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COVID-19 patients are known to have immunosuppression due to decreased lymphocytes and increased susceptibility to co-infections (Bacterial and fungal). We present a case of 61-year-old patient who had diabetes, hypertension and ischemic heart disease with COVID-19 infection admitted after RT-PCR positive result. He developed rhino-orbital Mucormycosis during treatment. He received Remdesivir with parenteral Methylprednisolone and Meropenem. While admitted in the ward, he developed signs of orbital cellulitis. Magnetic resonance imaging (MRI) of the brain, orbits, and paranasal sinuses revealed right frontal, ethmoidal, and maxillary sinusitis with the extension of the sinisuidal disease to the orbit. A nasal biopsy revealed broad aseptate filamentous fungal hyphae suggestive of Mucormycosis. Long-term use of steroids/monoclonal antibodies/broad-spectrum antibiotics may contribute to the predisposition to fungal disease. Early diagnosis and prompt management are warranted to avoid morbidity. Key Words: Mucormycosis, COVID – 19, Orbital Cellulitis.

Background: In this cross-sectional, international study, we aimed to analyze vector-borne and zoonotic infections (VBZI), which are significant global threats. Method: VBZIs’ data between May 20–28, 2018 was collected. The 24 Participatingcountries were classified as lower-middle, upper-middle, and high-income. Results: 382 patients were included. 175(45.8%) were hospitalized, most commonly in Croatia, Egypt, and Romania(P = 0.001). There was a significant difference between distributions of VBZIs according to geographical regions(P < 0.001). Amebiasis, Ancylostomiasis, Blastocystosis, Cryptosporidiosis, Giardiasis, Toxoplasmosis were significantly more common in the Middle-East while Bartonellosis, Borreliosis, Cat Scratch Disease, Hantavirus syndrome, Rickettsiosis, Campylobacteriosis, Salmonellosis in Central/East/South-East Europe; Brucellosis and Echinococcosis in Central/West Asia; Campylobacteriosis, Chikungunya, Tick-borne encephalitis, Visceral Leishmaniasis, Salmonellosis, Toxoplasmosis in the North-Mediterranean; CCHF, Cutaneous Leishmaniasis, Dengue, Malaria, Taeniasis, Salmonellosis in Indian Subcontinent; Lassa Fever in West Africa. There were significant regional differences for viral hemorrhagic fevers(P < 0.001) and tick-borne infections(P < 0.001), and according to economic status for VBZIs(P < 0.001). The prevalences of VBZIs were significantly higher in lower-middle income countries(P = 0.001). The most similar regions were the Indian Subcontinent and the Middle-East, the Indian Subcontinent and the North-Mediterranean, and the Middle-East and North-Mediterranean regions. Conclusions: Regional and socioeconomic heterogeneity still exists for VBZIs. Control and eradication of VBZIs require evidence-based surveillance data, and multidisciplinary efforts.

