A Suspected Case of COVID-19 with High Altitude-associated Massive Pulmonary Embolism and Right Ventricular Clots

Pulmonary Embolism (PE) is an elusive entity that has long baffled physicians. At times, it can present as a diagnostic and therapeutic challenge. The aim of this report is to emphasise that high altitude is one of the risk factors for PE. Physicians must keep a high index of suspicion for PE, especially in patients being evacuated from high altitudes with respiratory symptoms. A case of massive PE with right ventricular clots initially suspected to be high altitude-associated pulmonary edema (HAPE) and then novel coronavirus disease 2019 (COVID-19) pneumonia was managed. Computed tomography (CT) pulmonary angiography could not be done initially. The case was managed in intensive care settings. The patient had to be treated with thrombolytic therapy owing to hemodynamic compromise. Significant clinical improvement was noted after thrombolysis. A high index of suspicion is required for the diagnosis and management of PE. If standard imaging techniques cannot be used due to clinical constraints, ancillary techniques must be effectively employed during management. Key Words: Pulmonary embolism, Thrombolysis, High altitude, COVID-19.

EXPERIENCE OF SEVERE ACUTE RESPIRATORY SYNDROME CORONAVIRUS-2 (SARS-COV-2) - COVID-19 AT A TERTIARY CARE HOSPITAL IN QUETTA, BALUCHISTAN

Objective: To share the experience of Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2)-COVID-19 at a tertiary care hospital in Quetta, Baluchistan. Study Design: Cross-sectional study. Place and Duration of Study: Department of Pathology, Combined Military Hospital Quetta, from Mar to Dec 2020. Methodology: This study included 14,741 study participants presenting to CMH Quetta with signs and symptoms of Coronavirus Disease-19 (COVID-19) and others undergoing COVID-19 PCR for screening purpose. Nasopharyngeal swab collected from these study participants were tested for COVID-19 viral RNA by real-time Reverse Transcription Polymerase Chain reaction (RT-PCR) assay. Results: Out of these 14,741 study participants, 1886 (12.7%) were found to be SARS-CoV-2 PCR positive. Among 1886 study participants, 1503 (80%) were males while 383 (20%) were females. Mean age of the study participants was 36 ± 14 years. Most frequent clinical presentations were body aches (96.5%), fever (94.1%), cough (66.8%) and loss of appetite (68.2%). Around 67 (3.5%) positive study participants were asymptomatic. Conclusion: In this study, we observed male predominance but severity of signs and symptoms among female study participants. SARS-COVID-19 caused disease with wide range of clinical spectrum and disease can be fatal as well.

Comparison of Turbidimetric Inhibition Immunoassay, High-Performance Liquid Chromatography, and Capillary Electrophoresis Methods for Glycated Hemoglobin Determination

OBJECTIVE

The purpose of this study was to compare the performances of and evaluate the agreement among glycated hemoglobin values analyzed by using National Glycohemoglobin Standardization Program-certified and International Federation of Clinical Chemistry-standardized analyzers.

THIS CROSS-SECTIONAL STUDY WAS CONDUCTED AT THE

Armed Forces Institute of Pathology, Department of Chemical Pathology from March 2019 to May 2019.

METHODS

Glycated hemoglobin (HbA1c) was measured in the blood specimens from 100 patients on an ADVIA 1800 by a turbidimetric inhibitory immunoassay (TINIA), Sebia instrument by electrophoresis, and Bio-Rad Variant II Turbo system by high-performance liquid chromatography (HPLC). Quantitative variables were calculated as the mean ± standard deviation (SD). Precision and method comparisons were carried out according to Clinical and Laboratory Standards Institute recommendations. The results obtained from each analyzer were compared by correlation analysis. Method comparison was done by linear regression and Bland-Altman plots using the SPSS software version 24.

