Covid-19 Vaccination: A Bird’s Eye View

Covid-19 pandemic plagued this world since the beginning of 2020 AD. It is caused by a new positive-strand RNA virus of coronaviridae family [1]. It causes Coronavirus disease 2019 (hence the name COVID-19). It is a contagious disease predominantly causes severe acute respiratory syndrome, hence the name SARS-CoV-2. It started from Wuhan, China, in December 2019. Since then, it has spread globally. It is reported to be a new virus therefore it’s properties, pathogenesis, virulence, immunogenicity, variants, and how will host body will react to this virus was unknown. Despite of 22 months since this virus started to spread worldwide, researchers and clinicians continued to learn about it on daily basis. Newer information about it poured in daily in scientific journals as well as in print / electronic media. Mostly, newer information continued to negate earlier information. Social media disinformation continued to confuse the masses.

Is The Theoretical Knowledge Reflected in Current Practice: Histopathological Helicobacter Pylori Research?

Objective: Helicobacter pylori (H. pylori) is considered in the category of biological agent directly responsible for cancer. Guidelines recommend discontinuing suppressive conditions prior to histopathological helicobacter pylori testing, but there is little clinical trial data on how outcome is affected if this is not done. Optimal test recommendations in the guidelines are based on in vitro study results. In present study, we aimed to observe whether there was a difference in the prevalence of H. pylori histopathologically in patients who met the necessary prerequisites before Esophago-Gastro-Duodenoscopy (EGD) compared to the subjects group who did not meet the PPI discontinuation condition. Materials & Methods: This retrospective study was conducted between October 2015 and August 2016 in a reference hospital with 1.5 million hinterlands. Patients who underwent EGD by meeting all the prerequisites recommended by the guidelines for the H. pylori test were included in the study group (n=213), and those who discontinued other suppressive drugs except PPI were included in the control group (n=193). Results: While H. pylori was found to be 74.6% positive in the study group that provided all the prerequisites for histopathological H. pylori detection, H. pylori was found to be 64.9% positive in the control group continuing to receive PPI treatment (p=0.02). Conclusion: In conclusion, we suggest that it is necessary to proceed with the guidance of classical knowledge in determining the presence of H. pylori, which is a common public health problem that is up-to-date. Keywords: Helicobacter pylori, Suppressive condition, Proton pump inhibitor, Histopathology, Cancer, Guideline.

Comparison of Open Gastrostomy and Percutaneous Endoscopic Gastrostomy in Head and Neck Cancer Patients, Tertiary Care Hospital Experience

Objective: The current study was conducted to review and compare PEG and Gastrostomy in terms of early complications in head and neck cancer patients. Materials and Methods: This was prospective comparative study recruited total 60 patients as per the inclusion criteria, 30 in each group. Patients were assigned to the groups based on the surgeon’s choice. Ethical clearance was taken from ethical review board. Informed consent was taken from patients before enrolling them into the study. Non-probability consecutive sampling technique was used to enroll study participants. Data was collected on pre-designed performa and analyzed using SPSS version 16. Setting: Section of Otolaryngology, Department of Surgery, Aga Khan University Hospital Karachi. Results: The two groups did not differ on basis of age, gender and tumor site. The outcomes variables including pain and bleeding from post-operative day1 to day 5 were significantly lower in patients who underwent PEG placement as compared to patients whom we performed OPEN gastrostomy. None the patient had peristomal infection in PEG group throughout the study. However, difference between the groups was statistically significant from post-operative day 3 to day 5. Conclusion: In our study, PEG was associated with lesser complications than open gastrostomy. Recently clinicians are using newer modalities like radiological and laparoscopic gastrostomy at various centres in Pakistan as the first option for placing feeding gastrostomy. Therefore, future studies are warranted to compare their efficacy and post-operative complications PEG. Keywords: Head and neck cancer, Open gastrostomy, Percutaneous endoscopic gastrostomy, Complications, Pain, Peristomal infection, Bleeding

Pediatric Chronic Myeloid Leukemia with Megakaryocytic Blast Crisis as Initial Presentation: Case Report and Review of Literature

