Combined Military Hospital Lahore Research Articles

Observational Study on Adherence to modified Clinical and Laboratory Standard Institute H3-A6 Guidelines on Blood Sampling Procedures

Background: The accuracy of clinical laboratory results is paramount for effective patient diagnosis and treatment. However, errors in the pre-analytical phase, particularly during phlebotomy, significantly impact the reliability of laboratory data. With the Clinical and Laboratory Standards Institute (CLSI) guidelines serving as a benchmark for best practices in blood collection, adherence to these standards is crucial for minimizing errors. Objective: This study aimed to assess compliance with modified CLSI guidelines in phlebotomy procedures within a healthcare setting and identify the most prevalent errors in the pre-analytical phase that could compromise patient safety and the integrity of laboratory results. Methods: Conducted at the Combined Military Hospital Lahore from January to March 2023, this observational study scrutinized phlebotomy practices across three distinct healthcare settings: emergency department, outpatient department, and clinical wards. A structured checklist, adapted from the European Federation for Clinical Chemistry and Laboratory Medicine (EFLM) guidelines and aligned with local modifications, was employed to evaluate compliance in 20 specific areas of phlebotomy practice. A total of 285 phlebotomies were observed by specialized staff, with data analyzed using SPSS version 25 to compare error frequencies and compliance rates across different settings and among various healthcare professionals. Results: The study revealed an overall compliance rate of 88% for identified request forms, 76% for patient identification according to local guidelines, and 66% for proper hand sanitization. However, significant errors were identified in checking for potential complications of venipuncture (34% compliance), with tubes being clearly under or overfilled (46% compliance), and in verifying that patients were prepared for phlebotomy (46% compliance). The error frequency varied across settings, with the highest discrepancies observed in the emergency department. Differences in compliance rates between laboratory staff and nurses were statistically significant in key areas, including patient identification (p<0.001) and tube labeling (p=0.081). Conclusion: The study highlights a critical need for improving adherence to CLSI guidelines within phlebotomy practices to enhance patient safety and the accuracy of laboratory results. Targeted educational and training interventions are essential for addressing the identified gaps in compliance, particularly in patient identification, sample volume control, and verification of patient preparation for phlebotomy.

Diagnostic Accuracy of Heart Type Fatty Acid Binding Protein and Conventional Cardiac Troponin I in Early Diagnosis of Acute Myocardial Infarction

Background: Acute myocardial infarction (AMI) remains a leading cause of global morbidity and mortality, with early diagnosis being crucial for effective treatment and improved patient outcomes. The search for reliable early biomarkers to supplement traditional cardiac markers has been ongoing, with heart-type fatty acid-binding protein (H-FABP) emerging as a potential candidate due to its rapid post-ischemic release into the bloodstream. Objective: This study aimed to evaluate the diagnostic accuracy of H-FABP in comparison to conventional cardiac troponin I for the early detection of AMI in patients presenting with acute chest pain. Methods: A descriptive cross-sectional study was conducted at the Chemical Pathology Department of Combined Military Hospital Lahore from December 21, 2022, to April 21, 2023. Eighty patients presenting with symptoms suggestive of AMI were enrolled. Serum concentrations of H-FABP and cardiac troponin I were measured using the sandwich ELISA method. Diagnostic performance was assessed in terms of sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and receiver operating characteristic (ROC) curves. Statistical analysis was performed using SPSS version 25. Results: H-FABP demonstrated a sensitivity of 96.2%, specificity of 60.0%, PPV of 91.3%, and NPV of 81.8%. In contrast, cardiac troponin I had a sensitivity of 81.3% and a specificity of 60.0%, with PPV and NPV values of 91.3% and 81.8%, respectively. The area under the ROC curve (AUC) for H-FABP was 0.640 (p=0.031), slightly higher than that for cardiac troponin I, which was 0.624 (p=0.057). Conclusion: H-FABP shows promise as a more sensitive early biomarker for AMI compared to cardiac troponin I, suggesting its potential utility in enhancing early diagnosis and improving patient care. However, its lower specificity highlights the need for its combined use with traditional markers for a more accurate diagnosis.

