Cryptogenic Stroke Complicated by Infective Endocarditis: Exploring the Multidisciplinary Interplay.

Infective endocarditis (IE) poses a significant clinical challenge due to its non-specific symptoms and variety of complications. Complications can include ischaemic stroke, valve dysfunction, discitis, and osteomyelitis, highlighting the complexity of IE management. We present a case of a male in his 40s, admitted with an ischaemic stroke, eventually being found to have underlying IE with a plethora of complications. This case highlights the importance of collaboration among specialists to form a multidisciplinary team, which is essential for the effective delivery of care. Furthermore, there is a critical need to explore the psychological impact of IE on patient outcomes, advocating for a holistic approach that considers psychological well-being alongside medical management. Future research should address these underexplored facets to improve patient care and outcomes in IE.

National guidelines for the diagnosis and treatment of hilar cholangiocarcinoma.

A consensus meeting of national experts from all major national hepatobiliary centres in the country was held on May 26, 2023, at the Pakistan Kidney and Liver Institute & Research Centre (PKLI & RC) after initial consultations with the experts. The Pakistan Society for the Study of Liver Diseases (PSSLD) and PKLI & RC jointly organised this meeting. This effort was based on a comprehensive literature review to establish national practice guidelines for hilar cholangiocarcinoma (hCCA). The consensus was that hCCA is a complex disease and requires a multidisciplinary team approach to best manage these patients. This coordinated effort can minimise delays and give patients a chance for curative treatment and effective palliation. The diagnostic and staging workup includes high-quality computed tomography, magnetic resonance imaging, and magnetic resonance cholangiopancreatography. Brush cytology or biopsy utilizing endoscopic retrograde cholangiopancreatography is a mainstay for diagnosis. However, histopathologic confirmation is not always required before resection. Endoscopic ultrasound with fine needle aspiration of regional lymph nodes and positron emission tomography scan are valuable adjuncts for staging. The only curative treatment is the surgical resection of the biliary tree based on the Bismuth-Corlette classification. Selected patients with unresectable hCCA can be considered for liver transplantation. Adjuvant chemotherapy should be offered to patients with a high risk of recurrence. The use of preoperative biliary drainage and the need for portal vein embolisation should be based on local multidisciplinary discussions. Patients with acute cholangitis can be drained with endoscopic or percutaneous biliary drainage. Palliative chemotherapy with cisplatin and gemcitabine has shown improved survival in patients with irresectable and recurrent hCCA.

Prevalence of BRCA1 and BRCA2 germline variants in an unselected pancreatic cancer patient cohort in Pakistan.

BACKGROUND: BRCA1 and BRCA2 (BRCA1/2) are the most frequently investigated genes among Caucasian pancreatic cancer patients, whereas limited reports are available among Asians. We aimed to investigate the prevalence of BRCA1/2 germline variants in Pakistani pancreatic cancer patients. METHODS: One hundred and fifty unselected and prospectively enrolled pancreatic cancer patients were comprehensively screened for BRCA1/2 germline variants using denaturing high-performance liquid chromatography and high-resolution melting analyses, followed by DNA sequencing of the variant fragments. The novel variants were analyzed for their pathogenic effect using in-silico tools. Potentially functional variants were further screened in 200 cancer-free controls. RESULTS: Protein truncating variant was detected in BRCA2 only, with a prevalence of 0.7% (1/150). A frameshift BRCA2 variant (p.Asp946Ilefs*14) was identified in a 71-year-old male patient of Pathan ethnicity, with a family history of abdominal cancer. Additionally, we found a novel variant in BRCA2 (p.Glu2650Gln), two previously reported variants in BRCA1 (p.Thr293Ser) and BRCA2 (p.Ile2296Leu) and a recurrent nonsense variant in BRCA2 (p.Lys3326Ter). These variants were classified as variants of uncertain significance (VUS). It is noteworthy that none of these VUS carriers had a family history of pancreatic or other cancers. CONCLUSIONS: In this first study, BRCA1/2 pathogenic variant is identified with a low frequency in pancreatic cancer patients from Pakistan. Comprehensive multigene panel testing is recommended in the Pakistani pancreatic cancer patients to enhance genetic understanding in this population.

Usual Presentation Of An Unusual Pathogen - Cryptococcus Laurentii Meningitis: A Case Report.

