Extraosseous Ewing Sarcoma Manifesting as an Acute Abdomen in a Young Adult Male: a Case Report.

Ewing sarcoma is a tumor primarily affecting children and young adults, and usually affects long bones. Extraosseous Ewing sarcoma (EES) is a rare primary tumor of soft tissues. We present a case of abdominal EES with metastasis to thoracic cavity, which presented as abdominal pain and vomiting in a 21-year-old previously healthy gentleman.

Post-Intensive Care Syndrome - An Opportunity For Collaborative Transition Between the Intensive and Primary Settings.

Critical care advancements have allowed clinicians to discover the many functional disabilities that survivors suffer. Recent research has focused on improving the long-term outcomes of critical illness survivors and optimizing their functional recovery. Post-intensive care syndrome (PICS) describes the disability that remains in those surviving critical illness following discharge from the intensive care unit (ICU). This comprises impairment in cognition, neuropsychiatric health, and physical function of the ICU survivor. Consequent to this, the health of family members of the survivor may also be affected adversely, termed PICS-family. PICS is defined as a new or worsening impairment in physical (ICU-acquired neuromuscular weakness), cognitive (thinking and judgment), or mental health status arising after critical illness and persisting beyond discharge from the acute care setting.

Lower intensity regimens for acute myeloid leukemia: opportunities and challenges.

Acute myeloid leukemia (AML) is an aggressive hematological malignancy for whom most patients a hematopoietic stem cell transplant (HSCT) is the only curative treatment modality. Intensive chemotherapy has been the first-line treatment for AML for many years but has significant morbidity and mortality in elderly patients and those with comorbidities, who constitute the majority of patients with this disease. Since 2017, multiple new lower intensity therapies have been approved for the treatment of AML. Their advantages include decreased hematological and non-hematological side effects, lower rates of infections and the ability to be given in an outpatient setting. For HSCT, reduced intensity conditioning (RIC) regimens have improved for older and comorbid patients, allowing potent graft vs. tumor effects with lower toxicity profiles, resulting in the expansion of this therapy to more patients. More studies are required to improve and refine lower intensity regimens as well as RIC, as they are increasingly utilized in AML treatment.

Impact of COVID-19 in hematopoietic stem cell transplant recipients: A systematic review and meta-analysis.

BACKGROUND: Hematopoietic stem cell transplant (HSCT) recipients are at increased risk of mortality and morbidity with coronavirus disease 2019 (COVID-19) due to severe immune dysfunction. METHODS: A literature search was performed on PubMed, Cochrane, and Clinical trials.gov from the date of inception to 12/08/2021. We identified 19 original studies reporting data on COVID-19 in HSCT recipients after screening 292 articles. Data were extracted following preferred reporting items for systematic reviews and meta-analysis guidelines. Quality evaluation was done using the National Institutes of Health (NIH) quality assessment tool. Inter-study variance was calculated using Der Simonian-Laird Estimator. Pooled analysis was conducted using MetaXL. A random-effects model was used to estimate the proportions with 95% confidence intervals (CI). RESULTS: Of 6711 patients in 19 studies, 2031 HSCT patients with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection were analyzed. The median age of patients was 56.9 (range 1-81.6) years, and 63% patients were men according to 14 studies. The median time from transplant to SARS-CoV-2 infection for autologous (auto) and allogeneic (allo) HSCT patients was 23.2 (0.33-350.5) months and 16.4 (0.2-292.7) months, respectively. The median follow-up time after COVID-19 diagnosis was 28 (0-262) days. The COVID-19 mortality rate was 19% (95% CI 0.15-0.24, I2  = 76%, n = 373/2031). The pooled mortality rate was 17% (95% CI 0.12-0.24, I2  = 78%, n = 147/904) in auto-HSCT patients and 21% (95% CI 0.16-0.25, I2  = 60%, n = 231/1103) in allo-HSCT patients. CONCLUSIONS: HSCT recipients have a high risk of mortality and clinical complications due to COVID-19. There is a need for ongoing vigilance, masks, and social distancing, vaccination, and aggressive management of SARS-CoV-2 infection in HSCT recipients.

Radiological and clinical outcomes in patients undergoing anterior cervical discectomy and fusion: Comparing titanium and PEEK (polyetheretherketone) cages.