NEONATE WITH PNEUMONIA CAUSED BY BURKHOLDERIA CEPACIA COMPLEX – A STITCH IN TIME

As rightly said, a stitch in time saves nine. On 22 November 2022, a neonate was brought by his parents to emergency department of Combined Military Hospital (CMH) Lahore, on third day of his life with symptoms of breathlessness for last two days and poor feeding for last one day. Baby was delivered by emergency Cesarean-section owing to premature rupture of membranes at 38 weeks of gestation, at a private medical center at Borewala, Punjab and the Apgar Score was 10/10. The diversity of etiology of neonatal respiratory distress paused a greater challenge for targeted management. Along with various radiological and laboratory investigations, single blood culture specimen taken by the microbiology team at CMH Lahore, timely and rightly identified the causative pathogen Burkholderia cepacia complex. Neonate was treated according to Antibiotic Sensitivity Testing (AST) given and was discharged from hospital as a healthy baby.

Validation of “TOPRS” Score to Predict Outcome in Paediatric Patients in a Tertiary Care Hospital of Pakistan

Objective: To validate a clinical scoring system for defining the severity of ailment that will assist in developing strategies for management prioritisation. Study Design: Cross-sectional analytical study. Place and Duration of Study: Paediatric Department, Combined Military Hospital Lahore, Pakistan, form Jan 2020 to Jul 2021. Methodology: The paediatric patients who reported to the Medical Reception Centre and were admitted to an Inpatient Facility were enrolled. Demographic profile, temperature, oxygen saturation, pulse, respiratory rate, seizures, and sensorium labelled as “TOPRS” score was recorded with “0 – Normal” and “1 – Abnormal” and scores calculated for each patient with the incorporation of systemic inflammatory response and advanced paediatric life support criteria. Results: A total of 300 paediatric patients with an age range of 1-18 years (mean: 3.86±5.43) were included. Of 300 patients, 237(79%) were discharged after improvement, and the mortality rate was 63(21%). A significant association with the mortality rate was deciphered with temperature, oxygen saturation, and respiratory rate variables. In contrast, pulse rate, sensorium, and seizures were concluded to have an insignificant association. Score “0” mortality was associated with the 4.4% mortality, whereas score “5” enumerated an 80% death rate. Conclusion: The TOPRS clinical scoring system has significant value in the diagnosis of mortality and morbidity of paediatric patients and, hence, can assist in early recognition and triage of patients, consequently aiding in the provision of prioritisation protocols and management in a befitting manner.

Sub-conjunctival injection of 5 Fluorouracilversus Bevacizumab in Treatment of Primary Pterygium

Purpose: To compare effectiveness and safety of 5 Fluorouracil versus Bevacizumab as sole therapy in the treatment of primary pterygium. Study Design: Quasi-experimental study. Place and Duration of Study: Combined Military Hospital Lahore, from January 2022 to January 2023. Methods: A total of 64 patients were included and divided into 2 groups of 32 patients each. Group A patients received monthlyinjection of 0.1ml, Fluorouracil(5FU) for 3 months while 3 injections of 0.1ml Bevacizumab were administered in group B. Primary outcome measure was effectiveness (defined as improvement in Pterygiumgrade), at 4 weeks following the administration of last injection. Patients were examined for pterygium grading as well as any side effects of injections on each follow up visit. Data analysis was done bySPSS, Version 23.0. Results: Mean age of patients in group A was of 33.53±11.3 yearsversus 30.97±12.6 years in group B with a range of 15–55 years. There were 45 (70.3%) males and 19 (29.7%) females. Improvement was seen in 21 patients (65.6%) in group A, as compared to only 2 (6.3%) in group B. There was a significant difference in pterygium improvement between the two groups (p<0.001). Conclusion: 5 Fluorouracil is more effective than Bevacizumab as sole therapy in treatment of primary pterygium but equally safe in terms of side effects.

Impact of Comorbid Conditions on Severity of Dengue Fever: A Comparative Study

Objective: to identify the comorbid conditions associated with an increased risk of severe Dengue in clinically diagnosed patients with Dengue viral infections.
 Study Design: Comparative cross sectional study.
 Place and Duration of Study: Dengue ward, Department of Medicine, Combined Military Hospital Lahore, from Oct to Nov 2021.
 Methodology: Three hundred patients with confirmed Dengue infection were enrolled in the study. These patients were divided into two groups: 150 patients with comorbids (diabetes mellitus, hypertension, ischemic heart disease) and 150 patients without comorbids. The impact of comorbid conditions on the severity of dengue fever was studied.
 Results: Seventy-three out of the 300 patients had Dengue Fever without warning signs, while 79 out of the 300 patients had Severe Dengue Fever. Almost half of the patients (148) 300 had Dengue Fever with warning signs. The mean age of participants is 45.62±14.06 years. Patients with diabetes mellitus were more likely to develop Dengue without warning signs. Patients with hypertension were more likely to develop severe Dengue.
 Conclusion: This study showed that comorbid conditions such as Diabetes and Hypertension are important risk factors for developing severe Dengue.

