Correlation of lymphocyte subsets and inflammatory biomarkers with disease severity in COVID-19 patients.

Objective: To determine the correlation of lymphocyte subsets and soluble serum inflammatory biomarkers with disease severity in coronavirus disease-2019 infection. METHODS: The retrospective study was conducted at the Department of Immunology, Sindh Institute of Urology and Transplantation (SIUI), Karachi, Pakistan from September 1 to November 30, 2021, and comprised data of patients admitted from June to July 2021 who tested positive for coronavirus disease-2019 on the basis of reverse transcription-polymerase chain reaction of nasopharyngeal swab specimens. The patients were categorised into severe group A and non-severe group B. Initial investigations included complete blood count, neutrophil-to-lymphocytes ratio, C-reactive protein, D-Dimers and serum ferritin levels. Lymphocyte subsets included cluster of differentiation-3+, cluster of differentiation-4+/ cluster of differentiation-3+, cluster of differentiation-8+ T lymphocytes, cluster of differentiation-19+B lymphocytes, cluster of differentiation-16+ cluster of differentiation-56+ Natural Killer cells and serum cytokine levels of interleukin-2, interleukin- 4, interleukin-6, interleukin-10, tumour necrosis factor-alpha and interferon gamma. They were correlated with disease severity. Data was analysed using SPSS 20. RESULTS: Of the 54 patients, 33(61.1%) were males and 21(38.9%) were females. There were 29(53.70%) patients in group A with median age 52 years (interquartile range: 43.5-65 years), and 25(46.29%) in group B with median age 50 years (interquartile range: 36.5-59 years) (p=0.241). Disease was significantly more severe in male patients compared to female (p=0.002). In group A, cluster of differentiation-3+ T cells were reduced in 21(72.4%) patients, cluster of differentiation-8+ T cells in 16(55.2%), cluster of differentiation-4+ T cells in 23(79.3%) and cluster of differentiation-19+ B cells in 8(27.6%). In group B, cluster of differentiation-3+ T cells were reduced in 10(40%) subjects, cluster of differentiation-8+ T cells in 7(28%), cluster of differentiation-4+ T cells in 12(48%) and cluster of differentiation-19+ B cells in 4(16%) patients. Serum cytokine levels were not significantly different between the groups (p>0.05). In group A, 7(24.13%) patients died, and in such cases, the neutrophil-to-lymphocytes ratio was significantly higher (p=0.037). Conclusion: Pro-inflammatory markers and cytokine levels increased, while lymphocyte subsets decreased with increasing severity of the disease.

Vaping, an emerging public health concern in South Asia: a short communication.

Electronic cigarettes, or "vaping," are battery-operated devices that heat a liquid containing propylene glycol, nicotine, and some flavoring agents, which aerosolize to produce vapors that the user inhales. They were introduced in 2003 and became popular worldwide as a less irritating alternative to combustible cigarettes. While they were initially advertised as smoking cessation aids, their use has taken the shape of an epidemic in some regions of the world. Vaping prevalence is high in South Asia, where a significant number of people use tobacco and smokeless tobacco. According to data from Pakistan, 6.2% of the population uses vaping/e-cigarettes, while 15.9 million (12.4%) use smokeless tobacco. Vaping may be a safer alternative to cigarette smoking, as e-cigarettes do not contain all the toxins that regular cigarettes do, and the aerosol from e-cigarettes has no appreciable cytotoxic, genotoxic, or inflammatory effects when inhaled. However, nicotine addiction is a concern, as it is the main culprit behind smoking addiction, and e-cigarettes may become a new pathway toward nicotine addiction. Hence, their effectiveness in smoking cessation is still debatable, and their role as a tool for smoking cessation needs further research.

The Effect of Dexamethasone on Postoperative Pain Management in Patients Undergoing Total Knee Arthroplasty: A Randomized Controlled Trial.