Background The Ad5-nCoV vaccine is a single-dose adenovirus type 5 (Ad5) vectored vaccine expressing the SARS-CoV-2 spike protein that was well-tolerated and immunogenic in phase 1 and 2 studies. In this study, we report results on the final efficacy and interim safety analyses of the phase 3 trial. Methods This double-blind, randomised, international, placebo-controlled, endpoint-case driven, phase 3, clinical trial enrolled adults aged 18 years older at study centres in Argentina, Chile, Mexico, Pakistan, and Russia. Participants were eligible for the study if they had no unstable or severe underlying medical or psychiatric conditions; had no history of a laboratory-confirmed SARS-CoV-2 infection; were not pregnant or breastfeeding; and had no previous receipt of an adenovirus-vectored, coronavirus, or SARS-CoV-2 vaccine. After informed consent was obtained, 25 mL of whole blood was withdrawn from all eligible participants who were randomised in a 1:1 ratio to receive a single intramuscular dose of 0·5 mL placebo or a 0·5 mL dose of 5 × 1010 viral particle (vp)/mL Ad5-nCoV vaccine; study staff and participants were blinded to treatment allocation. All participants were contacted weekly by email, telephone, or text message to self-report any symptoms of COVID-19 illness, and laboratory testing for SARS-CoV-2 was done for all participants with any symptoms. The primary efficacy objective evaluated Ad5-nCoV in preventing symptomatic, PCR-confirmed COVID-19 infection occurring at least 28 days after vaccination in all participants who were at least 28 days postvaccination on Jan 15, 2021. The primary safety objective evaluated the incidence of any serious adverse events or medically attended adverse events postvaccination in all participants who received a study injection. This trial is closed for enrolment and is registered with ClinicalTrials.gov (NCT04526990). Findings Study enrolment began on Sept 22, 2020, in Pakistan, Nov 6, 2020, in Mexico, Dec 2, 2020, in Russia and Chile, and Dec 17, 2020, in Argentina; 150 endpoint cases were reached on Jan 15, 2021, triggering the final primary efficacy analysis. One dose of Ad5-nCoV showed a 57·5% (95% CI 39·7–70·0, p=0·0026) efficacy against symptomatic, PCR-confirmed, COVID-19 infection at 28 days or more postvaccination (21 250 participants; 45 days median duration of follow-up [IQR 36–58]). In the primary safety analysis undertaken at the time of the efficacy analysis (36 717 participants), there was no significant difference in the incidence of serious adverse events (14 [0·1%] of 18 363 Ad5-nCoV recipients and 10 [0·1%] of 18 354 placebo recipients, p=0·54) or medically attended adverse events (442 [2·4%] of 18 363 Ad5-nCoV recipients and 411 [2·2%] of 18 354 placebo recipients, p=0·30) between the Ad5-nCoV or placebo groups, or any serious adverse events considered related to the study product (none in both Ad5-nCoV and placebo recipients). In the extended safety cohort, 1004 (63·5%) of 1582 of Ad5-nCoV recipients and 729 (46·4%) of 1572 placebo recipients reported a solicited systemic adverse event (p

Evaluating trends in antibiotic resistance is a requisite. The study aimed to analyze the profile of multidrug-resistant organisms (MDROs) among hospitalized patients with bacteremia in intensive care units (ICUs) in a large geographical area. This is a 1-month cross-sectional survey for blood-borne pathogens in 57 ICUs from 24 countries with different income levels: lower-middle-income (LMI), upper-middle-income (UMI), and high-income (HI) countries. Multidrug-resistant (MDR), extensively drug-resistant (XDR), or pan-drug-resistant isolates were searched. Logistic regression analysis determined resistance predictors among MDROs. Community-acquired infections were comparable to hospital-acquired infections particularly in LMI (94/202; 46.5% vs 108/202; 53.5%). Although MDR (65.1%; 502/771) and XDR (4.9%; 38/771) were common, no pan-drug-resistant isolate was recovered. In total, 32.1% of MDR were Klebsiella pneumoniae, and 55.3% of XDR were Acinetobacter baumannii. The highest MDR and XDR rates were in UMI and LMI, respectively, with no XDR revealed from HI. Predictors of MDR acquisition were male gender (OR, 12.11; 95% CI, 3.025-15.585) and the hospital-acquired origin of bacteremia (OR, 2.643; 95%CI, 1.462-3.894), and XDR acquisition was due to bacteremia in UMI (OR, 3.344; 95%CI, 1.189-5.626) and admission to medical-surgical ICUs (OR, 1.481; 95% CI, 1.076-2.037). We confirm the urgent need to expand stewardship activities to community settings especially in LMI, with more paid attention to the drugs with a higher potential for resistance. Empowering microbiology laboratories and reports to direct prescribing decisions should be prioritized. Supporting stewardship in ICUs, the mixed medical-surgical ones in particular, is warranted.

