Objective: To analyze the management of severe necrotizing pancreatitis in a specialized center of a lower middle-income country, Pakistan using multiple outcome measures. Methods: All the patients in this prospective observational study with severe necrotizing pancreatitis being referred to Pak Emirates Military Hospital from January 2017 to December 2019 were followed over the course of their admission. Demographic data and disease outcomes were duly noted. Cox regression analysis was used to predict fatality outcome. Results: A total of 57 patients with 48 (84.6%) infected necrotizing pancreatitis were managed in our set up. The most common etiology reported was gall-stones (37%) with male preponderance (72%) and a mean age of 50±11.3 years. The most common complications were acute-kidney-injury (63%), splenic-vein-thrombosis (21%) and ascites (21%). Fourteen patients required mechanical-ventilation with a mean duration of 7±1.4 days on respiratory support. Eight (14%) patients required Endoscopic-Ultra-Sound guided drainage and six (10.5%) underwent surgical-necrosectomy depending upon the patients’ condition and collections characteristics. Mortality, as one of the main outcome measures, was reported to be 12.3% and was statistically related to mechanical-ventilation, organ failure and surgical-necrosectomy while 22 (38.6%) patients were discharged on pancreatic enzymes supplements and 7% required insulin. Conclusion: Survival outcomes with acute severe necrotizing pancreatitis are improving in a dedicated hepato-biliary unit internationally in lieu with a multidisciplinary team approach. Percutaneous and EUS guided drainage of pancreatic collections have turned out to be an important procedure to manage infected pancreatic necrosis that helps to avoid a morbid procedure in the form of necrosectomy. doi: https://doi.org/10.12669/pjms.37.3.3440 How to cite this:Alam L, Khan RSA, Kazmi SKH, Rafi ud Din. Outcome of patients with acute severe necrotizing pancreatitis in a dedicated hepato-biliary unit of Pakistan. Pak J Med Sci. 2021;37(3):---------.   doi: https://doi.org/10.12669/pjms.37.3.3440 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 assess the prevalence of abnormal radiological changes and their impact on lung function in post tuberculosis cases. Study Design: Descriptive cross-sectional study. Place and Duration of Study: The study was conducted in medical Outpatient Department (OPD) of CMH, Quetta from 30th Nov 2018 to 30th May 2019. Materials and Methods: A total of sixty treated cases of pulmonary tuberculosis, presenting in medical OPD of CMH Quetta for regular follow-up, were included in the study. The subjects were recruited by non-probability consecutive sampling technique according to predefined inclusion criteria. Demographic data including age, gender, post treatment duration, clinical features and history of asthma, atopy, rhinitis, biomass exposure, coalmine exposure, animal and pet exposure was collected. Their lung function was assessed using spirometry and radiological changes were assessed by either chest X-ray or high resolution CT chest. Results: Among the 60 patients, mean age was 36.32 + 9.95 years. The majority (70%) of subjects were males (n=42).The mean duration post treatment was 4.79 + 4.25 years. Among the study population 51.7% (n=31) were symptomatic, 73.3% (n=44) had abnormal lung function tests. With those having abnormal lung functions tests, 23.3% (n=14) had obstructive, 43.3% (n=26) had restrictive and 6.7% (n=4) had mixed airway disease. The radiological investigations were abnormal in 80% (n=48) of the patients showing various radiological changes such as reticular shadows, nodules, pleural thickening, collapse, fibrotic bands, hilar calcifications, lung volume reduction and traction bronchiectasis. Conclusion: Our study showed that the restrictive pattern was most common finding on spirometry while, fibrotic bands were the most common radiological findings in post tuberculosis cases in our population.