Infections caused by non-neoformans Cryptococcus spp., including Cryptococcus laurentii, previously thought to be saprophyte and non-pathogenic, have become more common during the past few years, particularly in immunocompromised hosts. To the best of our knowledge here, we present the first case of meningitis in an immunocompromised patient due to a fungus that has never been reported in Pakistan. Our patient, a 40-year old male, who had acquired immunodeficiency syndrome (AIDS) was diagnosed as Cryptococcus laurentti meningitis, with a rare neurological manifestation i.e., cryptococcomas and lepto-meningitis. We presume that exposure to pigeon droppings and acquired immunodeficiency syndrome were the risk factors for this case report. He was treated with liposomal Amphotericin (LAMB) and fluconazole but unfortunately, he rapidly deteriorated and ultimately succumbed to the infection. This case underscores the significance of prompt diagnosis and vigorous treatment of Cryptococcus laurentii meningitis, as well as the need for continued surveillance in immunocompromised individuals.

Quorum Quenchers from Reynoutria japonica in the Battle against Methicillin-Resistant Staphylococcus aureus (MRSA).

Over the past decade, methicillin-resistant Staphylococcus aureus (MRSA) has become a major source of biofilm formation and a major contributor to antimicrobial resistance. The genes that govern biofilm formation are regulated by a signaling mechanism called the quorum-sensing system. There is a need for new molecules to treat the infections caused by dangerous pathogens like MRSA. The current study focused on an alternative approach using juglone derivatives from Reynoutria japonica as quorum quenchers. Ten bioactive compounds from this plant, i.e., 2-methoxy-6-acetyl-7-methyljuglone, emodin, emodin 8-o-b glucoside, polydatin, resveratrol, physcion, citreorosein, quercetin, hyperoside, and coumarin were taken as ligands and docked with accessory gene regulator proteins A, B, and C and the signal transduction protein TRAP. The best ligand was selected based on docking score, ADMET properties, and the Lipinski rule. Considering all these parameters, resveratrol displayed all required drug-like properties with a docking score of -8.9 against accessory gene regulator protein C. To further assess the effectiveness of resveratrol, it was compared with the commercially available antibiotic drug penicillin. A comparison of all drug-like characteristics showed that resveratrol was superior to penicillin in many aspects. Penicillin showed a binding affinity of -6.7 while resveratrol had a score of -8.9 during docking. This was followed by molecular dynamic simulations wherein inhibitors in complexes with target proteins showed stability inside the active site during the 100 ns simulations. Structural changes due to ligand movement inside the cavity were measured in the protein targets, but they remained static due to hydrogen bonds. The results showed acceptable pharmacokinetic properties for resveratrol as compared to penicillin. Thus, we concluded that resveratrol has protective effects against Staphylococcus aureus infections and that it suppresses the quorum-sensing ability of this bacterium by targeting its infectious proteins.

The mystery of post-cholecystectomy persistent bile leak: a case report.

Laparoscopic cholecystectomy (LC) is commonly performed for benign gallbladder diseases. Biliary leak is the most common complication of bile duct injury following this surgery. We report a case of persistent bile leak following the procedure despite endoscopic and radiological management. A female patient presented to the hepatopancreatobiliary unit of the Bahria International Hospital (Orchard), Lahore, with complaint of persistent bile leakage after laparoscopic cholecystectomy performed elsewhere. She had been investigated in various hospitals but the cause of the persistent bile leak remained a mystery and she was offered surgery. After real time fluoroscopic contrast enhanced imaging, further confirmed by a Computerised Tomography (CT) Scan of the abdomen, it was revealed that the persistent bile leak in the drain was due to iatrogenic injury of the duodenum secondary to percutaneous catheter insertion. The patient was managed non-surgically. She remained stable. This is a rare complication of one of the most common surgical procedures performed in the world.

Assessing Colistin Resistance by Phenotypic and Molecular Methods in Carbapenem-resistant Enterobacterales in a Tertiary Care Hospital in Pakistan.