Background: Hepatitis is a serious public health issue in the present era. More than 2 billion population is suffering from Hepatitis infection. Similarly, there are about 36 million healthcare professionals globally, out of which approximately 3 million per year get an injury from some sharps, thus resulting in 2 million subjects being infected with HBV and 1 million with HCV (WHO). A systematic study of 2015 showed HCV seroprevalence in the adult population of Pakistan was 6.8 whereas individuals infected with HCV were 6%. Methods: A qualitative study, with Phenomenological approach, was conducted among wardboys of Islamabad. Two Tertiary care hospitals of Islamabad, one in the public sector and the other in the private healthcare sector were selected as a study site. In-depth interviews with purposely and conveniently with selected ward-boys working in both the hospitals. A total of 25 in-depth interviews were conducted by the principal researcher from wardboys, 12 and 13 from the public and private sector hospital till the saturation was achieved. Results: 25 participants were interviewed on the basis of the interview guide and asked in detail about hepatitis B and C disease, their risk factors and causes. It was found that wardboys lacked comprehensive knowledge about the disease process. They did not adopt preventive strategies and precautionary measures and they lack refresher training and possess knowledge about the spread of infection which was close to none. Little efforts were made in these hospitals to ensure the safety of this group which would render them at high risk of attaining infection as well as transmitting it. Apart from health care workers, especially the wardboys that are subjects of this study were not compelled and penalize to follow infection control standards which led to the downfall of the system and provided a way for infection to proliferate and prosper. Conclusion & Recommendations: From this study, it is concluded that ward boys in private and public tertiary care hospitals are at high risk of acquiring Hepatitis B and C infection. They lacked knowledge about the infective disease and its preventions. Certifications should be made mandatory for ward boys to allow for work in this environment. Hospitals do not have an efficient system for infection control measure and lack of infection control training. It is important to make infection control processes strong and conduct regular refresher training for all health care workers.

The new pandemic coronavirus disease (COVID-19) has affected children, including neonates, who mostly comprise of approximately 2% of total confirmed cases. Most children are asymptomatic or have mild disease and much lower mortality compared to adults for yet unknown reasons. Recovery from illness has largely been universal and

Objective: The objective of the study was to assess the outcome of upper respiratory tract infections (URTI) in healthy children. Methods: This descriptive study was conducted on 314 children aged 3-36 months in the paediatric outpatient clinic and emergency department with symptoms of URTI (fever, cough, rhinorrhoea) for ≤5 days. Patient’s demographics, clinical features, laboratory data and outcome were recorded. Follow up phone calls were made to parents on day 7 (response 93.6%) and day 14 (response 94.6%) to record outcome. Results: A total of 314 children with URTIs were included. Majority (57.6%) were males and

Objective: The objective of the study was to assess the outcome of upper respiratory tract infections (URTI) in healthy children. Methods: This descriptive study was conducted on 314 children aged 3-36 months in the paediatric outpatient clinic and emergency department with symptoms of URTI (fever, cough, rhinorrhoea) for ≤5 days. Patient’s demographics, clinical features, laboratory data and outcome were recorded. Follow up phone calls were made to parents on day 7 (response 93.6%) and day 14 (response 94.6%) to record outcome. Results: A total of 314 children with URTIs were included. Majority (57.6%) were males and

