Showing papers in "Jcpsp-journal of The College of Physicians and Surgeons Pakistan in 2021"

CT Chest Severity Score for COVID 19 Pneumonia: A Quantitative Imaging Tool for Severity Assessment of Disease.

Abstract: OBJECTIVE: To determine a cut-off value of Chest CT severity score (CT-SS) in order to discriminate between the clinical types of COVID-19 pneumonia. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Radiology, Shifa International Hospital, from 1st March to June 30th, 2020. METHODOLOGY: One hundred and three consecutive patients' RT PCR positive for COVID-19 were included. Two consultant radiologists, with experience of 7 to 10 years in body imaging, evaluated their HRCT studies in consensus and calculated the CT severity score. A scoring of all 20 individual regions in each lung were assigned by the radiologists attributing a score of 0, 1 or 2 to each region, if parenchymal opacification was none, less than 50%, or 50% or more, respectively. The CT severity score was a summation of scores of all 20 regions of both lungs combined with a range of 0 to 40 points. The scores were compared for clinically mild and severe disease. RESULTS: Significant differences were noted regarding the scoring of lung opacity in mild and severe groups in each lung segment, p <0.05. The most significantly involved segments were right lower lobe's medial and lateral basal segment, left upper lobe's superior lingular segment and left lower lobe's medial basal and lateral basal segments. To discriminate mild versus severe disease, CT-SS threshold value turned out to be 19.5 Conclusion: CTSS may be of value for a prompt and objective means of assessing the degree of severity and disease burden in lungs. Key Words: COVID-19, COVID-19 diagnosis, Pneumonia, Novel coronavirus, CT severity score, Respiratory tract infection, Triage, Pandemic, RT-PCR, SARS-COV 2, Outbreak.

Rhabdomyolysis Leading to Acute Kidney Injury

Abstract: Rhabdomyolysis constitutes an uncommon cause of acute kidney injury (AKI). A large variety of causes with different pathogenic mechanisms may involve skeletal muscles resulting in rhabdomyolysis with or without acute kidney injury. Crush syndrome and unaccustomed physical exertion are the most common causes of rhabdomyolysis. This study reports local cases of AKI secondary to rhabdomyolysis that presented to a tertiary care centre over a period of four years. Most of them were males and belonged to younger age group. Muscle enzyme creatine phosphokinase level was raised in all patients, while myoglobinuria was detected only in one patient. Most of the patients (10/16) were managed conservatively with fluid replacement; and some of them (6/16) needed dialysis. AKI was resolved in all the patients after a variable period of time. Key Words: Rhabdomyolysis, Acute kidney injury, Myoglobinuria, Creatine phosphokinase, Trauma.

Is Spontaneous Pneumomediastinum a Poor Prognostic Factor in Covid-19?

Abstract: OBJECTIVE: To determine the risk factors for spontaneous pneumomediastinum (SPM), its clinical course and effect on prognosis in patients with Coronavirus disease-19 (COVID-19) pneumonia. STUDY DESIGN: Descriptive study. PLACE AND DURATION OF STUDY: Kayseri City Training and Research Hospital, Turkey, from April to September 2020. METHODOLOGY: All COVID-19 patients' clinical, laboratory, and radiologic characteristics, as well as treatment outcome data, were obtained through medical record extraction. Group A had 50 patients (22 men and 28 women) without SPM, and Group B had 20 patients (10 men and 10 women) with SPM. RESULTS: Considering the accompanying comorbidities, the frequencies of asthma and inhaler-use was significantly higher in Group B than in Group A (p <0.05). In the CT evaluation at presentation, the rate of involvement of all five lobes of the lung in Group B was significantly higher than in Group A. Rates of tube thoracostomy, mechanical ventilator requirement, length of stay in hospital, and exitus were significantly higher in Group B than in Group A (p <0.05). CONCLUSION: SPM development in a patient with COVID-19 pneumonia is a sign that the prognosis will not be good, and these patients need a more aggressive treatment. Key Words: Spontaneous pneumomediastinum, COVID-19, Pneumothorax, Real-time polymerase chain reaction, Subcutaneous emphysema.

Platelet-to-Lymphocyte and Neutrophil-to-Lymphocyte Ratio as Predictive Biomarkers for Early-onset Neonatal Sepsis.

Abstract: OBJECTIVE To determine the predictive significance of platelet-to-lymphocyte ratio (PLR) and neutrophil-to-lymphocyte ratio (NLR) in early-onset neonatal sepsis (EONS). STUDY DESIGN A descriptive study. PLACE AND DURATION OF STUDY The Neonatal Intensive Care Unit (NICU), Affiliated Hospital of Yanbian University, Jilin, China, from January 2018 to January 2020. METHODOLOGY Of the total 124 children, 74 children with EONS were enrolled in group A and 50 children without infection-related diseases were enrolled in group B (control). The EONS risk factors were evaluated by logistic regression. Besides, the PLR and NLR diagnostic performances in EONS were evaluated by plotting the receiving operating characteristic (ROC) curves. RESULTS In the univariate analysis, the differences for platelet count, lymphocyte number, neutrophil number, NLR, and PLR, between group A and group B were of statistical significance (p = 0.02, 0.021, <0.001, <0.001, and <0.001 respectively). As suggested by logistic regression, PLR and NLR were identified as the factors to independently predict the risk of EONS (p = 0.012, and 0.003, respectively). In addition, the value of area under the ROC curve (AUC) of NLR in predicting EONS was 0.788 (95% CI: 0.708-0.868; p <0.001), which was greater than that of PLR. At the NLR value of ≥3.169, the sensitivity of predicting EONS was 77%, and the specificity was 78%. CONCLUSION Peripheral blood NLR and PLR have high predictive value for EONS. The predictive value of NLR as a biomarker for EONS evaluation was greater than that of PLR. Key Words: Neonatal sepsis, Logistic models, ROC curve, Blood cell count.

