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Objective: To determine the effect of thymic response to COVID-19 pneumonia on imaging and its impact on disease severity and outcome. Study Design: Cross-sectional study. Place and Duration of Study: Armed Forces Institute of Radiology and Imaging (AFIRI), Rawalpindi Pakistan, from Mar to Jul 2020. Methodology: A total of 1620 COVID-19 patients above the age of 18, of either gender, were included in the study. Their findings on High-Resolution CT (HRCT) chest were recorded and graded according to the CT severity score (CTSS) out of a total of 40; less than or equal to 19 was taken as mild while >20 scores were considered as severe disease. The thymic response was assessed by imaging appearance on CT and was graded from 0-3 as follows: fatty, predominantly fatty, mixed density (fat and soft density), and soft density. Fatty replacement implied thymic involution, while soft density depicted a reactivation of thymic tissue after a disease process depictive adequate thymic response. Results: A significant difference in thymic response was observed in patients of different age groups (p<0.001), with the younger age group demonstrating thymic reactivation/ response in the majority (170/244, 69.7%). CT severity score and mortality were significantly higher in older patients demonstrating poor thymic response to COVID pneumonia. Conclusion: Response of the thymus to acute viral infection by Sars COVID-19 is impaired as age progresses; this accounts for greater disease severity, morbidity and mortality in older patients.

Objectives: To assess the validity of pre-test evaluation of patients with Modified Wells score at our facility to improve diagnostic yield of CT pulmonary angiography for pulmonary embolism. Study Design: Prospective longitudinal study. Place and Duration: Department of Computed Tomography, Armed Forces Institute of Radiology & Imaging, Pak Emirates Military Hospital, Rawalpindi Pakistan, from Feb to Jul 2019. Methodology: After approval from the Ethical Review Board, 60 patients with clinical suspicion of pulmonary embolism were selected. Modified Wells score was calculated for each patient, and a senior consultant reviewed their CT Pulmonary Angiograms. Results: Sixty patients were assessed from February to July 2019. Pulmonary embolism was diagnosed in 21(35%) patients; 22(37%) patients were unremarkable, while alternate diagnosis was provided for 17(28%) patients. Modified Wells score was 66.6% sensitive and 74.3% specific for diagnosis of pulmonary embolism, with a positive predictive value of 58.3% and a negative predictive value of 80.5%. Conclusion: Modified Wells score carries a good negative predictive value for ruling out pulmonary embolism. Hospitals must devise their departmental protocol utilizing risk stratification tools, lab tests and other safer imaging alternatives, where applicable.

This paper embeds a bi-fold contribution for Underwater Wireless Sensor Networks (UWSNs); performance analysis of incremental relaying in terms of outage and error probability, and based on the analysis proposition of two new cooperative routing protocols. Subject to the first contribution, a three step procedure is carried out; a system model is presented, the number of available relays are determined, and based on cooperative incremental retransmission methodology, closed-form expressions for outage and error probability are derived. Subject to the second contribution, Adaptive Cooperation in Energy (ACE) efficient depth based routing and Enhanced-ACE (E-ACE) are presented. In the proposed model, feedback mechanism indicates success or failure of data transmission. If direct transmission is successful, there is no need for relaying by cooperative relay nodes. In case of failure, all the available relays retransmit the data one by one till the desired signal quality is achieved at destination. Simulation results show that the ACE and E-ACE significantly improves network performance, i.e., throughput, when compared with other incremental relaying protocols like Cooperative Automatic Repeat reQuest (CARQ). E-ACE and ACE achieve 69% and 63% more throughput respectively as compared to CARQ in hard underwater environment.

Objective: To determine the frequency of aspergilloma in clinically diagnosed and undiagnosed patients of cavitatory pulmonary tuberculosis. Study Design: Cross-sectional study. Place and Duration of Study: Armed Forces Institute of Radiology, and Imaging Rawalpindi Pakistan, from May to Oct 2019. Methodology: Total of 236 patients with clinically diagnosed or having suspicion of cavitatory pulmonary tuberculosis were included. High-resolution computed tomography showing a single or multiple well defined cavities within consolidation with cavities having aspergilloma, nodules with tree in bud configuration in upper lobes of lung or superior segments of lower lobes were recorded. Results: Out of these 236 patients, 140(59.32%) were males and 96(40.68%) were females. The age of patients ranged from 18- 70 years with mean age of 43.56±10.13 years. In our study, aspergilloma in clinically diagnosed and undiagnosed patients of cavitatory pulmonary tuberculosis was found in 27(11.44%) patients. Conclusion: This study revealed that incidence of aspergilloma in clinically diagnosed and undiagnosed patients of cavitatory pulmonary tuberculosis is quite high.

