Acute physiology and chronic health evaluation score and mortality of patients admitted to intermediate care units of a hospital in a low- and middle-income country: A cross-sectional study from Pakistan.

Background: Intermediate care units (IMCUs) serve as a bridge between general wards and intensive care units by providing close monitoring and rapid response to medical emergencies. We aim to identify the common acute medical conditions in patients admitted to IMCU and compare the predicted mortality of these conditions by acute physiology and chronic health evaluation-II (APACHE-II) score with actual mortality. Methods: A cross-sectional study was conducted at a tertiary care hospital from 2017 to 2019. All adult internal medicine patients admitted to IMCUs were included. Acute conditions were defined as those of short duration (<3 weeks) that require hospitalization. The APACHE-II score was used to determine the severity of these patients' illnesses. Results: Mean (standard deviation [SD]) age was 62 (16.5) years, and 493 (49.2%) patients were male. The top three acute medical conditions were acute and chronic kidney disease in 399 (39.8%), pneumonia in 303 (30.2%), and urinary tract infections (UTIs) in 211 (21.1%). The mean (SD) APACHE-II score of these patients was 12.5 (5.4). The highest mean APACHE-II (SD) score was for acute kidney injury (14.7 ± 4.8), followed by sepsis/septic shock (13.6 ± 5.1) and UTI (13.4 ± 5.1). Sepsis/septic shock was associated with the greatest mortality (odds ratio [OR]: 6.9 [95% CI (confidence interval): 4.5-10.6]), followed by stroke (OR: 3.9 [95% CI: 1.9-8.3]) and pneumonia (OR: 3.0 [95% CI: 2.0-4.5]). Conclusions: Sepsis/septic shock, stroke, and pneumonia are the leading causes of death in our IMCUs. The APACHE-II score predicted mortality for most acute medical conditions but underestimated the risk for sepsis and stroke.

Patient's Perspective of Awake Proning: A Cross-Sectional Interview-Based Survey From COVID-19-Recovered Patients.

To assess the knowledge, attitude, and practice of the patients who underwent prone positioning during their COVID-19 illness in the hospital. DESIGN: Cross-sectional study. SETTING: Aga Khan University Hospital, Karachi, Pakistan. PARTICIPANTS: COVID-19-recovered patients. INTERVENTIONS: None. MAIN OUTCOMES AND MEASURES: Knowledge was assessed by five questions with a dichotomous response (yes/no). An yes response was awarded 1 score. Since there were five questions, five would be the highest score. Patients' perceptions of the therapy were assessed by four questions, each scored on a Likert scale of 5 (5 = strongly agree, 4 = agree, 3 = neither agree nor disagree, 2 = disagree, and 1 = strongly disagree). As it had four questions, the maximum score achieved could therefore be 20. Proning practices were assessed using seven questions: four were used to calculate practice scores, whereas three were open-ended regarding the patient's experience. Each question carries a different score, and the maximum score was 8. RESULTS: The study included 98 patients. The mean age of the patients was 57 years (sd, 12.2 yr). Majority of the patients were males (70.4%). 69.1% of males and 76.6% of females fell in the poor knowledge group. The poor knowledge cohort had an educational level of 48% in high school, 45.5% in graduates, and 6% in postgraduates. Compared with 56.5% of males, 73% of females preferred prone positioning. Sixty percent of those with a high school education viewed prone positioning favorably, whereas 46% of those with graduate and postgraduate did. Seventy-nine percent of males and 63% of females scored positively on the practice questionnaire. Eighty percent of graduates and postgraduates preferred proning practices to 67% of participants with high school education levels. CONCLUSIONS AND RELEVANCE: Our study population had a little understanding of awake proning, found it unpleasant, and practiced for a shorter period than advised. Despite the overall negative attitude toward the position, our patients highly recommend this position to future patients.

An audit of gynae-oncology practices in ovarian cancer treatment based on enhanced recovery after surgery (ERAS) protocol amongst two gynae-oncology units, in UK and in Pakistan.

OBJECTIVE: To compare peri-operative practices and complications in ovarian cancer patients undergoing upfront surgery for primary disease under enhanced recovery after surgery protocol and traditional practices. METHODS: The retrospective cross-sectional study was done at the gynaecology departments of St Georges Hospital, United Kingdom, and the Aga Khan Hospital, Pakistan, and comprised data of an equal number of ovarian cancer patients from each centre who underwent ovarian cancer surgery from January 2015 to December 2016. The former centre practiced the enhanced recovery after surgery protocol, while the latter centre followed traditional practices. Data was analysed using SPSS 19. RESULTS: Of the 100 patients, there were 50(50%) in each group. Baseline variables were comparable except for diabetes which was more prevalent in the local group (p=0.03). Mechanical bowel preparation was performed in 47(94%) of local patients compared to 1(2%) in the other group, while the duration for nil-per-mouth status as well as the use of nasogastric tube and peritoneal drain were significantly different (p<0.05). Epidural anaesthesia was used in 39(78%) of patients in Pakistan compared to 4(8%) in the United Kingdom. The duration of thromboprophylaxis was also significantly different (p<0.05). CONCLUSIONS: Implementation of enhanced recovery after surgery protocol was found to have the potential to improve postoperative outcomes and good functional recovery without compromising patient safety.