Comparing the Efficacy of Patelet-rich Plasma (PRP) versus Tranexamic Acid (4mg/mL) as Intradermal Treatments of Melasma.

Abstract: Objective To compare the efficacy of intradermal platelet-rich-plasma vs. intradermal tranexamic acid in treatment of melasma. Study design Non-randomised controlled trial. Place and duration of study Sheikh Zayed Hospital, Rahim Yar Khan from 1st October 2019 to 30th April 2020. Methodology Cases of melasma from either gender with age 20-40 years, were included. Diagnosis of melasma was made clinically on the basis of hyperpigmentation at sun-exposed areas and by Wood's lamp. Severity was labelled on the basis of melasma area and severity index (MASI) score. Cases in group A were managed with 1 ml of intradermal platelet-rich plasma (PRP) and those in group B were offered intradermal tranexamic acid in a dose of 4 mg. The treatment was offered every 4th week and for a total period of 12 weeks; and final outcome was seen at 24th week. At every visit, the cases were noted for their mean MASI score. Results In this study, there were a total of 64 cases, 32 in each group. There were 19 (59.38%) males in group A and 16 (50%) in group B (p=0.61). Mean age in group A and B was 24.63 ± 9.87 vs. 23.94 ± 8.93 years (p= 0.76). Mean MASI score at baseline was 29.84 ± 5.14 vs. 29.56 ± 4.39, p=0.21. MASI was significantly better in group A at 4 weeks where score was 29.44 ± 5.35 vs. 28.69 ± 4.10, p=0.01. Mean MASI was 12.81 ± 1.78 vs. 18.38 ± 3.50, p=00001 at 12 weeks and 8.72 ± 3.40 vs. 14.97±4.33, p=0.02 at 24 weeks in group A and B, respectively. Conclusion Intradermal PRP is significantly better than intradermal tranexamic acid in management of melasma. Key Words: Melasma, Tranexamic acid, PRP, MASI.

Diagnostic Accuracy of Serum Procalcitonin (PCT) as an Early Biomarker of Neonatal Sepsis using Blood Culture as Gold Standard.

Abstract: Objective To ascertain the diagnostic accuracy of serum PCT as an early biomarker of neonatal sepsis using blood culture as gold standard, so that the condition could be diagnosed and managed early to prevent and reduce morbidity and mortality in neonates. Study Design: Cross-sectional study. Place and duration of study Dr. Ziauddin University Hospital, Karachi, from March 2019 to December 2019. Methodology A total of 171 neonates, 1-29 days of age, presented with clinical diagnosis of neonatal sepsis, were included in this study. Patients' data regarding age, gender, birth weight, prematurity and premature rupture of membranes (PROM) were collected. Blood cultures were performed in Microbiology Department; and Serum PCT was analyzed on Electrochemiluminescence Immunnoassay Analyzer (Cobas e601). Diagnostic accuracy, including sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of PCT were calculated with contingency tables using blood culture findings as gold standard. Results Out of 171 clinically diagnosed cases of neonatal sepsis, 86 (50.3%) were confirmed as having neonatal sepsis (blood culture positive). There was a significant difference in serum PCT levels in both the groups. The sensitivity of PCT was 97.7%; specificity 70.6%; PPV 77.1; NPV 96.8%; likelihood ratio of a positive test (LR+ve) 3.32; likelihood ratio of a negative test (LR -ve) 0.03, and cumulative diagnostic accuracy of PCT 84.2%. Conclusion PCT is a very useful biomarker for the early diagnosis of neonatal sepsis, showing 84.2% diagnostic accuracy. Thus PCT can help in making early clinical decisions regarding management of patients. Key Words: Diagnostic accuracy, PCT, Neonatal sepsis.

Risk Factors for Systemic Inflammatory Response Syndrome in Patients with Negative Preoperative Urine Culture after Percutaneous Nephrolithotomy.

Abstract: OBJECTIVE To explore the risk factors for systemic inflammatory response syndrome (SIRS) after percutaneous nephrolithotomy (PCNL) in patients with preoperative negative urine culture (UC). STUDY DESIGN Observational study. PLACE AND DURATION OF STUDY Department of Urology, Gazi Hospital, Samsun, Turkey, from January 2015 to January 2020. METHODOLOGY Two hundred and twenty-eight patients, who underwent conventional PCNL for renal stones, were evaluated. The patients were divided into non-SIRS (Group 1) and SIRS (Group 2) groups, and the effects of the variables were investigated to predict the development of SIRS. RESULTS Despite preoperative sterile UC, SIRS developed postoperatively in 29 (12.7%) patients. The univariate analysis revealed a statistically significant difference between groups in preoperative serum C-reactive protein (CRP) (p 117.36 (p 3.16 mg/L (p 471 mm2 (p = 0.023) and hemoglobin drop >2.3 g/L (p <0.001) are independent risk factors for post-operative SIRS after PCNL. CONCLUSION PLR, CRP, stone size, and hemoglobin drop can predict SIRS after PCNL. This finding may help classify risk in patients before PCNL, especially in those with a sterile urine culture. Key Words: C-reactive protein, Percutaneous nephrolithotomy, Platelet/lymphocyte ratio, Systemic inflammatory response syndrome.