Objective: To compare the effectiveness of plasma D-dimer levels with findings of 128-slice spiral computed tomography pulmonary angiography (CTPA) in patients with clinical suspicion of pulmonary embolism. Study Design: Retrospective observational study Place and Duration of Study: Department of Computed Tomography, Armed Forces Institute of Radiology & Imaging, Pak Emirates Military Hospital Rawalpindi, from Jan 2018 to Dec 2018. Methodology: A total of 59 patients were inducted who presented in Emergency Department, Pak Emirates Military Hospital Rawalpindi with clinical suspicion of Pulmonary Embolism. The main symptoms were shortness of breath and chest pain. Plasma D-dimer levels of all patients were sent to laboratory and CTPA was performed at Computed Tomography department, Armed Forces Institute of Radiology & Imaging using 128-slice spiral computed tomography. Results: 36 patients (61%) were males and 23 (39%) were females with an average age of 48.03 ± 18.06 years (range 23-85 years). Out of 59 patients, D-dimer levels were raised in 28 cases (47.4%) while 31 patients (52.6%) showed normal levels. Pulmonary Embolism was detected by CTPA in 30 cases (50.8%) while 29 patients (49.2%) were without obvious abnormality. Conclusion: Plasma D-Dimer levels show low sensitivity, specificity and negative predictive value and cannot exclude Pulmonary Embolism without CTPA. Computed Tomography Pulmonary Angiography (CTPA) remains diagnostic modality of choice for definitive assessment of Pulmonary Embolism in patients reporting at the emergency reception.

Neonatal jaundice, particularly unconjugated hyperbilirubinemia, is a common condition that can lead to bilirubin-induced neurologic dysfunction (BIND) if severe. Physiological jaundice is typically benign, but exaggerated forms may necessitate interventions like phototherapy or exchange transfusion. This study aimed to determine the incidence and contributing factors of exaggerated physiological jaundice requiring exchange transfusion in neonates. This retrospective case series analyzed medical records from January 2020 to January 2023 at Northwest General Hospital, Peshawar. Neonates with physiological hyperbilirubinemia (serum bilirubin ≥17 mg/dL) who underwent exchange transfusion were included. Data on demographics, clinical signs, feeding, and laboratory findings were extracted using a structured tool and analyzed with IBM SPSS Statistics for Windows, version 25. Out of 136 neonates with exaggerated physiological jaundice, 20 (14.7%) required exchange transfusion. The mean age at presentation was 5.2 ± 1.9 days. Males constituted 61.9%, and 81.0% were full-term. Exclusive breastfeeding was reported in 76.2% of cases. The mean total serum bilirubin at admission was 26.52 ± 7.7 mg/dL, reducing to 14.16 ± 2.6 mg/dL post-transfusion. Exclusive breastfeeding (76.2%), low birth weight (23.8%), and prematurity (14.3%) were identified as leading factors. A significant proportion (14.7%) of neonates with exaggerated physiological jaundice required exchange transfusion. Exclusive breastfeeding, low birth weight, and prematurity were common contributing factors. These findings highlight the importance of early identification, close monitoring, and targeted management to reduce the need for aggressive interventions in this vulnerable population.

In this paper, we propose innovative schemes for relay selection that jointly explore packet selection and relay selection for buffer-aided amplify and forward (AF) cooperative relaying networks. The first proposed scheme chooses the most suitable channel based on link quality from all active channels, i.e., channels with neither empty nor full corresponding buffers. In the second proposed scheme, the most suitable channel is chosen based on buffer status. When the source-relay channel is determined, the corresponding relay collects data in the buffer. Likewise, when the relay-destination channel is picked, the most suitable packet is dispatched from the buffer. The most suitable packet is one that provides the highest end-to-end equivalent signal-to-noise ratio. We simulated the outage probability, average throughput and packet delay and analyzed the proposed protocol for both symmetric and asymmetric channel conditions. Comparison is made against the existing buffer-aided schemes. The results show that the proposed relay and packet selection systems help to reduce the outage probability, diversity gain and delay.