Objective The objective of this study was to evaluate the effectiveness of dexamethasone in treating postoperative pain in patients undergoing total knee arthroplasty (TKA). Methodology This randomized controlled trial (RCT) was completed over the course of two years (September 7, 2015, to September 6, 2017). In the course of their treatment for osteoarthritis of the knee, all of the patients who had primary unilateral total knee replacement (TKR) participated in the research. Under spinal anesthesia, each patient had medial para-patellar approach medial orthopedic surgery. Patients were assigned to group A or group B based on a random selection. Each of the groups consisted of 79 individuals. Group A was given dexamethasone through intravenous administration at a dose of 0.1 mg/kg before the operation. During the subsequent period of 24 hours, no more treatment was administered (control group). On a predesigned questionnaire, postoperative pain was measured using the visual analog scale (VAS) for pain. Functional results, duration of hospital stay, and complications were all recorded on the questionnaire (VAS). Analysis of data was carried out using the Statistical Package for the Social Sciences (SPSS) version 23 (IBM SPSS Statistics, Armonk, NY, USA). Results There were 158 patients in total in the study, out of which 98 were females and 60 were males in the group. The patients' average body mass index (BMI) was 26.94 ± 3.14 kg/m2. Patients in group A had lower postoperative analgesic and antiemetic needs and higher VAS scores and spent less time in the hospital than patients in group B. There were no postoperative problems in either group. Conclusion In patients undergoing TKA, the use of dexamethasone during and after surgery decreases pain, the need for analgesics, and the duration of hospital stay.

Impact of pre-transplant donor specific antibodies detected by Luminex with negative microlymphocytotoxicity assay and flow crossmatch in live-related renal transplant recipients.

INTRODUCTION/AIM: The Luminex assay, where beads are coated with a single HLA antigen, has been shown to detect HLA antibodies with more sensitivity and specificity as compared to microlymphocytotoxicity (CDC) assay and flow cross match (FCXM). We report the impact of low Mean Flourescence intensity (MFI) pre-transplant DSA by Luminex with negative CDC and FCXM on acute rejection, graft function, and survival. METHODS: In this retrospective study between January 2015 to December 2021, 45 recipients had pre-transplant anti-HLA donor-specific antibodies (DSAs) detected by Luminex. Two control groups of 45 patients each matched for age and gender, first with non-DSA HLA antibodies and second with no antibodies by Luminex were selected to compare outcomes with DSA group. RESULTS: In the DSA group of 45, 22 (48.8%) had class I (MFI mean 4043 ± 1909, range: 1096-7111), 20 (44.4%) class II (MFI mean 3601 ± 2310, range: 1031-9259), and 3 (6.6%) both class I (MFI mean 4746 ± 1922) and class II (MFI mean 3940 ± 2312) antibodies. Acute rejection episodes were reported in 15.6%, DSA group, 17.8% in non-DSA, and 24.4% in no antibody group (p = .538). Death censored graft survival at 1 and 5 years was 98% and 93% in DSA group, 100% and 95% in non-DSA and 93% and 85% in the no antibody group (p = .254). CONCLUSIONS: Patients with low MFI DSA pre-transplant, with a negative CDC and FCXM under ATG induction, have similar graft outcomes at 1 and 5 years when compared to non-DSA and no antibody groups.

Efficacy of multiple Biomarkers: NGAL, KIM1, Cystatin C and IL18 in predicting pregnancy related acute kidney injury.

Objective: Several biomarkers like NGAL, KIM-1, IL-18, and Cystatin C has been previously reported as reliable marker to predict AKI. However, their predictive accuracy varies widely. We aim to observe the efficacy of multiple markers, NGAL, KIM-1, Cystatin C and IL-18, in obstetric population who are at risk of developing AKI. Methods: This prospective study was carried out between June 2021 to March 2022 at Department of Obstetrics & Gynecology Unit II, Ruth Pfau KM Civil Hospital and Sindh Institute of Urology & Transplant (SIUT), Karachi Pakistan. On women brought to OBGYN-ER with the diagnosis of hemorrhage (antepartum and postpartum), hypertension (pre-eclampsia and eclampsia) and sepsis. The urine samples and 3cc blood was collected at the time of admission, blood sample processed for biochemistry at time of admission and repeat blood samples for serum creatinine at 24 and 48 hours. Urine was stored at -80ºC and later evaluated for NGAL, KIM-1, Cystatin C and IL-18. Serum Cystatin C was also processed for the time zero sample. The biomarkers were tested using ELISA assays. Results: A total of 149 women were included in the study, 83% of these women were non-booked. Twenty-six (17%) women developed AKI. Serum Cystatin C, urinary Cystatin C and urinary NGAL were found significantly raised in women who developed AKI. While KIM-1 and IL-18 were not raised to statistical significance in this population. However, urinary KIM-1 along with urinary Cystatin C were significantly raised in women with positive quick sequential organ failure assessment (qSOFA). Conclusion: This study validates the use of serum and urinary Cystatin C and urinary NGAL as highly predictable biomarkers for the development of AKI and nullifies urinary IL-18 and KIM-1 in this regard.