Introduction: Members of Enterobacterales are very common pathogens, which continue to show resistance to many antibiotics. Carbapenem performed well for some time. Colistin was the final hope for the carbapenem-resistant Enterobacterales, but resistance against it has virtually tied the clinician's hands, especially when it comes to treating critically ill patients. Purpose: Detection of colistin resistance by the agar method as well as by the polymerase chain reaction (mobilized colistin resistance-1 gene) in carbapenem-resistant Enterobacterales. Materials and Methods: A cross-sectional study from Dec 2019 to Dec 2020 was conducted at the Department of Microbiology, Army Medical College, National University of Medical Sciences Rawalpindi Pakistan. Antimicrobial susceptibility of Enterobacterales was determined according to the Kirby-Bauer disc diffusion method except for colistin. Colistin agar was used, in concentrations of 2 µg/mL and 4 µg/mL. Results were interpreted according to Clinical and Laboratory Standards Institute guidelines 2020. Mobilized colistin-resistant-1 gene in the carbapenem resistant Enterobacterales was detected by performing real-time polymerase chain reaction assay. Results: Among the 172 carbapenem-resistant Enterobacterales 18 isolates were resistant using the colistin agar test. Whereas by molecular method colistin resistance was detected among 10 isolates that carried mobilized colistin resistance 1 gene, making the frequency of the MCR-1 gene 5.81%. Seventy percent of isolates were from paired blood samples. Eight patients, from whom the colistin resistant gene was isolated expired. Conclusion: Colistin resistance is a very serious issue and should not be missed in a clinical microbiology laboratory. The phenotypic agar test method is an excellent option for routine use, as it combines ease of performance with affordable cost. However, molecular methods are essential for the detection of mobilized colistin resistance gene (1-9) for epidemiological purposes.

Contribution of germline PALB2 variants to an unselected and prospectively registered pancreatic cancer patient cohort in Pakistan.

BACKGROUND: Partner and localizer of BRCA2 (PALB2) is a pancreatic cancer (PC) susceptibility gene reported in Caucasians. However, limited data are available among Asians. We investigated the contribution of PALB2 germline variants to Pakistani PC patients. METHODS: 150 unselected and prospectively enrolled PC patients were comprehensively screened for PALB2 variants, using denaturing high-performance liquid chromatography and DNA sequencing. Novel variants were investigated for their pathogenic effect using in-silico tools. Potentially functional variants were screened in 200 controls. RESULTS: Twenty-two different PALB2 variants were identified. A missense variant (p.Arg37His) was identified in a 48-years-old male patient with a family history of breast cancer. Another missense variant (p.Trp898Arg) was identified in a 48-years-old male patient with a family history of esophageal cancer. A novel 3' downstream variant (c.∗480A>G) was detected in a 34-years-old female patient with family history of lung cancer. Another novel 3' downstream variant (c.∗417A>C) was identified in a 41-years-old male patient. All these variants were absent in 200 controls. p.Arg37His and p.Trp898Arg were predicted as likely pathogenic. c.∗417A>C and c.∗480A>G were classified as variants of uncertain significance. CONCLUSION: This is the first study that suggests a minimal contribution of PALB2 variants to PC risk in Pakistani population.

Clinical outcomes of hepato-pancreato-biliary surgical patients during COVID-19 pandemic.

OBJECTIVE: To determine the outcome of hepato-pancreato-biliary patients who were operated upon during the pandemic under a safety protocol devised to minimise the risk of coronavirus disease-2019 infection in patients and staff during the perioperative period. METHODS: The retrospective study was conducted at the Hepato-Pancreatico-Biliary (HPB) Unit of Bahria International Hospital Orchard, Lahore, Pakistan, in February 2021, and comprised data of all patients who were discussed in the multidisciplinary meeting of the Unit between May 1 and December 31, 2020. The coronavirus disease-2019 screening protocol was a negative polymerase chain reaction test just before admission and a second negative test 24-48 hours pre-surgery. All patients had computed tomography scan of chest to rule out atypical pneumonia due to coronavirus disease-2019 infection. Surgery was deferred for positive patients for at least 2 weeks until their test was negative. Surgeries were carried out with full personal protective equipment. Further testing was carried out if clinically indicated. Data was collected of 30-day coronavirus disease-2019-related morbidity and mortality. Data was analysed using SPSS 20. RESULTS: Of the 44 patients, 29(65.9%) were males and 15(34.1%) were females. Overall, 32(72.7%) patients were aged >40 years, 8(18.2%) were aged 20-40 years and 4(9%) were aged <20 years. Of the total, 7(15.09%) patients were found to be positive for coronavirus disease-2019 during preoperative screening. Among them, 5(71.4%) had successful surgery post-recovery, 1(14.3%) died without surgery due to pulmonary complications related to coronavirus disease-2019 and 1(14.3%) patient was lost to follow-up. Among the 42(95.5%) patients who underwent any procedure, 2(4.7%) patients turned positive for coronavirus disease-2019 in the postoperative period. There was 1(2.4%) mortality in the 30-day post-operative period which was not related to coronavirus disease-2019. Complications were seen in 5(11.90%) patients. Three (9.3%) out of 32 staff members were found to be asymptomatic carriers. CONCLUSIONS: Hepato-pancreatico-biliary surgery could be safely carried out during coronavirus disease-2019 pandemic if strict safety protocols were followed.

