Background Cytokine release syndrome (CRS) plays a pivotal role in the pathophysiology and progression of Coronavirus disease-2019 (COVID-19). Therapeutic plasma exchange (TPE) by removing the pathogenic cytokines is hypothesized to dampen CRS. Objective To evaluate the outcomes of the patients with COVID-19 having CRS being treated with TPE compared to controls on the standard of care. Methodology Retrospective propensity score-matched analysis in a single centre from 1st April to 31st July 2020. We retrospectively analyzed data of 280 hospitalized patients developing CRS initially. PSM was used to minimize bias from non-randomized treatment assignment. Using PSM 1:1, 90 patients were selected and assigned to 2 equal groups. Forced matching was done for disease severity, routine standard care and advanced supportive care. Many other Co-variates were matched. Primary outcome was 28 days overall survival. Secondary outcomes were duration of hospitalization, CRS resolution time and timing of viral clearance on Polymerase chain reaction testing. Results After PS-matching, the selected cohort had a median age of 60 years (range 32–73 in TPE, 37–75 in controls), p = 0.325 and all were males. Median symptoms duration was 7 days (range 3–22 days’ TPE and 3–20 days controls), p = 0.266. Disease severity in both groups was 6 (6.6%) moderate, 40 (44.4%) severe and 44 (49%) critical. Overall, 28-day survival was significantly superior in the TPE group (91.1%), 95% CI 78.33–97.76; as compared to PS-matched controls (61.5%), 95% CI 51.29–78.76 (log rank 0.002), p<0.001. Median duration of hospitalization was significantly reduced in the TPE treated group (10 days vs 15 days) (p< 0.01). CRS resolution time was also significantly reduced in the TPE group (6 days vs. 12 days) (p< 0.001). In 71 patients who underwent TPE, the mortality was 0 (n = 43) if TPE was done within the first 12 days of illness while it was 17.9% (deaths 5, n = 28 who received it after 12th day (p = 0.0045). Conclusion An earlier use of TPE was associated with improved overall survival, early CRS resolution and time to discharge compared to SOC for COVID-19 triggered CRS in this selected cohort of PS-matched male patients from one major hospital in Pakistan.

Background: Coronavirus disease 2019 (COVID-19) is a novel infectious disease of multi-system involvement with significant pulmonary manifestations. So far, many prognostic models have been introduced to guide treatment and resource management. However, data on the impact of measurable respiratory parameters associated with the disease are scarce. Objective: To demonstrate the role of Comorbidity-Age-Lymphocyte count-Lactate dehydrogenase (CALL) score and to introduce Respiratory Assessment Scoring (RAS) model in predicting disease progression and mortality in COVID-19. Methodology: Data of 252 confirmed COVID-19 patients were collected at Pak Emirates Military Hospital (PEMH) from 10th April 2020 to 31st August 2020. The CALL score and proposed factors of RAS model, namely respiratory rate, oxygen saturation at rest, alveolar arterial gradient and minimal exercise desaturation test, were calculated on the day of admission. Progression of disease was defined and correlated with measured variables. Univariate and multivariate Cox regression analysis for each variable, its hazard ratio (HR) and 95% confidence interval (CI) were calculated, and a nomogram was made using the high-risk respiratory parameters to establish the RAS model. Results: Progression of disease and death was observed in 124 (49.2%) and 49 (19.4%) patients, respectively. Presence of more than 50% of chest infiltrates was significantly associated with worsening disease and death (p-value <0.001). Death was observed in 100% of patients who had critical disease category on presentation. Regression analysis showed that the presence of comorbidity (n: 180), in contrast to other variables of CALL score, was not a good prognosticator of disease severity (p-value: 0.565). Nonetheless, the CALL model itself was validated to be a reliable prognostic indicator of disease progression and mortality. Some 10 feet oxygen desaturation test (HR: 0.99, 95%CI: 0.95-1.04, p-value: 0.706) was not a powerful predictor of the progression of disease. However, respiratory rate of more than 30 breaths/minute (b/m) (HR: 3.03, 95%CI: 1.77-5.19), resting oxygen saturation of less than 90% (HR: 2.41, 95%CI: 1.15-5.06), and an elevated alveolar-arterial oxygen gradient (HR: 2.14, 95%CI: 1.04-4.39) were considered statistically significant highrisk predictors of disease progression and death, in the formed RAS model. The model resulted in 85% (95%CI: 80%-89%) of area under the receiver operating characteristic curve (AUROC), with substantial positive (76%, 95%CI: 68%-83%) and negative predictive values (80%, 95%CI: 73%-87%) for a cutoff value of seven. Patients with higher CALL and RAS scores also resulted in higher mortality. Conclusion: CALL and RAS scores were strongly associated with progression and mortality in patients with COVID-19.

