimated Glomerular filtration rate (eGFR) below 60 ml/min/1.73m2 for at least three months and chronic renal parenchymal changes on ultrasound. Two study groups were identified based on ongoing hemodialysis, while two further study groups were identified based on radiological evidence of fatty liver disease. Results The mean age of the study population was 48.52 ± 9.44 years with no difference amongst hemodialysis status, females elder than males (p= 0.027), those with fatty liver were much younger (p=0.014), and the most common age group below 50 years (p=0.005) among the fatty liver group. Radiological evidence of NAFLD was found amongst two-third of the study group with the status of hemodialysis indifferent among the study population (p=0.436). The mean values amongst fatty liver versus non-fatty liver groups revealed high creatinine, alanine transaminase (ALT), high-density lipoprotein (HDL), triglycerides (TG), and very-low-density lipoprotein (VLDL) in the fatty liver group, low-density lipoprotein (LDL) and total cholesterol (TC) were indifferent amongst the groups, while LDL/HDL ratio was higher in the non-fatty liver group. Conclusion A significantly higher HDL was found in fatty liver associated with CKD as compared to the non-fatty liver group.

We are presenting a case of pericardial tumor in an elderly female patient who presented with low-grade fever, purpuric rashes all over the body, grittiness in the eyes, and dry mouth with decreased oral intake, night sweats, weight loss, chest pain, and dyspnea. She was diagnosed with Sjögren’s syndrome secondary to systemic lupus erythematosus (SLE) with positive anti-nuclear antibody (ANA), anti-double-stranded DNA (anti-ds-DNA), and anti-Sjögren's-syndrome-related antigen A autoantibodies (SS-A/Ro) antibodies. Computerized tomography scan of the chest with contrast showed multiple calcified mediastinal lymph nodes and a well-defined solid cystic lesion adjacent to the left atrial appendage in favor of a pericardial tumor with minimal pericardial effusion. Biopsy could not be done due to the risk of cardiac tamponade and pneumothorax secondary sensitive location of the tumor. The patient was referred to the oncology and cardiothoracic surgery department for an opinion regarding resection of the tumor and further palliative management. This case is unique in a way that the current literature does not associate SLE with pericardial tumor, while our patient had no other primary malignancy or secondary metastasis ruled out on a positron emission tomography (PET) scan.

Background and objectives Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is the pathogen responsible for the coronavirus disease 2019 (COVID-19) pandemic. The disease mainly affects the respiratory system of the patient, in particular, the lungs, which leads to patients presenting with acute respiratory distress syndrome and acute respiratory failure, with 5-15% of patients requiring observation in the intensive care unit (ICU) with respiratory support in the form of ventilation. This study was aimed at identifying the role of biochemical markers in the risk stratification of invasive and non-invasive ventilation of hospitalized COVID-19 patients. Materials and methods The study was conducted as a prospective, observational study of all admitted COVID-19 patients. A comparative analysis was performed of the survivors who were on invasive versus (vs) non-invasive ventilation and the non-survivors similarly. After computing the descriptive statistics, a multinomial logistic regression model was applied to obtain an unadjusted odds ratio (OR) at 95% confidence interval (CI), with Hosmer-Lemeshow (HL) goodness-of-fit test used to predict the fitness of the data. Kaplan-Meier survival curves were obtained for each of the laboratory investigations predicting survival along with the intensive care stay and invasive ventilation. A log-rank test was carried out to compare the survival distributions. Results A total of 373 included patients in the study had a mean age of 52.78 ± 15.76 years with females younger than males, and indifference amongst invasive vs non-invasively ventilated (p=0.821). Females were slightly more prone to invasive ventilation (p=0.097). Overall, 39% of the subjects did not need respiratory support, while 13% were on a ventilator, 16% on bilevel positive airway pressure/continuous positive airway pressure (BiPAP/CPAP), and 31% on supplemental oxygen therapy. Among the laboratory markers, mean hemoglobin was evidently lower in the invasive group, leukocytosis and thrombocytopenia were present in both invasively ventilated and non-surviving patients, while neutrophilia and lymphocytopenia were statistically indifferent among the mode of ventilation. Elevated urea, creatinine, and sodium were also significantly deranged laboratory markers amongst the invasively ventilated group. C-reactive protein (CRP) and lactate dehydrogenase (LDH) were elevated significantly in the invasive group, while serum ferritin was more frequently raised in the non-invasively ventilated group. Procalcitonin (PCT) was significantly associated with invasive ventilation as opposed to the non-invasive group. D-dimer was equally raised in both the groups at admission but significantly elevated in the invasive group at discharge. A multinomial regression model signified D-dimer (OR: 16.301), hypernatremia (OR: 12.738), creatinine (OR: 12.589), urea (OR: 12.576), and LDH (OR: 12.245) most significantly associated with death, while those for invasive ventilation were D-dimer (OR: 8.744), hypernatremia (OR: 4.532), PCT (OR: 3.829), neutrophilia (OR: 3.804), leukocytosis (OR: 3.330), and serum urea (OR: 3.312). Kaplan-Meier curves conclude total leucocyte count (TLC), neutrophils, lymphocytes, urea, creatinine, sodium, CRP, LDH, PCT, and D-dimer all significantly contributing to an early death. Conclusion The most significant marker for mortality was D-dimer, followed by serum sodium, urea/creatinine, LDH, ICU stay, and invasive ventilation.

