The Clinical Implementation of NEWS, SOFA, and CALL Scores in Predicting the In-Hospital Outcome of Severe or Critical COVID-19 Patients.

OBJECTIVE: To date, there is no specific validated coronavirus disease 2019 score to assess the disease severity. This study aimed to evaluate the performance of the National Early Warning Score, Sequential Organ Failure Assessment, and Comorbidity-Age-Lymphocyte count-Lactate dehydrogenase scores in predicting the in-hospital outcome of critical or severe coronavirus disease 2019 patients. MATERIALS AND METHODS: Single-centered analytical study was carried out in the coronavirus disease 2019 high dependency unit from April to August 2020. National Early Warning Score, Sequential Organ Failure Assessment, and Comorbidity-Age-Lymphocyte count-Lactate dehydrogenase scores were calculated for each critical to severely ill coronavirus disease 2019 patient. The diagnostic accuracy of these 3 scores in determining the in-hospital outcome of coronavirus disease 2019 patients was assessed by area under the receiver operating characteristic curve. The cut-off value of each score along with sensitivity, specificity, and positive and negative likelihood ratio were calculated by Youden index. Predictors of outcome in coronavirus disease 2019 patients were analyzed by Cox-regression analysis. RESULTS: The area under the curve was highest for the Comorbidity-Age-Lymphocyte count-Lactate dehydrogenase score (area under the curve=0.85) while the Sequential Organ Failure Assessment score had an area under the curve of 0.72. The cut-off values for National Early Warning Score score was 8 (sensitivity=72.34%, specificity=76.10%), Sequential Organ Failure Assessment score was 3 (sensitivity=68.97%, specificity=67.42%), and Comorbidity-Age-Lymphocyte count-Lactate dehydrogenase score was 8 (sensitivity=88.89%, specificity=66.67%). The pairwise comparison showed that the difference between the area under the curve of these 3 scores was statistically insignificant (P > .05). The rate of mortality and invasive ventilation was significantly high in groups with high National Early Warning Score, Sequential Organ Failure Assessment, and Comorbidity-Age-Lymphocyte count-Lactate dehydrogenase scores (P > .0001). These 3 scores, age, low platelets, and high troponin-T levels were found to be statistically significant predictors of outcome Conclusion:Comorbidity-Age-Lymphocyte count-Lactate dehydrogenase score had a good area under the curve, the highest sensitivity of its cut-off value, required only 4 parameters, and is easy to calculate so it may be a better tool among the 3 scores in outcome prediction for coronavirus disease 2019 patients.

Bifunctional iron molybdate as highly effective heterogeneous electro-Fenton catalyst and Li-ion battery anode.

Three-dimensional materials have attracted considerable interest in energy and environmental remediation fields. Iron molybdate (FMO) materials have prepared via a facile hydrothermal technique with glycerol assistance, and their structural and chemical composition confirmed using various physico-chemical techniques. The prepared bi-functional material is a strong candidate for energy storage and electrocatalytic degradation of Methylene blue and Congo red. Experimental results confirmed the synthesized FMO-10 catalyst was extremely efficient for methylene blue and Congo red breakdown, achieving 91 % and 96 % degradation in 36 h, respectively. This high catalytic activity was attributed to FMO significant visible light absorption, and reactive OH formation from H2O2 synergistically triggered by both Fe3+ and MoO42-. Prepared FMO samples demonstrated excellent potential as negative electrode material for lithium ion batteries. Electrode specific capacity initially dropped then rebounded to 1265 mAh g-1 after 100 cycles at 100 mA g-1 change rate between 0.01 and 3.0 V.

Ternary Zn1-xNixSe nanostructures as efficient photocatalysts for detoxification of hazardous Congo red, methyl orange, and chrome yellow dyes in wastewater sources.