BackgroundHydroxychloroquine (HCQ) has been considered for the treatment of coronavirus disease 2019 , but data on its efficacy are conflicting. We analyzed the efficacy of HCQ along with standard of care (SOC) treatment, compared with SOC alone, in reducing disease progression in mild COVID-19. MethodsA single-center open-label randomized controlled trial was conducted from April 10 to May 31, 2020 at Pak Emirates Military Hospital, Rawalpindi. Five hundred patients of both genders between the ages of 18 and 80 years with mild COVID-19 were enrolled in the study. A total of 349 patients were assigned to the intervention group (standard dose of HCQ plus SOC) and 151 patients were assigned to SOC only. The primary outcome was progression of disease while secondary outcome was polymerase chain reaction (PCR) negativity on days 7 and 14. The results were analyzed on Statistical Package for Social Sciences (SPSS; IBM Corp., Armonk, NY) version 23. A p-value <0.05 was considered significant. ResultsThe median age of the intervention group was 34 ± 11.778 years and control group was 34 ± 9.813 years. Disease progressed in 16 patients, 11 (3.15%) of which were in the intervention group and 5 (3.3%) in the control group (p-value = 0.940). PCR negative cases in intervention and control groups on day 7 were 182 (52.1%) and 54 (35.8%), respectively (p-value = 0.001); and on day 14 were 244 (69.9%) and 110 (72.9%), respectively (p-value = 0.508). Consecutive PCR negativity on days 7 and 14 was observed in 240 (68.8%) patients in the intervention group compared to 106 (70.2%) in the control group (p-value = 0.321). ConclusionThe addition of HCQ to SOC in hospitalized mild COVID-19 patients neither stops disease progression nor helps in early and sustained viral clearance.

Background: Diabetes mellitus (DM) is a major health problem globally and so are misconceptions. Misconceptions can lead to poor glycemic control among diabetic patients and hence may results in complications and therefore increased incidence of morbidity and mortality. Objective: Assessment of knowledge and dietary misconceptions among diabetic patients. Methodology: A cross-sectional prospective study was conducted among diabetic patients for a period of 6 months, using a validated questionnaire. Patients were contacted while attending to a health care facility in Quetta, Pakistan. A self-administered questionnaire was introduced among participants. Assistance was provided to those who could not read or understand the questionnaire. The questionnaire was designed in English and then translated in to Urdu by a language expert. The data were coded and entered to statistical package for social sciences (SPSS) version 20. The responses to the questionnaire were analyzed by performing descriptive and inferential statistics. Results: Study showed that almost 83% of diabetic subjects believed that "in diabetes sugar cannot be used at any cost", while 68% believed that special diabetic food is used in diabetes; almost 66% patients admitted that they can suffer from other diseases and infections due to diabetes. Misconceptions were more common among uneducated and low income people. Conclusion: The prevalence of misconceptions about Diabetes is high among uneducated and low income people.