Frequency of High Cup to Disc Ratio amongst Healthy Young Population of Central Punjab Province of Pakistan

Objective: To determine the frequency of high cup-to-disc ratio amongst the healthy young population of the Central Punjab province of Pakistan. Study Design: Cross-sectional study. Place and Duration of Study: Department of Eye, Combined Military Hospital Lahore, from Jun 2022 to Feb 2023. Methodology: One hundred fifteen candidates who presented for medical fitness examinations were enrolled; they all belonged to the Central Punjab province of Pakistan. All the participants underwent thorough ocular examination, including visual acuity testing, slit lamp bio-microscopy, fundoscopy and tonometry. Candidates with a cup-to-disc ratio >0.6 were further investigated to rule out glaucoma using pachymetry, visual field (VF) testing and spectral-domain optical coherence tomography.Results: The mean age of participants of the study was 18.97±2.60 years. There were 72(62.6%) males and 43(37.4%) females.The mean intraocular pressure was 13.08±2.40 mmHg. The mean cup-to-disc ratio was calculated to be 0.34±0.11. It was found that 7 out of 115(6.1%) participants have a cup-to-disc ratio of more than 0.6, whereas the remaining 108(93.9%) participants had less than 0.6 cup-to-disc ratio. Conclusion: The screened population revealed a high cup-to-disc ratio in 6.1% of the candidates.

SERUM FERRITIN; A STRONG NON-INVASIVE PREDICTOR FOR NAFLD PROGRESSION

Objective: To determine and compare serum ferritin in non-alcoholic fatty liver disease (NAFLD) patients of our ethnicity and to find a predictive value of serum ferritin in designating the progression of the disease. Study Design: Cross-sectional diagnostic study Place and Duration of Study: Shalamar Hospital and Combined Military Hospital Lahore Pakistan, from Mar to Jul 2019. Methodology: On abdominal ultrasonography and raised LFTs, age, gender and BMI matched 129 subjects were classified as cases and controls. After that NAFLD fibrosis score (NFS) was calculated in the cases who had hyper-echoic liver margins and later subjects were divided into 43 healthy controls (group A), 66 subject with steatosis (group B) and 20 subjects with steatohepatitis (group C). Fasting serum ferritin, insulin, glucose levels were measured and HOMA-IR was calculated using {Glucose (mg/dl) × insulin (μlU/ml) / 405} formula. Data was entered and analysed on SPSS version 21. For group compari...... Results: There was a significant difference between the serum ferritin among all the groups. Area under the curve of serum ferritin for group B and group C were 0.603 and 0.885 and serum ferritin levels of ≥40.75 ng/ml with sensitivity of 94% and specificity of 69% were declared to be of the best diagnostic value. While the value of ≥67.55ng/ml of serum ferritin is the best predictor ......... ... Conclusion: Serum ferritin has a good positive predictive value.

Barriers to Research Perceived by Medical Students of Private Medical College, Lahore- Pakistan