RESULTS

The mean ± SD HbA1c values from TINIA, electrophoresis, and HPLC were 7.188% ± 1.89%, 7.164% ± 1.866%, and 7.160% ± 1.85%, respectively. The between-run coefficients of variation for TINIA, electrophoresis, and HPLC were 0.64%, 0.61%, and 0.60%, respectively. All 3 showed good correlation (TINIA, R2 = .994, P = .00; electrophoresis, R2 = .992, P = 0.00; and HPLC, R2 = .994, P = 0.00).

CONCLUSION

The good clinical agreements of HbA1c and strong correlations between analyzers indicate that these analyzers can be used interchangeably.

DETERMINATION OF REFERENCE INTERVAL OF LIVER FUNCTION TESTS DURING PREGNANCY IN URBAN AREA OF DISTRICT RAWALPINDI PAKISTAN

Objective: To determine the reference Interval of liver function tests during uncomplicated pregnancy inpopulation of Rawalpindi and assess their correlation over first and second trimesters of pregnancy. Study Design: Cross sectional study. Place and Duration of Study: Department of Chemical Pathology & Endocrinology Armed Forces Institute ofPathology Rawalpindi from Feb 2017 to Jun 2018. Methodology: Seven hundred and fifty four pregnant women with uncomplicated, single intrauterine pregnancy were recruited from Rawalpindi. Thirteen patients with known history of Diabetes Mellitus, hypertension, liver disease, renal disorders and those on anti-epileptics, non-steroidal anti-inflammatory drugs and steroids were excluded from the study. Blood sample was taken from each subject to analyze serum bilirubin, albumin, total alkaline phosphates and alanine aminotransferase on random access discrete auto analyser, ADVIA 1800 Chemistry system manufactured in Japan for Siemens Healthcare Diagnostics Inc. Data for serum bilirubin, albumin, ALP and ALT were expressed as mean ± standard deviation. As the reference data followed the Gaussian distribution, therefore the 2.5th and 97.5th percentiles were estimated by values approximately 2SD on each side of mean. Results: After analysis of serum samples of 754 subjects, the reference intervals for bilirubin, albumin, ALP andALT during first trimester were; bilirubin 3-9 µmol/l, albumin 31-45 g/L, ALP 122-224 U/l and ALT 3-35 U/l, while of second trimester were: bilirubin 2- 7µmol/l, albumin 28-45 g/L, ALP131-300U/l and ALT 1-33U/l. Conclusion: First and second trimester wise reference values of Liver Function Tests have been determined inpregnancy in this study. This would not only........

Triglycerides-to-HDLC Ratio as a Marker of Cardiac Disease and Vascular Risk Factors in Adults

OBJECTIVE

To find out correlation of triglycerides-to-HDL cholesterol ratio in elders with cardiac risk factors like obesity, diabetes, and hypertension.

STUDY DESIGN

Observational cross-sectional study.

PLACE AND DURATION OF STUDY

Department of Chemical Pathology and Endocrinology, Combined Military Hospital, Rawalpindi, from January to June 2018.

METHODOLOGY

Inclusion standards were participants aged 20-59 years .Patients with comorbidity and chronic illness were excluded from the study. A planned standardised homogeneous survey was conducted as a pilot study. Social, economic and physical variables like age, gender, marital status and presence of diseases, all were taken into consideration. To check association among cardio metabolic risk factors like diabetes, obesity, hypertension, and TG/HDL-C ratio, Chi-square test was computed for all cardio metabolic risk factors.

RESULTS

Overall 350 participants were studied after attainment of authorisation from Ethical Review Board of Combined Military Hospital, Rawalpindi, in which 268 (76.6%) were women; whereas, 82 (23.4%) were men with mean age of 37 ± 11.64 years. There was strong association of TG/HDL ratio with BMI, HOMA-IR, WBISI, visceral fats, smooth muscle mass, HDL, LDL, and triglycerides with p <0.04, p <0.001, p <0.01, and p <0.001, respectively.