Objective: To compare the outcome in COVID 19 patients on oxygen managed with 6mg and 12 mg Dexamethasone at Pak Emirates Military Hospital Rawalpindi. Study Design: Comparative cross-sectional study. Place and Duration of Study: Pak Emirates Military Hospital Rawalpindi Pakistan, from Aug 2020 to Aug 2021. Methodology: Patients diagnosed with COVID-19 on PCR and were oxygen-dependent but not mechanical ventilation dependent were included in the study. They were randomly divided into two groups. Group-I received 6mg Dexamethasone, while Group-II received 12 mg Dexamethasone for ten days. They were followed up for 30 days to look for the outcome (prolonged admission, high dependency unit admission, intensive care admission, death). The difference in outcome in both groups was studied using the Pearson chi-square test. Results: Out of 600 patients included in the study, 401 (66.8%) were male, while 199 (33.2%) were female. The mean age of the study participants was 47.81 ± 8.716 years. 306 (51%) were given 6mg of Dexamethasone for ten days, while 294 (49%) were given 12mg of Dexamethasone for a similar time. prolonged admission (p-value-0.178), high dependency unit admission (pvalue-0.409), intensive care admission (p-value-0.176) and mortality (p-value-0.588) were not statistically significantly different in both the groups. Conclusion: All the outcome variables, including mortality and admission to the critical care unit, were not statistically significant in groups taking 6mg or 12 mg of Dexamethasone, so it could be concluded that a high dose of this medication is not superior in terms of efficacy when compared to the low dose.

Objective: The study intended to assess the impact of educational intervention on knowledge of osteoporosis among female university students of Quetta. Methods: This interventional study was conducted on female university students by using convenience sampling technique. A total of 163 female students were enrolled for the study, these are those female students who did not heard about the disease named as osteoporosis. These subjects were provided with a selfexplanatory brochure that contains basic information regarding osteoporosis. The intervention was completely theoretical in nature. After two days interval participants were contacted again and asked to complete a pre-validated questionnaire containing 20 questions related to osteoporosis knowledge. Descriptive analysis was used to demonstrate the demographic characteristics of the study population. Inferential statistics (Mann-Whitney U test and Kruskal Wallis tests and Wilcoxon mean rank test, p<0.05) were used to assess the significance among study variables and to assess the impact of educational intervention on knowledge. Results:Average score of knowledge was 14.18 ± 2.7. Although educational intervention had a significant effect on knowledge scores of the respondents (Wilcoxon rank test p<0.005) (considering the pre-intervention knowledge score as zero) certain demographic characteristics (academic degree and living status) does affect knowledge scores of the study respondents. Conclusion: Although adequate improvement of knowledge scores of osteoporosis was reported after educational intervention, yet efforts should be made to bring change in the attitudes and practices of the female students by the help of intensive educational programs based on behavioral learning theories for better disease knowledge and prevention.

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Importance: Cytokine release storm (CRS) plays pivotal role in pathophysiology and progression of COVID-19. Objective: To evaluate the outcomes of COVID-19 patients having CRS treated with Therapeutic Plasma Exchange (TPE) as compared to controls not receiving TPE. Design: Retrospective propensity score (PS) matched analysis, 1st April to 30th June 2020. Setting: Tertiary care hospital, single centre based. Participants: Using PS 1:1 matching, 90 patients were assigned 2 groups (45 receiving TPE and 45 controls). Forced matching and covariate matching was done to overcome bias between two groups. Main outcomes and measures: Primary outcome was 28 days overall survival. Secondary outcomes were duration of hospitalization, CRS resolution time and timing of PCR negativity. Results: Median age was 60 years (range 32-73 in TPE, 37-75 in non-TPE group), p= 0.325. Median symptoms duration 7 days (range 3-22 days TPE and 3-20 days non-TPE), p=0.266. Disease severity in both groups was 6.6% moderate, 44.4% severe and 49% critical. Twenty-eight-day survival was significantly superior in TPE group (91.1%) as compared to controls (61.5%), HR 0.21, 95% CI for HR 0.09-0.53, log rank 0.002. Median duration of hospitalization was significantly reduced in TPE treated group as compared to non-TPE controls 10 days and 15 days respectively (p< 0.01). CRS resolution time was also significantly reduced in TPE treated group (6 days vs. 12 days) (p< 0.001). Conclusion and Relevance: Use of TPE is associated with superior overall survival, early CRS resolution and time to discharge as compared to standard therapy for COVID-19 triggered CRS.