Association of Blood Groups with the Severity and Outcome of COVID-19 Infection in Children.

Abstract: The objective of this study was to find out the association of ABO blood groups with the severity and outcome of corona virus disease 2019 (COVID-19) in children. It included all laboratory-confirmed cases of COVID-19 and post-COVID multisystem inflammatory syndrome in children (MIS-C)/ Kawasaki disease (KD) like illness, admitted from March to September, 2020 to The Children's Hospital, Lahore. Out of 66 children, 45 (68.2%) were COVID-19 and 21 (31.8%) MIS-C/KD temporally associated with SARS-C0V-2. The mean age was 7.9 ± 4.2 years. Majority of children had mild to moderate illness 38 (57.6%), while 23 (34.8%) had severe or critical disease. Among all patients, 24 (36.4%) had some underlying comorbidity. Blood group A was significantly associated with severe and critical disease (p=0.030). COVID-19 in children had generally a good outcome, but children with blood group A were more susceptible to severe/critical disease. Key Words: Coronavirus disease 2019, ABO blood groups, Children, Severity, Outcome.

CROSS or FLOT in Distal Esophageal and Gastroesophageal Cancer.

Abstract: Objective To compare the chemoradiotherapy for esophageal cancer followed by surgery study (CROSS) and continuous infusion 5-FU, leucovorin, oxaliplatin, and docetaxel (FLOT) protocols administered in distal esophageal and gastroesophageal junction (GEJ) tumors in terms of effectiveness and toxicity Study design Descriptive study Place and duration of study Ankara Oncology Training and Research Hospital, Turkey between 2015 and 2020 Methodology Patients diagnosed with distal esophageal and GEJ squamous cell carcinoma (SCC) or adenocarcinoma (ADC), older than 18 years of age, in localised or locally advanced stage were included Metastatic stages were excluded Kaplan-Meier was used for survival analysis, log-rank test was performed for comparisons between groups Results A total of 25 patients (446%) were treated with CROSS protocol (15 distal esophageal and 10 GEJ tumor), 31 patients (554%) with GEJ tumors were treated with the FLOT regimen Eight of the patients who were administered the CROSS protocol before the operation demonstrated complete pathologicial response, no patients in the FLOT group had complete response to the treatment In patients with GEJ tumors and ADC histopathology, CROSS and FLOT group had similar second years survival (60% and 593%, respectively) (p = 0803) The frequency of neutropenia was significantly higher in the CROSS group compared to the FLOT group (p = 0004) Conclusion: Postoperative pathological response rate in the CROSS group was significantly higher compared to the FLOT group CROSS and FLOT protocols contributed to survival similarly in patients with GEJ ADC, hematological side effects were more pronounced in patients receiving CRT Key Words: GEJ cancer, Esophageal cancer, Cross, Flot

Post-COVID Neuromyelitis Optica Spectrum Disorder.

Abstract: After novel coronavirus pandemic that emerged from Wuhan, China in December 2019, several cases of inflammatory and immune-mediated disorders have been reported, thought to be triggered by SARS-CoV-2 infection. Neuromyelitis optica spectrum disorder (NMOSD) is one of the autoimmune demyelinating disorders, which is thought to be triggered by viral infection. Herein, we describe a case of NMOSD in a pediatric patient with a previous SARS-CoV-2 infection, acting as a possible triggering factor. Key Words: Neuromyelitis optica spectrum disorder (NMOSD), Aquaporin 4 (AQP-4), Severe acute respiratory syndrome (SARS).

Dehydroepiandrosterone Sulfate (DHEAS) Levels in Polycystic Ovarian Syndrome (PCOS).

Abstract: OBJECTIVE To compare DHEAS levels among subjects with and without PCOS, evaluating differences between lean-PCOS or obese-PCOS phenotype for insulin resistance, anthropometric indices, glycemic and lipid parameters. STUDY DESIGN Descriptive study. Study Place and Duration of Study: PNS Hafeez Naval Hospital, Islamabad, Pakistan, from January 2018 to August 2019. METHODOLOGY Three hundred and twenty-eight subjects were included in the study for evaluation. PCOS was defined as per Rotterdam criteria, while insulin resistance, anthropometric measurements, various hormonal and biochemical analyses were carried out as per standard protocols. Hirsutism was calculated as per modified Ferrimen Gallwey score and free androgen index (FAI) was calculated using formula as: FAI = [(Total testosterone/Sex hormone binding globulin (SHBG)] x100. These subjects underwent clinical biochemical evaluation and were segregated into 2 groups: lean-PCOS and obese-PCOS. Results: DHEAS levels were higher in subjects with PCOS [(171.50) (111.75-244.25) ug/dl], n=164] than in subjects without PCOS [(130.50) (78.95-189.75) ug/dl, n=164, p<0.001]. Area under curve (AUC) in diagnosing PCOS was highest for modified FG score [0.802, p<0.001], followed by FAI [0.785, p<0.001]. Total testosterone [0.743, p<0.001] and DHEAS [0.637, p<0.001]. DHEAS levels were found to be inversely related to age, anthropometric indices, glycemia, dyslipidemia, nephropathy and reproductive hormones. The DHEAS in lean-PCOS was higher than obese female subjects with or without PCOS. CONCLUSION DHEAS levels were high in lean-PCOS in comparison to obese-PCOS and non-PCOS females. However, receiver operating curve (ROC) analysis showed DHEAS as a weaker marker for diagnosing PCOS than FAI and modified FG score. Key Words: DHEAS, Polycystic ovarian syndrome (PCOS), Homeostasis model assessment for insulin resistance (HOMAIR), Rotterdam criteria, Free androgen index.