CONCLUSION

TG/HDLC ratio can be considered as a potential biomarker for the early prediction of cardiometablic risk factors.

Efficacy of Antimicrobials Against Multidrug-Resistant Acinetobacter baumannii from Patients in a Tertiary Care Hospital

Introduction: In just two decades Acinetobacter baumannii has attained considerable importance, evolving from an insignificant organism to a leading pathogen especially in intensive care unit settings globally. Treatment options are already very limited and have almost run out due to the rapid emergence of antimicrobial resistance. Evaluation of antimicrobials that are currently in use to determine their effectiveness against multidrug-resistant (MDR) strains and developing newer options is of utmost importance. We thus set out to determine the efficacy of routinely used antibiotics against MDR A. baumannii. Materials and Methods: This was a cross-sectional study conducted at the Department of Microbiology, Army Medical College, National University of Medical Sciences (Rawalpindi, Pakistan) from December 2015 to June 2016. The organisms were identified on the basis of colony morphology, gram staining, catalase, oxidase, motility test, and API (analytical profile index) 20NE. The organisms were considered to be MDR when the isolate was found to be resistant to at least one agent in more than three antimicrobial groups. Antibiotic sensitivity was determined using the modified Kirby-Bauer disc diffusion method according to Clinical Laboratory Standards Institute (CLSI) guidelines. Results: The 77 isolates were found to have good sensitivity to tigecycline (94.8%) and minocycline (80.5%). Most of the isolates were resistant to other routinely used antibiotics. Conclusion: A few antibiotics, tigecycline and minocycline, are still effective against these MDR A. baumannii. We need to remain up to date regarding the efficacy of antibiotics to effectively treat patients with these MDR bacteria.

Hypertension associated risk factors in Pakistan: A multifactorial case-control study

OBJECTIVE

To shed light on the association of age, smoking, educational status, family history, diabetes and kidney diseases with hypertension.

METHODS

The case-control study was conducted at three different medical centres of Rawalpindi, Pakistan, from December 2016 to July 2017. Data from 549 hypertensive cases and 1451 normotensive controls was collected using a detailed questionnaire and through personal interviews by adopting nonprobability consecutive sampling technique. Overall 2000 adult individuals, both males and females excluding pregnant women, were the part of this study. Those with blood pressure ≥140/90mmHg and taking anti-hypertensive treatment were designated as the cases, while the rest were taken as normotensive controls. Blood pressure was measured by a physician. Multivariate logistics regression analysis was used to estimate the association of various different risk factors with hypertension. All the analysis was performed using software R 3.4.2 and SPSS 24.

RESULTS

Of the 2,000 subjects, 549(27.45%) were hypertensive cases and 1451(72.55%) were normotensive controls. Mean age of the cases was 43.32}9.7 years and it was 31.8}10.1 years among the normotensives. Higher age, smoking, lower educational status, presence of kidney diseases, diabetes and family history of hypertension were significantly associated with hypertension (p<0.01 each).

CONCLUSIONS

In Pakistani population, age, smoking, illiteracy, kidney diseases, diabetes and family history were found to be associated with hypertension.

Growth Hormone and ACTH Deficiency in a Diabetic Adult

Adult growth hormone deficiency (AGHD) syndrome has a constellation of features, like impaired cognitive function, altered body composition, poor quality of life and various metabolic changes. Most of its features resemble signs of aging as growth hormone (GH) secretion decreases with age. Hypothalamic-pituitary-adrenal (HPA) axis should be thoroughly investigated in this disease as patients with AGHD are at risk of life-threatening consequences due to partial or complete ACTH deficiency, especially in stressful conditions. GH deficiency has also been related to diabetes or glucose intolerance. It is relatively underdiagnosed problem in adults and requires a thorough workup including dynamic function tests like insulin tolerance test (ITT), which has been termed as the gold standard for the diagnosis of patients with ACTH deficiency.