Objective: To determine the diagnostic accuracy of cerebrospinal fluid lactate level in confirmed cases of acute bacterial meningitis in children Methods: This cross sectional study was conducted in the Department of Paediatrics, King Edward Medical University/ Mayo Hospital, Lahore from January to December 2018. A total of 250 children, between two months - 12 years of age, of both the genders, with suspected acute bacterial meningitis were included by non-probability consecutive sampling. Each child was subjected to lumbar puncture for biochemistry, cytology, culture, and lactate level. CSF lactate level of 1.1-2.4 mmol/L was taken as normal, and >2.4 mmol/L was taken as cut off for acute bacterial meningitis. All collected data was entered and analyzed in SPSS version 22. A 2 x 2 table was made to calculate diagnostic accuracy, sensitivity, specificity, positive and negative predictive value for CSF Lactate. Results: The sensitivity, specificity, positive predictive value, negative predictive value and diagnostic accuracy of CSF lactate taking CSF culture as gold standard was 100%, 60.61%, 17.27%, 100% and 63.6% respectively, with kappa of 0.19 and p value of 0.000. Conclusion: At a cut off value of 2.4 mmol/L, cerebrospinal fluid lactate level has a high diagnostic accuracy for acute bacterial meningitis. doi: https://doi.org/10.12669/pjms.36.7.1682 How to cite this:Nasir H Afzal MF, Hamid MH, Laeeq A. Diagnostic accuracy of cerebrospinal fluid lactate in confirmed cases of acute bacterial meningitis in children. Pak J Med Sci. 2020;36(7):1558-1561. doi: https://doi.org/10.12669/pjms.36.7.1682 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Objective: To review all the patients of spinal dysraphism referred to our center over a three year period in order to identify the most typical neuro-radiological appearances on Magnetic Resonance Imaging. Study Design: Cross sectional study. Place and Duration of Study: Armed Forces Institute of Radiology and Imaging, Rawalpindi from Jan 2016 to Dec 2018. Methodology: MR spine reports of 144 patients of spinal dysraphism were retrospectively analyzed. Age, gender, indication for MRI, operative status, and neuro-radiological features (including site and type of lesion) were recorded for these patients. Results: Congenital spinal malformations were more frequent among females87 (60.4%) and between 0-20 years 135 (93.9%) of age. Tethered cord 97 (67.4%) was the most common congenital spinal abnormality followed by spina bifida, diastematomyelia, vertebral segmentation anomalies, myelomeningocele, menigocele. Lip-myelomeningocele, lipoma of filum terminale, and sacral agenesis. Frequently observed associated abnormalities included scoliosis 61 (42.4 %), syrinx 47 (32.6%) and dural ectasia 40 (27.8 %). Conclusion: Congenital spinal malformations are usually complex with variable radiological appearances. Modern high resolution MRI screening is the examination of choice for identification, preoperative evaluation, and long term follow up of such congenital anomalies.

The pharmaceutical sector in Pakistan has grown over a period with export potential, however, there are certain barriers in the framework that regulate the growth and export of domestically manufactured pharmaceuticals. The purpose of this study was to highlight the current challenges that hinder the export of pharmaceuticals, especially to the countries with stringent regulatory authorities (SRA), as perceived by the domestic pharmaceutical industry experts, and to highlight the facilitators that may help to resolve the identified challenges. In a qualitative study, the data were collected from the consented experts from the pharmaceutical industries in Lahore, Karachi, Peshawar, and Quetta. Industrial experts with a minimum of 10 years of experience and who were serving at managerial levels or above were recruited through purposive sampling. The semi-structured interviews were conducted for the collection of data from industrial experts. Thematic content analysis was applied to conclude the data. Data analysis generated 4 themes and 16 codes. The export of pharmaceuticals, despite having greater potential was regarded as poor, which was attributed to the following: (a) inadequate industrial research and development, particularly on new molecules (b) non-compliance with the cGMP standards, (c) absence of high-tech equipment, (d) unwillingness of the pharmaceutical companies for bioequivalence studies on their generics, (e) unavailability of locally manufactured active pharmaceutical ingredients, (f) disruption in the supply of imported raw material, (g) poor international market perception about local pharmaceutical products and (h) lack of support from regulatory in process expedition. The respondents also suggested the measures for overcoming the above challenges to boost the export of domestic pharmaceuticals and expand their international market share in countries with SRA. Export from Pakistan to the SRA countries can be enhanced with mandatory bioequivalence studies during generic registration. The pharmaceuticals export could effectively contribute to the national economy.