Adverse outcomes in coronavirus infection disease-19 patients are not always due to the direct effects of the viral infection, but often due to bacterial coinfection. However, the risk factors for such bacterial coinfection are hitherto unknown. A case-control study was conducted to determine risk factors for bacterial infection in moderate to critical COVID-19. Out of a total of 50 cases and 50 controls, the proportion of cases with severe/critical disease at presentation was 80% in cases compared to 30% in controls (p < 0.001). The predominant site was hospital-acquired pneumonia (72%) and the majority were Gram-negative organisms (82%). The overall mortality was 30%, with comparatively higher mortality among cases (42% vs. 18%; p = 0.009). There was no difference between procalcitonin levels in both groups (p = 0.883). In multivariable logistic regression analysis, significant independent association was found with severe/critical COVID-19 at presentation (AOR: 4.42 times; 95% CI: 1.63-11.9) and use of steroids (AOR: 4.60; 95% CI: 1.24-17.05). Notably, 64% of controls were administered antibiotics despite the absence of bacterial coinfection or secondary infection. Risk factors for bacterial infections in moderate to critically ill patients with COVID-19 include critical illness at presentation and use of steroids. There is widespread empiric antibiotic utilization in those without bacterial infection.

Highlights Anakinra averted need for mechanical ventilation in patients with severe COVID-19 pneumonia. Anakinra accelerated weaning off oxygen therapy and hastened transition to room air. Patients treated with anakinra had significant reduction in biomarkers of inflammation. Study results did not demonstrate significant difference in in-hospital mortality. We provided further evidence for the utility of anakinra in severe COVID-19 pneumonia.

ObjectiveBacterial infections are known to complicate respiratory viral infections and are associated with adverse outcomes in COVID-19 patients. A case control study was conducted to determine risk factors for bacterial infections where cases were defined as moderate to severe/critical COVID-19 patients with bacterial infection and those without were included as controls. Logistic regression analysis was performed.ResultsOut of a total of 50 cases and 50 controls, greater proportion of cases had severe or critical disease at presentation as compared to control i.e 80% vs 30% (p<0.001). Hospital acquired pneumonia (72%) and Gram negative organisms (82%) were predominant. Overall antibiotic utilization was 82% and was 64% in patients who had no evidence of bacterial infection. The median length of stay was significantly longer among cases compared to controls (12.5 versus 7.5 days) (p=0.001). The overall mortality was 30%, with comparatively higher proportion of deaths among cases (42% versus 18%) (p=0.009). Severe or critical COVID-19 at presentation (AOR: 4.42 times; 95% CI; 1.63-11.9) and use of steroids (AOR: 4.60; 95% CI 1.24-17.05) were independently associated with risk of bacterial infections. These findings have implications for antibiotic stewardship as antibiotics can be reserved for those at higher risk for bacterial superinfections.

Background Neutrophil to lymphocyte ratio (NLR) can be easily calculated from the white cell differential count and is considered an auspicious marker for predicting different diseases, including sepsis. In this study, we aimed to compare the efficacy of NLR as a sepsis marker by comparing it with other markers of sepsis, such as Creactive protein (CRP), procalcitonin, and the Sequential Organ Failure Assessment (SOFA) score. Methods A cross-sectional analytical study was conducted at the Aga Khan University Hospital from July 2019 to December 2019. A total of 168 patients who were admitted to the medicine department with a diagnosis of sepsis on arrival or during the hospital stay were enrolled. The neutrophil to lymphocyte ratio was calculated to form venous samples taken on admission and compared to the level of CRP, procalcitonin, culture reports, and the SOFA score as a predictor of sepsis. Results Out of 168 patients, 55.3% were male. The median age of the participants was 68.40 (interquartile range (IQR): 19.5) years in males and 64.0 (IQR: 18.0) in females. Procalcitonin was performed in 121 (72%) and CRP performed in 61 (36.3%) patients. The NLR showed significant associations with all the tested lab parameters of sepsis, such as CRP (p = 0.02), procalcitonin (p = 0.01), and SOFA score (p = 0.01). Values when analyzed according to culture-positive showed higher values in culture-positive samples but were not statistically significant. Conclusion Neutrophil to lymphocyte ratio is a cheap and rapidly available predictor of sepsis and has shown a significant correlation with other relatively expensive and non-rapidly existing markers of inflammation and sepsis. However, large prospective studies are needed to prove its real effectiveness as a marker of sepsis and its prognosis

Background A pattern of both clinical and biochemical abnormalities is associated with dengue virus infection (DVI). Among the various DVI-related biochemical defects, electrolyte imbalance is one that can alter the morbidity and mortality among patients. However, there is a dearth of evidence to assess the relationship between electrolyte imbalance and the length of stay or mortality in dengue-infected patients in Pakistan. In the current study, we aimed to investigate the association between electrolyte imbalance at the time of admission and the length of stay and mortality among dengue-infected patients. Methods We conducted a retrospective study at a large tertiary care hospital from November 2018 to November 2019. All patients with known chronic diseases and coinfections or those who were taking diuretics therapies or angiotensin-converting enzyme inhibitors were excluded. Our main exposure of interest was electrolytes imbalance and the outcome measure was the length of stay and mortality. Results A total of 1,008 dengue patients were enrolled with a mean length of stay of 2.56 days. Around 29.3% had hyponatremia and 23.2% had hypokalemia at the time of admission, and 21.9% of patients had a stay beyond three days. In multivariable analysis, hyponatremia [adjusted odds ratios (aOR) = 1.29; 95% confidence interval (CI): 0.59-2.84] and hypokalemia (aOR = 2.36; 95% CI: 0.91-6.10) were not found to be associated with the length of stay. However, patients with high troponin levels at admission had a prolonged stay beyond three days (aOR = 5.74; 95% CI: 2.34-14.11). There was a statistically significant association of creatinine levels (aOR = 14.74; 95% CI: 4.19-15.85) and diabetes mellitus (DM) (aOR = 4.36; 95% CI: 1.21-15.74) with mortality after controlling for potential confounders. Conclusion Electrolyte imbalance at admission is not a predictor of length of stay or fatalities in the hospital among patients with DVI. However, troponin levels at admission can increase hospitalization days whereas DM and renal injury have been found to worsen mortality rates.