Student's perception of E-learning during COVID-19 pandemic and its positive and negative learning outcomes among medical students: A country-wise study conducted in Pakistan and Iran.

Background: Since the emergence of coronavirus diseases 2019 (COVID-19) not only have social and the economical dimension of life been disturbed but it has also shattered educational activities as well. Due to fear of disease spread educational institutes are forced to implement online educational systems to teach their pupils. This study aims to explore the student's perceptions related to E-learning and their positive and negative outcome among medical students in Pakistan and Iran. Method: ology: This cross-sectional questionnaire-based study was conducted at Rawalpindi Medical University, Rawalpindi, Pakistan, and Islamic Azad University of Medical Sciences Tehran, Iran. This study involved 402 medical students of Rawalpindi Medical University, Rawalpindi, Pakistan (n = 202), and Islamic Azad University of Medical Sciences Tehran, Iran (n = 200) who were actively involved in the online mode of education. A self-administered validated questionnaire was used for data collection. Descriptive statistics and chi-square analysis was used and analysis was done through SPSS V.23. A P-value of 0.05 was taken as significant. Results: A total of 402 students were enrolled, 202 from Pakistan and 200 from Iran. About 68.2% of the students were acquainted with moderate levels of IT skills. About 75.8% of the students were not showing any previous experience with E-learning. The most common advantage of E-learning was the ability to stay at home. The technical problem was the most common disadvantage in our study. Finally, face-to-face learning in terms of increasing knowledge, skill, and social competence was considered the best mode of learning both by Pakistani and Irani students. Country-wise effectiveness of face-to-face learning in terms of increasing knowledge is statistically significant (p-value = 0.019). Acceptance of E-learning is statistically associated with the country of learning (p-value = 0.020). E-learning was rated as enjoyable by 51.5% of the students. Conclusion: E-learning has its associated advantages and disadvantages as perceived by medical students but still face-to-face learning is considered the most effective form of learning as responded by medical students.

Poliomyelitis in Pakistan: Challenges to polio eradication and future prospects.

Poliomyelitis is a viral disease that causes acute paralysis, muscle weakness and autonomic dysfunction. It primarily affects children under the age of five. It is mainly transmitted via the feco-oral route, through contaminated water. As of the year 2022, Pakistan remains one of the two countries where polio is still endemic, the other being Afghanistan. Numerous myths and misconceptions regarding the polio vaccine, lack of awareness and proper governance, terrorism and difficult access to remote areas due to poor infrastructure are just some of the reasons why polio remains endemic in Pakistan to this day. Therefore, the government should take measures to ensure the safety and wellbeing of health care workers, as well as spread awareness regarding the importance of polio vaccines, while addressing the myths and misconception regarding said vaccines.

Adequacy of nitisinone for the management of alkaptonuria.

Alkaptonuria is a rare hereditary disease with a defective enzyme that results in increased homogentisic acid levels in the body. Homogentisic acid accumulates in multiple body parts and initializes tissue damage. Clinical manifestations such as pigmentation of the skin areas and joint destruction result in ochronosis. Nitisinone decreases serum and urinary homogentisic acid levels, improving morbidity by preventing and slowing the progression of alkaptonuria. Nitisinone-induced hypertyrosinemia causes keratopathy and mental ill effects, which can be managed by diet restriction and regular check-ups. A personalized approach is required for treatment by nitisinone. Low-dose oral nitisinone is associated with overall good results and a better safety profile.

Surgical safety checklist compliance: The clinical audit.

