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

Lactate Dehydrogenase Like Crystallin: A Potentially Protective Shield for Indian Spiny-Tailed Lizard (Uromastyx hardwickii) Lens Against Environmental Stress?

Taxon specific lens crystallins in vertebrates are either similar or identical with various metabolic enzymes. These bifunctional crystallins serve as structural protein in lens along with their catalytic role. In the present study, we have partially purified and characterized lens crystallin from Indian spiny-tailed lizard (Uromastyx hardwickii). We have found lactate dehydrogenase (LDH) activity in lens indicating presence of an enzyme crystallin with dual functions. Taxon specific lens crystallins are product of gene sharing or gene duplication phenomenon where a pre-existing enzyme is recruited as lens crystallin in addition to structural role. In lens, same gene adopts refractive role in lens without modification or loss of pre-existing function during gene sharing phenomenon. Apart from conventional role of structural protein, LDH activity containing crystallin in U. hardwickii lens is likely to have adaptive characteristics to offer protection against toxic effects of oxidative stress and ultraviolet light, hence justifying its recruitment. Taxon specific crystallins may serve as good models to understand structure-function relationship of these proteins

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\u3c0.001), 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

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\u3c0.05). 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\u3c0.05).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

Učinak zamjene obroka od pšeničnih mekinja obrokom sa sjemenkama kima na nesenje, kvalitetu jaja i masnokiselinski profil u kokoši nesilica

The objective of the present study was to investigate the effect of substituting wheat bran (WB) with cumin seed meal (CSM) on laying performance, egg quality characteristics and egg-yolk fatty acids profile in laying hens. A total of 180 Bovans hens at 55 weeks of age were divided randomly into three treatments. The CSM was incorporated into a standard corn- and soybean meal-based diet by replacing 0, 50, and 100% of WB [i.e., 100% WB (control), 50% WB+50% CSM and 100% CSM] from 55 to 61 weeks of age. Body weight was measured at the beginning and end of the experiment. Feed intake, hen-day egg production and egg weight were recorded daily. At 61 weeks of age, 30 eggs were taken at random from each treatment group to determine the egg quality characteristics. Replacing 100% of WB by CSM did not affect body weight, however, hen-day egg production, egg weight and egg mass significantly increased, while feed conversion ratio significantly decreased (P<0.05). Haugh unit, shell thickness and yolk color significantly increased by CSM substitution in comparison with 100% WB. Plasma concentrations of total cholesterol, triglycerides, LDL-cholesterol and glutamic oxalacetic transaminase (GOT) significantly decreased by replacing WB with CSM, while, plasma HDL-cholesterol significantly increased. Furthermore, the liver malondialdehyde (MDA) concentration significantly decreased, while vitamin E, linoleic acid and alpha-linolenic acid significantly increased (P<0.05) due to CSM inclusion. Therefore, it could be concluded that substitution of WB with CSM could improve laying performance and egg quality characteristics, and reduce lipid peroxidation in laying hens.Cilj ovoga rada bio je istražiti učinak zamjene obroka s pšeničnim mekinjama (WB) obrokom sa sjemenkama kima (CSM) na nesenje, kvalitetu jaja te profil masnih kiselina u žumanjku jajeta kokoši nesilica. Ukupno je 180 Bovans kokoši u dobi od 55 tjedana slučajnim odabirom podijeljeno u tri pokusne skupine, u kojima su sjemenke kima dodane u standardni obrok s kukuruzom i sojom zamjenjujući 0, 50 i 100 % pšeničnih mekinja. Tako je kontrolna skupina hranjena obrocima sa 100 % pšeničnih mekinja, druga skupina s 50 % obroka s pšeničnim mekinjama i 50 % obroka sa sjemenkama kima, a treća skupina obrokom koji je sadržavao 100 % sjemenki kima. Pokusno razdoblje je trajalo od 55. do 61. tjedna starosti nesilica. Tjelesna je masa mjerena na početku i na kraju pokusa. Unos hrane, dnevna proizvodnja jaja i njihova masa bilježili su se svaki dan. U dobi od 61 tjedna iz svake je skupine slučajnim odabirom uzeto 30 jaja kako bi se odredila njihova kvaliteta. zamjenjujući 100 % obrok od pšeničnih mekinja sjemenke kima nisu utjecale na tjelesnu masu, no ipak su dnevna proizvodnja, težina i masa jaja znakovito porasle, dok se stopa konverzije hrane znakovito smanjila (P<0,05). Haugh-ova jedinica, debljina ljuske i boja žumanjka znakovito su porasle u skupinama u kojima su pšenične mekinje zamijenjene sjemenkama kima u odnosu na kontrolnu skupinu. Ukupni kolesterol, trigliceridi, LDL-kolesterol i glutaminska oksalooctena transaminaza (GOT) znakovito su sniženi u skupinama u kojima su pšenične mekinje zamijenjene sjemenkama kima, dok je HDL-kolesterol znakovito povišen. nadalje, koncentracija malondialdehida (MDA) u jetri znakovito je snižena, dok su vitamin E, linolna i alfa-linolna kiselina znakovito porasli (P<0,05) uslijed dodanih sjemenki kima. Može se zaključiti da zamjena obroka s pšeničnim mekinjama obrokom sa sjemenkama kima može poboljšati nesenje i kvalitetu jaja te smanjiti lipidnu peroksidaciju u kokoši nesilica