Aim: To assess the quality of life, perceived social support, and death anxiety among people having cardiovascular disorders Study type: A Cross-sectional study Place and Duration: This study was conducted at Civil Hospital, BMCH Quetta Pakistan from June 2020 to June 2021 Methodology: This study was designed to evaluate the correlation between quality of life, hope, and death anxiety among people having cardiovascular disorders. We gathered data by using a convenience sampling technique for 4 months. We used the questionnaire method for our survey. Our questionnaire was based on five sections including basic demographic, the 17-item McGill QoL (MQoL) Questionnaire, Herth hope to score, Thorson-Powell Death Anxiety Scale (TPDAS), and Death depression scale (DDS). Results: Out of 500 participants half of them were female (52.4%), most of the participants were married with no formal education and belonged to poor or middle-class families. Participants with intermediate education levels who were financially dependent on the government had a better quality of life than others. We observed that patients with myocardial infarction (MI) had higher levels of anxiety. Furthermore, we observed that patients with a belief in life after death had higher death anxiety than those who don't believe. Conclusion: Our results concluded a positive association among quality of life and hope. We examined that social support plays a vital role in managing CVD disorders. However, patients with myocardial infarction had high levels of death anxiety than others. Keywords: Cardiovascular disorders, coronary artery disease, myocardial infarction, death anxiety, quality of life, social support.

Background: COVID-19 is having many impacts on health, economy and social life; some due to the indirect effects of closure of health facilities to curb the spread. Closures were implemented in Pakistan from March 2020, affecting provision of reproductive, maternal, newborn and child health (RMNCH) services. Aims: To appraise the effects of containment and lockdown policies on RMNCH service utilization in order to develop an early response to avoid the catastrophic impact of COVID-19 on RMNCH in Pakistan. Methods: Routine monitoring data were analysed for indicators utilization of RMNCH care. The analysis was based on Period 1 (January–May 2020, first wave of COVID-19); Period 2 (June–September 2020, declining number of cases of COVID-19); and Period 3 (October–December 2020, second wave of COVID-19). We also compared data from May and December 2020 with corresponding months in 2019, to ascertain whether changes were due to COVID-19. Results: Reduced utilization was noted for all RMNCH indicators during Periods 1 and 3. There was a greater decline in service utilization during the first wave, and the highest reduction (~82%) was among children aged < 5 years, who were treated for pneumonia. The number of caesarean sections dropped by 57%, followed by institutional deliveries and first postnatal visit (37% each). Service utilization increased from June to September, but the second wave of COVID-19 led to another decrease. Conclusion: To reinstate routine services, priority actions and key areas include continued provision of family planning services along with uninterrupted immunization campaigns and routine maternal and child services.

Background: Myocarditis is a challenging diagnosis due to the heterogeneity of clinical presentations. Myocarditis can present with a mildly raised cardiac enzyme to severe myocarditis leading to congestive heart failure, arrhythmias, cardiogenic shock, and death. It is a predictor of morbidity and mortality in dengue-infected patients. The exact prevalence of dengue myocarditis and its outcomes are unknown in Pakistan. Objectives:We aim to study the prevalence and association of myocarditis with the length of stay in the hospital and mortality of dengue-infected patients.Methods: A retrospective observational study done at a tertiary care hospital. We reviewed hospital record files of 1008 consecutive patients with dengue viral infection admitted from November 2018 to November 2019.Results: Out of 1008 dengue-infected patients, 55.4% of patients were older than 35 years and 68.4% were males. Hypertension (HTN) was the most common comorbid condition. The prevalence of myocarditis in hospitalized dengue-infected patients was 4.2%. All (100%) of dengue myocarditis patients had raised cardiac troponin I (cTn-I), 59.5% of patients had at least one electrocardiography (ECG) change, and 24% had reduced ejection fraction (EF) (defined as EF < 55%). On multivariable analysis, patients with raised cTn-I levels (adjusted odds ratios = 5.29; [95% confidence interval (CI): 2.16-12.96]) and abnormal echocardiography (ECHO) [aOR = 4.38;] had a prolonged hospital stay (>3 days). Raised cTn-I levels (aOR = 8.2; [95% CI: 1.83-36.84]) was significantly associated with in-hospital mortality. Conclusions:Raised cTn-I is the predictor of length of stay and in-hospital mortality in dengue-infected patients. Atrial fibrillation, diabetes mellitus, hypertension, low serum bicarbonate, high serum creatinine, and any abnormality on echocardiography were associated with adverse outcomes in dengue-infected patients.