Aim: To identify the major barriers to conducting research perceived by medical students and their association with various years of study and gender. Methodology: This was an analytical cross-sectional study conducted from 9th March 2021 to 6th June 2021. It was conducted among the medical students of all years studying in Combined Military Hospital Lahore Medical College (CMHLMC) & Institute of Dentistry (IOD). Non- probability convenient sampling technique was used. The questionnaire was self-administered and data was analyzed by using SPSS version 20.0.Descriptive statistics of qualitative variables were calculated as frequencies and percentage. Chi-square test of significance was used to see impact of gender and year of study on barriers perceived. P value<0.05 was considered statistically significant. Results: There was significant difference in barriers perceived by male and female students (p <0.05). The most prevalent barrier in males was extracurricular activities (p=0.001) while major barrier in females was fatigue (p=0.006). Prevalence of barriers was found to be greater among students of 2nd year MBBS (39.3%) and 4th year MBBS (31.3%).The most significant barrier among 2ndyear MBBS was fatigue (p=0.006) while in 4th year MBBS the common barriers perceived were lack of previous exposure (p=0.003), uncooperative colleagues (p=0.003) and finding a mentor (p=0.018). Practical implications: By using this research as a template we can identify ways in which our education system can probe about flaws in promotion and execution of research among students and how to rectify these so that more students can be urged to go forth in medical field as competent researchers so to advance current methods of treatment and bring forth new queries .Pakistan being a third world country is in dire need of young medical professionals who can bring about a new perspective in field of medicine and we can only do so by facilitating them . This article will give an insight in the current difficulties faced by students whether from personal or administrative point of view which is proving to hinder their progress. Conclusion: The results of study showed that major barriers perceived by medical students were curriculum overload, finding a mentor, lack of previous exposure to research. There was significant difference in barriers perceived by various classes and males and females. Keywords: Barriers, medical students, research, gender, medical research, Pakistan, curriculum

Determining Awareness of Vitamin D Necessity, Deficiency and its Appropriate Attainment among Medical undergraduate students of a private medical college: A Descriptive cross-sectional study

Aim: To assess the awareness of the necessity, deficiency of vitamin D, and knowledge about its appropriate attainment among the medical students at Combined Military Hospital Lahore Medical College (CMH LMC) Methods: The study undertaken was an observational cross-sectional one conducted among the medical students of CMH LMC. A structured questionnaire was distributed among the medical students from first-year to fifth-year levels. The questionnaire consisted of two parts. The first part was based on socio-demographic information like age, sex, nationality, and the second half were based on questions regarding awareness of the benefits, deficiency and, attainment of Vitamin D. Results: The results were likely to highlight the mean awareness score with poor and good awareness identified among medical students. The questionnaire evaluated awareness regarding the main source and dietary source of vitamin D like milk, cheese, and fish; factors that affect vitamin D manufacture; the influence of vitamin D on health, and effects of its deficiency on body health; identifying high-risk groups; and significance of supplements in overcoming deficiency. Practical implication: The study would help increase and improve awareness of vitamin D necessity and deficiency issues among medical students. The awareness in the new generation of professionals can impact the evolution of future health education programs, policy development, the construction of social rules, and views about health and health-endorsing attitudes. Conclusion: The study concluded that the respondents were more aware of the necessity of vitamin D (M = -.05) and less aware of the deficiency and attainment level of vitamin D. (M = -.32; M = -.36) respectively. Keywords: Vitamin D, awareness, deficiency, attainment, medical students, health

Comparison of Characteristics of Methotrexate Tolerant and Intolerant Patients Having Rheumatoid Arthritis

Objectives: To compare the characteristics of methotrexate-tolerant and intolerant patients having rheumatoid arthritis. To determine the association of methotrexate intolerance with the patient and disease-related factors. Method: This cross-sectional study was carried out at the rheumatology department of Combined Military Hospital Lahore from 31st April to 30th June 2022. It included 181 rheumatoid arthritis (RA) patients using methotrexate (MTX) for > 3 months. Patient demographic variables, disease duration and activity, and information regarding MTX intake were recorded. English methotrexate intolerance severity score (MISS) questionnaire was used to calculate MTX intolerance. Different variables were compared between methotrexate-tolerant and intolerant patients. Association of age, disease duration, and activity, MTX route/dose with MTX intolerance was determined. Results: The majority of patients were females 140(77%). The median disease duration was 6(1-40) years. MTX intolerance was found in 48(26.5%) of RA patients. Intolerant patients had a higher disease activity score (DAS 28>5.1 in 20.8 vs 3.8%; P = 0.002) and longer duration of MTX intake in months (23.5 vs 12; p=0.018) compared to tolerant patients. Additionally, MTX intolerance was associated with younger age, longer disease duration and higher MTX dose>10mg/wk (P=0.007, P=0.025, P=0.050). There was no significant difference between the two groups in gender, marital status, education, and use of other DMARDs or steroids. (P >0.05). Conclusion: There was a significant association between age, disease duration, and MTX dose with MTX intolerance. We also noted a significant association between disease activity and route of intake with MTX intolerance but this was lost when adjusted for multiple confounders.