Rapid detection of ceftriaxone resistance in clinical isolates of extensively drug resistant Salmonella enterica serovar Typhi.

OBJECTIVE: To see the efficacy of rapid colour test for the sensitivity of ceftriaxone against clinical isolates of salmonella typhi. METHODS: The cross-sectional validation study was conducted at the Department of Microbiology, Pakistan Navy Ship Shifa Hospital, Karachi, from Nov 2018 to April 2019, and comprised clinical isolates of salmonella typhi that were obtained from five different hospitals in Karachi and Hyderabad. The isolates were tested using the rapid colour test. All the isolates were also tested using the conventional disc diffusion method and minimum inhibitory concentrations on the Vitek-2 version 8.01. RESULTS: Of the 97 isolates, 83(85.5%) were ceftriaxone-resistant and 14(14.4%) were ceftriaxone-sensitive. Sensitivity and specificity of the rapid colour test were 100% when compared with the results of the other methods. All the results were readable within 2 hours on the colour test. CONCLUSIONS: The colour test was found to be a rapid, accurate and inexpensive tool to screen for ceftriaxone resistance in typhoid-endemic areas.

Is it necessary to measure hepatic venous pressure gradient before liver resection in cirrhotic patients? A single center audit.

OBJECTIVE: To determine whether routine preoperative hepatic venous pressure gradient measurements are necessary in child's-A cirrhotic patients undergoing liver resection for hepatocellular carcinoma, and to assess immediate post-operative liver dysfunction and 30-day mortality in such cases. METHODS: The 3-year audit was done at Shuakat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, and comprised data from January 1, 2015, to December 31, 2017, of all Child's class "A" patients with hepatocellular carcinoma without any clinical signs of portal hypertension who had preoperative hepatic venous pressure gradient measurements done. A proforma was used to collect the required data from patient files. Data was analysed using SPSS 21. RESULTS: Of the 20 patients, 11(55%) were males. The overall mean age was 60.6±7.4 years. Only 2(10%) patients had raised hepatic venous pressure gradient. Of the total, 14(70%) patients underwent surgery. Mean duration of surgery was 222±82.5 minutes and mean hospital stay was 6.8±3.2 days. None of the patients had deranged prothrombin-time or bilirubin on postoperative day 5. CONCLUSIONS: The incidence of subclinical portal hypertension was very low. Hepatic venous pressure gradient measurement can be avoided in early stage hepatocellular carcinoma for child's A cirrhotic patients undergoing liver resection.

Primary hepatic neuroendocrine tumour: A rare entity - multimodal approach for diagnosis and management.

Neuroendocrine tumours (NETs) of the liver are generally metastatic lesions from broncho-pulmonary or gastrointestinal primary lesions. Liver is an unusual primary site for a NET with only 150 reported cases in literature. We encountered two cases of primary hepatic NET (PHNET) at the Shaukat Khanum Memorial Cancer Hospital, Lahore. Both the patients had abdominal pain and hepatomegaly. Imaging revealed a large mass in the right lobe of the liver in both the cases. The tru-cut biopsy showed neuroendocrine tumour. Extensive workup to look for primary lesion elsewhere in the body turned out to be negative. One patient received neo-adjuvant chemotherapy along with right main portal vein embolisation. Once adequate future liver remnant was achieved, the patient underwent right hepatic trisectionectomy. In the other patient, anticipated future liver remnant was sufficient and underwent surgery without portal vein embolization. No immediate postoperative complication was observed, and both the patients were followed for more than one year.

Diagnostic Accuracy Of Rapid Fosfomycin Np Test For Detection Of Fosfomycin Resistance In Escherichia Coli In A Tertiary Care Hospital In Pakistan.