Determination of reference intervals of thyroid markers during pregnancy in Urban area of District Rawalpindi Pakistan

OBJECTIVE

To determine the reference values for thyroid stimulating hormone, free tetra-iodothyronine and total tri-iodothyronine for healthy pregnant women.

METHODS

This cross sectional study was conducted at the Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from January 2016 to June 2017. Pregnant women with normal, single intrauterine, uncomplicated pregnancy were recruited from the local population. Blood sample was taken to analyse thyroid stimulating hormone, free tetra-iodothyronine and total tri-iodothyronine using chemiluminescence immunoassay. For thyroid hormone levels during each trimester 5th and 95th percentiles were calculated as reference intervals. Data was analysed using SPSS 24.

RESULTS

Out of 384 subjects, 188(48.95%) were in their first trimester and 196(51.04 %) females were in their second trimester. There were 109(57.97%) primigravida in the first trimester and 137(69.9%) in the second trimester. Mean age of subjects presenting in the first and second trimester was 25.37±3.78 years and 26.54±4.65 years respectively. Reference intervals for those in the first trimester for thyroid stimulating hormone was 0.05-2.8uIU/ml, for free tetra-iodothyronine14.4-22.7pmol/l and total tri-iodothyronine1.5-3.3nmol/l. For those in second trimester the corresponding values were 0.16-3.3 uIU/ml, 14.2-24.6.0 pmol/l and 1.6-3.1nmol/l.

CONCLUSIONS

Laboratories should adopt trimester-specific reference intervals for thyroid function tests in pregnancy..

Acrophobia in a Young Girl with Parathyroid Hormone Resistance (Pseudohypoparathyroidism)

Pseudohypoparathyroidism (PHP) is an extremely rare group of disorders. It is a spectrum of disorders caused by end organ resistance to parathyroid hormone (PTH) and is represented by impaired signalling that activates cAMP dependent pathways via alpha subunit of G-protein (GS). It is characterised by hypocalcemia, hyperphosphatemia, raised PTH levels due to insensitivity to biological activity of PTH, and normal renal function tests. We describe a case of 10-year girl who presented with fear of falling down from heights. Her laboratory evaluation and skeletal survey showed evidence of PHP along with features of Albright's hereditary osteodystrophy (AHO) pointing towards the diagnosis of PHP type 1a.

Spectrum of renin angiotensin aldosterone system disorders in young hypertensives

OBJECTIVE

To analyse the spectrum of renin angiotensin aldosterone system disorders in young hypertensive patients in hospital settings.

METHODS

This cross-sectional study was conducted at the Department of Chemical Pathology and Endocrinology, Armed Forces Institute of Pathology, Rawalpindi, Pakistan, from January to December, 2016. It comprised hypertensive subjects aged 17-40 years of either gender presenting in the outpatient department. All subjects were having blood pressure more than 140/90mmHg and were not on any anti-hypertensive medicine. Blood sample was taken from each patient to analyse arterial blood gases, plasma renin, serum aldosterone and electrolytes. Association of qualitative variables like age, systolic and diastolic blood pressure with essential hypertension and primary hyperaldosteronism was explored.

RESULTS

Of the 80 patients, 72(90%) were diagnosed with essential hypertension and 8(10%) with primary hyperaldosteronism. None of the patients had Liddle syndrome, apparent mineralocorticoid excess or Gordon syndrome. Mean age of patients having essential hypertension was 30.97±7.1 years, whereas, for those with primary hyperaldosteronism it was 29.25±7.1 years. Systolic blood pressure was significantly higher (p = 0.000) among all patients. No statistically significant association was found between age, systolic and diastolic blood pressure (p<0.05).

CONCLUSIONS

Primary hyperaldosteronism as compared to other renin angiotensin aldosterone system disorders was found to be the leading cause of hypertension in young population.