Background and objective COVID-19 is a highly disseminating viral disease imparted by severe acute respiratory syndrome coronavirus 2 (SARS-COV-2), which was declared a global pandemic by the World Health Organization. In our study, we aimed to describe the clinical characteristics of the first 100 hospitalized patients of confirmed COVID-19 in a developing country. Materials and methods The study included all the admitted patients (n = 100) having COVID-19 polymerase chain reaction (PCR) positive, and evaluated clinical profiles and characteristics of the patients linking to disease severity. Results Out of the 100 patients, 67 were in the ward, 33 were in ICU, 78 of them recovered, while 22 deaths reported. The mean age was 52.58 ± 15.68, with most frequent comorbidities are diabetes and hypertension while frequent symptoms are fever and dry cough. Bilateral lower zone patchy infiltrates are frequent chest radiographic findings. Amongst the patients admitted in ICU, there were significant differences in the total leukocyte count (P = 0.001), neutrophils and lymphocytes (P =< 0.001), monocytes (P = 0.027), urea (P =< 0.001), creatinine (P = 0.002), neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) increasing with disease severity, lymphocyte-to-monocyte ratio (LMR) and lymphocyte-to-C‐reactive protein ratio (LCR) decreasing with mortalities. Gamma-glutamyl transferase (GGT) followed by aspartate aminotransferase (AST) are frequent hepatic derangements, while C-reactive protein (CRP) levels predicting ICU admission with area under the curve (AUC): 0.806, positive predictive value (PPV): 85.1% and lactate dehydrogenase (LDH) predicting mortality with AUC: 0.877, PPV: 97.3%, while NLR (AUC: 0.806, PPV: 95.8%) for mortality and neutrophils (AUC: 0.773, PPV: 87.5%) for ICU patients. Conclusion A number of factors are linked with disease severity and mortality along with dynamic changes of the laboratory investigations during hospital stay affecting prognosis.

Background and objectives Infections with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) are rapidly spreading, posing a serious threat to the health of people worldwide, resulting in the World Health Organization officially declaring it a pandemic. There are several biochemical markers linked with predicting the severity of coronavirus disease. This study aims to identify the most effective predictive biomarker such as C-reactive protein (CRP), ferritin, lactate dehydrogenase (LDH), procalcitonin (PCT), and D-dimer, among others, in predicting the clinical outcome of the disease. Materials and methods This study was conducted as a retrospective, observational, multi-centric study, including all admitted COVID-19 positive patients only. The disease outcome was followed along with the hospital course of every patient at the time of analysis. Baseline laboratory investigations of all patients were monitored both at admission and discharge. A comparative analysis was done between the survivors (n=263) and non-survivors (n=101). Statistical analysis was conducted using IBM SPSS Statistics for Windows Version 25 (Armonk, NY: IBM Corp.). Results Of 364 patients, 65.7% were in the isolation ward, and 34.3% were in the intensive care unit; 72.3% of patients survived, while 27.7% of patients died. The mean age of the study population was 52.6 ± 15.8 years with female patients significantly younger than male patients (p=0.001) and 50 to 75 years being the most common age group (p=0.121). Among the survivors versus non-survivors of COVID-19, there were significant differences in total leukocyte count (p

Background & Objectives: COVID-19 is a global pandemic, also affecting Pakistan with its first case reported on 26th February 2020. Since then, it has been a total of 217,809 positive cases and 4473 deaths in Pakistan so far. Deranged liver function enzymes levels are prominently detected extra-pulmonary clinical manifestation of COVID-19 reported by at least one-half of the patients. Our study aimed to evaluate these derangements in our population. Methods: A retrospective, observational study was conducted to include all the admitted patients having COVID-19 positive, and evaluated those for derangements of liver function enzymes (n=77). The statistical analysis was conducted to compare those derangements amongst the disease severity, prognostic markers, and death. Results: Out of the 77 patients, 55 were admitted in the ward, 22 were in ICU, 61 of them recovered, while 16 deaths reported. The most deranged liver enzyme was found out to be Gamma-glutamyl transferase (51.94%), followed by Aspartate transferase (41.55%), Alanine transferase (28.57%), and Alkaline phosphatase (14.28%). Total bilirubin was deranged in only 10 patients, however, direct bilirubin was above the normal range in 33 patients, while indirect component in only 4 patients. Increased direct bilirubin, Aspartate aminotransferase, and Gamma-glutamyl transferase were associated with increased mortality, increased ICU admissions, increased neutrophils, lymphocytopenia, leukocytosis, and neutrophil to lymphocyte ratio>3, while Alanine aminotransferase and Alkaline phosphatase were not associated with the above factors. Conclusion: The deranged values of liver function enzymes in COVID-19 are correlated with an increased number of ICU admissions, mortalities as well as prognostic markers.

