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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]

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

Objective: To 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]

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]

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]

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 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 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.

Objective: To determine the clinical characteristics in adults with confirmed pandemic influenza A (H1N1) infection 2009., Study Design: A case series., Place and Duration of Study: The study was carried out at the Department of Pulmonology and Critical Care, Military Hospital, Rawalpindi, from 1st December 2009 to 30th May 2010., Methodology: Thirty six adults with confirmed 2009 pandemic H1N1 infection by reverse transcriptase polymerase chain reaction (RT-PCR) were included in the study. All patients were followed in-hospital and clinical features, laboratory and radiological investigations and management data was collected on a pre-designed patient data collection form., Results: Mean age was 34.24±13.92 years with 61.1% females. Seventeen (47.2%) had at least one risk factor for complications with 2009 H1N1 infection; namely obesity in 19.4%, pregnancy in 8.3%, COPD in 5.6%, cardiac failure in 5.6%, chronic liver disease in 5.6%, Diabetes mellitus in 5.6%, immunosuppression in 2.3%, smoking in 25%. Fever (97.2%), cough (97.2%), rhinnorhea (80.6%), and shortness of breath (58.3%) were the commonest symptoms. Radiographic abnormalities were interstitial/reticular infiltrates (30.6%), patchy consolidations (11.1%) and reticular shadows with areas of consolidation (25%). PaO2/FiO2 ratio was less than 200 in 27.8% cases. Thirty six percent cases had creatinine kinase (CK) levels greater than 400 U/L and lactate dehydrogenase (LDH) levels higher than 1000 U/L. Twenty seven percent cases were managed in ICU and 16.7% cases died during hospital stay., Conclusion: The 2009 pandemic H1N1 virus infection had a wide clinical spectrum with a potential to cause high morbidity and mortality. Early empirical antiviral therapy for hospitalized suspected influenza A (H1N1) is vital to prevent the rapid disease progression.

Objective: To compare the diagnostic yield of AFB positivity with sputum induction to spontaneous sputum examination in suspected cases of pulmonary tuberculosis., Study Design: Comparative study., Place and Duration of Study: Military Hospital, Rawalpindi, from January to December 2006., Methodology: Sputum specimens were collected by both techniques from 164 patients with clinical and radiological suspicion of pulmonary tuberculosis admitted in medical wards. All specimens were examined for AFB smear and culture positivity. Sputum induction was done for 15-20 minutes with 3% sterile hypertonic saline solution by nebulization in all cases. Proportions were compared using Chi-square test., Results: Among 164 patients, 32 patients (19.5%) were not expectorating spontaneously. Sputum induction was successful in 22 (68.75%) cases and AFB smear was positive in 03 (9.37%) and AFB culture was positive in 7 (21.8%) of these cases. One hundred and thirty two (80.5%) patients were already expectorating and both Day-1 (spontaneous) and Day-2 (induced) sputum samples were available. Day-1 (spontaneous) sputum specimens revealed AFB smear positive results in 20 (15.15%) patients, and AFB culture positive results in 24 (18.18%) patients. Smear positivity on Day-2 (induced) sputum samples was 21.21% (28) with 27.27% (36) culture positivity., Conclusion: In expectorating patients, AFB smear and culture positivity results remain comparable with spontaneous and induced sputum sampling. Sputum induction improves the diagnostic yield for AFB in patients unable to expectorate adequate sputum sample.

Objective: To determine the efficacy of our modified anti-tuberculosis regimen in adult patients with multi-drug-resistant tuberculosis (MDR-TB) in the re-treatment category., Methods: Retrospective chart review of 176 patients in re-treatment category with diagnosis of MDR-TB from 1st Jan 1993 to 31st Dec 2002 managed at the Department of Pulmonology Military Hospital Rawalpindi, Pakistan. All the patients were given four standard first line anti-TB drugs along with any two second line drugs out of Ofloxacin/Ciprofloxacin/Levofloxacin, Amikacin, or Clarithromycin and treatment was modified after availability of drug susceptibility testing (DST)., Results: Seventy-two percent of the patients were young men with mean age of 32.28 +/- 8.7 yrs, 53.4% had moderately advanced while nearly 30% had extensive disease. One-third cases had contact with a patient of pulmonary tuberculosis out of which one fifth had contact with a MDR-TB patient. Mean duration of diagnosis of tuberculosis before therapy was 41.11 +/- 14.32 months and 70% of the cases had received at least 2 prior anti-TB regimens. They had received a median of four anti-TB drugs in past and were infected with organisms that were resistant to a median of 3 first line anti-TB drugs. Resistance to Ethambutol and PZA was about 18% and 11% respectively. A median of six anti-TB drugs was used while mean duration of therapy was 22.17 +/- 2.17 months. Bacteriological cure was achieved in about 90% cases while radiological response was documented in nearly 78%., Conclusion: Modified initial management strategy followed by DST guided therapy has yielded excellent results and needs to be assessed in further trials for wider application.

