Clinical characteristics, outcome, and factors associated with mortality of pulmonary mucormycosis: a retrospective single-center study from Pakistan.

Introduction and objective: Pulmonary mucormycosis is a rare but rapidly progressive fatal disease. Limited data exist on the outcomes and factors associated with poor prognosis of pulmonary mucormycosis. The objective of this study was to evaluate clinical characteristics, factors associated with mortality, and outcomes of pulmonary mucormycosis at a tertiary care hospital in Pakistan. Methods: This was a retrospective observational study conducted at a tertiary care hospital in Karachi, Pakistan. Medical records of hospitalized patients diagnosed with proven or probable pulmonary mucormycosis between January 2018 and December 2022 were reviewed. Univariate and regression analyses were performed to identify factors associated with mortality. Results: Fifty-three pulmonary mucormycosis patients (69.8% male) were included, with mean age of 51.19 ± 21.65 years. Diabetes mellitus was the most common comorbidity [n = 26 (49.1%)]. Chronic lung diseases were present in [n = 5 (9.4%)], and [n = 16 (30.2%)] had concurrent coronavirus disease 2019 (COVID-19) pneumonia. The predominant isolated Mucorales were Rhizopus [n = 32 (60.3%)] and Mucor species [n = 9 (17%)]. Main radiological findings included consolidation [n = 39 (73.6%)] and nodules [n = 14 (26.4%)]. Amphotericin B deoxycholate was prescribed in [n = 38 (71.7%)], and [n = 14 (26.4%)] of patients received combined medical and surgical treatment. The median [interquartile range (IQR)] hospital stay was 15.0 (10.0-21.5) days. Intensive care unit (ICU) care was required in [n = 30 (56.6%)] patients, with 26 (49.1%) needing mechanical ventilation. Overall mortality was seen in 29 (54.7%) patients. Significantly higher mortality was found among patients requiring mechanical ventilation 20/29 (69%, p = 0.002). Immunosuppression (p = 0.042), thrombocytopenia (p = 0.004), and mechanical ventilation (p = 0.018) were identified as risk factors for mortality on multivariable analysis. Conclusion: This study provides essential insights into the clinical characteristics, outcomes, and mortality factors associated with pulmonary mucormycosis. The mortality rate was high (54.7%), particularly in patients with immunosuppression, thrombocytopenia, and those who required mechanical ventilation.

Perceptions and use of evidence-based revision methods among undergraduate medical students.

Objective: To assess awareness, perceptions and use related to evidence-based revision methods by undergraduate medical students. METHODS: The descriptive cross-sectional study was conducted in three medical colleges of Rawalpindi, Islamabad, Pakistan, from December 01, 2019, to January 31, 2020, after approval from the ethics review committee of Army Medical College, Rawalpindi. The sample comprised undergraduate medical students of either gender. Data was collected online using a 10-item standardised questionnaire. Students were asked about the revision methods they used routinely and their perceptions of conventional and evidence-based revision methods. Data was analysed using SPSS 23. RESULTS: Of the total 136 respondents, 92(67%) were females and 44(32.3%) were male students. The response from preclinical and clinical years was 67 (50.7%) and 69(49.2%), respectively. Highlighting was the most widely used revision method among students (70 (51%) students), followed by re-reading important points (65 (47.7%) students). 126 (92%) students had the opinion that conventional revision methods were effective learning tools. Only 52 (38.2%) students were aware of the term 'evidence-based revision methods'. Digital tools based on principles of evidence-based revision were used by a minority of students which included use of online question banks by 21 (15.4%) students, osmosis by 40 (29.4%) students, sketchy pharma by 35 (25%)students, flashcards by 19 (14%) and picmonic by only 3 (2.2%). More than 114 (80%) students responded that they wanted evidence-based revision methods to be incorporated into curriculum, and 116 (85%) students said they would like to have a workshop on these techniques. Conclusion: Most medical students were not aware of and were not using evidence-based revision methods, and relied on conventional revision tools. They were, however, eager to learn about newer revision strategies.

Association between long COVID and vaccination: A 12-month follow-up study in a low- to middle-income country.

