Global Initiative for Asthma (GINA) guideline: achieving optimal asthma control in children aged 6-11 years.

The Global Initiative for Asthma (GINA) 2021 guidelines for asthma have been set forth with some alterations in Step 3, for children from 6-11-year-old age group. The low dose LABA-ICS, very low dose formoterol-ICS, medium dose ICS and ICS-LTRA combination were recommended in the guideline. We organized this study to draw an effective comparison between these three combinations of controller therapies in pediatric population. A retrospective study was conducted at the Aga Khan University Hospital, Karachi, Pakistan which enrolled 114 children aged 6-11 years old, from July 2021 to December 2022. These children were admitted with asthma exacerbations and were discharged on controller medications as per GINA guidelines on step 3 for control of asthma for 3 months. They were then followed for re-admission within 30 days of discharge, number of ER visits with asthma exacerbations for 1 year, number of admissions with asthma including HDU and PICU admissions, length of stay per admission for all admissions in subsequent one year. The pulmonary function test was done at 1 week follow-up in clinic after discharge and at 3 months visit post discharge. A total of 114 pediatric patients from age 6-11-year-old, were enrolled in the study period out of which 36 (31.57%), 33(28.9%) and 34 (29.82%) patients were categorized into ICS-LABA, ICS and ICS-LTRA groups respectively. ER visits were significantly low in ICS-LABA group followed by ICS-LRTA group and then ICS group (1.75±0.96 vs 2.93±1.412 vs 3.11±1.21, p<0.001). Similar statistically significant results were observed on average number of admissions per year (1.52±1.02 vs 1.96±0.84 vs 2.06±1.07, p=0.047) and number of patients needing PICU (13.88% vs 26.47% vs 39.39%, p=0.034) in these groups respectively. ICS- LABA group patients had the best values of FEV1 and FEV1/FVC ratio after pulmonary function tests at 3 months follow-up followed by ICS-LTRA and ICS group. Amongst the three options regimens for children managed at step 3 on GINA 2021 guidelines, ICS-LABA therapy helps attain optimal patient outcomes and lung functions in children with asthma followed by ICS-LTRA and ICS group respectively.

COVID-19 pandemic: from origins to outcomes. A comprehensive review of viral pathogenesis, clinical manifestations, diagnostic evaluation, and management.

Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2), the causative pathogen for the COVID-19, first emerged in Wuhan, China, in December 2019 and by March 2020, it was declared a pandemic. COVID-19 pandemic has overburdened healthcare systems in most countries and has led to massive economic losses. SARS-CoV-2 transmission typically occurs by respiratory droplets. The average incubation period is 6.4 days and presenting symptoms typically include fever, cough, dyspnea, myalgia or fatigue. While the majority of patients tend to have a mild illness, a minority of patients develop severe hypoxia requiring hospitalization and mechanical ventilation. Management is mostly supportive. However, several direct anti-viral agents, and immunomodulatory therapy with steroids and various cytokine blockers seem promising in early results. However, an effective vaccine has been established, which will help curb the pandemic.

Understanding The Rare Bone Tumor "ADAMANTINOMA".

Adamantinoma is a rare neoplastic bone tumor that has the potential to metastasize. The classic presentation is in the tibial region however; cases involving other bones of the body have been noticed. The tumour is very likely to be mistaken for other bone diseases and therefore it is important to investigate and study about its nature and thus differentiate it from other differentials. Nevertheless, literature on the presentation, findings, investigations and treatment options of adamantinomas are limited. In this case series, we report four cases from a local hospital in Karachi who were diagnosed, treated and followed up for adamantinoma. Studies regarding the disease will help us understand more about its features.

Past and current advances in Marburg virus disease: a review.

Marburg Virus (MARV), along with the Ebola virus, belongs to the family of Filovirus and is cause of a lethal and severely affecting hemorrhagic fever. The Marburgvirus genus includes two viruses: MARV and Ravn. MARV has been recognized as one of utmost importance by the World Health Organization (WHO). The case fatality rate of the virus ranges from 24.0 to 88.0% which demonstrates its lethal nature and the need for its widespread information. The first case of the Marburgvirus disease (MARD) was reported in 1967 when lab personnel working with African green monkeys got infected in Germany and Serbia simultaneously. Following the initial case, many more outbreaks occurred around the world such as Uganda, Angola, Congo, Kenya and even in the United States in 2008. It was soon found out that the MARV was a zoonotic virus and mainly contracted from animal-to-human contact and further transmitted via human-to-human contact. The Egyptian fruit bat (Rousettus aegyptiacus) is known to be one of the significant sources of the infection and tourists visiting caves inhabited by these bats or workers accessing mines, populated by the bats, are at an increased risk of contracting the illness. The incubation period ranges from 2-21 days and the clinical outcome can be broken down into three phases: initial generalized phase (day 1-4), early organ phase (day 5 to 13) and either a late organ/convalescence phase (day 13 onwards). Furthermore, the treatment of MARD is solely based on supportive care. Much has been investigated in over the past half-century of the initial infection but only a few treatment options show promising results. In addition, special precaution is advised whilst handling the patient or the biospecimens. Disease-modifying agents and inhibitors of viral replications show constructive outcomes. It is crucial to identify the host of the virus and educate the populations that are greatly at risk of the disease. While much is being investigated to devise a vaccine, it is important to educate Health Care Workers (HCWs) and close contacts facing the illness. Stopping the transmission remains the best measure that can be taken.