BACKGROUND: Emergence of resistance among Escherichia coli (E.coli) isolates against therapeutic options for UTIs (Urinary tract infections) has led to renewed interest in older antibiotics like Fosfomycin. In this study we evaluated diagnostic accuracy of Rapid Fosfomycin NP test based on glucose metabolism for rapid Fosfomycin susceptibility testing among urinary E.coli isolates. METHODS: In a cross-sectional validation study conducted in the Microbiology Department, Armed Forces Institute of Pathology, Rawalpindi, Pakistan from 15th March to 15th September 2020, 149 consecutive urine specimens were included as per selection criteria. Rapid Fosfomycin NP test was performed as per protocol of Nordmann P et al on urinary E.coli isolates for detection of Fosfomycin resistance and results were compared with reference modified Kirby-Bauer disk diffusion method. RESULTS: Out of total 149 E.coli isolates from 149 urine specimens, 80 were classified as Fosfomycin susceptible and 69 as Fosfomycin resistant by reference disk diffusion method. Sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of rapid Fosfomycin NP test was found to be 94.2%, 98.75%, 98.48%, 95.2% and 96.64%, respectively. In our study reliable results were achieved after 2.5 hours of incubation. CONCLUSIONS: The rapid Fosfomycin NP test is valid and user-friendly technique which can be performed with minimal technical expertise. It is less time consuming than disk diffusion and Etest strips and easy to perform as compared to agar dilution method. It can be useful as alternative to agar dilution in urinary E.coli isolates which would help in selecting appropriate therapeutic option for UTIs.

Pancreaticoduodenectomy: Outcomes of a complex surgical procedure from a developing country.

BACKGROUND: Pancreaticoduodenectomy (PD) plays an integral part in the management of pancreatic, periampullary and duodenal cancers, along with a few other pathologies of this region. Despite advances in surgery PD continues to have significant morbidity and noteworthy mortality. The aim of this study is to provide an in-depth report on the patient characteristics, indications and the outcomes of PD) in a tertiary cancer hospital in Pakistan. MATERIALS AND METHODS: The study population included patients who underwent PD between January 1, 2014 and march 31, 2019, at Shaukat Khanum Memorial Cancer Hospital and Research Center (SKMCH&RC) in Pakistan. The data was retrospectively analyzed from the Hospital Information System (HIS), which is a prospectively maintained patient electronic database of SKMCH&RC. Patient characteristics, procedural details and post-operative outcomes according to internationally accepted definitions were reported. RESULTS: A total of 161 patients underwent PD at our hospital in the study period at a median age of 53 years, ranging from 19 to 78 years. 62% of the patients were males while 37% were females. Jaundice was the most common presenting symptom (64.6%), followed by abdominal pain (26.7%). PD with pancreaticogastrostomy was performed in 110 patients (68.3%), while pancreaticojejunostomy was performed in the rest of the cohort. Surgical site infection (SSI) was observed in 64 patients (40%). The incidence of Pancreatic Fistula grade C based on the International Study Group on Pancreatic Fistula (ISGPF) definition was 7.45% (n = 12). The 30 days mortality rate was 3.1%. Median survival of the cohort was 21 ±1.13 months and disease-free survival was 16±2.62 months. CONCLUSION: PD can be performed with acceptable morbidity and mortality in a resource constrained country, as long as it is undertaken in a high-volume center. This is in keeping with data published from other well-reputed international centers.

Evaluation of rapid polymyxin Nordmann Poirel test for detection of polymyxin resistance in clinical isolates of Enterobacteriaceae.

Polymyxins play a significant role against carbapenem-resistant Enterobacteriaceae (CRE). A total of 121 clinical samples yielded growth of CRE that were included in the study. Rapid Polymyxin NP test was performed on all the isolates as described by Nordmann P et al. and results were compared with broth microdilution method. Majority of the isolates were Klebsiella pneumoniae (70.2%) followed by Escherichia coli (17.4%). A total of 71 isolates were found resistant and 50 as susceptible by broth microdilution. Sensitivity and specificity of rapid polymyxin NP test were found to be 97.2% and 100%, respectively. Our study concluded that rapid polymyxin NP test is reliable and can be used as an alternative to broth microdilution in resource limited settings.

Hepatic arterial system anomalies encountered during pancreaticoduodenectomy - our experience.