Introduction: The surgical safety checklist consists of three components: sign-in, performed before the induction of anesthesia; time-out, performed before skin incision; and sign-out, performed immediately after skin closure or before the patient leaves the operating theatre. This study aims to assess compliance with the World Health Organization (WHO) Surgical Safety Checklist (SSC) and explore the barriers facing in properly implementing the surgical safety checklist in operation theatres of a tertiary care hospital. Methodology: The observational clinical audit was conducted in Surgical Unit I, Benazir Bhutto Hospital, Rawalpindi, Pakistan. Compliance with the surgical safety checklist was observed before and after the educational intervention. After completion of the clinical audit operating theatre staff was asked about the barriers to compliance with the surgical safety checklist using an interview sheet. Mean, and standard deviation was calculated for quantitative variables, whereas frequencies and percentages were calculated for categorical variables using SPSS version 25.0. Results: Compliance with all the steps of the surgical safety checklist was improved after an educational intervention, with the highest improvement in compliance (66.7%) observed with the Sign-out step "Count of sponges and needles & instruments complete?" Moreover, filling of the patient board and documentation of procedure in the patient file were also improved. Lack of awareness and training to follow the surgical safety checklist was the commonest barrier to compliance with the surgical safety checklist. Conclusion: Implementing the surgical safety checklist will not only upgrade the patient safety measures but also integrate teamwork skills and improve the local departmental culture.

Management of Plasma Cell-Rich Acute Rejection in Living-Related Kidney Transplant: Role of Proteasome Inhibitor.

OBJECTIVES: Plasma cell-rich acute rejection is an aggressive form of acute rejection that occurs late after transplant and is usually resistant to standard antirejection therapy. This study reports the safety, efficacy, and outcomes of plasma cell-rich acute rejection after treatment with bortezomib, a proteasome inhibitor, in 10 patients after a first living-related renal transplant. MATERIALS AND METHODS: Plasma cell-rich acute rejection was diagnosed using the 2007 Banff classification. The treatment protocol for plasma cell-rich acute rejection included methylprednisolone (500 mg/kg), 7 sessions of plasmapheresis, antithymocyte globulin (3-5 mg/kg/day for 10 days), rituximab (2 doses at 375 mg/m2), and bortezomib (1 cycle at 1.3 mg/m2). RESULTS: The mean age of recipients and donors was 23.70 ± 11.39 and 37.30 ± 12.82 years, respectively. The mean time to plasma cell-rich acute rejection was 3.1 ± 2.5 years. The mean serum creatinine level at rejection was 4.8 ± 2.7 mg/dL. After treatment, serum creatinine decreased to 3.3 ± 1.8 mg/dL. Serum creatinine levels at 1-year and 2-year follow-up were 3.0 ± 2.3 and 3.3 ± 0.9 mg/dL, respectively. There was 1 graft failure due to recurrence of glomerulonephritis/de novo glomerulonephritis. No significant adverse effects were noted in the patients. Bortezomib successfully reverted plasma cell-rich acute rejection and stabilized graft function, with patients showing 2-year graft survival after rejection of 90%. CONCLUSION: Bortezomib-based treatment was successful in reverting plasma cell-rich acute rejection and stabilizing graft function, with graft survival of 90% at 2 years. Further studies with large cohorts and randomized trials with or without bortezomib will help in better evaluation of its efficacy, safety, and outcomes.

In-hospital mortality of patients with cardiogenic shock after acute myocardial infarction; impact of early revascularization.

OBJECTIVES: The purpose of this study was to determine the frequency of in-hospital mortality in 351 patients who developed cardiogenic shock after acute myocardial infarction and by determining this; we might find that how efficiently we could manage this serious condition in our population by knowing the factors which are associated with high mortality after cardiogenic shock. Moreover impact of early revascularization like thrombolytic therapy or angioplasty was also evaluated. RESULTS: Mean age was 65.41 ± 7.78 years in our study. In-hospital mortality with cardiogenic shock after acute myocardial infarction was found to be 44.73%. Significant association of in-hospital mortality was noted with age, hypertension, diabetes mellitus and BMI. Patients receiving early revascularization were noted to have lower in-hospital mortality compared to those in whom revascularization was not done due to delayed presentation. This study concluded that there is a high frequency (44.73%) of in-hospital mortality in patients with cardiogenic shock after acute myocardial in our population. So, we recommend that for achieving a good outcome and to reduce in-hospital mortality; in addition to rapid diagnosis of this condition, underlying risk factors like hypertension and diabetes should be evaluated and managed accordingly and early revascularization should be done when possible.

Living donor risk model for predicting kidney allograft and patient survival in an emerging economy.