Relationship between the ABO blood group and Rhesus factors with COVID-19 susceptibility

ABSTRACT Introduction The molecular research has raised copious hypotheses about different molecular effects on the variable expression of the current virus on the human body. The present prospective study aims to determine clinically as well as statistically, the relation between ABO blood groups and Rhesus (Rh) factor and the severity of the Covid-19 virus. Research design and methods We conducted a prospective, single-centered study at The Combined Military Hospital Lahore, Pakistan. Details of only those patients who exhibit COVID-19 symptoms were included. The odds ratios with a 95% confidence interval and the chi-square test of blood groups and Rhesus factor was also conducted individually with the severity of disease, outcomes, and respiratory symptoms. P-values less than 0.05 was considered significant. Results The chi-square test and odd ratio yielded no significant results when the covid-19 status was compared with the Rhesus factor (p-value > 0.05). However, the results were found to be significant when associations were run between Covid-19 status and all the blood groups (p-value < 0.05). Conclusion According to the analytical results of the present study, protective nature of all the blood antigens (A, B, AB, none) was observed in patients presenting with Covid-19 symptoms of varying severity.

Pre-Operative Evaluation of Petrous Temporal Bone Pathologies by CT and MRI in Cochlear Implant Candidates

Aim: To evaluate pathologies of the petrous temporal bone in cochlear implant candidates on CT and MRI preoperatively. Methods: A cross-sectional study was conducted at Combined Military Hospital Lahore from Jan 2014 to April 2016. 163 candidates were evaluated on CT and 149 were evaluated on MRI. All patients belonged to pediatric age group. Pathologies were grouped using classification of Sennaroglu &amp; Saatci and every pathology was sought in all the cases ensuring that the pathologiesare not missed. Results: High-resolution CT scan temporal bone revealed 69.9% normal studies. Chronic otitis media with mastoiditis was major abnormality observed in 16.6% of cases. Unilateral mastoiditis was seen in 6.1% of patients. Bilateral CSOM without mastoiditis was seen bilaterally in 1.8% of cases. While unilateral CSOM was observed 0.6 % of patients. Among inner ear malformations, Mondini malformation was seen in 4 cases (2.5%). A high jugular bulb was seen in 2 cases (1.2%).93.3% of cases were labeled as normal study on MRI. Four cases showed Mondini malformation. Infective process of middle ear showed a cumulative frequency of 2.7%. Inner ear aplasia was found in one patient. Sclerosing labyrinthitis was also found in one case. Conclusion: Both CT and MRI have substantial role in pre-operative evaluation of petrous temporal bone in cochlear implant candidates. Preoperative evaluation of petrous temporal bone by CT scan and MRI successfully identifies pathologies which can be absolute or relative contraindications of the cochlear implant as well as conditions in which surgical procedure needs to be modified. Keywords: Cochlear implants, HRCT temporal bone, MRI cochlea, Mastoiditis, Mondini malformation

Bacterial Co-infections and Susceptibility patterns among admitted COVID 19 patients during 3rd wave of pandemic, in a Tertiary Care Hospital. Lahore.

Objective: To check the Bacterial Co-infections and Susceptibility patterns among admitted COVID-19 patients during 3rd wave of pandemic. Study Design: Descriptive Cross Sectional study. Setting: Department of Microbiology, Combined Military Hospital Lahore Pakistan. Period: May 2021 to August 2021. Material &amp; Methods: Six hundred and twelve COVID-19 positive patients having positive bacterial cultures were processed, Antibiotic susceptibility testing was done by Kirby-Bauer diffusion technique, all antibiotics were reported using breakpoints recommended in clinical and laboratory standards institute (CLSI 2021). Results: Out of 612 patients, 348 (56.9%) were male and 264 (43.2%) were female. Mean age of the patients was 57.2 ± 14.4 years with a range of 22 to 89 years. Bacterial coinfection was present in 70.4% of the patients. Gram negative bacteria (94.4%) were more prevalent in COVID-19 patients as compared to gram positive isolates (5.6%). Antibiotic sensitivity pattern of Staphylococcus aureus showed a high resistance against penicillin, ampicillin, tetracycline and doxycycline. Conclusion: Our study reported a high prevalence of bacterial coinfections in COVID-19 patients infected during the third wave of pandemic. A high percentage of gram negative species were identified in our study population, this could be due to the suppression in the immunity of individuals due to severity of COVID-19 infection and already present Antimicrobial resistance.