Background: Pediatric Chronic Myeloid Leukemia (CML) is a rare entity accounting for 2-3% of pediatric malignancies. CML rarely presents as Blast Crisis (BC) at the time of diagnosis, and megakaryocytic blast crisis is even rarer. Case Presentation: We herein, report a case of a young female, 10-year-old who presented with anemia, leukocytosis and massive splenomegaly. Clinical features, peripheral film and bone marrow findings were consistent with CML in megakaryocytic blast crisis. Bone marrow cytogenetic analysis revealed karyotype of 46, XX, t(9:22)(q34;q11.2) in 20 metaphases and BCR-ABL P210 by PCR was detected with transcript level of 83%, which further confirmed our diagnosis. Conclusion: De novo presentation of chronic myeloid leukemia with megakaryocytic blast crisis is rarely observed in pediatric population with very few cases published till now. We are presenting this case because of its rarity, likelihood of misdiagnosis as AML (M7) and poor prognosis, if not treated precisely. Keywords: Chronic Myeloid Leukemia (CML), Acute Myeloid Leukemia (AML), Blast Crisis (BC), Acute Megakaryocytic Leukemia (AMKL), Chronic Phase (CP), Accelerated Phase (AP), Tyrosine Kinase Inhibitor (TKI).

Clinicohematological Characteristics and Survival Analysis of Aplastic Anemia in Pakistan; A Single Centre Experience

Objective: Aplastic anemia (AA) is characterized by pancytopenia and hypocellular bone marrow. Several factors like infections, toxins, chemotherapeutics and radiations are known causes for the suppression of hematopoietic cells which results in bone marrow failure but the exact etiology is unknown. The current study was conducted to assess the baseline demographics, laboratory and clinical characteristics of patients presenting with aplastic anemia and evaluate their cytogenetic profile. Materials and Methods: A retrospective cohort study conducted at National Institute of Blood Diseases and Bone Marrow Transplantation after approval by Institutional Ethics Committee. In this study, AA patients were enrolled from January 2010 to December 2018. Data collection included demographic, laboratory and clinical characteristics including age, gender, symptoms, treatment, and blood counts. Cytogenetic analysis was performed on bone marrow samples. Data analysis was done by using SPSS version 23. Results: Based on camitta classification, a total of 362 aplastic anemia patients were enrolled in the study. The frequency of severe aplastic anemia was most common 199(55%). Median and interquartile range (IQR) age of overall patients was 17(11-26) years, for children and adult population it was 12(9-14) years and 28 (21-43) years respectively. Male predominance was observed i.e.251(69%). The most common presenting complaint was fever 202(55.8%). The median and IQR of hemoglobin (Hb) was 7.8(5.8-9.4)g/dl, MCV 90(83-91)fl, total leucocyte count (TLC) 2.6 (1.9-3.6) × 109/l, absolute neutrophil count (ANC) 0.64 (0.27-1.2)×109/l and platelet count 13 (5-27) ×109/l. Bone marrow cytogenetics was done and 76 (67%) patients were found to have normal karyotype. CMV was positive in 24(6.6%). Majority of patients were treated with blood transfusion and supportive care only 230(64%) and the survival rate was 84%. Conclusion: In conclusion, the study represents a large cohort of aplastic anemia in the country. Majority of cases were acquired aplastic anemia predominantly being severe aplastic. Limited numbers of patients opted for standard treatment options probably due to financial reservations to afford standard treatments like immune suppression therapy and hematopoietic stem cell transplant. Further, local studies with larger number of sample size and provision of standard treatment options are needed to explore the treatment response, etiological factors, prognosis and outcomes. Keywords: Aplastic anemia, Cytogenetics, Clinicohematological characteristics, Laboratory analysis, Survival outcome, Pakistan.