AIM: Living donor kidney is the main source of donor organs in low to middle income countries. We aimed to develop a living donor risk model that predicts graft and patient survival in an emerging economy. METHODS: We used data from the Sindh Institute of Urology and Transplantation (SIUT) database (n = 2283 recipients and n = 2283 living kidney donors, transplanted between 1993 and 2009) and conducted Cox proportional hazard analyses to develop a composite score that predicts graft and patient survivals. RESULTS: Donor factors age, creatinine clearance, nephron dose (estimated by donor/recipient body weight ratio) and human leukocyte antigen (HLA) match were included in the living donor risk model. The adjusted hazard ratios (HRs) for graft failures among those who received a kidney with living donor scores (reference to donor score of zero) of 1, 2, 3 and 4 were 1.14 (95%CI: 0.94-1.39), 1.24 (95%CI:1.03-1.49), 1.25 (95%CI:1.03-1.51) and 1.36 (95%CI:1.08-1.72) (P-value for trend =0.05). Similar findings were observed for patient survival. CONCLUSIONS: Similar to findings in high income countries, our study suggests that donor characteristics such as age, nephron dose, creatinine clearance and HLA match are important factors that determine the long-term patient and graft survival in low income countries. However, other crucial but undefined factors may play a role in determining the overall risk of graft failure and mortality in living kidney donor transplant recipients.

Immunohistopathologic Characterization of Plasma Cell-Rich Acute Rejection in Living-Related Renal Transplant Recipients.

OBJECTIVES: Our aim was to analyze the immunohistopathologic features of plasma cell-rich acute rejection in a living-related renal transplant setting. MATERIALS AND METHODS: Renal allograft biopsies of 50 cases of plasma cell-rich acute rejection were reviewed, and the main immunohistopathologic features were analyzed. The biopsies were studied using light microscopy, immunofluorescence, and immunohistochemistry and reported according to Banff classification. Biopsy findings were correlated with graft function and outcome. RESULTS: From February 2012 to December 2013, 50/1630 (3%) dysfunctional renal allograft biopsies showed plasma cell-rich acute rejection. Among acute changes, interstitial inflammation was of moderate degree in 8 cases (16%) and severe in 42 cases (84%). Mild tubulitis was found in 4 cases (8%), moderate tubulitis in 8 cases (16%), and severe tubulitis in 38 cases (76%). Glomerulitis was found in 2 cases (4%). No presence of arteritis was found. All plasma cell-rich acute rejection cases were of tubulointerstitial type, and most were of type IB. The mean percent of plasma cells on light microscopy in all cases was 28.8 ± 11.7%, and the range was 10% to 60%, with 46 cases (92%) showing plasma cell percent of ≥ 20%. The mean plasma cell percent on immunohistochemistry for CD138 was 29.0 ± 12.4%. Microvascular inflammation was found in 34 cases (68%). C4d testing was done by immunofluorescence in 22 cases (44%) and was positive in 8 cases (36%). Interstitial fibrosis/tubular atrophy was mild in 18 (36%), moderate in 28 (56%), and severe in 4 cases (8%). Plasma cell enrichment did not correlate with a variety of clinical and pathologic features (all P > .05). CONCLUSIONS: Plasma cell enrichment is not an independent prognostic morphologic feature and may represent either T-cell-mediated or antibody-mediated rejection or a mixture of these processes. Further investigations regarding its pathogenesis, accurate categorization, and treatment are needed.

Designing novel bioconjugates of hydroxyethyl cellulose and salicylates for potential pharmaceutical and pharmacological applications.

This deals with fabrication of macromolecular prodrugs (MPDs) of salicylic acid (SA) and aspirin (ASP) based on a hydrophilic cellulose ether, hydroxyethyl cellulose (HEC). Degrees of substitution (DS) of SA and ASP per HEC repeating unit (HEC-RU) were achieved ranging from 0.60 to 2.18 and 0.53 to1.50, respectively. The amphiphilic HEC-SA conjugate 2 assembled into nanowire-like structures, while HEC-ASP conjugate 6 formed nanoparticles (diameter 300-00nm) at a water/DMSO interface. After oral administration in rabbit models, conjugates 2 and 6 showed plasma half-life of 6.96 and 7.01h with maximum plasma concentration (Cmax) of 15.27 and 23.01µg L-1, respectively, and each reached peak plasma concentration (tmax) at 4.0h. Immunomodulatory assays (interleukin 6 and tumor necrosis factor-α values) revealed that anti-inflammatory properties of SA and ASP were unaltered in conjugates. Swelling inhibition of 61 and 71% was observed for conjugates 2 and 6, respectively, in a carrageenan induced paw edema test. Cytotoxic profiling (MTT assay) showed that conjugates were safe for administration in the concentration range of 2-10mM up to 24h. Thermal analyses revealed that Tdm values of SA and ASP conjugates were increased by 99 and 154̊C, respectively, indicating extraordinary thermal stability imparted to drugs after MPD formation.

