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.

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.

Objective: To assess Bacterial spectrum and antimicrobial pattern of Blood Stream Infections associated with non-tunneled double lumen catheter in hemodialysis patients. Study Design: Prospective observational study. Place and Duration of Study: Department of Nephrology, Pakistan Emirates Military Hospital Rawalpindi Pakistan; Armed Forces Institute of Pathology Rawalpindi, Pakistan, from May 2019 to Apr 2020. Methodology: A total of 753 patients underwent placement of non-tunneled double lumen catheter (457 femoral, 296 Internal Jugular). Patients with clinically suspected bloodstream infections had their catheters removed with tips being sent for culture along with 2 sets of peripheral blood cultures. Patients were labelled as having bloodstream infection if growth of organism was detected in catheter tip and at least one peripheral blood culture. Susceptibility testing was done for available antimicrobials. Results: One hundred and thirty six (18.06%) incidences or 5.48 bloodstream infections per 1000 catheter days, with confirmed growth on blood cultures were identified. Gram positive infections were seen in 76 (55.88%) individuals with most common organism being coagulase-negative Staphylococcus (28.68%), followed by Staphylococcus aureus (21.32%). These organisms had low resistance rates to Vancomycin (0%), Tigecycline (0%), Doxycycline (6.6%) and Linezolid (9.5%). Gram negative infections were seen in 60 (44.11%) patients with Klebsiella pneumoniae (13.24%) being the most commonly identified pathogen followed by Acinetobacter baumannii (12.50%) and had relatively higher degree of antimicrobial resistance. Conclusion: Gram positive organisms were the most common cause of bloodstream infection in this study and were found susceptible to vancomycin and doxycycline whereas gram-negative organisms had high rates of antimicrobial......

Hyperthyroidism is one of the most commonly encountered endocrine disorder with potentially devastating health consequences. Radioactive iodine has been used for the treatment of hyperthyroidism since 1940s. It is now widely accepted as safe, cost-effective and reliable treatment option with 50–90% cure rate in first year after therapy. With long-term follow-up hypothyroidism is inevitable especially in Grave’s disease which can activate orbitopathy in predisposed individuals. Early and timely management of hypothyroidism is associated with better therapeutic outcomes. There is very little evidence of cardiovascular and cancer related mortality risk after radioactive iodine therapy. However, it is said that these risks appear to be thyroid hormone driven above all other factors.

Abstract: Background: Drug adherence to medications in diabetes is very necessary for strict glycemic control. Many factors in diabetics are associated with low adherence to drugs resulting in complications. Methods: This research was conducted as an observational study with cross-sectional study design. It was scheduled between July 2022 to December 2022 in medical outpatient department of Combined Military Hospital, Peshawar Results: 115 individuals were inducted over a period of 6 months from medical OPD ex Combined Military Hospital Peshawar. Five patients failed to follow-up with research team resulting in a total of 110 participants included in results. Average age across the study sample was 50.25 ± 11.97 years with 58 (52.73%) males and 52 (47.27%) females. Most participant in our study sample were educated up to matriculation with BMI <25kg/m2. Average duration of diabetes across the sample was 6.1 ± 3.69 years. In treatment options, 53 (48.18%) individuals were only managed with oral therapy, 16 (14.55%) on insulin only while 41 (37.27%) were prescribed with both oral hypoglycemic drugs and insulin. Most common comorbid across study population was hypertension, seen in 59 (53.94%) diabetic patients, followed by cataract in 41 (37.47%) and IHD in 33 (30%) patients.  In all 110 individuals, only 29 (26.36%) individuals had good glycemic control i.e., HbA1c <7% with average glycosylated hemoglobin percentage measuring 8.29% ± 1.59%. As per MMAS-8 score, 25 (22.73%) patients reported good adherence, 31 (28.18%) patients reported fair adherence while rest 54 (49.09%) were found to have bad adherence. Average MMAS-8 score was 5.17. Conclusion: There is a correlation between medication adherence as measured by MMAS-8 score with control of diabetes as measured by HbA1c score in the range of 1.824% across the range of MMAS-8 score from 0-8. Sleep quality, BMI and multiple comorbid conditions were also linked with raised HbA1c. Key words: Drug adherence, Morisky Medication Adherence Scale, Diabetes, Non-diabetes, diabetic medications

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 commonbeing 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 variouscomplications.