Water contamination by hazardous organic pollutants poses an extreme threat to the environment and globally endangers aquatic life and human health. Hence, the removal of toxic organic effluents from water sources is necessary to ensure a healthy green environment. To this end, a new class of emerging, visible-light-driven Zn- and Ni-based ternary metal-selenide (Zn1-xNixSe) nanophotocatalysts, with tunable nanostructures via regulation of the stoichiometric ratios of Zn and Ni, were synthesized for efficient water purification by a facile one-pot hydrothermal process. These catalysts exhibit outstanding porous properties, with large surface areas and average particle sizes of around 80 ± 10 nm. The as-prepared ternary Zn1-xNixSe catalysts enable improved optical properties, intrinsic conductivity, bandgap reductions, and large numbers of active sites compared with pristine materials, thereby exhibiting outstanding degradation properties against various dye molecules, including Congo red, methyl orange, and chrome-IV upon visible light irradiation. The improved photodegradation capabilities of the Zn1-xNixSe catalysts may be attributed to the synergistic combinations of Zn and Ni selenides, which in turn minimize the recombination rates of the photogenerated carriers compared to their individual constituents. These findings clearly demonstrate that the proposed ternary Zn1-xNixSe catalysts could be potentially used to remove toxic organic contaminants from industrial wastewater.

Highly Fast Response of Pd/Ta2O5/SiC and Pd/Ta2O5/Si Schottky Diode-Based Hydrogen Sensors.

Herein, the fabrication of a novel highly sensitive and fast hydrogen (H2) gas sensor, based on the Ta2O5 Schottky diode, is described. First, Ta2O5 thin films are deposited on silicon carbide (SiC) and silicon (Si) substrates via a radio frequency (RF) sputtering method. Then, Pd and Ni are respectively deposited on the front and back of the device. The deposited Pd serves as a H2 catalyst, while the Ni functions as an Ohmic contact. The devices are then tested under various concentrations of H2 gas at operating temperatures of 300, 500, and 700 °C. The results indicate that the Pd/Ta2O5 Schottky diode on the SiC substrate exhibits larger concentration and temperature sensitivities than those of the device based on the Si substrate. In addition, the optimum operating temperature of the Pd/Ta2O5 Schottky diode for use in H2 sensing is shown to be about 300 °C. At this optimum temperature, the dynamic responses of the sensors towards various concentrations of H2 gas are then examined under a constant bias current of 1 mA. The results indicate a fast rise time of 7.1 s, and a decay of 18 s, for the sensor based on the SiC substrate.

Influence of selenium precursors on the formation of iron selenide nanostructures (FeSe2): Efficient Electro-Fenton catalysts for detoxification of harmful organic dyestuffs.

In this investigation, a sequences of iron diselenide (FeSe2) nanomaterials as the competent and highly stable catalysts for the detoxification of aqueous organic dye pollutants such as Congo red (CR) and methylene blue (MB) through Electro-Fenton (EF) process using hydrogen peroxide as an initiator have been studied. The utilized selenium precursors include selenium metal, selenious acid (H2SeO3) and selenium dioxide (SeO2) which were employed for the synthesis of FeSe2 catalysts through a wet chemical strategy. It has been observed that based on the employed precursors, different morphologies ranges of the FeSe2 catalysts were obtained: microgranualr particles to nano-stick to nanoflakes. The crystalline nature and phase purity of the obtained FeSe2 catalysts were determined through XRD, Raman and HR-TEM analyses which confirmed their orthorhombic ferroselite structure. Among the prepared FeSe2 catalysts, FS-2 (using H2SeO3) displayed better porous properties as compared to other catalysts and achieved the highest surface area of 74.68 m2g-1. The narrow bandgap (0.88 eV) and fast conversion of Fe2+/Fe3+ cycle of FeSe2 led CR and MB degradation of 93.3% and 90.4%, respectively. The outcome of this study demonstrates improved catalytic properties of FeSe2 nanostructures for the efficient detoxification of hazardous and toxic effluents.