Presentation with Personality changes and Tinnitus to a Vascular Intervention: Rare case of Carotid Body Paraganglioma

Background:&nbsp;Carotid body paragangliomas are rare neuroendocrine neoplasms of chromaffin negative glomus cells. This case report explains an atypical case with unusual presentation and treatment. Case Report: A healthy smoker technician by profession was brought to the emergency room (ER) with coprolalia. The general physical exam did not reveal any information. His history revealed unilateral tinnitus and odynophagia leading to a consultation by the neurologist with head imaging. Acoustic neuroma was ruled out and the caregiver was asked to elaborate the events mentioned in the history and a psychiatric examination was done. The personality changes were evaluated by the psychiatrist that showed overlapping of delirium and depression. The patient was further examined by a vascular surgeon. After careful revisiting of the history, examination and indication of tender mass in the neck by the patient's vascular surgeon, the diagnosis of carotid body paraganglioma was made which was followed by surgical resection for treatment. Conclusion:&nbsp;Carotid Body Paragangliomas are very vascular structures and their manipulation in a surgery setting requires expertise.&nbsp;This case presented with personality changes and tinnitus, a very less likely event to occur in a carotid body tumor. The present care report, thus adds on to the literature of carotid body tumors and its presenting symptoms

Subcutaneous emphysema and pneumomediastinum in patients with COVID-19 disease; case series from a tertiary care hospital in Pakistan

Since December 2019, the clinical symptoms of coronavirus disease 2019 (COVID-19) and its complications are evolving. As the number of COVID patients requiring positive pressure ventilation is increasing, so is the incidence of subcutaneous emphysema (SE). We report 10 patients of COVID-19, with SE and pneumomediastinum. The mean age of the patients was 59 ± 8 years (range, 23-75). Majority of them were men (80%), and common symptoms were dyspnoea (100%), fever (80%) and cough (80%). None of them had any underlying lung disorder. All patients had acute respiratory distress syndrome on admission, with a median PaO2/FiO2 ratio of 122.5. Eight out of ten patients had spontaneous pneumomediastinum on their initial chest x-ray in the emergency department. The median duration of assisted ventilation before the development of SE was 5.5 days (interquartile range, 5-10 days). The highest positive end-expiratory pressure (PEEP) was 10 cmH2O for patients recieving invasive mechanical ventilation, while 8 cmH2O was the average PEEP in patients who had developed subcutaneous emphysema on non-invasive ventilation. All patients received corticosteroids while six also received tocilizumab, and seven received convalescent plasma therapy, respectively. Seven patients died during their hospital stay. All patients either survivor or non-survivor had prolonged hospital stay with an average of 14 days (range 8-25 days). Our findings suggest that it is lung damage secondary to inflammatory response due to COVID-19 triggered by the use of positive pressure ventilation which resulted in this complication. We conclude that the development of spontaneous pneumomediastinum and SE whenever present, is associated with poor outcome in critically ill COVID-19 ARDS patients