Objective: To describe the demographics; clinical, laboratory, echocardiographic findings; treatment and outcome in a cohort of children with Kawasaki disease in a tertiary care hospital. Methods: This is a descriptive, observational, retrospective cohort study conducted at Shifa International Hospital, Islamabad, from January 2013-June 2019. Children who met the criteria for Kawasaki disease according to the American Heart Association and American Academy of Pediatrics guidelines were included. Results: A total of 25 children who met the criteria of Kawasaki disease were included. Their mean age was 43 months (4-150 months). Majority (76%) were males. Eighteen (72%) had complete Kawasaki disease and 7 (28%) had incomplete Kawasaki disease. Fever (> five days) was present in 20 (80%) patients. Eight patients (32%) had echocardiographic changes, out of which two patients (25%) had complete Kawasaki disease and six patients (75%) had incomplete Kawasaki disease. Intravenous immunoglobulin was given to all patients. Fifteen children (60%) received intravenous immunoglobulin within 10 days of fever. None required a second dose. All patients received high dose aspirin at diagnosis which was reduced to antiplatelet dose after resolution of fever for ≥48hrs. Eighteen patients (72%) came for regular follow up. Follow up at 6 months showed complete resolution of echocardiographic changes in six patients (75%), 1 (12.5%) was lost to follow up and one (12.5%) child had persistent coronary artery dilatation. Conclusion: Complete KD was present in 72% of our cohort of children. Coronary artery abnormalities were present in one third of these children, at younger age and more common in those with incomplete KD but recovered in most. doi: https://doi.org/10.12669/pjms.36.2.910 How to cite this:Sakina S, Owais SS, Khan EA, Sheikh AM. Kawasaki disease: Clinico-laboratory spectrum & outcome in a cohort of children treated at a tertiary care hospital in Islamabad, Pakistan. Pak J Med Sci. 2020;36(2):260-264. doi: https://doi.org/10.12669/pjms.36.2.910 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Infective endocarditis is a growing problem with many shifts due to ever-increasing comorbid illnesses, invasive procedures, and increase in the elderly. We performed this multinational study to depict definite infective endocarditis. Adult patients with definite endocarditis hospitalized between January 1, 2015, and October 1, 2018, were included from 41 hospitals in 13 countries. We included microbiological features, types and severity of the disease, complications, but excluded therapeutic parameters. A total of 867 patients were included. A total of 631 (72.8%) patients had native valve endocarditis (NVE), 214 (24.7%) patients had prosthetic valve endocarditis (PVE), 21 (2.4%) patients had pacemaker lead endocarditis, and 1 patient had catheter port endocarditis. Eighteen percent of NVE patients were hospital-acquired. PVE patients were classified as early-onset in 24.9%. A total of 385 (44.4%) patients had major embolic events, most frequently to the brain (n = 227, 26.3%). Blood cultures yielded pathogens in 766 (88.4%). In 101 (11.6%) patients, blood cultures were negative. Molecular testing of vegetations disclosed pathogens in 65 cases. Overall, 795 (91.7%) endocarditis patients had any identified pathogen. Leading pathogens (Staphylococcus aureus (n = 267, 33.6%), Streptococcus viridans (n = 149, 18.7%), enterococci (n = 128, 16.1%), coagulase-negative staphylococci (n = 92, 11.6%)) displayed substantial resistance profiles. A total of 132 (15.2%) patients had cardiac abscesses; 693 (79.9%) patients had left-sided endocarditis. Aortic (n = 394, 45.4%) and mitral valves (n = 369, 42.5%) were most frequently involved. Mortality was more common in PVE than NVE (NVE (n = 101, 16%), PVE (n = 49, 22.9%), p = 0.042)., SCOPUS: ar.j, info:eu-repo/semantics/published

Leukocyte adhesion deficiency (LAD) is a rare primary immunodeficiency disorder with autosomal recessive inheritance which is characterized by presence of a defect of phagocytic function resulting from a lack of leukocyte cell surface expression of b2 integrin molecules (CD11 and CD18) that are essential for chemotaxis. The classic symptoms of the disease are failure of separation of the umbilical cord and recurrent bacterial infections, which continue throughout life. We describe here two cases of infants who presented with characteristic history of recurrent infections, delayed separation of umbilical cord and marked leukocytosis.

Neurobrucellosis is a rare complication of brucellosis, a common zoonosis with multisystem involvement. Its clinical presentation is quite heterogeneous and diagnosis requires a high index of suspicion in patients from endemic areas. We present two cases of neurobrucellosis with widely varying clinical involvement from a tertiary center in Pakistan. Our case report emphasizes that neurobrucellosis should be considered in evaluation of patients with unexplained neurological symptoms..

4 Abstract: Field experiment was conducted to evaluate difference among various levels of Nitrogen (N) fertilizer, its application techniques and their interaction on the growth, yield components and yield of wheat. Treatments of N fertilizer application techniques, viz., broadcast and side-dressing were allocated to main- plots and nitrogen levels, viz., 60, 90, 120, 150, 180 and 210 kg N/ha were placed in sub-plots. This experiment was repeated for two years with the same treatments. Results revealed that nitrogen application techniques had non-significant impact on most of the crop parameters except count of fertile tillers. Various rates of nitrogen showed significant influence on all the parameters under study and showed significantly higher grain yield of wheat with successive increase of dose up to 180 kg N/ha. Maximum plant height and biological yield were obtained under the highest nitrogen level, viz., 210 kg N/ha. However, the highest count of fertile tillers, spike length, number of grains, 1000-grain weight and harvest index were recorded in the treatment receiving 180 kg N/ha. Interactions between fertilizer application techniques and nitrogen levels were non-significant for all the crop parameters studied in this experiment on wheat.