Diagnosis, Management And Prevention Of Hepatitis C In Pakistan 2017.

AIMS AND OBJECTIVES: Since the advent of direct acting antiviral agents, there is a revolutionary change in the management of HCV infection. Newer drugs with different mechanism of action are being introduced and are expected to be available in coming few months in Pakistan as well. The main purpose of the guideline is to review and induct the latest research in field of HCV infection in Pakistani perspective so that our healthcare professionals can apply the new recommendations in timely and judicial manner. Target groups of guidelines are general physicians treating hepatitis C, hepatologists and gastroenterologists. Other beneficiaries of these guidelines are public health institutions of Pakistan, which provide free treatment to deserving patients under National Hepatitis Prevention and Control Program and Pakistan Bait-ul- Mal Program. METHODOLOGY: These guidelines are based on the review of National consensus practice guidelines: Diagnosis, Management and Prevention of Hepatitis C Pakistan 2009. Published data in National and International Journals searched with the help of Google search and pub med, and 2015-16 guidelines of HCV by AASLD, EASL, APASL and WHO. Local studies are preferably added with references to enhance the Pakistani perspective. Evidence was also taken from published studies. Recommendations have been based upon evidence from national publications on the subject and scientific presentations at national liver meeting as well from experts' personal experience and opinion.

Brain tuberculomas mimicking intracranial metastasis in a patient presenting with fits.

Brain tuberculosis is still prevalent in many developing countries, especially Asian countries. Tuberculomas should always be considered in the differential diagnosis of enhancing intra-axial lesions of the brain. Brain tuberculomas can present in many different clinical and radiological patterns clinically like headache, fits, cranial nerve palsies and very rarely as brain tuberculomas. We describe the case of a 48 years old male patient presenting with persistent headache and fits, referred for workup of brain metastasis or primary brain neoplasm. On further imaging, it turned out to be multiple tuberculomas of brain which resolved on anti-tuberculous treatment along with symptoms relief.

Ruptured hydatid cyst in biliary tract.

A lady aged 26 years reported with a 2 months history of fever, upper abdominal pain and weight loss. Her abdominal ultrasonographic scan revealed a complex cystic mass in left lobe of liver suggestive of hydatid cyst that was confirmed on magnetic resonance imaging of abdomen and magnetic resonance cholangiopancreatogram. With strong suspicion of a hydatid cyst, endoscopic retrograde cholangiogram was performed which confirmed the diagnosis. During the procedure, hydatid membranes protruding from the papilla were removed after sphincterotomy. She was put on albendazole 400 mg twice daily after the procedure and showed a remarkable clinical improvement.

Interferon-alpha induced and ribavirin induced thyroid dysfunction in patients with chronic hepatitis C.

Chronic hepatitis C (CHC) is one of the commonest infectious diseases of the liver and may lead to cirrhosis or hepatocellular carcinoma. Combination therapy with pegylated interferon (PEG-IFN) and Ribavirin is the treatment of choice for CHC. Combination therapy is thought to act by means of antiviral mechanisms and immunomodulation. Thyroid dysfunction is the most common autoimmune adverse effect associated with combination therapy; hypothyroidism is more common than hyperthyroidism. Antithyroid antibodies and female sex have a predictive value in the development of interferon induced thyroid disease (IITD). Patients with CHC should be informed of the possibility of side effects on the thyroid gland. Screening for antithyroid antibodies and thyroid function tests should be performed in patients with CHC before the commencement of antiviral treatment, and during and after it. This article reviews different aspects of IITD, including its pathogenesis, clinical manifestations, association with treatment regimens and treatment response and the outcome of thyroid dysfunction.

Comparison of diagnostic yield of AFB with sputum induction to spontaneous sputum examination in suspected pulmonary tuberculosis.