OBJECTIVE: There is a lack of estimates regarding the at-risk population associated with long COVID in Pakistan due to the absence of prospective longitudinal studies. This study aimed to determine the prevalence of long COVID and its association with disease severity and vaccination status of the patient. DESIGN AND DATA SOURCES: This prospective cohort study was conducted at the Aga Khan University Hospital and recruited patients aged > 18 years who were admitted between February 1 and June 7, 2021. During this time, 901 individuals were admitted, after excluding patients with missing data, a total of 481 confirmed cases were enrolled. RESULTS: The mean age of the study population was 56.9±14.3 years. Among patients with known vaccination status (n = 474), 19%(n = 90) and 19.2%(n = 91) were fully and partially vaccinated, respectively. Severe/critical disease was present in 64%(n = 312). The mortality rate following discharge was 4.58%(n = 22). Around 18.9%(n = 91) of the population required readmission to the hospital, with respiratory failure (31.8%, n = 29) as the leading cause. Long COVID symptoms were present in 29.9%(n = 144), and these symptoms were more prevalent in the severe/critical (35.5%, n = 111) and unvaccinated (37.9%, n = 105) cohort. The most prominent symptoms were fatigue (26.2%, n = 126) and shortness of breath (24.1%, n = 116), followed by cough (15.2%, n = 73). Vaccinated as compared to unvaccinated patients had lower readmissions (13.8% vs. 21.51%) and post-COVID pulmonary complications (15.4% vs. 24.2%). On multivariable analysis, after adjusting for age, gender, co-morbidity, and disease severity, lack of vaccination was found to be an independent predictor of long COVID with an Odds ratio of 2.42(95% CI 1.52-3.84). Fully and partially vaccinated patients had 62% and 56% reduced risk of developing long COVID respectively. CONCLUSIONS: This study reports that the patients continued to have debilitating symptoms related to long COVID, one year after discharge, and most of its effects were observed in patients with severe/critical disease and unvaccinated patients.

Clinical Outcomes And Predictors Of Mortality In COVID-19 Patients Admitted To A High Dependency Unit In Pakistan-A Cross-Sectional Study.

Objectives: To determine the outcomes and predictors of in-hospital mortality of patients admitted to high dependency unit with coronavirus disease 2019 infection. METHODS: The retrospective study was conducted at a tertiary care hospital in Karachi, and comprised data of adult coronavirus disease 2019 patients of either gender admitted to the high dependency unit from March 1 to June 30, 2020. Outcomes were categorised as patients 'recovered without deterioration', 'deteriorated but survived', and 'deteriorated but expired'. Data was analysed using SPSS 22. RESULTS: Of the 525 patients with confirmed infection, 245(46.6%) were admitted to the high dependency unit. Leaving out 38(15.5%) cases with missing data, 207(84.5%) cases formed the study sample; 156(75.4%) males and 51(24.6%) females. The overall mean age was 56.9±14years (range: 24-86 years). The most common comorbid condition was hypertension 105(50.7%), and the most common reason for critical care was hypoxic respiratory failure 199(96.1%). Of the total, 153(74%) patients recovered, 31(15%) deteriorated, and mortality was the outcome in 23(11%). There was no significant effect of drug treatment on mortality (p>0.05). Age, multimorbidity and high D-Dimer level were significantly associated with disease progression and mortality (p<0.05). CONCLUSIONS: Mortality was high among coronavirus disease 2019 patients who were older and had multimorbidity.

Early Lactate Clearance as a Determinant of Survival in Patients with Sepsis: Findings from a Low-resource Country.

Background: Single lactate measurements have been reported to have prognostic significance, however, there is a lack of data in local literature from Pakistan. This study was done to determine prognostic role of lactate clearance in sepsis patients being managed in our lower-middle income country. Methods: This prospective cohort study was conducted from September 2019-February 2020 at the Aga Khan University Hospital, Karachi. Patients were enrolled using consecutive sampling and categorized based on their lactate clearance status. Lactate clearance was defined as decrease by 10% or greater in repeat lactate from the initial measurement (or both initial and repeat levels <=2.0 mmol/L). Results: A total 198 patients were included in the study, 51% (101) were male. Multi-organ dysfunction was reported in 18.6% (37), 47.7% (94) had single organ dysfunction, and 33.8% (67) had no organ dysfunction. Around 83% (165) were discharged and 17% (33) died. There were missing data for 25.8% (51) of the patients for the lactate clearance, whereas 55% (108) patients had early lactate clearance and 19.7% (39) had delayed lactate clearance.On univariate analysis, mortality rate was higher in patients with delayed lactate clearance (38.4% vs 16.6%) and patients were 3.12 times (OR = 3.12; [95% CI: 1.37-7.09]) more likely to die as compared with early lactate clearance. Patients with delayed lactate clearance had higher organ dysfunction (79.4% vs 60.1%) and were 2.56 (OR = 2.56; [95% CI: 1.07-6.13]) times likely to have organ dysfunction. On multivariate analysis, after adjusting for age and co-morbids, patients with delayed lactate clearance were 8 times more likely to die than patients with early lactate clearance [aOR = 7.67; 95% CI:1.11-53.26], however, there was no statistically significant association between delayed lactate clearance [aOR = 2.18; 95% CI: 0.87-5.49)] and organ dysfunction. Conclusion: Lactate clearance is a better determinant of sepsis and septic shock effective management. Early lactate clearance is related to better outcomes in septic patients.

