Evolutionary analysis of seasonal influenza A viruses in Pakistan 2020-2023.

INTRODUCTION: Influenza A viruses cause global health concerns due to their high amino acid substitution rates. They are linked to yearly seasonal epidemics and occasional pandemics. This study focused on sequencing influenza A virus strains in Pakistan. MATERIALS AND METHODS: We analyzed the genetic characteristics of influenza A(H1N1)pdm09 and A(H3N2) viruses circulating in Pakistan from January 2020 to January 2023. Whole genome sequences from influenza A (n = 126) virus isolates were amplified and sequenced by the Oxford Nanopore (MinION) platform. RESULTS: The HA genes of influenza A(H1N1)pdm09 underwent amino acid substitutions at positions K54Q, A186T, Q189E, E224A, R259K, and K308R in sequenced samples. The HA genes of influenza A(H3N2) had amino acid substitutions at G53D, E83K, D104G, I140M, S205F, A212T, and K276R in the sequenced samples. Furthermore, the HA gene sequences of influenza A(H1N1)pdm09 in this study belonged to subclade 6B.1A.5a.2a. Similarly, the HA gene sequences of influenza A(H3N2) were classified under six subclades (3C.3a.1 and 3C.2a1b.2a [2, 2a.1, 2b, 2c, and 2a.3b]). Notably, amino acid substitutions in other gene segments of influenza A(H1N1)pdm09 and A(H3N2) were also found. CONCLUSION: These findings indicate influenza A(H1N1)pdm09 and A(H3N2) viruses co-circulated during the 2020-2023 influenza season in Pakistan. Continued surveillance is crucial for real-time monitoring of possible high-virulence variation and their relevance to existing vaccine strains.

Post-operative Scar Comparison With Supraorbital Eyebrow and Upper Blepharoplasty Approach in the Management of Zygomaticomaxillary Complex Fractures.

Study Design: A prospective randomized comparative study was conducted to evaluate the postsurgical scar with Supraorbital Eyebrow (SE) Approach and Upper Blepharoplasty (UB) Approach used for open reduction and internal fixation (ORIF) of zygomaticomaxillary complex (ZMC) fractures. Objective: To evaluate and compare the post-operative scar using Vancouver Scar Scale (VSS) following ORIF of ZMC fractures with SE and UB approaches. Methods: In this study, 88 patients with ZMC fractures requiring ORIF and meeting the inclusion criteria were recruited between 2019 and 2020. Patients were randomly divided into SE and UB group, 44 patients in each. Clinical and radiological assessment was done preoperatively and post-operative scar evaluation was carried out at different intervals over a period of 6 months using VSS. A blinded observer rated the scar. Results: The results showed that after 6 months of surgery, all the 44 (100%) patients in UB group had a mild scar (VSS score 1-5), while in the SE group 34 (77.3%) patients had a mild scar (VSS score 1-5) and 10 (22.7%) had a moderate scar (VSS score 6-10). The difference between the 2 groups was statistically significant (P-value = .001). Conclusions: The UB approach has been established to be superior to SE approach in terms of post-operative scar as the results were statistically significant. This study can be used to advocate more frequent use of UB approach as compared to the previously popular SE approach for the management of ZMC fractures.

Aplastic Anemia Mimicking Myelofibrosis: A Diagnostic Dilemma.

Hematological disorders pose a diagnostic challenge due to overlapping clinical features, as demonstrated by the difficulty in differentiating between aplastic anemia (AA) and primary myelofibrosis (PM). Myeloproliferative disorders, characterized by aberrant proliferation of bone marrow stem cells, present complexities in diagnosis, often requiring a comprehensive evaluation to distinguish between disorders with similar manifestations. The distinctions between myelofibrosis and AA lie not only in clinical presentations but also in genetic and molecular markers, necessitating a nuanced diagnostic approach. We present a case of a 37-year-old male initially diagnosed with myelofibrosis based on a history of pancytopenia, warm submandibular and submental swelling, and negative BCR-ABL and JAK2 mutations. Further examination revealed empty fragmented cells, hypoplastic bone marrow, and suppressed erythropoiesis and myelopoiesis. Subsequent core biopsy showed increased megakaryocytes, prompting a revised diagnosis of AA. This case underscores the importance of a meticulous diagnostic journey, incorporating physical examination, genetic testing, and advanced imaging to unravel the complexities of hematological disorders. The intricacies of this case prompt a reevaluation of diagnostic paradigms, highlighting the limitations of relying solely on specific mutations for diagnosis. The absence of BCR-ABL and JAK2 mutations in AA raises questions about its genetic landscape, necessitating further exploration. Immunological considerations, given the immune-mediated nature of AA, provide a foundation for future research into immune dysregulation and potential therapeutic interventions. The clinical management challenges posed by AA underscore the need for personalized treatment strategies, guided by a deeper understanding of its underlying pathophysiology. Advanced imaging techniques, in conjunction with traditional diagnostic methods, emerge as crucial tools for enhancing diagnostic accuracy in hematological disorders. This case serves as a paradigm for ongoing medical education, multidisciplinary collaboration, and innovative approaches in the evolving landscape of hematology, emphasizing the imperative for continuous refinement in diagnostic strategies and patient care.