To document spectrum of paediatric liver disorders confirmed on liver biopsy.The retrospective review of patients was conducted at Shifa International Hospital, Islamabad, Pakistan, and comprised data of all children who underwent ultrasound-guided percutaneous liver biopsy between December 2008 and June 2015. Frequency of individual diagnosis was assessed and compared on gender basis. SPSS 16 was used for statistical analysis.There were medical records of 74 patients in the study with an overall median age of 6.9 years (interquartile range: 0.2-17.7 years). Metabolic 27(36.5%) and inflammatory 19(25.6%) disorders were the most common aetiologies. At presentation 29(39.1%) patients had cirrhosis; and 25(34%) children were5 years of age. Metabolic disorders were the most common aetiology in children upto 10 years of age with 19(25.6%) patients. Above the age of 10 years, inflammatory disorders were more frequent and were seen in 10(13.5%). Based on gender, a trend towards significance was observed for metabolic disorders (p=0.08) and children who presented with cirrhosis (p= 0.07), but it was not statistically significant.Metabolic disorders were the most common cause of liver disorders. A number of children at presentation had underlying cirrhosis.

To describe demographic, clinical and immunologic features of children with human immunodeficiency virus.This descriptive study was conducted at the Shifa International Hospital, Islamabad, Pakistan, from 2005 to 2011, and comprised children with human immunodeficiency virus and acquired immune deficiency syndrome. Patients with detailed physical examination and appropriate investigations and those eligible for therapy were included. SPSS 21 was used for data analysis.Of the 43 patients, 27(62.8%) were boys and 16(37.2%) were girls. The overall median age was 5 years (interquartile range: 3-8.5 years). Moreover, 18(42%) children were aged equal to or below 5 years. Fathers of 5(12%) children and mothers of 6(14%) children had died. Siblings of 3(7%) patients, fathers of 20(47%) patients and mothers of 31(72%) patients had human immunodeficiency virus or acquired immune deficiency syndrome. The median duration of breastfeeding was 24 months (interquartile range: 15-24 months). Risk factors identified were foreign job by father in 12(28%) patients, birth by vaginal delivery in 20(47%), breastfeeding6 months in 34(79%), fathers with human immunodeficiency virus or acquired immune deficiency syndrome in 20(47%), mothers with human immunodeficiency virus or acquired immune deficiency syndrome in 31(72%) and lack of maternal anti-retrovirals during pregnancy in all (100%). There were 27(63%) children being symptomatic and 29(67%) had advanced disease at diagnosis with World Health Organisation's classification stage 3 or 4. The pretreatment median CD4 count was 294.5 cells/mm3 (IQR, 208.5-808) and a follow-up CD4 of 757 cells/mm3 (IQR, 352-874) which was significant (p0.005). The intial median HIV viral load was 83 RNA copiesx105/mm3 (IQR, 1.8-8.25). Anti-retroviral therapy (ARV) was initiated in 65% (28/43) with good compliance. The mean duration of follow-up was 12 months. There was clinical and immunologic improvement in 65% (18/28) in first 12 months. There were opportunistic infections in 20 children (46%), serious side effects in 5 (18%), progression of disease or poor response in 7 (16%) and discontinuation or switch of therapy in 2 (7%). Four children had suspected HIV drug resistance but confirmed in 2 (6.7%) requiring second-line therapy. Five children (12%) died, two within one week of diagnosis.Most human immunodeficiency virus-infected children had risk factors, present with severe immune suppression and had improved CD-4 after anti-retroviral therapy.