COVID-19 infection among vaccinated and unvaccinated: Does it make any difference?

OBJECTIVE: There is a probability that vaccination may lead to reduction in the severity and complications associated with COVID-19 infection among hospitalized patients. This study aimed to determine the characteristics, clinical profiles, and outcomes of COVID-19 infection in vaccinated and non-vaccinated patients. DESIGN AND DATA SOURCES: This prospective observational cohort study was conducted at the Aga Khan University Hospital (AKUH) and recruited COVID-19 patients admitted between June 1st and September 30th, 2021. Patients' demographics, date of admission and discharge, comorbid conditions, immunization status for COVID-19 infection, presenting complaints, lab workup and computed tomography (CT) scan findings were obtained from the medical records. The primary outcome of the study was patients' condition at discharge and the secondary outcomes included level of care, length of stay (LOS), requirement of non-invasive ventilation (NIV) and inotropic support. RESULTS: Among a cohort of 434 patients, 37.7% (n = 164), 6.6% (n = 29) and 55.5% (n = 241) were fully vaccinated, partially vaccinated, and unvaccinated, respectively. Around 3% and 42.9% of the patient required inotropic and NIV support respectively; however, there was no discernible difference between them in terms of vaccination status. In case of unvaccinated patients there were significantly increased number of critical care admissions (p-value 0.043). Unvaccinated patients had significantly higher median serum procalcitonin, ferritin, LDH and D-dimer levels. Around 5.3% (n = 23) of the patient required invasive ventilation and it was more common in unvaccinated patients (p-value 0.04). Overall, mortality rate was 12.2% (n = 53) and this was higher (16.2%, n = 39) in unvaccinated patients as compared to fully vaccinated patients (6.1%, n = 10, p-value 0.006). CONCLUSIONS: Through this preliminary data, we can conclude that patient can develop severe and critical COVID-19 infection despite being vaccinated but this proportion is low as compared to unvaccinated population. So, uninterrupted endeavors need to be done to vaccinate as many individuals as possible. Furthermore, more effective vaccinations need to be developed to lessen the high death toll of COVID-19 infection.

Clinical Features and Outcomes of Acute Chlorine Gas Inhalation; a Brief Report.

Introduction: On March 6th,2020, chlorine gas leak was reported at Engro Polymer & Chemicals Plant in Karachi City, Pakistan. This study aimed to evaluate the clinical features and outcomes of patients who presented to emergency department (ED) following this event. Methods: This retrospective cross-sectional study, evaluated the clinical features and outcomes (length of hospital stay, complications, and mechanical ventilation requirement) of patients presenting to ED of Aga Khan University Hospital, Karachi, Pakistan, with history of chlorine gas exposure at the Engro Plant from 6th March to 14th March 2020. Results: 38 patients with mean age of 33.1 ± 8.1 years presented to ED with history of chlorine gas exposure (100% male). 4 (10.5%) cases had comorbid diseases. Most common presenting symptom was dyspnea, observed in 33 (86.8%) cases, followed by cough, seen in 27 (71.1%) subjects. 13.2% (5/38) patients had infiltration on chest x-ray and 33 (86.8 %) required hospitalization. 6 (15.8%) patients had repeat presentation requiring hospitalization or ED visit. 18 (47.4%) were managed with high flow oxygen therapy, 9 (23.7%) required non-invasive ventilation and one patient was intubated due to development of pneumo-mediastinum. Mean length of stay was 1.55 ± 1.58 days and no patients died. Presence of tachycardia was the only finding significantly associated with need for oxygen (p = 0.033) and non-invasive ventilation (p = 0.012). Conclusion: The majority of patients presenting with acute chlorine gas exposure showed good clinical outcomes and rapid recovery, however, a high index of suspicion and vigilance should be maintained for complications such as pneumomediastinum and acute respiratory distress syndrome in these patients.

Clinical Characteristics and Outcomes of COVID-19 Acute Respiratory Distress Syndrome Patients Requiring Invasive Mechanical Ventilation in a Lower Middle-Income Country.