Diagnostic Performance of Three Serological Assays for Anti-SARS-CoV-2 Antibody Detection

Objective: To evaluate the diagnostic performance of Electrochemiluminescence (ECLIA) enzyme linked immunosorbent (ELISA) and lateral flow Immunofluorescence (LFIA) for anti-SARS-COV-2 antibody detection. Materials and Methods: Sensitivity was calculated with convalescent plasma (CP) donor’s samples. Specificity was checked by using pre-pandemic October 2019 samples. All samples were tested for anti-SARS-COV-2 antibody by using Electrochemiluminescence (ECLIA), Enzyme Linked Immunosorbent Assay (ELISA) and Lateral flow Immunofluorescence (LFIA) assay. Results: Total 55 patients were included, 45 patients were CP donors and 10 were Pre-Pandemic October 2019 samples archived from our blood bank. The ECLIA-total antibody, ELISA-IgG and LLFIA-IgG were positive in 41 (91.1%), 34 (75.5%) and 44 (97.75%) respectively. The highest sensitivity was observed for LFIA with highest specificity among all three assays. There was almost perfect agreement between LFIA and ECLIA (k=0.936, p<0.001) but there was fair agreement between LFIA and ELISA (k=0.412, p=0.001) and ECLIA and ELISA (k=0.357, p=0.001). Conclusion: The LFIA showed a higher sensitivity and specificity in comparison with ECLIA and ELISA. It might be due to fact that LFIA detect antibody against ncleocapsid and spike protein as well of SARS- COV-2 virus, while ECLIA and ELISA detects antibodies only against “N” Protein of SARS- COV-2 virus. Keywords: Convalescent plasma donors, Lateral flow Immunofluorescence assay, Electrochemiluminescence assay, Enzyme linked immunosorbent assay, Performance.

A Case Report: An Overweight Patient with High Dose Insulin Usage

Insulin is vital for patients with type 1 diabetes and useful for certain patients with type 2 diabetes [1]. In this article we aim to explain a case wrongly using high dosage insulin. A 68-year-old female patient with known 10 years of type 2 diabetes mellitus and hypertension came to our outpatient clinic because her blood glucose levels were high at home. She was using perindopril 10 mg, metformin and insulin. Since the patient did not want to make multiple injections her previous doctor has changed her therapy from glargine u300 1x50 units and insulin aspart 3x30 units to a mixed insulin; insulin degludec + insulin aspart, as 2x 40 units per day. However, the patient did not understand the change of treatment and made the combination of insulin glargine u300 1x50 units and insulin degludec + insulin aspart two times a day as 30 units. She was using this therapy more than two months. Diabetes and complications of diabetes is a challenging healthcare problem. Especially patients’ education is as important as the drug therapy [2, 3]. Among serious side-effects of insulin therapy are overdose, resulting in severe hypoglycemia, causing seizures, coma and even death [1]. Patients must be well educated about the risks of using high doses of insulin. Keywords: High dose insulin, Obesity, Type 2 diabetes mellitus, Patient education, Hypoglycemia, Insulin overdose

Variceal Bleeding in Patients with Initation of Sofosbuvir and Ribavirin – Case Reports

Sofosbuvir is an oral nucleoside analogue and potent inhibitor of the Hepatitis C virus (HCV) RNA polymerase that is used in combination with other antiviral agents to treat chronic Hepatitis C Nevertheless, and for unknown reasons, successful antiviral therapy of Hepatitis C with Sofosbuvir and other direct acting agents in patients with cirrhosis is occasionally complicated by hepatic decompensation. Here we describe 2 case report of upper gi bleed at initial days of treatment with Sofosbuvir and Ribavirin. Keywords: Variceal bleeding , Sofosdbuvir, Ribavirin, Heptitis C, Nucleoside analogue, Antiviral.

Median Arcuate Ligament Syndrome: An Exceptional Cause of Abdominal Pain

Median Arcuate Ligament Syndrome (MALS) is caused by the compression of celiac artery by median arcuate ligament and may cause serious symptoms; such as abdominal pain and weight loss. Here we present a 56 year old man with MALS, whom suffered of postprandial abdominal pain, weight loss, nausea and vomiting. Laparoscopic surgery revealed his symptoms after MALS diagnosis was established. In conclusion, MALS should be considered in the differential diagnosis of patients with complaints of postprandial abdominal pain, nausea and weight loss. Laparoscopic surgery could be as successful as other treatment options in these patients. Keywords: Median arcuate ligament syndrome, Postprandial abdominal pain, Laparoscopic surgery, Nausea, Celiac disease, Coronary artery disease.