Association of Early-onset Androgenetic Alopecia and Metabolic Syndrome.

Abstract: Objective To evaluate the association of early-onset AGA (androgenetic alopecia) and metabolic syndrome in the younger male population. Study design Case-control study. Place and duration of study Department of Dermatology, Mayo Hospital Lahore, from October 2017 to March 2018. Methodology A total of 202 patients were enrolled, 101 male patients with early-onset AGA (cases with a alopecia between 20-36 years of age), and were matched with 101 controls. All measurements regarding BMI, metabolic syndrome, and grades of alopecia were recorded on a pre-designed proforma. Results Of the 101 cases (mean age 27.77 ± 5.04 years), 27 (26.7%) had grade 3, 41 (40.6%) had grade 4, 29 (28.7%) had grade 5 and 4 (4%) had grade 6 AGA. Patients of AGA had an approximate four times increased frequency of metabolic syndrome. Of the cases 12 (11.9%) had metabolic syndrome whereas it was found in 3 (3%) of the control group. A significant association was found between cases of AGA and metabolic syndrome (p=0.016). Conclusion This study suggests a significant association of AGA with metabolic syndrome. Key Words: Androgenetic alopecia, Metabolic syndrome, Early-onset alopecia, Cardiovascular disease.

At What Age Threshold does the Decline in Semen Parameters Begin

Abstract: OBJECTIVE To analyse changes in semen parameters according to different age groups in men presenting to an infertility clinic, and determine the age threshold for decline in semen quality STUDY DESIGN Observational study PLACE AND DURATION OF STUDY Andrology Laboratory, Department of Urology, Kahramanmaras Sutcu Imam University, Turkey, from January 2018 to December 2019 METHODOLOGY Semen analysis records of infertile men, who were referred to Andrology Laboratory, were retrospectively evaluated The age groups were categorised as 20-29, 30-34, 35-39, 40-44, and 45-55 years Each group was completed to 100 semen samples retrospectively and sequentially without any preferences The differences of semen parameters between age groups were analysed with the one-way ANOVA test Linear relationship was checked by ANOVA RESULTS The mean age of 500 patients was 3718 ± 811 years While no linear relationship was observed in semen volume, concentration, and total sperm count with age (p=0133, p=0290 and p=0261, respectively) A linear decline was observed in progressive motility, vitality, and morphology parameters with advancing age (all, p<0001) In linear contrast analysis according to the 20-29 age group; significant decline in progressive sperm motility, morphology, and vitality started and continued in the 35-39 age group (all, p<0001) CONCLUSION With advancing age, a significant linear decrease in sperm motility, morphology and vitality was observed in infertile men This significant decline in sperm motility, morphology and vitality continues at age 35 and over Therefore, infertile men who plan to postpone paternity should consider the age factor Key Words: Aging, infertility, Paternal age, Semen analysis, Sperm

Chest CT Severity Score as an Auxiliary Grading Tool to COVID-19 Pneumonia Imaging Classification: A Tertiary Care Experience in Pakistan.

Abstract: OBJECTIVE: To identify utility of chest computed tomography severity score (CT-SS) as an additional tool to COVID-19 pneumonia imaging classification in assessing severity of COVID-19 STUDY DESIGN: Descriptive analytical study Place and Duration of Study: Armed Forces Institute of Radiology and Imaging, (AFIRI) Rawalpindi, from April 2020 to June 2020 METHODOLOGY: Five hundred suspected COVID-19 cases referred for high resolution computed tomography - chest were included in the study Cases were categorised by radiological findings using COVID-19 pneumonia imaging classification, proposed in the radiological society of North America expert consensus statement on reporting chest CT findings related to COVID-19 CT-SS was calculated for all scans Patients were clinically classified according to disease severity as per 'Diagnosis And Treatment Program of Pneumonia of New Coronavirus Infection' recommended by China's National Health Commission The relationships between radiological findings, CT-SS, and clinical severity were explored RESULTS: Based on the radiological findings, 298 cases were graded as typical, 34 as indeterminate, 15 as atypical, and 153 as negative for pneumonia The apical and posterior basal segments of lower lobes were most commonly involved The CT-SS showed higher values in patients of severe group as compared to those in moderate group (p < 005) CT-SS threshold for recognising severe COVID-19 was 185 (area under curve, 0960), with 843% sensitivity and 925% specificity CONCLUSION: In coherence with COVID-19 pneumonia imaging classification, CT-SS may provide a comprehensive and objective assessment of COVID-19 severity Key Words: COVID-19, COVID-19 pneumonia, CT-SS, High resolution computed tomography

Online medical education and examinations during COVID-19: Perspectives of a teaching associate

Abstract: The novel coronavirus disease 2019 (COVID-19) pandemic has not only challenged global health systems but also social, economic, and educational systems. In this short communication, our focus is on its impact on medical education in Pakistan. We discuss the structure of undergraduate medical education in Pakistan; and how it has evolved in the wake of COVID-19. We describe our role as teaching associates (TAs) at the Aga Khan University (AKU); and how it has enabled us to be a part of the transition to online medical education, with a specific focus on online examinations in medical schools. Key Words: Medical education, Online examinations, COVID-19, Pandemic.