OBJECTIVE: To compare the diagnostic yield of AFB positivity with sputum induction to spontaneous sputum examination in suspected cases of pulmonary tuberculosis. STUDY DESIGN: Comparative study. PLACE AND DURATION OF STUDY: Military Hospital, Rawalpindi, from January to December 2006. METHODOLOGY: Sputum specimens were collected by both techniques from 164 patients with clinical and radiological suspicion of pulmonary tuberculosis admitted in medical wards. All specimens were examined for AFB smear and culture positivity. Sputum induction was done for 15-20 minutes with 3% sterile hypertonic saline solution by nebulization in all cases. Proportions were compared using Chi-square test. RESULTS: Among 164 patients, 32 patients (19.5%) were not expectorating spontaneously. Sputum induction was successful in 22 (68.75%) cases and AFB smear was positive in 03 (9.37%) and AFB culture was positive in 7 (21.8%) of these cases. One hundred and thirty two (80.5%) patients were already expectorating and both Day-1 (spontaneous) and Day-2 (induced) sputum samples were available. Day-1 (spontaneous) sputum specimens revealed AFB smear positive results in 20 (15.15%) patients, and AFB culture positive results in 24 (18.18%) patients. Smear positivity on Day-2 (induced) sputum samples was 21.21% (28) with 27.27% (36) culture positivity. CONCLUSION: In expectorating patients, AFB smear and culture positivity results remain comparable with spontaneous and induced sputum sampling. Sputum induction improves the diagnostic yield for AFB in patients unable to expectorate adequate sputum sample.

Indications for endoscopic ultrasound and diagnosis on fine-needle aspiration and cytology.

OBJECTIVE: To determine common indications for requesting Endoscopic Ultrasound (EUS) and to describe the diagnosis made after endoscopic ultrasound/Fine-Needle Aspiration and Cytology (FNAC) during two years at a tertiary gastrointestinal unit. STUDY DESIGN: Cross-sectional descriptive study. PLACE AND DURATION OF STUDY: The study was carried out in Gastrointestinal Department of Military Hospital, Rawalpindi, from March 2006 to February 2008. METHODOLOGY: One hundred and eighty nine patients who underwent EUS during study period at Military Hospital were included in the study. Patients too ill (hypoxemic/hypotensive) to undergo procedure safely and those with complete esophageal blockage at upper end by tumour not allowing scope/EUS probe to advance beyond were excluded. EUS was done with Olympus Exera EUS 160, linear or radial scope, as required. EUS findings were recorded against indications as enlarged lymph nodes, tumour, staging, normal or incomplete. Fine-Needle Aspiration (FNA) was done as per findings on EUS using 21-22 G needle. An on-site cytopathologist made the provisional cytopathological diagnosis. Final cytology/histopathology report was given after review of slides by consultant histopathologists at Armed Forces Institute of Pathology (AFIP), Rawalpindi, and were documented as tuberculosis, malignancy, chronic pancreatitis or reactive hyperplasia. Data was analyzed for documentation of patients' age, gender, common indications, findings on EUS/FNAC, using SPSS version 10. Percentages and frequencies were calculated for the presence of these above-mentioned variables. RESULTS: Of the 189 patients, 145 (77%) were male and 44 (23%) female. Age was 18-80 years (mean 49 years). Major indications for referral were lymphadenopathy in 92 (49%), suspected growth pancreas in 57 (28%), growth of stomach in 20 (11%) and a heterogeneous group included esophageal, liver, retroperitoneal masses, rectal and other pathologies. Findings on EUS included lymphadenopathy in 76, mostly in sub-carina and AP window. Mass in pancreas was seen in 36, followed by stomach tumour in 17 and esophagus in 9. FNAC was done in 142 out of 189 patients. Final diagnosis out of 67 FNAC/histopathology of lymph nodes were tuberculosis in 26 and malignant lesions in 23. These included metastatic adenocarcinoma in 8, lymphoproliferative disorder in 7, metastatic squamous cell carcinoma in 5, small cell carcinoma in 2 and anaplastic in 1. Pancreatic tumours were adenocarcinoma in 16, poorly differentiated in 3 and neuroendocrine in 2. Stomach tumours were found in 11, and included lymphomas 5, GIST 3, carcinoids 2, metastatic choriocarcinoma 1 and adenocarcinoma in 1. Therapeutically, 3 celiac blocks and one pancreatic pseudocyst drainage was done. CONCLUSION: The main indication of EUS and pathology of mediastinal and celiac nodes were metastatic malignancy and tuberculosis. Pancreatic adenocarcinoma was another common cause for asking EUS.