OBJECTIVES: To study clinical and radiological outcomes in patients who had undergone the procedure of anterior cervical discectomy and fusion with titanium or PEEK (polyetheretherketone) cages for cervical disc prolapse. METHODS: This is a retrospective/non-randomized study which was conducted at the Combined Military Hospital Peshawar. Study interval was four years from 1st October, 2010 to 31st September, 2014. Total number of included patients were 149. All of the patients had undergone the procedure of anterior cervical discectomy and fusion with titanium or PEEK (polyetheretherketone) cages. All of the patients had plain MRI cervical spine done for diagnosis of anterior cervical disc prolapse. RESULTS: Most of the patients had stenosis at the C5 / C6 (PEEK cage group 63% and titanium cage group 47.6%) and C6 / C7 (PEEK cage group 15.38% and titanium cage group 19.04%) cervical level. Bi-level involvement was also seen. In the patients who complained of brachialgia, total resolution of symptoms was seen after the operation. Three (2.01%) of the patients in titanium cage group, who presented with axial neck pain, continued to complain of pain after the operation. Four (2.6%) of the patients in PEEK (polyetheretherketone) cage group and 2 (1.3%) in titanium cage group complained of pain at the donor site (iliac crest). Fusion rate was 100% with both titanium and PEEK (polyetheretherketone) cages at one year. CONCLUSION: Results with titanium and PEEK (polyetheretherketone) cages are excellent. There was no significant difference in clinical and radiological outcome between two groups of patients (p > 0.05). Fusion rate was 100% at one year with both cages.

The Telemedicine Landscape in Pakistan- Why are we falling behind?

Telemedicine is the provision of healthcare using information and communication technology-based methods. In the past decade, the sector has grown exponentially and become a billion-dollar industry in the developed world. While telemedicine holds the promise to transcend many of the barriers impeding healthcare delivery in emerging markets, unfortunately Pakistan has not been able to obtain any significant benefit from these advancements. The lack of a regulatory framework and lack of interest from the government makes it difficult for new companies to set up projects in Pakistan which will deliver healthcare in innovative, cost-effective ways. A survey conducted across different levels of the medical community showed that only a small minority of the medical community is familiar with the concept and applications of telemedicine. From a business perspective, the landscape is ripe in Pakistan. Since other developing countries have been able to use telemedicine effectively, Pakistan should also look into the options available and catch up soon.

An experience with ventriculoperitoneal shunting at keen's point for hydrocephalus.

OBJECTIVE: This study was conducted to assess outcomes in patients with hydrocephalus who underwent ventriculoperitoneal shunting at Keen's point. METHODS: This retrospective study was conducted in Combined Military Hospital (CMH) Peshawar. Time frame was four years from January 2011 to January 2015. The presenting complaints, clinical findings, investigations, treatment plans and surgical outcomes were noted. Ventriculo-Peritoneal (VP) shunting was done at Keen's point. The presence of shunt complications in the first week post-surgery was noted and at a three-month follow up in the outpatient department. General condition of the patient, shunt complications, presence of seizure and worsening of vision were noted. RESULTS: Study included 143 patients, out of whom 46 were females and 95 were male patients. Most common causes of hydrocephalus were congenital (79). Majority of adults had hydrocephalus due to central nervous system tumors while congenital hydrocephalus in children was most frequently due to aqueductal stenosis. Good clinical improvement was seen in 114 patients after shunt placement, satisfactory in 20 patients, 7 patients died while we observed no change in two patients. CONCLUSION: Our experience with VP shunting at Keen's point resulted in excellent outcomes. It can be used for the management of hydrocephalus both in pediatric as well as adult population.

Disseminated Infection with Multiple Cold Abscesses Caused by Rhizopus Arrhizusin an Immunocompetent Girl.

Although infections with fungi, such as Rhizopus species,usually occur in diabetics or immunocompromised patients, they can also rarely affect immunocompetent individuals. We present a case of disseminated infection with multiple cold abscesses in a 13-year, otherwise healthy girl caused by Rhizopus arrhizus.

Awareness of Hepatitis 'B' Among People of Khyber Pakhtunkhwa Province of Pakistan.

Hepatitis B virus is causing serious health concerns in countries like Pakistan. In Khyber Pakhtunkhwa province, 0.6 milion people were estimated to be infected with this virus in 2008. The authors aimed to assess knowledge regarding vaccination, testing and routes of transmission of hepatitis B virus among people of Khyber Pakhtunkhwa, as such knowledge among masses will help limit the infection. People belonging to 12 different districts of Khyber Pakhtunkhwa province were interviewed over a period of 5 months from October 2013 to February 2014. Apre-tested questionnaire was used and in-person survey of randomly selected 1,938 people was carried out throughout the province. Ninety-nine percent people said they knew about hepatitis B virus and 42% said they had got tested for it too. Out of them, 63.2% knew that a vaccine is available for hepatitis B virus. The proportion of respondents, who said hepatitis B virus can spread by sharing razors, toothbrush, syringes or sexual contact, was 97.94%, 95%, 99.3% and 77%, respectively. Only 28.7% knew, it can also spread vertically from mother to child during childbirth. People were quite aware of the routes of transmission of this disease, but they lacked knowledge regarding vaccination and prevention of this menace. Settings should be set up where routine preventive care and immunization services are provided.