Frequency and Outcome of Hepatic Arterial Thrombosis in Recipients of Living Donor Liver Transplantation.

Abstract: ABASTRACT Objective: To determine the frequency, risk factors, and management of hepatic arterial thrombosis (HAT) in recipients of living donor living transplantation. STUDY DESIGN Cohort study. PLACE AND DURATION OF STUDY Department of Liver Transplant, Pir Abdul Qadir Shah Jeelani Institute of Medical Sciences, Gambat, Sindh, Pakistan, from 1st January 2019 to 31st July 2020. METHODOLOGY Two hundred and forty living donor liver transplants (LDLT) recipients' data were evaluated. Frequencies of HAT were recorded, and various risk factors for the development of HAT were analysed by comparing HAT group (n = 12) and non-HAT group (n = 228). Management and outcome of HAT cases were also reviewed. Statistical analysis of this study was done with SPSS software version 21. RESULTS Out of 240 patients, 212 (88.3%) were males. Overall mean age was 39.40 ± 12.14 years. Mean model for end-stage liver disease (MELD) score was 18.70 ± 4.98. Overall male to female ratio was 7.5:1. The common indication for LDLT in these patients was chronic liver disease secondary to hepatitis B and C virus infection in 85% of patients. Postoperative HAT incidence was found as 5%. Risk factor found statistically significant was intraoperative platelet transfusion. CONCLUSION HAT is a deadly complication and needs early detection to avoid graft loss. The risk factor documented in this study should be avoided, if possible. Moreover, prompt and quick action is necessary for re-vascularisation to avoid re-transplantation. Key Words: Living donor, Hepatic arterial thrombosis, Liver transplantation.

Prognostic Role of Red Distribution Width (RDW) Value in Gastric Cancer.

Abstract: OBJECTIVE To investigate the prognostic effect of red distribution width (RDW) in patients with gastric cancer STUDY DESIGN Observational study PLACE AND DURATION OF STUDY Department of Surgical Oncology, Ankara University School of Medicine, between November 2010 and January 2020 METHODOLOGY Patients diagnosed with adenocarcinoma by biopsy, who underwent radical surgery and lymph node dissection, and had preoperative RDW value, were inducted Patients who had history of active inflammation in the past three months, received treatment for hematology disorder, blood transfusion, malignancy other than gastric cancer, autoimmune disease, venous thrombosis, or under 18 years of age, and those having cardiac and cerebrovascular diseases and distant metastases were excluded from the study Apart from diagnosis, preoperative blood values, clinicopathologial, demographic features, and follow-up data were included in the study RESULTS RDW average value was 1511 ± 287 and median value was 143% For RDW cut off value, 134% was accepted as reference from previous studies was divided into two groups as <134% and ≥134% While it was <134% in 119 patients; in 292 patients, it was "≥134%" High RDW value showed poor survival (p<0001) CONCLUSION RDW, the current hematological marker, can be used as an important indicator for monitoring the progression and prognosis of gastric cancer Key Words: Gastrectomy, Gastric cancer, Laparoscopy, Surgical oncology, Red distribution width, survival

Predictors of Mortality in Patients with COVID-19 Infection-associated Acute Kidney Injury.

Abstract: Objective To determine clinical characteristics, renal replacement therapy (RRT) requirements, and predictors of mortality in critically ill patients with COVID-19 associated AKI. Study design Descriptive study. Place and duration of study Sakarya University Education and Training Hospital, Sakarya, Turkey, between April 1 and 30, 2020. Methodology The study included 55 patients who were admitted with diagnosis of COVID-19, and whose illnesses showed a critical course that leads to AKI. The variables were studied as per objective. Results During the follow-up, 43 out of 55 patients (78.2%) died and 12 (21.8%) were discharged with recovery. The mortality was higher in patients at stage 3 (88.9% mortality) compared to stage 2 (53.8% mortality) (p=0.014). In the nonsurvivor group, RDW (red cell distribution width) and albumin levels were lower at admission; whereas, the LDH levels and CRP/albumin ratios were higher. On regression analysis, low albumin level (OR: 12.793, p = 0.010), high LDH level (OR: 8.454, p = 0.026), and presence of stage 3 AKI (OR: 10.268, p = 0.020) were found as independent risk factors for mortality in COVID-19 patients, who developed AKI. Conclusion In critically ill patients with COVID-19 pneumonia, who developed AKI, it was seen that the presence of low albumin, high LDH, and stage 3 AKI at the time of admission could be used as predictors of mortality. Moreover,, it was shown for the first time that in these patients, the high CRP/albumin ratio and low RDW could be associated with mortality. Key Words: Acute kidney injury, Mortality, COVID-19.