Lessons Learned From the COVID-19 Pandemic: Factors Affecting Decreased Incidence of Influenza.

INTRODUCTION: Our goal was to identify if the cases of influenza declined in the state of Wisconsin during the COVID-19 pandemic and, if so, what factors may have been responsible for this decline. METHODS: Influenza rates during the 2018-2019 and 2020-2021 seasons were compared using data from Respiratory Virus Surveillance Reports from the Wisconsin Department of Health Services and the Centers for Disease Control and Prevention. RESULTS: The number of cases and hospitalizations due to influenza decreased significantly during the 2020-2021 influenza season compared to the 2018-2019 season, although mortality rates increased during 2020-2021. DISCUSSION: Reducing the burden of illnesses, hospitalizations, and deaths due to influenza on the health care system is imperative. Taking the same preventive measures used during the COVID-19 pandemic, such as wearing masks, physical distancing, and frequent handwashing, should be advised, especially for the most vulnerable patient populations.

Osteoid Osteoma of Retromolar Trigone: Report of a Rare Case.

Osteoid osteoma is a rare benign bone lesion that is often confused with the osteoblastoma. The osteoid osteoma comprises of 3% of all the primary bone tumours usually found in the long bones and vertebrae with the facial skeleton being the most infrequent site. The lesion usually presents with the swelling and pain that resolves with non-steroidal anti-inflammatory drugs (NSAIDs). Here, we report a case of osteoid osteoma of retromolar trigone, the site which has not been reported in the literature, in a 50-year male patient with a complaint of hard swelling on retromolar trigone associated with the mild intermittent localised pain that aggravated at night and on mastication. Excision of the lesion was carried out with chisel and mallet under local anesthesia with uneventful recovery and no recurrence at the 6 months follow-up. Key Words: Benign, Osteoid osteoma, Retromolar trigone.

Prevalence Of Gustatory And Olfactory Impairment In Different Stages Of Sars-Cov-2 Infected Pateints In Isolation Ward.

BACKGROUND: To evaluate the prevalence of gustatory and olfactory impairment and its correlation with the severity of SARS-Cov-2 infection as per WHO guidelines. METHODS: A total of 241 patients of both gender having age from 15-80 years were included in the study. It was cross Sectional study conducted at SARS-COV-2 Isolation wards of Pakistan institute of medical science Islamabad from 15thSeptember 2020 to 15th January 2021. Convenient sampling technique was used to collect data. A proforma was designed for this purpose. Participants were divided into 3 groups on the basis of age. Group-1 (15-30 years), group-2 (31-50 years) and group 3 (51-80 years). Further the participants were graded into mild, moderate and severe stages of Sars-Cov-2 infection according to WHO guidelines. Statistical analysis was performed by using SPSS version 20. RESULTS: In this study 66% were male and 34% population were the female. Regarding the age groups 72% population were from the group-3. Results of study shows 47% in mild stage, 45% in moderate stage and 8% severe stage. The results regarding the Gustatory and Olfactory impairment showed that 126 had gustatory impairment while 130 patients had olfactory impairment. CONCLUSIONS: We found strong relationship of olfactory and gustatory changes associated with SARS-COV-2 patients. It is premature to conclude that taste and smell changes are strongly linked to SARS-COV-2 diagnosis. Further multi center researches are required to find out possible pathophysiological mechanism.

Chikungunya virus: Molecular epidemiology of nonstructural proteins in Pakistan.

Chikungunya virus (CHIKV) is considered a public health problem due to its rapid spread and high morbidity. In 2016-2017 an outbreak of CHIKV was occurred in Pakistan but the data regarding the genomic diversity of CHIKV was not reported. Hence, the current study aimed to determine the genetic diversity of CHIKVs in Pakistan. A cross sectional study was carried out using sera of infected CHIKV patients (n = 1549) during the outbreak in Pakistan (2016-2018). Nucleotide sequencing of non-structural genes of CHIKV from eight isolates were performed followed by phylogenetic analysis using Bayesian method. Phylogenetic analysis suggested that the Pakistani CHIKV strains belonged to Indian Ocean Lineage (IOL) of genotype ECSA and C1.3a clade. Furthermore, the Pakistani isolates showed several key mutations (nsP2-H130Y, nsP2-E145D, nsP4-S55N and nsP4- R85G) corresponding to mutations reported in 2016 Indian strains of CHIKV. The molecular analysis revealed high evolutionary potential of CHIKV strains as well as better understanding of enhanced virulence and pathogenesis of this outbreak. The study highlights the need to continue surveillance in order to understand viral diversity over time and to devise preventive measures to limit diseases transmission in the region.