Background: COVID-19 related acute respiratory distress syndrome (ARDS) requires intensive care, which is highly expensive in lower-income countries. Outcomes of COVID-19 patients requiring invasive mechanical ventilation in Pakistan have not been widely reported. Identifying factors forecasting outcomes will help decide optimal care levels and prioritise resources. Methods: A single-centre, retrospective study on COVID-19 patients requiring invasive mechanical ventilation was conducted from 1st March to 31st May 2020. Demographic variables, physical signs, laboratory values, ventilator parameters, complications, length of stay, and mortality were recorded. Data were analysed in SPSS ver.23. Results: Among 71 study patients, 87.3% (62) were males, and 12.7% (9) were females with a mean (SD) age of 55.5(13.4) years. Diabetes mellitus and hypertension were the most common comorbidities in 54.9% (39) patients. Median(IQR) SOFA score on ICU admission and at 48 hours was 7(5-9) and 6(4-10), and median (IQR) APACHE-II score was 15 (11-24) and 13(9-23), respectively. Overall, in-hospital mortality was 57.7%; 25% (1/4), 55.6% (20/36) and 64.5% (20/31) in mild, moderate, and severe ARDS, respectively. On univariate analysis; PEEP at admission, APACHE II and SOFA score at admission and 48 hours; Acute kidney injury; D-Dimer>1.5 mg/L and higher LDH levels at 48 hours were significantly associated with mortality. Only APACHE II scores at admission and D-Dimer levels> 1.5 mg/L were independent predictors of mortality on multivariable regression (p-value 0.012 & 0.037 respectively). Admission APACHE II scores, Area under the ROC curve for mortality was 0.80 (95%CI 0.69-0.90); sensitivity was 77.5% and specificity 70% (cut-off ≥13.5). Conclusion: There was a high mortality rate in severe ARDS. The APACHE II score can be utilised in mortality prediction in COVID-19 ARDS patients. However, larger-scale studies in Pakistan are required to assess predictors of mortality.

COVID-19 encephalopathy: an unusual presentation with new-onset seizure causing convulsive status epilepticus.

Although neurological manifestations such as headache and myalgias have been observed with COVID-19, presentation with more serious neurological illness is uncommon and rare. We report a case of a middle-aged woman who presented to the emergency department of a tertiary care hospital. Her clinical presentation was primarily neurological rather than the more common presentation with respiratory manifestations. She presented with generalised tonic-clonic seizures, along with history of undocumented low-grade fever and generalised body aches. The positive SARS-CoV-2 RT-PCR nasal swab, the cerebrospinal fluid analysis (lymphocytic pleocytosis) and electroencephalogram were consistent with viral encephalitis; brain imaging was unremarkable. This case highlights the variable presenting features of COVID-19 infection as patients can primarily present with neurological manifestations in the absence of significant respiratory symptoms. We believe it is important to recognise neurological disease associated with SARS-CoV-2 in patients with asymptomatic respiratory infection.

Clinico-radiological and bronchoscopic predictors of microbiological yield in sputum negative tuberculosis in Pakistan.

To determine association of clinico-radiological factors and radiological activity with diagnostic yield in sputum-smear negative tuberculosis (TB). Prospective observational study in the Military Hospital Rawalpindi (Pakistan) from July to December 2018. Adult patients having no contraindications to bronchoscopy were included. HIV positive patients and those on anti-tuberculosis therapy for more than one week were excluded. High-resolution computed tomography (HRCT) findings were classified based on active and inactive tuberculosis features. Washings were sent for acid-fast bacillus (AFB) smear, GeneXpert assay and cultures. Out of 215 patients, 42.3% (91) were diagnosed with microbiological or histological evidence of TB. On univariate analysis, cavitation (p-value <0.001), soft-tissue nodules (p-value 0.04), and endobronchial mucosal changes (p-value 0.02) were associated with culture positivity. Presence of cavitation (OR= 4.10; CI= 2.18,7.73; p-value<0.001) was the only independent predictor of microbiological yield. Diagnostic yield was 70%, 50%, 12.5% and 8.6% in patients with definitely active, probably active, indeterminate and inactive tuberculosis HRCT features respectively. Sensitivity, specificity, positive predictive value and negative predictive value of HRCT active TB were 95.38% (95% CI 87.10-99.04), 48.00 % (95% CI 39.78-56.30), 44.29% (95% CI 40.31-48.33), 96.00 % (95%CI 88.70-98.66) respectively. There was no significant association between age groups, smoking status and gender with diagnosis of tuberculosis in our study. Radiological activity and certain visualized bronchoscopic changes were associated with good diagnostic performance and can be used as predictive factors in diagnosis of active smear negative tuberculosis.

Spontaneous pneumomediastinum in accidental chlorine gas inhalational injury: case report and review of literature.