In Vitro Effect of New Antibiotics Against Clinical Isolates of Salmonella Typhi.

OBJECTIVE: To determine the in vitrodisk diffusion and MIC patterns of the therapeutic alternatives for Salmonella Typhi. STUDY DESIGN: Across-sectional study. PLACE AND DURATION OF STUDY: Armed Forces Institute of Pathology, Rawalpindi, from June 2011 to May 2013. METHODOLOGY: Clinical samples were collected from suspected cases of Salmonella infections. Culture was obtained on standard media. Suspected Salmonella colonies were tested by API 20E and confirmed by serology. The isolates were tested for resistance to various antibiotics by Kirby-Bauer disc diffusion method. MIC was done on MDR and ciprofloxacin intermediate or resistant cases by E-strips for selected antibiotics. RESULTS: One hundred and twenty-eight isolates of Salmonella Typhi were recovered from 2230 specimens. Resistance by disk diffusion technique was 72% for ampicillin, 41.2% for cotrimoxazole, 38% for chloramphenicol, 8% for ciprofloxacin, 4.7% for cefpodoxime, 3.5% each for ertapenem aztreonam and moxifloxacin 2.4% for ceftriaxone and 2.3% for doripenem. No resistance was noted for imipenem, cefepime and gatifloxacin. Imipenem MIC90was 0.38 and MIC50 was 0.25. For cefpirome, MIC90was 0.64 and MIC50 was 0.09. For aztreonam, MIC90 was 0.12 and MIC50 was 0.09. For cefpodoxime MIC90 was 0.75 and MIC50 was 0.38. For azithromycin, these values were 16.0 and 7.0; and for tigecycline they were 0.25 and 0.09. CONCLUSION: Imipenem, azithromycin, tigecycline, aztreonam, cefpodoxime and cefpirome are potential therapeutic agents for resistant Salmonella Typhi infection.

Knowledge, Attitude And Practice Of Common Cold And Its Management Among Doctors Of Pakistan.

BACKGROUND: Antibiotic misuse for upper respiratory tract infections such as the common cold is widespread in clinical practice. Excessive prescription of antibiotics by doctors has resulted in increased antimicrobial resistance. This led to our objective of determining the percentage of doctors in Pakistan prescribing antibiotics for the treatment of common cold and to know about their knowledge in preventing the spread of this disease. METHODS: It was a cross-sectional descriptive study, conducted in 9 cities of Pakistan including Rawalpindi, Islamabad, Peshawar, Lahore, Karachi, Faisalabad, Sargodha, Multan and D.G. Khan over a period of 03 months -from October to December, 2013. Questionnaire regarding the disease spread and its treatment was distributed among 300 randomly selected doctors in nine cities of Pakistan from both public and private sector. RESULTS: Eighteen percent of the doctors prescribe antibiotics for common cold. Only 113 (37.7%) doctors correctly responded that mean incubation period for common cold was 1-2 days. Two hundred and nine (69.7%) answered correctly that cold weather increases susceptibility to common cold. Only 84 (28%) responded correctly by choosing that regular and frequent hand-washing with good quality soaps was the most effective way to prevent spread of this disease in day-to-day life. CONCLUSIONS: Antibiotics are being prescribed for treatment of common cold by a large proportion of doctors. There is insufficient knowledge among our doctors regarding the factors which aggravate or alleviate common cold symptoms as well as the methods by which these infections can be prevented.

EXPLORING DEMOGRAPHICS AND OUTCOMES FOR SPINAL TUMOURS FOLLOWING SURGERY IN COMBINED MILITARY HOSPITAL, PESHAWAR.

BACKGROUND: Tumours of the spinal cord, spinal meninges and cauda equina are relatively rare and their spectrum has not been studied extensively in Khyber Pakhtun Khawa province. We describe here the cases of spinal tumours treated in our setup over a period of two years. METHODS: This Descriptive Case Series was carried out with of 80 patients operated in our centre from January 2013 to January 2015. The clinical presentation of these tumours as well as demographic findings was analysed. Patients who underwent surgery for their tumours were included in the study. Patients were selected for surgery depending on their radiological and clinical findings. Lesions that were suggestive of metastasis were biopsied and further care was shared between specialized departments depending on the primary source. RESULTS: Male to female ratio was 1.5:1. Most of the spinal tumours were secondary tumours while meningiomas were the most common primary tumours. Most commonly patients belonged to young age group A (below 30 years.) 32.5%. Most common presentation was with paraparesis (27.5%) and paralysis (25%). A majority of patients regained good neurological function and did not show signs of recurrence at 1 year follow up. CONCLUSION: Given the limited experience at our centre, we believe that a wide range of spinal tumours can be successfully treated provided that clinical end points are kept in mind and treatment is individualized. Frankel grading is useful to assess surgical outcome in the patients.