In Vitro Efficacy of Doripenem against Pseudomonas aeruginosa and Acinetobacter baumannii by E-Test

OBJECTIVE

To assess the in vitro efficacy of doripenem against Pseudomonas aeruginosa and Acinetobacter baumannii using Epsilometer strips.

STUDY DESIGN

Cross-sectional study.

PLACE AND DURATION OF STUDY

Department of Microbiology, Army Medical College, Rawalpindi and National University of Sciences and Technology, Islamabad, from May 2014 to September 2014.

METHODOLOGY

A total of 60 isolates of Acinetobacter baumannii and Pseudomonas aeruginosa collected from various clinical samples received from Military Hospital were included in the study. The specimens were inoculated onto blood, MacConkey and chocolate agars. The isolates were identified using Gram staining, motility, catalase test, oxidase test and API 20NE (Biomeriux, France). Organisms identified as Acinetobacter baumannii and Pseudomonas aeruginosa were included in the study. Bacterial suspensions equivalent to 0.5 McFarland turbidity standard of the isolates were prepared and applied on Mueller Hinton agar. Epsilometer strip was placed in the center of the plate and incubated for 18-24 hours. Minimum Inhibitory Concentration (MIC) was taken to be the point where the epsilon intersected the E-strip. MIC of all the isolates was noted.

RESULTS

For Pseudomonas aeruginosa isolates, MIC(50) was 12 µg/mL and MIC(90) was 32 µg/mL. For Acinetobacter baumannii MIC(50) and MIC(90) was 32 µg/mL.

CONCLUSION

Doripenem is no more effective against Pseudomonas aeruginosa and Acinetobacter baumannii in our setting.

Role of appropriate surgery in survival of patients with epithelial ovarian cancer

OBJECTIVE

Management of epithelial ovarian cancer (EOC) patients is largely based on appropriate surgery. The principle treatment of early stage is competence of surgical staging surgery and surgical management of all patients with advance EOC is approach in a similar manner with cytoreduction surgery. We decided to evaluate the impact of appropriate surgery as a scale on 2 and 5-year survival in EOC patients.

METHODS

In a descriptive analytic study a total 186 patients were divided into 62 with early stage of EOC equivocal FIGO stage I and 124 with advanced disease at Vali-e-Asr Hospital affiliated with Tehran University of Medical Science, Iran, from 1998 to 2008. Two and 5-year disease free survival (DFS) and overall survival rates were determined and compared between the two groups using chi-squared test' Kaplan Meier and Cox regression.

RESULTS

Five-year DFS in patients with early stage of disease was 85% for the surgical staging group and 38% for non-surgical staging group (P = 0.037). Two-year DFS and overall survival did not differ between the groups. Also 5-year survival rates in subjects with surgical staging surgery were 42% and 40% for non staging group. For patients assigned to advanced disease group, 5-year DFS in subjects with cytoreductive surgery was 73% and the figure for the remainder was 58%. Five-year overall survival rate in cytoreductive surgery group was 43% in comparison to 38% in the second group.

CONCLUSION

Maximal effort for appropriate surgery appears to be a corner stone for optimal survival.

Nutritive value of human milk and nutritional status of wives of army personnel of low income from Rawalpindi

The nutritional status and proximate composition, fatty acid profile and mineral composition of milk from 26 wives of army personnel of low income group from Rawalpindi was investigated. The body mass index ranged from 13.5 to 23.7, hemoglobin from 8.6 to 14.8 G/dl, serum protein from 4.8 to 7.5 G and serum albumin from 3.3 to 4.8 G%. Milk protein content varied from 0.6 to 2.4%, fat from 1.0 to 3.7% [corrected]. Palmitic acid was the major fatty acid in milk whose concentration ranged from 34.4 to 47.1% [corrected] and the linoleic acid from 6.9-15.4% [corrected]. The calcium content of milk varied from 7.9-87.1 mg%, iron from traces to 0.44 mg% and zinc from 0.02-1.28 mg%.