A young man presented in emergency department with shortness of breath and cough after accidental inhalation of chlorine gas. Initial presentation was unremarkable; therefore, he was kept under observation for 8 hours and was later discharged. After 5 hours, the patient presented again in emergency department with sudden-onset shortness of breath and chest discomfort. On examination, subcutaneous crepitation around the neck and chest was found. Chest and neck X-ray revealed subcutaneous emphysema and pneumomediastinum. CT neck and chest was done, which revealed subcutaneous emphysema and pneumomediastinum and a linear air density in close approximation to right posterolateral wall of trachea at the level of superior margin of sternum was reported. These findings raised the possibility of tracheal injury which was later confirmed by fiberoptic laryngoscopy. The patient was intubated due to hypercapnic respiratory failure resulting from hypoventilation and respiratory distress. Bilateral chest tube insertion was done due to worsening subcutaneous emphysema, high ventilator parameters and prevention of progression to pneumothorax. He was extubated after 5 days; bilateral chest tubes were removed before discharge and underwent uneventful recovery.

Outcomes and Predictors of In-hospital Mortality in Critically Ill Acute Kidney Injury Patients: A Tertiary Care Center Experience.

Acute kidney injury (AKI) is associated with high mortality and morbidity risk. Factors predictive of mortality can guide in early identification of high-risk patients and escalation of therapy to improve outcomes. There is a paucity of data on AKI in Pakistan, and this study was done to determine in-hospital AKI mortality and the associated predictors of mortality. This was a prospective observational study conducted in the Acute Medical Unit and High Dependency Unit of Pak Emirates Military Hospital, Rawalpindi, from June to December 2018. Based on the Kidney Disease Improving Global Outcomes (KDIGO) AKI definition, 130 critically ill patients were included, while patients with chronic kidney disease were excluded. Data were collected on demographic profile-morbid conditions, etiology, laboratory values, and outcomes. The overall mortality was 45.4% (59/130) and varied with the stage of AKI, as it was 21.6%, 36.0%, and 61.8% in KDIGO stages 1, 2, and 3, respectively (P <0.05). There was a significant association (P <0.001) between sepsis, age >65 years, and mortality. Patients with inhospital mortality had higher median serum creatinine and mean potassium levels (P <0.01), with lower mean sodium levels and bicarbonate levels <10 mmol/L. However, on multivariate analysis using variables age >65 years, AKI stage 3, oliguria, bicarbonate <10 mmol/L, and sodium levels <130 mmol/L, only age [odds ratio (OR): 3.16, confidence interval (CI) 95%: 1.40-7.15), AKI stage 3 (OR: 3.12, CI 95%: 1.32-7.38], and low sodium levels <130 mmol/L (OR: 4.52, CI 95%: 1.40-14.61) were found to be independent predictors of mortality. Diabetes mellitus need for vasopressors, oliguria, hemodialysis requirement, and mean leukocyte counts had no significant association with mortality. AKI was associated with high in-hospital mortality in critically ill patients. Sepsis, hypertension, older age, Stage 3 AKI, higher mean creatinine, and potassium were predictive of increased mortality risk.

The influence of operation theatre environment on patients' perceptions during awake procedures: a cross-sectional study.

OBJECTIVE: To determine the perceptions of patients regarding operation theatre conversation and environment during an awake procedure. METHODS: The descriptive, cross-sectional study was conducted from February to August 2017 in postoperative wards of Military Hospital, Rawalpindi, Pakistan, and comprised women undergoing gynaecological or obstetric procedures under regional anaesthesia. Closedended questionnaires were distributed via nonprobability convenient sampling. Operation theatre data was collected from the anaesthesia notes, and data was analysed using SPSS 22. RESULTS: There were 93 female subjects with a mean age of 28.23}5.42 years (range: 19-48 years). Overall, 90(96.8%) subjects regarded the conduct of operation theatre staff as cooperative and friendly with 64(68.8%) viewing the conversation among the staff as helpful in relieving anxiety. The thought of anaesthesia waning caused anxiety in 40(43%) subjects, but there was no difference in perceived anxiety between those counselled 61(65%) and not counselled by the anaesthetist. With regards to the environment, 41(44%) subjects said more measures were required to prevent patients from seeing the operating field. Besides, 30(32.2%) and 20(21%)subjects had reservations regarding the presence of male staff and medical students respectively. The opinion regarding medical professionals did not change for 60(64%) subjects after the procedure, and 37(39.8%) recommended that communication skills of medical professional needed improvement. CONCLUSIONS: The environment in the theatre can have an influence on the patient's anxiety levels. Counselling by surgeons, casual conversations in the theatre can help alleviate apprehensions of the patients.