The Spectrum of Oesophagal Varices, Portal Hypertensive Gastropathy and Child Pugh’s Class in Cirrhotic Patients at Tertiary CareHospital

Objective: To find the association of Child-Pugh’s Class with oesophagal varices and portal hypertensive gastropathy in cirrhotic patients at CMH Lahore.&#x0D; Study Design: Cross sectional study&#x0D; Place and Duration of Study: Department of Gastroenterology and Department of Pathology, Combined Military Hospital Lahore Pakistan, from Feb to May 2021.&#x0D; Methodology: All patients with cirrhosis of the liver, irrespective of aetiology, who underwent upper gastrointestinal endoscopy, were included in the study. Lab data was retrieved from the Pathology Department to calculate Child Pugh’s score. Endoscopic findings of oesophagal varices and portal gastropathy were recorded and their correlation/association with Child-Pugh’s Class was calculated separately by using Pearson’s coefficient.&#x0D; Results: A total of 148 patients were included in the study. Male patients were 90(60.8%) and female were 58(39.2%). The age range was 27-85 years, with the mean of patients being 55.93±13.19 years. Association of Child Pugh’s Class with oesophagal varices and portal hypertensive gastropathy revealed that higher grades of oesophagal varices (Grade-lll) and severe portal hypertensive gastropathy were found in Child Pugh’s Class-B (13.51%, 14.18%) and C (15.54%, 16.2%) as compared to Class- A (4.72 %, 1.35%). Child-Pugh’s Class positively correlates with both oesophagal varices and portal hypertensive gastropathy by Pearson’s coefficient r=0.594 and 0.035, respectively; both have significant p values (p &lt;0.05).&#x0D; Conclusion: Child-Pugh’s Class has a positive correlation with both oesophagal varices and portal hypertensive gastropathy in patients with cirrhosis

Post COVID-19 Pandemic Generalized Anxiety Status of Health Professional undergraduate students

Aim: To assess the psychological impact of COVID-19 on mental status of undergraduate medical students, after reopening of educational institutions. Methods: This descriptive, online cross-sectional study was conducted on medical students of Combined Military Hospital Lahore Medical College &amp; Institute of Dentistry, Lahore Pakistan for 6 months from 1st June to 30th November, 2021. Generalized Anxiety Disorder Scale (GAD-7) was used as the study tool. Data was analyzed by using statistical software SPSS - 23. Frequencies and percentages were used for descriptive variables. A univariate analysis was utilized to identify the noticeable associations between traits of sample and the anxiety level in current scenario of COVID-19 pandemic. Finally multivariate logistic regression analyses, odds ratio (OR), and Spearman's correlation coefficient, r, was used to evaluate the association between COVID-19-related stressors and anxiety level. Results: Of the 324 respondents, majority were females residing in urban areas with their parents. Severe anxiety was experienced by 23.8% of students. Female respondents were found to have more anxiety as compared to males (OR = 1.81; 95% CI = 1.173 – 2.815). Moreover, respondents having a relative or an acquaintance infected with COVID-19 reported to have more anxiety (OR = 3.007, 95% CI = 2.377 - 3.804). Conclusion: A significant number of students are experiencing anxiety in the post COVID-19 phase, especially those that had an acquaintance infected with COVID-19. There is a need to look after student's mental health and to implement appropriate psychological strategies and interventions to deal with this level of psychological distress in the students at this phase of pandemic for optimum training of future health professionals. Keywords: Anxiety, COVID-19, healthcare professionals, mental health, medical students, pandemic

The role of bone marrow biopsy in patients with pyrexia of unknown origin

Background: Pyrexia of unknown origin (PUO) is a major complication which remains undiagnosed. Different diagnostic test were used to arrive at final investigation. Bone marrow biopsy (BMB) plays a vital role in diagnosis of PUO. The objective of current study was to determine the role of bone biopsy in diagnosing various types of causes of pyrexia of unknown origin.&#x0D; Patients and methods: A prospective cross-sectional study was conducted from 1st September 2018 to 28th February 2019 at Department of Hematology, Combined Military Hospital Lahore, Pakistan. The data of 120 patients who were remained undiagnosed for at least 1 week were enrolled. Standard procedures were used to obtain the biopsy specimens and bone marrow aspiration was sent for microbiological examination. All the demographic information was kept on a structured self-designed proforma. Data was entered and analyzed using SPSS v.24.&#x0D; Results: Out of 120 patients recruited in the study there were 67 (55.8%) were from age group 16 to 35 years, were males (65.8%) and 65.0% patients were suffering from fever for more than 3 days. The majority of the participants (30%) were diagnosed with infections, fever due to reactive changes (10.0%), acute leukemia (14.2%), lymphoma (11.7%), chronic leukemia (10.0%), aplastic anemia (4.2%), multiple myeloma (2.5%) and 11.7% patients were undiagnosed&#x0D; Conclusion: In the diagnosis of pyrexia of unknown origin, morphological and histological investigation of bone marrow plays a vital role. However, if it is combined with other diagnostic modalities such as radiological, microbiological, and serological examinations, the efficiency of diagnosis can be improved.