Predictors of mortality in hospitalized patients with influenza: a five-year experience from a tertiary care centre in Pakistan.

Influenza outbreaks are associated with significant morbidity. Our aim was to determine the factors associated with increased mortality in hospitalized patients admitted with diagnosis of influenza, at a tertiary care center in Pakistan. This study included all adult patients with an influenza infection, confirmed by realtime reverse-transcriptase polymerase-chain-reaction (RT-PCR) at Aga Khan University Hospital Pakistan. In our study, 112 patients with laboratory-confirmed influenza virus infection were admittedat our hospital from the 1st of January 2013 to the 31st of December 2018. Eighty-nine patients (79.46%) were managed in ward or special care units and 23 patients (20.5%) received treatment in intensive care unit (ICU). The overall mortality in our study was 15/112 (13.4%) with the mortality rate of ICU patients being 47.8% while the mortality rate of patients treated in special care units and wards was only 4.5%. The mean age of patients with influenza infection was 58.1 years (±16.6). Influenza virus type A was found in 87 patients (77.6%), while influenza type B was present in only 25 (22.4%) patients. Out of the 15 non-survivors, 14 had influenza A. Only 17 patients (15.2%) were found to have positive culture of respiratory specimen, out of which 3 were non-survivors and 14 were survivors. Our analysis identified septic shock (odds ratio 45.24; 95%, confidence interval 6.20-330; p<0.001), renal failure (odds ratio 10.88; 95%, confidence interval 1.61-73.52; p=0.01) and ICU stay (odds ratio 17.22; 95%, confidence interval 2.68-110.5; p=0.003) as independent risk factors associated with in-hospital mortality.

Novel Use of Fresh Frozen Plasma in Treating Hereditary Angioedema: A Success Story From Pakistan.

Hereditary angioedema (HAE) due to a C1-esterase inhibitor(C1-INH) deficiency is a rare and potentially life-threatening disorder. It is characterized by an episodic and self-limiting increase in vascular permeability. The condition manifests itself as recurrent attacks of swelling in any part of the body. The angioedema can cause the involvement of the respiratory tract, skin, and gastrointestinal tract. Laryngeal involvement can make the condition life-threatening. It does not respond well to conventional angioedema therapy of steroids, adrenaline, and antihistamines. The targeted therapy for HAE consists of plasma-derived or recombinant C1-INH, ecallantide, and icatibant or bradykinin receptor antagonist. In the absence of these therapies, it becomes difficult to manage this condition effectively. We present a case of hereditary angioedema, who presented with life-threatening laryngeal edema, causing asphyxia, leading to cardiac arrest. Due to a lack of availability of C1-INH concentrate, he was given fresh frozen plasma (FFP). His condition gradually improved, and he was successfully extubated after three days. This is the first time we are reporting a case from Pakistan in which the patient was successfully treated with FFP for an acute attack of hereditary angioedema.

Association of SNPs in EGR3 and ARC with Schizophrenia Supports a Biological Pathway for Schizophrenia Risk.

We have previously hypothesized a biological pathway of activity-dependent synaptic plasticity proteins that addresses the dual genetic and environmental contributions to schizophrenia. Accordingly, variations in the immediate early gene EGR3, and its target ARC, should influence schizophrenia susceptibility. We used a pooled Next-Generation Sequencing approach to identify variants across these genes in U.S. populations of European (EU) and African (AA) descent. Three EGR3 and one ARC SNP were selected and genotyped for validation, and three SNPs were tested for association in a replication cohort. In the EU group of 386 schizophrenia cases and 150 controls EGR3 SNP rs1877670 and ARC SNP rs35900184 showed significant associations (p = 0.0078 and p = 0.0275, respectively). In the AA group of 185 cases and 50 controls, only the ARC SNP revealed significant association (p = 0.0448). The ARC SNP did not show association in the Han Chinese (CH) population. However, combining the EU, AA, and CH groups revealed a highly significant association of ARC SNP rs35900184 (p = 2.353 x 10(-7); OR [95% CI] = 1.54 [1.310-1.820]). These findings support previously reported associations between EGR3 and schizophrenia. Moreover, this is the first report associating an ARC SNP with schizophrenia and supports recent large-scale GWAS findings implicating the ARC complex in schizophrenia risk. These results support the need for further investigation of the proposed pathway of environmentally responsive, synaptic plasticity-related, schizophrenia genes.