Could C-Reactive Protein/Albumin Ratio be an Indicator of Activation in Axial Spondyloarthritis?

Abstract: OBJECTIVES To evaluate the relationship of C-reactive protein (CRP)/albumin ratio (CAR), neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio with Bath Ankylosing Spondylitis Disease Activity Index (BASDAI) in axial spondyloarthritis (Ax-SpA). STUDY DESIGN Cross-sectional study. PLACE AND DURATION OF STUDY Clinic of Rheumatology, Diskapi Education and Research Hospital, Health Sciences University, Turkey during January 2020-2021. METHODOLOGY One-hundred and nine patients aged >18 years were included. Age, gender, duration of disease, BASDAI scores were recorded. CRP, erythrocyte sedimentation rate (ESR), albumin values, leukocyte, neutrophil, lymphocyte, platelet counts were determined. RESULTS The mean age and median disease duration of the patients were 45.03±10.63 and 5 (2-6.5) years, respectively. Among these, 28 (58.3%) female and 44 (72.1%) male patients were found to be HLA-B27 positive. BASDAI≥ 4 was observed in 61 (56%) patients and <4 in 48 (44%) patients. CRP, albumin, ESR, NLR and CAR values between the patient groups were significantly different. There was high correlation between BASDAI and CAR. There was a moderate correlation between CAR and BASDAI in the patient group with normal acute phase reactants. CONCLUSION There is a significant correlation between CAR value and composite score such as BASDAI, which is commonly used to assess systemic inflammation in Ax-SpA. These methods are reliable, recognised by reimbursement institutions and include measurements that physicians can use practically in routine outpatient clinics. Key Words: Spondylitis, Ankylosing, HLA-B27 antigen, C-reactive protein/metabolism, Serum albumin/metabolism, Neutrophils, Lymphocytes, Platelet count.

Recurrence of COVID-19 documented with RT-PCR

Abstract: We present a case of coronavirus disease 2019 (COVID-19) re-infection where the time interval between two COVID-positive episodes is the longest in the literature. A 40-year male patient was admitted to the Emergency Department with complaints of sore throat, cough and diarrhea; and was re-diagnosed as COVID-19 positive after a virus-free period. He did not have a chronic disease in his anamnesis and used no medication. After COVID-19 infection and a long recovery period, he became COVID-19 positive again. In this case, the time to second COVID-19 infection was 94 days from the first positive PCR test and 86 days from the complete resolution of symptoms. This is one of the longest COVID-19-free period between two episodes of infection in the literature. Key Words: COVID-19, Recurrence, Re-infection, Recovery.

Comparison of Retinal Nerve Fibre Layer versus Bruch Membrane Opening-Minimum Rim Width as an Optical Coherence Tomography-based Marker for Glaucoma in Myopia.

Abstract: OBJECTIVE To compare the reliability of Bruch Membrane Opening-Minimum Rim Width (BMO-MRW) Optical Coherence Tomography (OCT) with Retinal Nerve Fibre Layer (RNFL) in myopic patients. STUDY DESIGN Cross-sectional study. PLACE AND DURATION OF STUDY LRBT Free Base Eye Hospital, Karachi, from May 2019 to July 2020. METHODOLOGY Moderate myopes with refractive errors between -3 to -6 diopters were examined by 2 glaucoma consultants separately, who performed fundoscopy to evaluate the optic nerve head, checked IOP and assessed CCT and visual fields to stratify the eyes into myopic normal and myopic glaucomatous eyes. All eyes were imaged with SD OCT of Spectralis version 1.10.2.0 of Heidelberg Engineering. Two scanning patterns, one for BMO-MRW and the other for RNFL thickness analysis, were performed. RESULTS Fifty eyes of 50 patients were diagnosed with glaucoma in 50% (25 out of 50 patients). OCT RNFL detected glaucoma in 72% (36 out of 50 patients). While OCT BMO-MRW detected glaucoma in 56% (28 out of 50 patients). There was strong agreement between the consultant's judgements and BMO-based test (κ = 0.800, p <0.001), but the association was comparatively weaker with RNFL-based prediction (κ = 0.480, p <0.001). Specificity was better with OCT BMO-MRW (85.7%) than RNFL (66.7%). There were lower false positive rates with BMO-MRW (14.3%) than RNFL (33.3%). CONCLUSION OCT BMO-MRW is a better indicator of glaucomatous damage in moderately myopic eyes as compared to OCT RNFL analysis. Key Words: Glaucoma, Myopia, Optical Coherence Tomography (OCT), Bruch Membrane Opening-Minimum Rim Width (BMO-MRW), Retinal Nerve Fibre Layer (RNFL).