Ghaydaa, Shehata/0000-0002-3631-893X; Radic, Ljiljana Betica/0000-0002-8778-106X; Silva-Pinto, Andre/0000-0002-2077-3356; Cascio, Antonio/0000-0002-1992-1796; Bossi, Paolo/0000-0003-0135-0224; Stebel, Roman/0000-0001-6922-4465; Namani, Sadie/0000-0002-2411-8623; Chan, Phillip/0000-0002-4071-4409; Hargreaves, Sally/0000-0003-2974-4348; Artuk, Cumhur/0000-0003-0827-990X; Harxhi, Arjan/0000-0001-8518-7377; Larsen, Lykke/0000-0002-4113-4182; Uysal, Serhat/0000-0002-4294-5999 WOS: 000407582200010 PubMed: 28397100 Risk assessment of central nervous system (CNS) infection patients is of key importance in predicting likely pathogens. However, data are lacking on the epidemiology globally. We performed a multicenter study to understand the burden of community-acquired CNS (CA-CNS) infections between 2012 and 2014. A total of 2583 patients with CA-CNS infections were included from 37 referral centers in 20 countries. Of these, 477 (18.5%) patients survived with sequelae and 227 (8.8%) died, and 1879 (72.7%) patients were discharged with complete cure. The most frequent infecting pathogens in this study were Streptococcus pneumoniae (n = 206, 8%) and Mycobacterium tuberculosis (n = 152, 5.9%). Varicella zoster virus and Listeria were other common pathogens in the elderly. Although staphylococci and Listeria resulted in frequent infections in immunocompromised patients, cryptococci were leading pathogens in human immunodeficiency virus (HIV)-positive individuals. Among the patients with any proven etiology, 96 (8.9%) patients presented with clinical features of a chronic CNS disease. Neurosyphilis, neurobrucellosis, neuroborreliosis, and CNS tuberculosis had a predilection to present chronic courses. Listeria monocytogenes, Staphylococcus aureus, M. tuberculosis, and S. pneumoniae were the most fatal forms, while sequelae were significantly higher for herpes simplex virus type 1 (p < 0.05 for all). Tackling the high burden of CNS infections globally can only be achieved with effective pneumococcal immunization and strategies to eliminate tuberculosis, and more must be done to improve diagnostic capacity.

In arid areas of central Pakistan application of 2800 and 2200 mm irrigation water in 28 and 22 irrigations on sandy loam and silty soils, respectively to autumn sugarcane through flooding is a common practice. Whether this irrigation depth and frequency is sufficient to fulfill the requirements of autumn sugarcane is not established. This study was conducted to evaluate the optimum water requirements by applying direct method of soil water measurement through gravimetric procedure. A three years field study was conducted on autumn sugarcane cv. HSF 240 at research area of MLL (Main Line Lower) Land Reclamation Research Station Chak No. 37 TDA (Thal Development Authority) Bhakkar, Pakistan on sandy loam and Gomal University Dera Ismail Khan Pakistan on silty clay soil from 2003–04 to 2005–06. The experiment was laid out in randomized complete block design with factorial arrangement in four replications and net plot size was 24 m 2 . The four available soil moisture depletion levels under study were ASMDL 1 (20%), ASMDL 2 (40%), ASMDL 3 (60%) and ASMDL 4 (80%) and four planting patterns G 1 (60 cm), G 2 (75 cm) spaced single row planting patterns, G 3 (30/90 cm) and G 4 (30/120 cm) spaced paired row strip planting patterns were tested. The analysis of three years pooled data showed that maximum shoot dry weight, sugar yield, water use efficiency and benefit cost ratio were recorded in the treatment interaction of ASMDL 2 (40%) × G 3 (30/90 cm) followed by ASMDL 2 (40%) × G 2 (75 cm), ASMDL 2 (40%) × G 1 (60 cm), respectively, whereas minimum in the interaction of ASMDL 4 (80%) × G 4 (30/120 cm) at both soils. Maximum sugar recovery percentage (10.87 and 10.78%) was recorded in ASMDL 4 (80%) × G 4 (30/120 cm) planting pattern and minimum values of 8.44 and 7.28% on sandy loam and silty clay soils, respectively was recorded in ASMDL 1 (20%) × G 1 (60 cm) planting pattern. It was concluded that irrigation application on the basis of direct method of soil water measurement through gravimetric procedure saved 15.56 and 10.29% irrigation water by applying 38 and 23 irrigations keeping the depth of each irrigation 54 and 74 mm on sandy loam and silty clay soils, respectively as compared with traditional method of irrigating autumn sugar cane crop through flooding under arid conditions. Therefore maximum bio economic benefits could be obtained from autumn sugarcane crop by irrigating it at 40% ASMDL and sowing in 30/90 cm spaced paired row strips in arid conditions on sandy loam and silty clay soils.