We present our experience of incidence and management of aberrant hepatic arterial anatomy encountered during pancreaticoduodenectomy (PD). Patients undergoing PD between December 2014 and November 2016 at the Shaukat Khanum Memorial Cancer Hospital, Lahore were included in this short report. Preoperative imaging and operative findings of these patients were reviewed to evaluate the hepatic arterial anatomy and classified according to Hiatt classification. Sixty-four PD were performed with aberrant arterial anatomy identified in 24 (37.5%) of the cases. Most common anomaly was replaced right hepatic artery (rRHA) arising from the superior mesenteric artery seen in seven (11%) of the patients. Aberrant vessels were recognised and preserved in 23 cases. In one patient, the rRHA was coursing through the pancreatic parenchyma needing resection and reconstruction with uneventful postoperative recovery. Hepatic arterial anomalies are common and it is possible to preserve these vessels with careful surgical dissection using artery first technique.

Hepatic Artery Variations in a Sample of Pakistani Population.

OBJECTIVE: To identify the frequency of different arterial variants of common hepatic artery (CHA) overview identified at abdominal CT angiography (CTA) performed in a large series of patients undergoing CT scans for various reasons. STUDY DESIGN: Observational study. PLACE AND DURATION OF STUDY: Department of Surgical Oncology and Radiology, Shaukat Khanum Memorial Cancer Hospital & Research Centre, Lahore, Pakistan, from October 2016 to September 2018. METHODOLOGY: Findings in randomly selected 1000 patients who underwent CTA were retrospectively evaluated. The pattern of aortic origin of branches of the celiac trunk and superior mesenteric arteries was analysed. The CHA anatomy was then investigated. Hepatic artery anomalies were classified by the Hiatt's method. RESULTS: There were 629 males and 371 females with a median age of 54 years. Type 1 variation (normal anatomy) was seen in 644 patients. Type 2 variation (left hepatic artery, LHA, aberrations), was seen in 135 patients. LHA was seen arising from left gastric artery or common hepatic artery (CHA) in most of the cases. One patient had a replaced LHA from superior mesenteric artery (SMA). Sixteen patients had an accessory LHA and 119 had a replaced LHA. Type 3 variation (unusual anatomy of right hepatic artery, RHA) was seen in 121 patients, 7 patients had an accessory and 114 had a replaced RHA . The replaced or accessory right hepatic artery originated anywhere from SMA, celiac trunk, aorta, CHA or gastroduodenal artery (GDA). Type 4 variation (unsual origin of both RHA and LHA) was seen in 73 patients. Type 5 variation (CHA arising from SMA) was seen in 23 patients. Type 6 variation (CHA arising directly from aorta) was seen in four patients. CONCLUSION: Arterial variations are common in our population of patients. A detailed understanding and knowledge of these variations is necessary for surgeons and radiologists to avoid any inadvertent injuries during various procedures.

Pancreaticogastrostomy: A Safe Option in Pancreaticoduodenectomy for Pancreatic Head and Periampullary Neoplasms.

OBJECTIVE: To determine the safety of pancreaticogastrostomy in pancreaticoduodenectomy in patients with periampullary and pancreatic head neoplasms in terms of surgical technique, pancreatic fistula rate, 30 days mortality and three years survival. STUDY DESIGN: Cohort study. PLACE AND DURATION OF STUDY: Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, from October 2014 to September 2017. METHODOLOGY: Patients undergoing pancreaticoduodenectomy for pancreatic head and periampullary tumors were included. Patients having metastatic disease or involvement of celiac artery, hepatic artery or superior mesenteric artery on preoperative scans, complete encasement of portal vein and superior mesenteric vein (SMV) were excluded. Patients' characteristics including the demographics, surgical technique, postoperative pancreatic fistula, 30 days mortality and three years survival were recorded. Mean ± standard deviation was used for continuous variables while frequencies and percentages were used for categorical variables. Kaplan-Meier method was used to estimate survival as a function of time, and survival differences were analysed by either Log-Rank test or Tarone-Ware test. Statistical significance was defined as a two-tailed p-value 0.05. RESULTS: One hundred and one patients underwent pancreaticoduodenectomy. Fifty-eight (57.4%) were males and 43 (42.4%) were females (n=43). Mean age was 51.5 ±14.17 years. The commonly found tumor was periampullary adenocarcinoma which was present in 49.5% (n=50) patients followed by pancreatic head adenocarcinoma which was present in 32.7% (n=33) patients and 17.8% (n=18) patients had other tumors. Most common pathological T-stage was T3 present in 47.5% (n=48) patients, followed by T2 found in 36.6% (n=37) patients and T1 stage was present in 15.8% (n=16) patients. 57.4% (n=58) patients had node positive disease. Pancreaticogastrostomy was done in 87.13% (n=88) patients, while pancreaticojejunostomy was done in 12.87% (n=13) patients. Recurrent disease was noticed in 11.9% (n=12) patients. Mean survival of pancreatic head adenocarcinoma was 787.04 ±81.89 days, which was comparatively less than periampullary adenocarcinoma, i.e. 983.10 ±52.27 days (p=0.08). Overall mean survival was 924 ±41.3 days. CONCLUSION: Patients with periampullary tumors had a better outcome than pancreatic head tumors in this series. Pancreaticogastrostomy can be a safe alternative to pancreaticojejunostomy, especially in patients having non-dilated pancreatic duct and soft pancreas.