Diagnostic Accuracy of Markers of Insulin Resistance (HOMA-IR) and Insulin Sensitivity (QUICKI) in Gestational Diabetes

Abstract: OBJECTIVES To determine the diagnostic accuracy of HOMA-IR, and QUICKI in diagnosing gestational diabetes mellitus (GDM) considering oral glucose tolerance test (OGTT) as gold standard. STUDY DESIGN Cross-sectional analytical study. PLACE AND DURATION OF STUDY Department of Chemical Pathology, Armed Forces Institute of Pathology, Rawalpindi from September 2020 to February 2021. METHODOLOGY Pregnant women with gestational age between 24 to 28 weeks, who reported to Endocrine Clinic of AFIP for OGTT, were included in the study. OGTT was performed by following ADA guidelines. Sample for fasting insulin was collected along with first fasting sample of OGTT. HOMA-IR and QUICKI were calculated simultaneously. Percentage was used for qualitative variable while median (IQR 25th-75th) was applied for quantitative variables. OGTT was used as gold standard for calculation of diagnostic accuracy of HOMA-IR and QUICKI. RESULTS Out of 182 patients, 74 (40.6%) were found to have GDM on OGTT while 108 (59.4%) had normal OGTT. Women with GDM (n=74) had median values of fasting insulin 15.9 (IQR 11.2-17.77), HOMA-IR 3.5 (IQR 2.6-4.1) and QUICKI 0.31 (IQR 0.30-0.33) as compared to median values of fasting insulin 8.0 (IQR 5.9-10.3), HOMA-IR 1.60 (IQR 1.12-2.03) and QUICKI 0.35 (IQR 0.34-0.37) in patients (n=108) with normal response to OGTT, (p <0.001). On logistic regression analysis, there was a strong association of HOMA-IR and QUICKI with gestational diabetes mellitus (p <0.001, accuracy 84.6%). HOMA-IR at cutoff of ≤2 had 94.5% sensitivity, 72.2% specificity, 70% PPV, 95.1% NPV, and 81.31% overall diagnostic accuracy with 0.913 AUC. QUICKI at cutoff of 0.34 had 86.4% sensitivity, 83.3% specificity, 78.0% PPV, 90.0% NPV, and 84.61% overall diagnostic accuracy with 0.905 AUC. CONCLUSION Fasting insulin and HOMA-IR were significantly higher while QUICKI was lower in patients of GDM as compared to non-GDM pregnant patients at 24 to 28 weeks of gestation. Being more convenient for patients, it has the potential to be used as screening tool for gestational diabetes. Key Words: HOMA IR, QUICKI, Gestational diabetes mellitus, Insulin.

Henoch-Schönlein Purpura Presenting with Acute Abdomen.

Abstract: Henoch-Schonlein Purpura (HSP) is an autoimmune, systemic, non-granulomatous vasculitis characterised by self-limiting clinical course, and leukocytoclastic vasculitis of small vessels. Deposition of immune complexes that contain IgA is the hallmark of vascular involvement. Adults with HSP have a higher incidence of complications and death. The most common gastrointestinal (GI) symptom of HSP is abdominal pain. Vasculitis-related colitis, causing extensive lower GI hemorrhage, is uncommon in the course of HSP, which increases the risk of renal involvement. Here, we present two cases of HSP with GI involvement. In the first case, surgery was performed. Whereas, the other patient was treated medically due to the experience gained from the first case. The HSP has no specific treatment. Most of the cases are mild and need only supportive care due to its self-limiting nature. Although corticosteroids do not prevent recurrences, evidence in literature suggests that these are beneficial in resolution of the arthritis and abdominal pain. Aggressive therapy with corticosteroids or cyclophosphamide is not successful in reducing renal damage, except in patients with crescentic nephritis. Key Words: Henoch-Schonlein purpura, Gastrointestinal complications, Steroids, Surgery.

Comparison of Guy's, S.T.O.N.E. and CROES Scoring Systems for Predicting Percutaneous Nephrolithotomy Outcomes in Eldery Patients.

Abstract: Objective To evaluate the efficacy and reliability of Guy's (GSS), STONE, and CROES scoring systems developed to predict percutaneous nephrolithotomy (PCNL) outcomes in aged patients Study Design: Descriptive study Place and duration of study Department of Urology, Ministry of Health University Izmir Bozyaka Training and Research Hospital and Department of Urology, Faculty of Medicine, Amasya University, Turkey, from April 2011 to January 2020 Methodology Patients aged 65 years and over, who underwent PCNL for kidney stones, were retrospectively analysed The patients' clinical and perioperative characteristics and the radiological features of the stones were obtained from the prospectively recorded data GSS, STONE and CROES nephrolithometry scores were calculated for each patient and their relation with stone-free status, complications, and perioperative findings were analysed Results A total of 147 patients were included in the study Stone-free status was achieved in 760% of the patients, and complications developed in 272% All three scoring systems were associated with stone-free status and complication development GSS (OR=0213,p=0005) and STONE (OR=0601, p=0042) scores were detected as independent markers for stone-free status, while the CROES score was not an independent marker Only diabetes mellitus was determined to be an independent marker for the development of complications (OR=2375, p=0045) Conclusion PCNL is an effective and safe treatment method with high stone-free rates in the treatment of large renal stones, but care should be taken in terms of cardiac risks The results of this study showed that GSS and STONE scoring systems were effective and reliable in predicting stone-free status Key Words: Aged, Nephrolithotomy, Percutaneous, Comorbidity, Stone-free status, Treatment outcome, Complications, Scoring systems

Efficacy of Standardised Treatments Combined with Ubenimex in Patients with Malignant Tumors.