Effects of combined interferon alpha and ribavirin therapy on thyroid functions in patients with chronic hepatitis C.

OBJECTIVE: To determine the frequency of thyroid dysfunction in patients of chronic hepatitis C during treatment with interferon alpha-2b and ribavirin therapy. STUDY DESIGN: A cohort study. PLACE AND DURATION OF STUDY: Army Medical College and Military Hospital, Rawalpindi, from February 2006 to January 2007. METHODOLOGY: One hundred and sixty seven non-cirrhotic chronic hepatitis C patients were grouped into treatment group (n=107) and control group (n=60) awaiting treatment. Baseline serum(s.) Alanine Transferase (ALT) and S. Aspartate Transferase (AST) were measured by IFCC method. Serum Thyroid Stimulating Hormone (S. TSH), serum free thyroxine (S. Free T4) and serum total triiodothyronine (S.T3) level were determined by chemiluminescence. Study group patients underwent 24 weeks IFN and ribavirin therapy and were followed-up for thyroid dysfunction at weeks 0, 12 and 24. Control group patients underwent the same tests at weeks 0, 12 and 24. Statistical analysis was done on SPSS 15. RESULTS: Out of 107 patients of treatment group, 20 patients (18.69%) developed thyroid dysfunction. Females were at higher risk with Relative Risk (RR) of 11.25 and Attributable Risk (AR) of 91%. Hypothyroidism was more common than hyperthyroidism. CONCLUSION: Interferon-alpha and ribavirin therapy induces thyroid dysfunction in chronic hepatitis C patients. Hypothyroidism was more common. Females are at a higher risk of developing thyroid dysfunction.

Association of response to combined interferon alpha-2b and ribavirin therapy in patients of chronic hepatitis c with serum alanine aminotransferase levels and severity of the disease on liver biopsy.

BACKGROUND: Raised serum alanine aminotransferase (serum ALT) levels indicate active liver disease while liver biopsy has been considered the 'gold standard' for assessing the severity of disease in patients of chronic Hepatitis C. The response of these patients to standard treatment regimen of interferon (INF)-alpha-2b and ribavirin for 24 weeks have been studied. OBJECTIVE: The objective of this study was to evaluate the association of response to combined INF alpha-2b and ribavirin therapy in patients of chronic hepatitis C with serum ALT levels and severity of the disease on liver biopsy. METHODS: This quasi experimental study-was conducted in Department of Physiology at Army Medical College and Military Hospital, Rawalpindi from January 2006 to February 2007. One hundred and seven diagnosed non cirrhotic chronic hepatitis C patients were studied. Prior to the commencement of treatment, qualitative assay of Hepatitis C Virus (HCV) Ribonucleic Acid (RNA) was done by Polymerase chain reaction (PCR). Knodell Histopathological Index (HPI) was determined on liver biopsy. The standard treatment of INF-alpha-2b, 3 million units 3 times a week subcutaneous, and Ribavirin 800-1200 mg per day was given for 24 weeks. Serum ALT levels were determined before the start of treatment and later at weeks 12 and 24. Qualitative assay of HCV RNA was done by PCR at the end of treatment to determine the response to treatment. Statistical analysis was done on SPSS 15. RESULTS: Out of 107 patients of chronic hepatitis C, 92 (69 males, 23 females) patients (84%) responded to INF-alpha-2b and ribavirin therapy and revealed negative qualitative assay of HCV RNA by PCR at the end of 24 weeks of treatment while serum ALT levels were normal in 88% of patients at 12 weeks and in 97% at the end of 24 weeks of treatment. Knodell HPI revealed mild, moderate and severe disease in 47.7%, 39.9% and 13.1% of patients respectively. No association was established between response to treatment and severity of the disease on liver biopsy (p < 0.11) and serum ALT levels (p = 0.09). CONCLUSION: Response to Interferon alpha-2b and ribavirin therapy in patients of chronic hepatitis C is not associated with the levels of serum ALT and the severity of the illness graded on liver biopsy.