Vocational Schools and Regional Development in China

This paper investigates the different impacts of vocational schools and universities on regional development in China. To account for a possible two-way causality between education and economic development, a system of supply and demand equations is introduced. The results show that vocational education has higher impact on regional development than university education in China. Concerning the reverse causality, the paper finds that effect of regional development on university education is higher than its effect on vocational school education

How vital are the vital signs? a multi-center observational study from emergency departments of Pakistan.

BACKGROUND: Vital signs play a critical role in prioritizing patients in emergency departments (EDs), and are the foundation of most triage methods and disposition decisions. This study was conducted to determine the frequency of vital signs documentation anytime during emergency department treatment and to explore if abnormal vital signs were associated with the likelihood of admission for a set of common presenting complaints. METHODS: Data were collected over a four-month period from the EDs of seven urban tertiary care hospitals in Pakistan. The variables included age, sex, hospital type (government run vs. private), presenting complaint, ED vital signs, and final disposition. Patients who were \u3e12 years of age were included in the analysis. The data were analyzed to describe the proportion of patients with documented vitals signs, which was then crossed-tabulated with top the ten presenting complaints to identify high-acuity patients and correlation with their admission status. RESULTS: A total of 274,436 patients were captured in the Pakistan National Emergency Department Surveillance (Pak-NEDS), out of which 259,288 patients were included in our study. Vital signs information was available for 90,569 (34.9%) patients and the most commonly recorded vitals sign was pulse (25.7%). Important information such as level of consciousness was missing in the majority of patients with head injuries. Based on available information, only 13.3% with chest pain, 12.8% with fever and 12.8% patients with diarrhea could be classified as high-acuity. In addition, hospital admission rates were two- to four-times higher among patients with abnormal vital signs, compared with those with normal vital signs. CONCLUSION: Most patients seen in the EDs in Pakistan did not have any documented vital signs during their visit. Where available, the presence of abnormal vital signs were associated with higher chances of admission to the hospital for the most common presenting symptoms

Sociodemographic, clinical characteristics, and outcomes of influenza pneumonia patients admitted in a tertiary care hospital in Karachi, Pakistan: Findings from a cross-sectional study

Objective: To determine the sociodemographic, clinical characteristics, and outcomes of influenza pneumonia patients in tertiary care hospital, Karachi Pakistan.Study design: A cross-sectional study.Place and duration of study: The Aga Khan University Hospital Karachi Pakistan from January 2013 to December 2018. Methodology: All adult patients who were older than 18 years and suspected to have viral pneumonia were included in the study. Data were abstracted on 105 patients and were entered on preformed proforma after reviewing the files of patients.Results: Ninety-four (89.5%) patients were influenza positive and 15.2% (n=16) had been vaccinated. Around 92.4% (n=97), 81.9% (n=86) and 61.9% (n=65) patients had cough, fever and shortness of breath, respectively; and 63.8% (n=67), 16.2% (n=17), and 2.9% (n=3) patients had consolidation, nodules, and cavitation, respectively. Almost 91.4% (n=96) patients were given treatment and discharged home; however, 7.6% (n=8) died. Procalcitonin, creatinine, HCO3 , lactate, and bilirubin level were increased in 2nd group (mortality group) after 48 hours; however, the results were only significant for HCO3 (p = 0.035).Conclusion: Influenza pneumonia is very common in our population and older people are more likely to be affected by this disease. Patients can be prevented from adverse outcomes and complications, if diagnosed and treated in time