Sjogren's syndrome most commonly presents with dry eyes, dry mouth, joint pain and fatigue. However, recurrent aseptic meningitis, reported as the most uncommon initial symptom, was the presenting feature in our case. We present the case of a 19-year-old female with recurrent episodes of aseptic meningitis. She presented with fever, headache, vomiting and photophobia. Neurological examination showed neck stiffness. Fundoscopy was normal. On two previous occasions her cerebrospinal fluid analysis was consistent with meningitis; however, it was normal at this presentation. Review of system revealed history of fatigue and sicca symptoms since early childhood. Autoimmune workup showed antinuclear antibodies with a titer of 1:400 and positive anti SSA (Ro) antibodies that led to the diagnosis of Sjogren's syndrome. She responded well to intravenous steroids, followed by oral prednisolone and hydroxychloroquine. To conclude, diagnosis of Sjogren's syndrome may also be considered in a patient presenting with recurrent aseptic meningitis.

To identify clinical spectrum, management and outcome of neonatal candidiasis.The retrospective study was conducted at the Shifa International Hospital, Islamabad, Pakistan, and comprised microbiological records of all the babies admitted to the Neonatal Intensive Care Unit from January 2009 to January 2014 that were reviewed to identify those with positive candida cultures. Medical records were analysed for demographic and clinical spectrum features, management and outcome. SPSS 16 was used statistical analysis.Of the total 1550 neonatal admissions, 560 (36%) had positive cultures, and, of them, candida was isolated in 49(8.8%) neonates. Among them, 13(26%) had candida albicans and the rest had candida species. Majority were males 34(70%), and preterm with 30(61%) being37 weeks. The mean birth weight was 2000±873 grams. Mean age at admission was 6±7.6 days. Overall, 39(80%) had ≥2 risk factors. The commonest site of isolation was blood in 41(84%). Besides, 32 (65%) received fluconazole alone for treatment. Mean duration of anti-fungal therapy was 10±5 days (range: 1-21 days). Twelve (24%) neonates expired and the cause of death was candida sepsis in 10(20%) cases. Mortality was not significantly associated with gender, place of birth, gestation, risk factors, length of stay, prior antibiotic exposure or receipt of antifungal prophylaxis except those who were ≤1500 grams (p0.05).Approximately one in ten at-risk neonates may develop candida sepsis with high mortality. Early institution of anti-fungal therapy may prove to be life-saving.

To assess a single-centre experience and outcome of premature neonates who received surfactant therapy.The prospective cohort study was done at Shifa International Hospital, Islamabad, from December 2005 to May 2007 and comprised premature neonates (37 weeks gestation) who had clinical and radiologic evidence of respiratory distress syndrome and had received surfactant therapy. SPSS 21 was used for statistical analysis.A total of 52 premature neonates received surfactant. Mean gestational age was 29±2.8 weeks and mean birth weight was 1273±487gms. Only 16(31%) mothers had received antenatal dexamethasone. Surfactant was used as single dose in 41(78%) neonates at 6.1±6.6hours of life or two doses in 11(22%). Chest X-ray and respiratory distress syndrome category showed an overall improvement in 29 (56%) neonates. Complications were seen in 17(33%) neonates, and 21(40%) died. Mortality was significantly associated with gestation (p0.000) and weight (p0.008).Surfactant administration is an option for respiratory distress syndrome in Pakistan.

To study the clinical presentation, diagnostic workup and outcome of children presenting with suspected inborn errors of metabolism.The cross-sectional study was conducted at the Shifa International Hospital, Islamabad, and included all patients diagnosed with the condition between January 2006 and June 2011. Medical records of the patients were reviewed to collect the relevant data.A total of 10 patients underwent diagnostic work-up. Majority 7 (70%) were males and 6 (60%) presented in the neonatal age group. Seizures and coma were the commonest presentations (n = 5; 50% each) followed by breathing difficulty (n = 4; 40%) and vomiting (n = 2; 20%). The commonest diagnoses were methyl malonic acidaemia (n=2; 20%), non-ketotic hyperglycinaemia (n=7; 10%), fructose 1,6 diphosphatase deficiency (n = 1; 10%), and biotinidase deficiency (n = 1; 10%). Mortality was high (n = 5; 50%) and half of the survivors had severe neurological impairment.The diagnosis of inborn errors of metabolism requires a high index of suspicion. These disorders have a high mortality and risk of long-term neurological disability.