Intracorporeal concealment of illicit drugs known as 'body packing' is uncommonly reported. A body packer with swallowed capsules containing Diacetylmorphine (heroin) for smuggling purposes presented with respiratory arrest and recovered after ventilatory support and nalaxone infusion.

Objective: To determine the High Resolution Computed Tomographic (HRCT) patterns in adults with Acid Fast Bacillus (AFB) positive new cases of Pulmonary Tuberculosis (PTB)., Study Design: A descriptive case series., Place and Duration of Study: The study was carried out at the Department of Pulmonology and Department of Radiology, Military Hospital, Rawalpindi, from June 2006 to August 2007., Methodology: Fifty adults with AFB positive new pulmonary tuberculosis were included in the study, while PTB cases in the retreatment category, Multi Drug Resistant (MDR) tuberculosis, PTB with Chronic Obstructive Airways Disease (COPD), pneumoconiosis, Diffuse Parenchymal Lung Diseases (DPLDs) etc. were excluded. All cases underwent HRCT chest with 2 mm collimations at 10 mm intervals. Relevant data was collected on a pre-designed patient proforma., Results: The mean age was 40.18 +/- 14.55 years with 88% males; 46% and 30% samples were sputum and endobronchial washings smear positive for AFB respectively, while the rest were culture positive. HRCT findings included centrilobular nodules in 92% cases, lobular consolidation in 84%, cavitation in 76%, 'tree-in-bud' appearance in 68%, lymphadenopathy in 8% and miliary nodules in 4% cases. HRCT patterns included centrilobular nodules and lobular consolidation in 80% cases, while centrilobular nodules with cavitation and centrilobular nodules with 'tree-in-bud' appearance were noted in 72% and 68% patients respectively. Thirty two (64%) cases had centrilobular nodules, cavitation and lobular consolidations and about half cases had centrilobular nodules, 'tree-in-bud' appearance and lobular consolidation., Conclusion: Centrilobular nodules and lobular consolidations (80%), centrilobular nodules with cavitation (72%) and centrilobular nodules with 'tree-in-bud' appearance (68%) were the most common HRCT patterns in adults newly diagnosed with pulmonary tuberculosis.

Background: In our clinical set up transbonchial needle aspiration of lymph node and parenchymal lesions is an underutilized technique. This study was done to highlight the usefulness of this technique in the pulmonologists armamentarium., Methods: Thirty procedures were performed on patients with intrathoracic lymphadenopathy or parenchymal lung lesions in this study from October, 2006 to April, 2007. Patients with an easily accessible peripheral lymph node, bleeding diathesis and an already confirmed diagnosis were excluded from the study as were patients with a well visualized biopsiable endobronchial lesion., Results: Nineteen patients (63.3%) on whom transbonchial needle aspirations were performed had intrathoracic lymphadenopathy while 11 (36.6%) had parenchymal lesions without endobronchial lesions which could be biopsied. Adequate samples were obtained in 23 patients (76.6%) chronic granulomatous inflammations which was diagnosed as tuberculosis in corroboration with other clinical and laboratory evidence was seen in 3 cases (10%). Carcinoma was diagnosed in 6 cases (20%). Thirteen cases (43%) were reported as normal and inadequate samples were obtained in 7 cases (23%)., Conclusion: Transbronchial Needle Aspiration (TBNA) is an effective method of obtaining cytological material from intrathoracic lymph nodes and parenchymal lesions and can provide a safe alternative to invasive mediastinotomy/mediastinoscopy and open lung biopsy.

Necrotizing fasciitis (NF) in an immunocompetent patient with multiple sites of involvement is very rare. We describe a case of E. coli associated necrotizing fasciitis in a middle aged female with three lesions of NF on her lower limbs at the time of presentation. She was managed with broad spectrum intravenous antibiotics, radical surgical debridements with skin grafting, and aggressive supportive care.

Cardiac myxomas are histologically benign tumors but they may be lethal because of their strategic position. These are mostly located in the left atrium and uncommonly in the right atrium. We report a case of a large right ventricular myxoma presenting with heart failure.