Abstract: Ubenimex is widely used as an immunomodulator in the treatment of leukemia and non-small cell lung cancer to improve the anti-tumor treatment effect. However, there has not been any multicenter randomised controlled trials to study its impact on the prognosis of cancer patients. The authors aimed to conduct a meta-analysis to initially study these issues. Pubmed, Cochrane Library and EMbase were searched. Randomised controlled trials of the effects of ubenimex on the survival rate of malignant tumor patients were included in the meta-analysis. Survival rate ratio (OR) and 95% confidence interval (95% CI) between two groups were used to evaluate the efficacy of ubenimex. Fixed effects models were used for meta-analysis. A total of 1,372 cases (684 in the ubenimex group and 688 in the control group) of five studies were included. Between the ubenimex group and the control group, the 1-year OR was 1.40 (95% CI = 1.06 to 1.85), the 2-year OR was 1.43 (95% CI = 1.08 to 1.89) and the 3-year OR was 1.39 (95% CI = 1.07 to 1.81). Standardised treatments combined with ubenimex may improve the survival rate of patients with malignant tumors. Key Words: Malignant tumors, Ubenimex, Randomised controlled trials, Meta-analysis.

Comparison of Balloon Trocar versus Telescopic Dissection Method for TEP Inguinal Hernia Repair.

Abstract: OBJECTIVE To compare the outcomes between two methods of dissection (balloon trocar vs. telescopic dissection) used in total extra-peritoneal (TEP) inguinal hernia repair. STUDY DESIGN Comparative study. PLACE AND DURATION OF STUDY Department of General Surgery, Faculty of Medicine, Sakarya University, conducted between January 2018 and January 2020. METHODOLOGY The study included patients who underwent elective TEP inguinal hernia repair. Preoperative and early postoperative results were compared, after the patients had been divided into a balloon trocar group (Group 1) and telescopic dissection group (Group 2). The technique performed depended on equipment availability. Permission was obtained from the Institutional Review Board. The study data are presented as descriptive statistics (mean, standard deviation, median, first quartile, third quartile, frequency and percentage); p-value 0.05). European Hernia Society Quality of Life pain score values ​​ were higher in Group 2 than Group 1 (p = 0.016). CONCLUSION Telescopic dissection was cheaper than balloon dissection. The bleeding values and operating time were similar between the two methods, but telescopic dissection caused more postoperative pain. Key Words: Inguinal hernia, Telescopic dissection, Balloon dissection, Total extra-peritoneal (TEP) surgery.

Targeted Next-generation Sequencing for Reliable Detection of Genetic Status in Breast Cancer.

Abstract: Objective To test the germline oncogenic mutations in BRCA1 and BRCA2 genes, associated with triple-negative breast cancer (TNBC) patients under study, by targeted sequencing of their DNA with next-generation sequencing (NGS) platform. Study design Cross-sectional observational study. Place and duration of study Histopathology Department, Armed Forces Institute of Pathology (AFIP) Rawalpindi, Pakistan from May to June 2020. Methodology Peripheral blood of 14 women (aged ≤60) with triple negative breast carcinoma (TNBC) was taken with the consent of performing germline genetic testing. Targeted NGS was performed for all coding regions and splicing sites of BRCA1 and BRCA2 genes, using AmpliSeq for Illumina BRCA Panel and Illumina MiSeq sequencer (placed at AFIP). Analysis and interpretation of the sequencing results have been done by using Illumina bioinformatics tools and external databases. Results Two hundred and fifty-four variants were detected in BRCA1 and BRCA2 genes, having variant quality score of 100 in all cases under study. As a result, two pathogenic variants and three variants of uncertain significance were interpreted in this germline pipeline. Cases with pathogenic variants had early onset breast cancer with age less than 35. Conclusion Germline variants in BRCA were detected in the known cases of TNBC, which will not only identify the most prevalent mutations in this region; but will also make them a candidate to receive targeted therapies, which was previously not possible without genetic testing. Moreover, this study further validates the importance of early BRCA genetic screening in young patients, who have positive family history of breast carcinoma. Key Words: Breast cancer, Triple negative, Next-generation sequencing, BRCA1, BRCA2.

Investigation of Hereditary Cancer Predisposition Genes of Patients with Colorectal Cancer: Single-centre Experience.

Abstract: Objective To investigate the genetic causes of colorectal cancers (CRCs); and to determine the genotype-phenotype correlation. Study design Descriptive study. Place and duration of study Department of Medical Genetics, Diskapi Yildirim Beyazit Training and Research, Hospital, Ankara, Turkey, between January 2018 and January 2020. Methodology 59 cancer susceptibility genes of 41 patients, included in the study and diagnosed with CRC, were examined using next generation sequencing (NGS) technique. Statistical analysis of the possible relationships among the mutation carrier status of the patients and the parameters of gender, age at diagnosis, and family cancer history, were performed. Results The mean age at diagnosis of all CRC patients was 48.7 years (range 28-74). Mutations in MLH1, MSH6, CHEK2, PMS2 and MUTYH genes were detected in 10 patients (24.4%). The mean age at diagnosis of CRC was 46.2 years in those who carried the mutation, while it was 49.5 years in those without. Carriers and non-mutation carriers, when compared in terms of age at diagnosis, gender, family cancer history, no significant difference was observed. Conclusion Genes that may cause susceptibility to cancer may play a role in the etiopathogenesis of the CRC. NGS-based multigene panels allow these genes to be detected in the patient and to identify an inherited cancer syndrome. Key Words: Colorectal cancer, Lynch syndrome, Hereditary cancer, Gene, Next generation sequencing.

From Digital to Computational Pathology and Integrated Diagnostics: The Future of Histopathology.

Abstract: Null.