Nipah virus - the rising epidemic: a review.

The Nipah virus was discovered twenty years ago, and there is considerable information available regarding the specificities surrounding this virus such as transmission, pathogenesis and genome. Belonging to the Henipavirus genus, this virus can cause fever, encephalitis and respiratory disorders. The first cases were reported in Malaysia and Singapore in 1998, when affected individuals presented with severe febrile encephalitis. Since then, much has been identified about this virus. These single-stranded RNA viruses gain entry into target cells via a process known as macropinocytosis. The viral genome is released into the cell cytoplasm via a cascade of processes that involves conformational changes in G and F proteins which allow for attachment of the viral membrane to the cell membrane. In addition to this, the natural reservoirs of this virus have been identified to be fruit bats from the genus Pteropus. Five of the 14 species of bats in Malaysia have been identified as carriers, and this virus affects horses, cats, dogs, pigs and humans. Various mechanisms of transmission have been proposed such as contamination of date palm saps by bat feces and saliva, nosocomial and human-to-human transmissions. Physical contact was identified as the strongest risk factor for developing an infection in the 2004 Faridpur outbreak. Geographically, the virus seems to favor the Indian sub-continent, Indonesia, Southeast Asia, Pakistan, southern China, northern Australia and the Philippines, as demonstrated by the multiple outbreaks in 2001, 2004, 2007, 2012 in Bangladesh, India and Pakistan as well as the initial outbreaks in Malaysia and Singapore. Multiple routes of the viremic spread in the human body have been identified such as the central nervous system (CNS) and respiratory system, while virus levels in the body remain low, detection in the cerebrospinal fluid is comparatively high. The virus follows an incubation period of 4 days to 2 weeks which is followed by the development of symptoms. The primary clinical signs include fever, headache, vomiting and dizziness, while the characteristic symptoms consist of segmental myoclonus, tachycardia, areflexia, hypotonia, abnormal pupillary reflexes and hypertension. The serum neutralization test (SNT) is the gold standard of diagnosis followed by ELISA if SNT cannot be carried out. On the other hand, treatment is supportive since there a lack of effective pharmacological therapy and only one equine vaccine is currently licensed for use. Prevention of outbreaks seems to be a more viable approach until specific therapeutic strategies are devised.

Poliovirus: a long-due battle for Pakistan.

Not available.

Anomalous Supradominant Left Circumflex Artery with Rare, Rudimentary Left Anterior Descending Artery.

Anomalies pertaining to the coronary vasculature are rare and generally asymptomatic, however, they can pose life-threatening risks in the form of sudden cardiac arrests or myocardial ischemia. We present a rare anomaly of a supradominant left circumflex artery (LCX) and a rudimentary left anterior descending artery (LAD). The patient presented in our outpatient department (OPD) with complaints of occasional chest pain and dyspnea on exertion. An exercise tolerance test (ETT) was carried out, which was inconclusive and an electrocardiogram (EKG) revealed a sinus rhythm with a nonspecific ST segment. Due to these findings, an angiography was performed via the trans-radial route using a TIG 5 French catheter (Terumo Medical Corporation, NJ, US). Coronary angiography revealed codominance because of the presence of a rudimentary LAD, a normal right coronary artery (RCA), and an extremely large LCX. As there was no significant stenosis or atherosclerosis in the coronary arteries, pharmacological treatment was chosen. The patient was discharged in a medically stable condition with a routine follow-up planned after one month. The identification of this supradominant LCX is crucial for diagnosis in possible future circumstances of percutaneous coronary intervention or coronary artery bypass grafting operations, ultimately improving the success rate of invasive cardiac therapies.

Prevalence and Predictors of Use of Home Sphygmomanometers Among Hypertensive Patients.

OBJECTIVE: Few studies have looked at the predictors of use of home sphygmomanometers among hypertensive patients in low-income countries such as Pakistan. Considering the importance of home blood pressure monitoring (HBPM), cross-sectional study was conducted to evaluate the prevalence and predictors of the usage of all kinds of HBPM devices. METHOD: This study was conducted in Karachi during the time period of January-February 2017. Adult patients previously diagnosed with hypertension visiting tertiary care hospitals were selected for the study. Interviews from the individuals were conducted after verbal consent using a pre-coded questionnaire. The data was analyzed using Statistical Package for the Social Sciences v. 23.0 (SPSS, IBM Corporation, NY, USA). Chi-squared test was applied as the primary statistical test. RESULTS: More than half of the participants used a home sphygmomanometer (n=250, 61.7%). The age, level of education, family history of hypertension, compliance to drugs and blood pressure (BP) monitoring, few times a month at clinics were significant determinants of HBPM (P values < 0.001). It was found that more individuals owned a digital sphygmomanometer (n=128, 51.3%) as compared to a manual type (n=122, 48.8%). Moreover, avoiding BP measurement in a noisy environment was the most common precaution taken (n=117, 46.8%). CONCLUSION: The study showed that around 40% of the hypertensive individuals did not own a sphygmomanometer and less than 25% performed HBPM regularly. General awareness by healthcare professionals can be a possible factor which can increase HBPM.