The high aridity index of Pakistan coupled with rapidly decreasing surface water resources demand supplemental irrigation for profitable agricultural production. An inadequate irrigation water supply is one of the major bottlenecks in enhancing domestic cane production in Pakistan. To discover appropriate water conservation techniques to combat irrigation deficit in the country, a field experiment was conducted with autumn sugarcane cv. HSF 240 as a test crop at two sites: Location-I (silty clay) and Location-II (sandy loam soil) during 2003–2004 and 2004–2005. The experiment was laid out according to a randomized complete block design (RCBD) with factorial arrangement in four replications through a net plot size was of 24 m2. The available soil moisture depletion levels were ASMDL1 (20%), ASMDL2 (40%), ASMDL3 (60%), and ASMDL4 (80%), while planting patterns were G-60 (60 cm), G-75 (75 cm) spaced single row planting patterns, G-30/90 (30/90 cm), and G-30/120 (30/120 cm) spaced paired row strip planting patterns. The pooled data of both locations showed maximum performance in terms of stripped cane yield, sugar yield, sugar recovery percentage, and net field benefit at 40% ASMD level followed by 60, 20, and a minimum of 80%. So far as planting pattern was concerned, maximum output was noted with 30/90 cm spaced paired row strip planting pattern followed by 75, 60, and 30/120 cm. The interactive effects of ASMD levels and planting patterns on agro physiological traits of sugarcane were significant at both locations. The maximum response in terms of plant height, weight per stripped cane, individual stripped cane length, cane diameter, unstripped cane yield, stripped cane yield and sugar yield, leaf area index (LAI), leaf area duration (LAD), net assimilation rate (NAR), harvest index (HI), sugar recovery percentage, and net field benefit were recorded with 40% ASMDL×30/90 cm spaced paired row strip planting followed by 40% ASMDL×75 cm and 40% ASMDL×60 cm plots, respectively. Therefore, maximum economic benefit could be obtained from sugarcane crop by irrigating it at the 40% ASMD level and sowing at 30/90 cm spaced paired row strips under arid conditions on silty clay and sandy loam soils.

Recurrent meningitis in children, although rare, results in an increased risk of acute complications and long-term morbidity. We did a retrospective case series to analyze the clinical presentation, predisposing factors, treatment and outcome of children with recurrent meningitis admitted at Shifa International hospital, Islamabad. All children presenting with recurrent meningitis from December 2006 to May 2011 were included in the study. There were a total of 8 children with a mean age of 6 +/- 2.97 years (2-10 years). Majority (87%) were males. There was an average of 4 +/- 4.92 (2-9) episodes of meningitis in each patient. Fever with vomiting was the most common (87%) presenting symptom, followed by seizures (62%) and headache (50%). The underlying etiology was confirmed on CSF analysis, computed tomography scan (CT) and magnetic resonance imaging (MRI). About half of them had history of head trauma. All responded to antibiotics and six needed surgery. On follow up, 2 (25%) children had some neurological impairment.

The aim is to evaluate the ease of access, surgical trauma and cosmetic results of posterior sagittal approach for sacrococygeal teratomas (SCTs). From January 2002 to June 2010, we operated 19 cases of SCT exclusively through posterior sagittal approach. Patients were placed in knee chest position. An elliptical incision was made for the excision of the tumor. Care was taken to preserve all the muscles and other vital tissue in this area. Coccygectomy was performed in all patients. Closure was performed in layers. It was possible to resect all tumors from this approach and none of the patients required revision of the incision. Complete resection was possible in 17 patients while two had residual disease due to local extension. Minimal wound dehiscence was noted in four patients that healed spontaneously. It was possible to perform excision even in very large masses. Wound scar was satisfactory in most patients with preservation of gluteal folds. It is therefore concluded that posterior sagittal approach for SCT is feasible, with good access and cosmetic results.