Peripheral Giant Cell Granuloma of Posterior Maxilla in a 9-Year Child.

Peripheral giant cell granuloma is a relatively uncommon benign reactive gingival lesion of the oral cavity. A 9-year boy presented with a painless, slow-growing, reddish-blue, soft tissue lesion on attached gingiva adjacent to maxillary right first and second premolars, which was interfering with eating. A periapical radiograph demonstrated focal alveolar bone loss and slight teeth displacement adjacent to the lesion. Diagnosis of peripheral giant cell granuloma was made through clinical and radiographic evaluation, by its typical presentation and correlation with histopathologic findings. Complete excision was carried out down to the underlying bone. A follow-up visit was scheduled after 7 days and deep scaling was performed. There was no recurrence three months post-excision. Timely detection and excision of this lesion is important to avoid future dentoalveolar problems. Key Words: Giant cell granuloma, Benign, Peripheral, Child.

Epidemiology of Chikungunya virus isolates 2016-2018 in Pakistan.

The chikungunya virus (CHIKV) is a mosquito-transmitted alphavirus, which has infected millions of people in Africa, Asia, Americas, and Europe since it remerged in India and Indian Ocean regions in 2005-2006. The purpose of this study was to evaluate the genetic diversity and evolutionary changes in CHIKV from 2016 to 2018 in Pakistan. Blood specimens were collected and processed following the Centers for Disease Control and Prevention Trioplex Protocol. Sequencing and phylogenetic analysis of complete coding sequence of representative isolates from the CHIKV outbreak was carried out during December 2016 to July 2018, a total of 1549 samples were received, out of which 50% (n = 774) were found positive for CHIKV RNA. Mean age of chikungunya positive patients was 31.8 ± 15.7 years and most affected were between 21 and 40 years of age. The Pakistan CHIKV strains clustered with the Indian Ocean sublineage of East/Central/South African with cocirculation of some variants In the structural proteins region, two noteworthy changes (A226V and D284E) were observed in the membrane fusion glycoprotein E1. Key substitutions in the neutralizing epitopes site and a few changes indicative of adaptive to other insect cells were also detected in Pakistani strains. This study provides the emerging trend of CHIKV in the country for early identification of potential variants of high virulence and preventive measures for vector borne disease especially in the endemic areas.

Evolutionary analysis of influenza A(H1N1)pdm09 during the pandemic and post-pandemic period in Pakistan.

BACKGROUND: The first case of influenza A(H1N1)pdm09 was detected in Pakistan in June 2009. Since then, it has continued to circulate causing considerable morbidity and mortality. The purpose of this study was to evaluate the evolutionary changes in influenza A(H1N1)pdm09 viruses from 2009 to 2016 and their relevance to the current vaccine viruses. METHODS: Respiratory specimens (throat or nasopharyngeal swabs) were collected from patients with influenza-like illness and severe acute respiratory illness. Samples were processed following the protocol of the US Centers for Disease Control and Prevention. Sequencing and phylogenetic analysis of Haemagglutinin and neuraminidase genes were carried out on representative isolates of Pakistan viruses. RESULTS: Between January 2009 and February 2016, out of 16,024 samples analysed, 1950 (12%) were positive for influenza A. During the pandemic period (2009-2010), influenza A(H1N1)pdm09 was the dominant strain with 366 out of 808 (45%) total influenza positive cases. In the post-pandemic period (2011-2016), a total of 1078 out of 1911 (56%) cases were positive for influenza A(H1N1)pdm09 with co-circulation of different influenza A subtypes. The Pakistan A(H1N1)pdm09 viruses belonged to two genetic clades: clade 7 in the pandemic period, and clade 7 (2011) and clade 6B (2015) in the post-pandemic period. Sequence analysis of genes coding for surface glycoprotein's of Haemagglutinin and neuraminidase had a high degree of sequence similarity with corresponding genes of regional viruses circulating in South-East Asia. CONCLUSION: Influenza A(H1N1)pdm09 viruses from Pakistan clustered into two genetic clades, with co-circulation of some variants. Key substitutions in the receptor binding site and a few changes indicative of virulence were also detected in the post-pandemic strains. Continued monitoring of the viruses is essential for early identification of potential variants of high virulence and their relevance to current vaccine strains.