Diagnostic evaluation of patients presenting with bleeding per rectum by colonoscopy.

BACKGROUND: Rectal bleeding is a manifestation of lower gastrointestinal bleed, which means bleeding from a site distal to ligament of Treitz. Annual incidence of this problem has been estimated to be 20% and mortality as 11%. Patients complaining of haematochezia are suspected of having lower GI bleeding and proctosigmoidoscopy followed by colonoscopy is the examination of choice for diagnosis and treatment. Previous evidence suggested that in our country, frequencies of different aetiologies of lower GI bleed are different from the West. This study validated the previous findings. The Objective of this study was to determine the causes of rectal bleeding in adult patients at Military Hospital, Rawalpindi. METHODS: One hundred and five adult patients with visible rectal bleed, irrespective of their gender were selected by non-probability convenient sampling from general medical OPD and general medical wards. Patients with suspected upper GI source of bleeding; haemorrhoidal bleed and acute infectious diarrhoea were excluded from the study. All patients were subjected to fibre-optic colonoscopy after necessary preparation and findings were recorded. Biopsies taken from suspected lesions were clinically indicated. Diagnosis was based on colonoscopic and histopathologic findings. RESULTS: A total of 105 patients (77 male and 28 female) with mean age 41.04 yrs were part of the study. Colonoscopy showed abnormal findings in 85 (84%) patients. The commonest diagnosis was ulcerative colitis, which was found in 48 (46%) patients. It was followed by colorectal carcinoma, 11 (10%) patients, and non-specific colitis, 9 (8%) patients. Other less frequent findings were colonic diverticuli, 7 (6%) patients, solitary rectal ulcer, 5 (4%) patients, colonic polyps in 3 (2.5%) patients and one case each of telangiectasia and Crohn's disease. CONCLUSION: Colonoscopy has very high diagnostic yield and would be recommended in the workup of patients presenting with bleeding per rectum. Ulcerative colitis was the leading cause of bleeding per rectum in this study; while infrequent findings of Crohn's disease, polyps and diverticuli indicate that these are uncommon in this region.

Halothane induced fulminant hepatic failure.

A rare case of halothane-induced fulminant hepatic failure is reported in a 22 years old male, who developed fever, jaundice, coma and deranged coagulation profile, 2 days after undergoing laparotomy under halothane anaesthesia. Despite all supportive care, he died of fulminant hepatic failure, 6 days after surgery. Postmortem liver biopsy revealed massive predominantly centrilobular hepatic necrosis.

Nutritional profile and inflammatory status of stable chronic hemodialysis patients at Nephrology Department, Military Hospital Rawalpindi.