Clinical and virological course of SARS-CoV 2 infected patients in a tertiary care hospital in Pakistan.

BACKGROUND: Acute respiratory illness caused by Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) involved the whole globe within no time. Various studies published globally have shown variable severity of disease and mortality. The objective of our study was to describe clinical and epidemiological characteristics of the disease in our setup. METHODS: in this descriptive case series, individuals with signs and symptoms of Coronavirus disease-19 (COVID-19) and asymptomatic patients with history of close contact to confirmed COVID-19 patients were considered for SARS-CoV-2 Polymerase chain reaction (PCR) assay. Epidemiological and clinical features of only PCR positive cases were recorded. Data regarding hospitalization status, exposure to known COVID-19 patients, clinical feature and clinical outcome of patients was collected and interpreted. RESULTS: A total of 266 patients were found to be SARS-CoV 2 PCR positive which were included in the study. Mean age of patients was 39.45±31.9 years and majority of the patients in our study were male, i.e., 238 (89.5%). Most common clinical features among COVID-19 symptomatic patients were fever and dry cough followed by myalgias and sore throat. Eighteen (7%) out of 266 died in our setup. Time duration of viral shedding after initial positive PCR varied between 11 days to up to more than 55 days. CONCLUSION: Coronavirus disease-19 (COVID-19) can present with wide range of clinical spectrum and disease can be life threatening. Severity of disease, requirement of ICU care and mortality were directly related to age of the patient and underlying comorbidities. Rigorous precautionary measures are of utmost importance particularly in this high-risk population.

Typhoidal Salmonella strains in Pakistan: an impending threat of extensively drug-resistant Salmonella Typhi.

The aim of this study is to see the frequency, clinical presentation, and therapeutic response of extensively drug-resistant Salmonella enterica serovar Typhi and current susceptibility pattern of typhoidal Salmonella strains in our setup. This study was carried out at the Department of Medical Microbiology and Immunology and Department of Medicine, Pakistan Navy Ship (PNS) Shifa Hospital, Karachi, from January 1 to December 31, 2018. All the blood culture samples of patients (indoor and outdoor) with suspicion of enteric fever were processed. Isolates were cultured and identified using standard microbiological procedures. The antimicrobial sensitivity against the typhoidal Salmonellae was determined using Kirby-Bauer disc diffusion method as per the guidelines of Clinical and Laboratory Standards Institute (2018) and all the extensively drug-resistant (XDR) isolates were confirmed by Vitek 2 system. Clinical presentation and response to treatment of patients were followed. A total of 292 typhoidal Salmonella isolates were cultured. Resistance to ciprofloxacin against both Salmonella Typhi and Salmonella Paratyphi A was found to be very high (91%). Percentage of multidrug-resistant (MDR) isolates in Salmonella Typhi was 76% (182 isolates) and in Salmonella Paratyphi it was 34% (18 isolates). XDR isolates in Salmonella Typhi were significant that is 48% (115 isolates). Only 10 cases were given azithromycin who responded to treatment in mean 4.3 days. Out of 115 cases of XDR Salmonella Typhi, 103 patients were given parenteral meropenem and clinical response was seen in mean 5 days. The emergence and rapid spread of extensively drug-resistant Salmonella Typhi is alarming and highlights the significance of strict antimicrobial susceptibility surveillance programs with antimicrobial stewardship.