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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 of 6mg. [ABSTRACT FROM AUTHOR]

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 <0.001). Length of hospital and Intensive Care unit stay and duration of oxygen supplementation were significantly less among those who underwent therapeutic plasma exchange than those who did not undergo this procedure (p-value <0.05). Conclusion: Therapeutic plasma exchange emerged as an effective procedure for patients of COVID-19 requiring Critical Care admission and organ support due to complications of this infection. Overall mortality and other clinical parameters were also significantly improved among patients undergoing therapeutic plasma exchange. [ABSTRACT FROM AUTHOR]

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. [ABSTRACT FROM AUTHOR]

Objective: To evaluate the diagnostic accuracy of Endo-bronchial ultrasound guided transbronchial needle Aspiration in patients with mediastinal lymphadenopathy and mass lesions especially in the context of granulomatous versus non granulomatous lung disorders. Study Design: Open label, unblended prospective observational cohort. Place and Duration of Study: Department of Pulmonology, Pak Emirates Military Hospital Rawalpindi, from Jul 2015 to Mar 2016. Patients and Methods: All patients presented during study periods with meditational lymphadenopathy or lesions in which the initial bronchoscopy did not reveal any diagnosis were included in the study. Endobronchial ultrasound-guided transbronchial needle aspiration was performed in the bronchoscopy suit under conscious sedation and local anesthesia. Rapid on site evaluation was available for most of the cases. The procedure was performed using an integrated fibreoptic bronchoscopy with 22G TBNA needle by an experienced Bronchoscopist. The data was analyzed by using SPSS version 21 Results: A total of 53 patients with mean age of 44 years underwent endobronchial ultrasound-guided transbronchial needle aspiration for evaluation of meditational or hilar lesions between Jul 2015 to Apr 2016. There were 43 (81.1%) male and 10 (18.8%) female patients. A total of 108 Lymph nodes were sampled in 53 patients, rapid on site evaluation was available in 41 (77.3%) patients. Adequate representative sample could be obtained in 45 of 53 (84.9%) patients. The overall diagnosis were chronic granulomatous lesion in 27 (50.9%) patients, squamous cell carcinoma in 10 (18.8%), lymphoproliferative disorder in 2 (3.7%), thymoma in 1 (1.3%) and reactive hyperplasia in 5 (9.4%) of cases. No major complication of the procedure was observed. Conclusion: End bronchial ultrasound-guided transbronchial needle aspiration was found useful diagnostic modality for lymph nodes sampling in patients with lymphadenopathy and mass like lesions in mediastinum. [ABSTRACT FROM AUTHOR]

Objective: To assess the outcome of patients admitted with head injury at an intensive care unit and look for the relationship of various factors with the poor outcome. Study Design: Cross-sectional Study. Place and Duration of Study: Pak Emirates Military Hospital, Rawalpindi Pakistan. Six months, from Oct 2018 to Apr 2019. Methodology: Patients presenting with head injury at our hospital and needed Intensive Care Unit admission were included. Fifty-eight patients with head injury were admitted in Intensive Care Unit during the six months study period. Outcome was broadly classified as survivor or non survivors. Various factors were correlated with presence of poor outcome among the patients. Results: A total of 58 patients were admitted in the intensive care unit with head injury during the study period. Twenty-nine patients (50%) survived and were shifted to the wards or High Dependency Unit while 29(50%) patients died in the critical-care-unit. Mean age of patients included in the study was 29.63±3.46 years. Low Glasgow-Coma-Scale (GCS) score at the time of presentation and severe Kampala-Trauma-Score (KTS) class was associated with the presence of poor outcome in our sample population. Conclusion: Head injury has emerged as a common reason for admission in the critical care setting. Mortality of such patients remained high even in the specialized and supportive setting of intensive care unit. Low Glasgow Coma Scale (GCS) score at time of presentation and severe Kampala Trauma Score (KTS) class emerged as strong predictors of poor outcome i.e, death in our target population. [ABSTRACT FROM AUTHOR]

Objective: To evaluate various demographic, clinical, radiological and hematological manifestations of moderate to critical coronavirus disease 2019 (COVID-19) and to assess its complications and outcomes in the Pakistani population. Study Design: Retrospective observational study. Place and Duration of Study: Pak Emirates Military Hospital, Rawalpindi, from Apr to Jul 2020. Methodology: Demographic, clinical, radiological and hematological data of 600 consecutive patients were retrieved and analyzed from hospital registry. Results: Overall, 449 (74.8%) patients had at least 1 comorbidity, diabetes mellitus being commonest; 228 (38%) [95% CI, 34.1- 42%]. The most common symptoms were cough; 451 (75.2%), fever; 450 (75%) and shortness of breath; 419 (69.8%). At presentation, 222 (37%) patients had moderate disease, 296 (49.3%) severe and 82 (12.7%) had critical disease. At admission, 277 (46.2%) patients required respiratory support and further 185 (30.8%) patients required treatment escalation later on correlated with disease severity and age (p<0.001). A total of 92 (15.3%) patients died out of which 38 (21.2%) were on noninvasive ventilation and 36 (66.6%) on invasive ventilation, (p<0.001). Overall survival (OS) was 84.7%; log rank <0.001. Mortality was highest in critical disease, 72 (31.3%) (p<0.001). A majority of patients, 440 (73.3%) developed complications, the most common being Cytokine release storm (CRS); 57.5% respiratory failure; 43.8% and Acute respiratory distress syndrome (ARDS); 38.8%. Thrombotic events occurred in 106 (17.6%). Conclusion: Majority of patients with moderate to severe COVID-19 had comorbidities and ended up in various complications. [ABSTRACT FROM AUTHOR]