BACKGROUND: Protein-energy malnutrition (PEM) is common in the haemodialysis population. Identification and management of these patients can result in significant reduction in morbidity and mortality. Aim of the study was to find the prevalence of PEM in otherwise stable haemodialysis patients at Military Hospital Rawalpindi at a single point in time with the help of established biochemical and physical markers. MATERIAL AND METHODS: Height, dry weight and body mass index (BMI) were recorded for 64, stable, 14-75 year-old patients who were on haemodialysis for > or = 3 months. Blood samples were drawn (pre-dialysis) for complete blood count, serum C-reactive protein, serum total protein, serum albumin and serum Creatinine. Ideal body weights and BMI were obtained from Pakistan Army Selection and Recruitment standards. RESULTS: Out of 64 patients 43 (67%) were males. Mean age was 44.5 +/- 14.3 yr. Mean haemoglobin was 8.84 +/- 2 g/dl. Fifty-seven patients (89%) had haemoglobin < or = 11 g/dl. Pearson correlation coefficient (r) with albumin was significant (p = 0.01). The mean serum albumin was 34.2 +/- 4.25 g/l. Serum albumin of less than 40 g/l in 58 patients (90.6%). C-Reactive protein was available for 58 (90.6%) of patients. It was positive in 23 (35.9%) and was associated with a lower mean serum albumin (32.7 g/l vs 35.4 g/l) which was statistically significant (p = 0.017). There was no significant relationship between the lymphocyte count and albumin levels. However, the Pearson correlation of albumin with the total WBC count gave ap value of 0.05. Mean BMI was 19.8 +/- 2.9 kg/m2. Thirty-seven (57.8%) patients had BMI in the normal range (18.5-24.6 kg/m2) and 24 (37.5%) were below normal (14.6-18.3 kg/m2). Correlation of albumin with BMI and serum creatinine was not significant (p = 0.46 and 0.53 respectively). CONCLUSION: Serum albumin is a strong marker of malnutrition but needs to be associated with other physical and inflammatory parameters to correctly identify malnourished haemodialysis patients.

Hyperventilatory capacity--a predictor of altitude sickness.

BACKGROUND: The aim of the study was to document link between hyperventilatory capacity and risk for developing acute mountain sickness (AMS). METHODS: This study was carried out at Karakorum Mountain ranges (Northern areas of Pakistan) from March till July 2004. 54 healthy male subjects were enrolled in this study. Arterial oxygen saturation (SpO2) of the subjects was measured by the pulse oximeter at rest and after 1 minute of voluntary hyperventilation at an altitude of 2833 meters. Symptoms of acute mountain sickness (AMS) were recorded on a questionnaire by using the Lake Louise consensus scoring system 24 hours after ascent to high altitude. RESULTS: Mean pre hyperventilation oxygen saturation (SpO2) was 94.07 + 0.26% whereas SpO2 after 01 minute of hyperventilation was 98.61 + 0.14% that was significantly increased (p<0.001). The mean increase in percent oxygen saturation of hemoglobin after one minute of hyperventilation (hyperventilatory capacity) for the study group was 4.61 +/- 0.24 % while the mean symptom score was 2.06 +/- 0.26. It was noted that 19 (35.2%) subjects did not develop AMS whereas 34(63.0%) subjects had mild AMS and only one subject developed moderate AMS. There was no case of severe AMS. The data reveals significant (P<0.01) association between hyperventilatory capacity and development of the symptoms of AMS (r = -0.664). It is evident that individuals with greater hyperventilatory capacity manifest less number of symptoms of mountain sickness. CONCLUSION: It is concluded that post hyperventilation increase in oxygen saturation at lower altitude may help to predict the susceptibility of subjects to develop high altitude sickness.

Hepatitis A virus infection -- shifting epidemiology.