Linseed hydrogel-mediated green synthesis of silver nanoparticles for antimicrobial and wound-dressing applications.

Polysaccharides are being extensively employed for the synthesis of silver nanoparticles (Ag NPs) having diverse morphology and applications. Herein, we present a novel and green synthesis of Ag NPs without using any physical reaction conditions. Linseed hydrogel (LSH) was used as a template to reduce Ag+ to Ag0. AgNO3 (10, 20, and 30 mmol) solutions were mixed with LSH suspension in deionized water and exposed to diffused sunlight. Reaction was monitored by noting the change in the color of reaction mixture up to 10 h. Ag NPs showed characteristic ultraviolet-visible (UV/Vis) absorptions from 410 to 437 nm in the case of sunlight and 397-410 nm in the case of temperature study. Transmission electron microscopy images revealed the formation of spherical Ag NPs in the range of 10-35 nm. Face-centered cubic array of Ag NPs was confirmed by characteristic diffraction peaks in powder X-ray diffraction spectrum. Ag NPs were stored in LSH thin films, and UV/Vis spectra recorded after 6 months indicated that Ag NPs retained their texture over the storage period. Significant antimicrobial activity was observed when microbial cultures (bacteria and fungi) were exposed to the synthesized Ag NPs. Wound-healing studies revealed that Ag NP-impregnated LSH thin films could have potential applications as an antimicrobial dressing in wound management procedures.

Borderline Changes on Dysfunctional Renal Allograft Biopsies: Clinical Relevance in a Living Related Renal Transplant Setting.

OBJECTIVES: Our aim was to determine the clinical significance of borderline lymphocytic infiltrates on indicated renal allograft biopsies in a living related renal transplant setting. MATERIALS AND METHODS: The study was conducted at the histopathology department of Sindh Institute of Urology and Transplantation. A retrospective review of 421 renal transplant patients was conducted from October 2007 to September 2008 to identify patients in whom a histologic diagnosis of borderline changes was made on dysfunctional renal allograft biopsies. Demographic, clinical, and laboratory data; biopsy findings; treatments given; and responses to treatment were collected and analyzed. Standard biopsy indications determined the need for graft biopsies. Biopsies were reported according to Banff criteria. RESULTS: Mean age was 26.92 ± 9.14 years (range, 10-45) for recipients and 38.46 ± 9.16 years (range, 19-50) for donors. Males were predominant among recipients (84.6% vs 15.4%), and females were predominant among donors (57.7% vs 42.3%). The best serum creatinine levels were 1.79 ± 1.15 mg/dL (range, 0.83-6.12). These were achieved after a median of 3 days (interquartile range, 2-7.25). Dysfunctional biopsies exhibiting borderline infiltrates were performed at a median duration of 5.5 days (interquartile range, 3-14.25). Mean serum creatinine at the time of biopsy was 2.34 ± 1.43 mg/dL (range, 1.25-8.25). The biopsies showed borderline cellular infiltrates (interstitial inflammation 1 [i1] and tubulitis 1 and [t1] lesions). All recipients except one received antirejection treatment (antithymocyte globulin, n = 5; escalation of mycophenolate mofetil dosage, n = 1; pulse steroids, n = 19); all recipients responded with a decline in serum creatinine toward baseline, with a mean serum creatinine of 1.31 ± 0.42 mg/dL (range, 0.40-2.71). This response was achieved at a median duration of 9.73 ± 5.32 days (range, 1-23) after starting treatment. CONCLUSIONS: The borderline cellular infiltrates on dysfunctional renal allograft biopsies signify evolving phases of acute cellular rejection. These infiltrates responded favorably to antirejection treatment in our setting.