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), p<0.001. Median duration of hospitalization was significantly reduced in the TPE treated group (10 days vs 15 days) (p< 0.01). CRS resolution time was also significantly reduced in the TPE group (6 days vs. 12 days) (p< 0.001). In 71 patients who underwent TPE, the mortality was 0 (n = 43) if TPE was done within the first 12 days of illness while it was 17.9% (deaths 5, n = 28 who received it after 12th 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. [ABSTRACT FROM AUTHOR]

Corona virus is a new disease. Its contagiousness, course of disease and treatment are unfolding with time. Health care systems all across the world have evolved to cope up with this crisis. Pakistan reported its first case on 26th February. Since then, with the increasing influx of patients³ our health care system has been greatly impacted. Significant numbers of patients require Intensive care services4 . Therefore, development of dedicated Intensive care units amid compromised resources has been our priority. Infrastructure development and modification, training of staff, Infection Prevention and Control (IPC) measures and staff well being are the main challenges faced. However, with meticulous planning and judicious use of limited resources our establishment has successfully developed Intensive care units that not only provide efficient patient care but also prioritizes on safety of its health care workers. [ABSTRACT FROM AUTHOR]

Objective: To determine the efficacy and safety of electroconvulsive therapy (ECT) for the management of neuroleptic malignant syndrome (NMS) in adults. Study Design: Open label, unblinded series. Place and Duration of Study: This study was carried out at the Department of Neurology, Military Hospital Rawalpindi, from Jan 2015 to Dec 2015. Material and Methods: All the patients with the diagnosis of NMS during the study period were included in the study. Consective non-probability sampling technique was used. Patients were divided into two groups; uncomplicated and complicated cases of NMS. Results: A total of nineteen patients were included in this pilot study. Out of all, thirteen (68.4%) were males and six (31.6%) were females. Mean age of the patients was 35.05 (SD 13.362) years. The drug classes causing NMS were antipsychotic medicines in 73.7% of patients and antiemetics in 26.3% of patients. Mean electroconvulsive therapy (ECT) sessions given were 6.16 (SD 2.062). Following treatment n=16 (84.2%) patients had complete recovery while n=3 (15.3%) patients died. Conclusion: In this small, open label, unblinded study ECT appears effective and safe in treating NMS in adults. Larger randomized studies will help to confirm data emerging from this preliminary study. [ABSTRACT FROM AUTHOR]

The COVID-19 pandemic took world by storm soon after its emergence. People living in all parts of world fell a prey to this deadly disease. It affected individuals in all walks of life in one way or the other. After declaration of Pak Emirates Military Hospital as COVID-19 specific hospital, development of four intensive care units and involvement of multiple specialties led us to new horizons of clinical care. We experienced a transition of usual medical practice. [ABSTRACT FROM AUTHOR]

Objective: To determine the correlation of positive blood cultures in septicemic COVID-19 patients with significantly raised serum inflammatory markers C-reactive protein, lactate dehydrogenase and lactate levels. Study Design: Cross-sectional study. Place and Duration of Study: Department of Microbiology, Pak Emirates Military Hospital (PEMH) Rawalpindi from Apr 2020 to Jun 2020. Methodology: This study included specimens from 69 adult COVID-19 hospitalized patients with moderate to severe infection. Blood cultures of cases with suspected blood stream infections were processed. Positive blood cultures were compared with markedly raised inflammatory markers. Results: From a of total 69 blood culture specimen, 36 (52.17%) showed bacterial growth whereas 33 (47.82%) had no bacterial growth. The values of serum C-reactive proteins were in moderate to severe range (≥10mg/l) for 33 (91.66%) out of 36 positive blood cultures. The Lactate dehydrogenase values for 34 (94.44%) out of 36 positive blood cultures were in moderate to severe range (≥300U/L). Serum lactate values for 30 (83.33%) out of 36 patients with positive blood cultures were in moderate to severe range (≥2.21mmol/l). This result was statistically significant. Conclusion: Serum C-reactive proteins, Lactate dehydrogenase and lactate were markedly high in patients with blood stream infections in patients with COVID-19. These inflammatory markers can be used, not only as early predictors of secondary bacterial infections in COVID-19 patients, but can also help to formulate empirical treatment. [ABSTRACT FROM AUTHOR]

The article discusses the use of endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) for lung cancer diagnosis. Topics include the use of radius EBUS for airway wall assessment, the development of lymph node map, and the use endobronchial ultrasound for tuberculosis diagnosis. It also mentions the role in non-small cell lung cancer (NSCLC) staging.