A young soldier with Susac syndrome: a case report

BackgroundSusac syndrome is a rare disease with multisystem manifestations. While the exact pathogenesis is not known, it has been proposed to be an autoimmune endotheliopathy affecting the microvasculature of the brain, retina, and inner ear. The disease is characterized by a triad of encephalopathy, vision loss, and hearing loss. However, patients may not have the triad at initial presentation and present with only a single finding.Case presentationA 25-year-old male resident of Panu Akil presented to Combined Military Hospital Lahore with complaints of dizziness and vertigo associated with severe migraine like headaches. He experienced sudden painless loss of vision in his right eye and was admitted to the medical intensive care unit. On examination, he had right-beating nystagmus and diplopia along with scintillating scotoma. After his admission, contrast-enhanced magnetic resonance imaging (MRI) was done which showed numerous enhancing bilateral white matter internal capsule micro-infarcts indicating typical “string of pearls” sign and a snowball lesion on the corpus callosum. His fundus fluorescein angiography (FFA) did not exhibit any branched retinal artery occlusions (BRAO). Fundoscopy showed the presence of drusen spots. His pure tone audiometry was unremarkable. Based on the highly characteristic findings present on the MRI, a diagnosis of Susac syndrome was made. He was started on injection methylprednisolone 1 gm IV in 500 ml normal saline over 1 h once a day for 5 days and then once a week for 8 weeks. He was also started on tablet mycophenolate mofetil 500 mg once daily for 7 days. Patient showed marked clinical improvement afterwards.ConclusionsSusac syndrome is a rare multisystem illness with an often insidious presentation. Patients can be misdiagnosed due to the nonspecific nature of the early complaints present in the disease. High index of suspicion is required for timely diagnosis and adequate management. Although no specific guidelines exist, management consists mainly of immunosuppressants.

Chronic Kidney Disease Patients: Collateral Damage Due to Suspension of Vascular Access Services

This study was conducted at the Department of Vascular Surgery at Combined Military Hospital Lahore from December 2019to June 2020. The mortality of patients on the waiting list for vascular access in our institution three months afterimplementing strict policies for elective surgeries (30th March 2020 to 29th June 2020) was compared with the preceding threemonths. The mortality of patients in the pre-COVID-19 periods on the waiting list for HD was 11 (7.9%) in the pre-COVID-19 period, while this increased to 5 (12.5%) in the post-COVID-19 period. COVID-19 related suspension of vascular access services negatively influences CKD patients waiting for permanent vascular access.

Frequency of Cervical Ribs in Healthy Asymptomatic Adolescents and Adults, Detected on Chest Radiograph for Medical Fitness Examination at CMH Lahore

Objective: To determine the frequency of cervical ribs on chest radiographs of asymptomatic candidates undergoing medical fitness.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Radiology Department Combined Military Hospital Lahore Pakistan from Feb 2020 to Mar 2021.&#x0D; Methodology: The study was conducted on 4247 chest radiographs of candidates who reported to CMH Lahore for medical examination. The latest chest radiographs of candidates reporting for medical examinations in the CMH Lahore were included. Technically poor radiographs were excluded.&#x0D; Results: The frequency of cervical ribs was 136 (3.2%) with 14 (5.6%) females and 122 (3.1%) male cases. Among cervical ribs cases, 85 (62.5%) were bilateral, and 51 (38%) were unilateral. Among unilateral cervical ribs, 28 (55%) were right-sided, and 23 (45%) were on the left side.&#x0D; Conclusion: The frequency of cervical ribs is comparatively higher than in most international studies. The frequency of bilateral cervical ribs and type 4 cervical ribs are higher in females than males.