OBJECTIVE OF THE STUDY: To determine the age distribution in HAV infection and seasonal variations in the prevalence of acute viral hepatitis caused by hepatitis A virus. STUDY DESIGN: A descriptive study. PLACE AND DURATION: The study was carried out on the patients reporting at Virology Department, Armed Forces Institute of Pathology (AFIP), Rawalpindi, for determination of hepatitis A virus (HAV) IgM antibody, from July 2003 to June 2004. PATIENTS AND METHODS: Altogether 626 patients with clinical suspicion of hepatitis A virus infection were referred to AFIP Rawalpindi for this test. Blood samples were collected and sera were separated and transferred to plastic aliquots that were stored at -20 degrees C in a retrievable fashion until utilized in testing. The testing for ant-HAV IgM was carried out with the help of a commercial Enzyme Linked Immunosorbant Assay (ELISA) using reagent kits of DiasSorin (Germany) for HAV IgM antibodies. RESULTS: The HAV IgM positive rate was 40.57% (252/626). Those tested included the sporadic cases as well as the patients from outbreak in two schools of Nowshera cantonment. The age of patients testing positive for HAV IgM, ranged from 03 to 27 years. There was a statistically significant seasonal difference in rate of positivity in different months of the calendar year. An outbreak of HAV infection was seen in the children of two neighboring schools of a cantonment, in which 44 children in different classes developed clinical jaundice. CONCLUSION: HAV infection occurs in a significant proportion of young people with a clinical suspicion of HAV infection. There is a changing trend of developing hepatitis A in the age beyond 18 years and in outbreaks, which was not there in our patients previously due to universal immunity found against HAV by the age of 18. It was because of chances of consumption of polluted food.

Clinicopathological features of lupus anticoagulant; experience at AFIP during last seven years.

BACKGROUND: The lupus anticoagulant (LA) belongs to family of immunoglobulins, most commonly an IgG isotype. These antibodies have been identified most frequently in association with thromboembolic events, recurrent fetal loss and thrombocytopenia. The aim of the present study was to evaluate the presenting clinical and pathological features in patients LA positive presenting at AFIP Rawalpindi over the period of Jan 1993 to Nov 2000. MATERIAL/METHODS: Retrospective analysis of patients presenting with positive LA was carried out. RESULTS: 1583 suspected cases were screened for LA including 1370 females and 213 males. 1024 cases presented with history of recurrent abortions, 292 with thrombosis, 152 with thrombotic strokes before the age of 45 years, 52 with thrombocytopenia and 63 with miscellaneous disorders. Out of 1024 patients tested for recurrent abortions, 130 (13%) females were positive for lupus anticoagulant. Ten (6.5%) of 152 patients presenting with strokes were found positive. Out of 292 cases presenting with thrombosis 17 (5.9%) were found positive. CONCLUSIONS: The lupus anticoagulant prevalence in Pakistani patients with recurrent fetal loss, stroke and thrombosis is statistically significant. Clinicians should be made aware of association of LA with various diseases. The successful management of these patients depends upon close liaison with obstetricians, physicians and haematologists.

Risk factors in high altitude pulmonary oedema.

OBJECTIVE: To identify the risk factors for high altitude pulmonary oedema. DESIGN: A case control study. PLACE AND DURATION OF STUDY: The study was conducted in the Department of Medicine, Military Hospital, Rawalpindi during October 1998 to October 2000. SUBJECTS AND METHODS: One hundred serving army personnel between 20 to 50 years of age were divided in two groups. First group comprised of 50 patients who developed high altitude pulmonary oedema at 4000 meters height and above. Second group consisted of 50 control subjects who accompanied the patients. Detailed history was obtained regarding height of native dwelling, rate of ascent, amount of exertion and preceding respiratory tract infection. The findings of both the groups were compared and statistically analyzed by application of Pearson's chi-square test. Difference was considered significant when p-value was < 0.05. RESULTS: All the subjects were male. Average age of the indexed group was 29.4(+/- 4) years as compared to 27(+/- 5) years in the control group. Six patients (12%) were highland dwellers whereas 44 patients (88%) were inhabitants of lower heights. Average rate of ascent from 4000 meters to 4500 meters of the indexed group was 5(+/- 2) days while in control group it was 10(+/- 3) days. Twenty cases (40%) had history of severe exertion whereas such history was not present in any of the control group subjects. Only 2 patients had signs and symptoms of preceding respiratory tract infection. CONCLUSION: Rapid rate of ascent, extreme physical exertion, low height of native dwelling and preceding respiratory tract infection are important risk factors for the development of high altitude pulmonary oedema. Proper acclimatization with gradual ascent plays important role in preventing this potentially fatal condition.