Sleep is an important part of one’s daily routine and sleeping less than 6 hours at night is considered decreased somnolence. The frequency of obesity is shooting up worldwide, mainly in developed countries. Obesity has become a very grave root cause of health issues in our society. Our study aims to find out the association between obesity and sleep, and the frequency of poor sleep quality among normal weight-bearing and overweight individuals. It was conducted as a cross-sectional, observational, questionnaire-based survey, a total of 380 subjects were randomly selected from the community. Sleep quality was compared among both the groups using standard validated scale questionnaire for sleep quality (Pittsburg Sleep Quality Index). Our study found out that out of 380 individuals who were being inquired 228 (60%) individuals were normal weight-bearing and 68 (30%) were overweight. Sleep quality was found to be impaired in 120 (52%) of normal-weight individuals as compared to 36 (45%) overweight individuals, although mean PSQI was higher in overweight’s (p=0.008). We further found that self-reported sleep duration was not different in normal as well as overweight individuals. The rate of poor sleep quality was found equal among male and female overweight individuals. It is concluded that sleep quality is dependent on various factors including sleep awareness, sleep hygiene, environment, and other factors that should be taken into account also regardless of the weight of the person. We also recommend that working on awareness regarding the importance of sleep and helping parents to establish an appropriate sleep routine for young children may be useful in preventing obesity.

Hepatocellular carcinoma is ranked as the sixth most common cancer globally. It also accounts for the second leading determinant of cancer-related mortalities worldwide. In the present day, transarterial chemoembolization (TACE) is the treatment modality of preference for high burden hepatocellular carcinoma. Our study aims to report the efficacy of TACE and alterations in laboratory parameters in patients of hepatocellular carcinoma before and after undergoing TACE in lieu with size >3 cm or 3cm tumor size (p=0.050). After TACE, bilirubin levels were remarkably improved in 3cm tumor size. Serum creatinine worsened in 3 cm tumor size, and SGPT was indifferent in 3cm tumor size. Mean meld score was found improved in both the study groups however, greater improvements were seen in >3cm tumor size group. Downstaging of child-pugh classes was statistically significant in both the study groups (p

Purpose of the study: Outbreaks of infectious diseases are known to have significant psychological effects not only on the general population but on health care workers as well. The COVID-19 pandemic also has been a challenge for Healthcare workers across the globe when it comes to their mental health. Study design: This is an observational cross-sectional study, carried out amongst the frontline doctors of COVID-19 units, by a well-structured questionnaire using Google Forms. The two scales used measure anxiety and depression among the healthcare workers were the Hamilton anxiety scale (HAM-A), and the hospital anxiety and depression scale (HADS). Results: The mean age of all the participants in the study was 25.40 ± 1.61, including 57% house officers/interns and 43% medical residents/postgraduate trainees. Both the anxiety and depression scales were significantly higher in house officers as compared to their senior doctors (residents/postgraduate trainees). According to HAM-A, 62% of respondents were in the mild category, 20% mild to moderate, 5% moderate to severe, while 14 respondents (13%) were in severe anxiety category. The HAM-A (P=0.078) and HADS for anxiety was significantly higher in females (P=0.001), while HADS for depression was statistically indifferent among the gender. The means of all scales got improved after the postings in Corona wards. The duration of practice also had an inverse correlation observed with all the studied scales. Conclusion: Depression and anxiety were seen quite higher in our population of health care workers with significant improvements that were observed after completing the rotations of corona units.

Thrombotic thrombocytopenic purpura (TTP) is a hematological disorder with an incidence of around 6.5 cases per million every year. It is characterized by the clot formation in blood vessels and resulting thrombocytopenia due to widespread utilization in the process. Other clinical features include hemolytic anemia, neurological abnormalities, fever, and renal failure. The cause can be either congenital or acquired secondary to infections, the use of certain drugs, and autoimmune disorders. On the other hand, Dengue fever is a viral infection that can result in multiple systemic complications including disrupted coagulation, renal dysfunction, and inflammation in the liver, brain, and myocardial pathology. In this case report, we present a rare presentation of thrombotic thrombocytopenic purpura in a patient with dengue fever. The mortality rate, in untreated cases, has been reported by up to 90%. With timely diagnosis and management with plasmapheresis, this can be reduced to 10-20%. Currently, it is important to control such an unknown outbreak of Dengue fever, as it is a serious health care issue of disease control and prevention in Pakistan.