Objective: To determine the characteristics of Hepatocellular carcinoma (HCC) in patients visiting PEMH Rawalpindi. Study Design and Setting: Cross-sectional Study conducted at Department of Gastroenterology/hepatology in Pak Emirates Military Hospital Rawalpindi (PEMH) from Oct 2015 to Jan 2018. Methodology: In this study total 100 patients, with HCC of both genders were included. All the cases were discussed in multidisciplinary team (MDT) meetings which were held once every week. A decision on the best possible management for the given case was arrived at in the MDT meeting. All the relevant features of each case were recorded in the Performa. Descriptive statistics were used to calculate mean, standard deviation and frequencies for gender, various presenting features, co-morbidities and clinical features. Data was analyzed on SPSS version 21. P value <0.05 was considered as statistically significant. Results: Sixty seven men and 33 women with HCC were included in this study with a mean age of 58.23 years. The abdominal pain was the most common symptom present in 66 (66%) patients. Edema was seen in 30 (30%) and palpable splenomegaly in 26(26%). Diabetes mellitus was the most common co-morbidity found in 20(20%) patients. HCV was the commonest cause of HCC present in 79(79%) patients. Vascular involvement was seen in 15 (15%) patients. Most (62%) patients had a single HCC lesion and most belonged to Child –Pugh class A (68%) and BCLC stage B (42%). ECOG performance status was good in most patients with 49% patients scoring 0. The AFP levels were raised in 58 (58%) of the patients. Conclusion: HCV was the most common underlying etiology. Most of the patients were asymptomatic at the time of diagnosis. Majority of subjects reported with the complaint of abdominal pain and had no underlying co morbidity. The metastasis was negative in majority of cases

Objectives: To determine the efficacy (in terms of recurrence) of rifaximin in Hepatic Encephalopathy (HE) in chronic liver disease. Study Design and Setting: A descriptive study carried out from 4th September 2018 to 3rd March 2019 at the department of Medicine, Combined Military Hospital, Quetta. Methodology: A total of 104 patients of chronic liver disease with HE, 25-65 years and both genders were included. Patients with gastrointestinal hemorrhage, chronic renal insufficiency and anemia were excluded. Then tab Rifaximin 550 mg twice daily along with standard prescription i.e. Lactulose 30 to 60 ml in two to three divided doses per day was given to each patient and efficacy was noted. Statistical analysis was carried out using SPSS version 20.0. Age, duration of disease and Conn’s score was presented as mean and standard deviation. A p value = 0.05 was considered as significant Results: Age range in our study was from 25 to 65 years with a mean of 45.73 ± 8.13 years. Most of the patients 54 (51.92%) were between 46 to 65 years of age range. Out of the 104 patients, 77 (74.04%) were male and male to female ratio was 2.9:1. Mean duration of disease was 13.66 ± 3.77 months. Mean conn’s score was 4.77 ± 1.43. Efficacy (no recurrence) of rifaximin in HE in chronic liver disease was found in 85 (81.73%) patients. Conclusion: It was inferred that rifaximin is useful in decreasing the recurrence of HE in chronic liver disease patients with previous episode/s of encephalopathy

Objective: To determine the frequency of large bowel causes of chronic diarrhea in adult Pakistani patients. StudyDesign: Cross sectional study. Setting: Medical unit 1 at Combined Military Hospital Lahore, Pakistan. Duration: Six months (from 01-11-2007 to 30-4-2008). Subjects and Methods: Fifty adult patients with chronic diarrhea, irrespective of their gender were selected by nonprobability convenient sampling. Patients already diagnosed with diseases known to cause diarrhea and those with toxic mega colon wereexcluded from the study. All patients were subjected to fiberoptic colonoscopy and findings were recorded. Biopsies were taken fromsuspected lesions or from normal looking mucosa. Diagnosis was made with colonoscopic and histopathologic findings. Results: Thirty two(64%) patients had abnormal findings visible on colonoscopy. Histopathology was normal in 18 (36%). Twenty (40%) patients hadulcerative colitis, seventeen (34%) had IBS, five (10%) had CA colon and three (6%) patients had crohn’s disease. Other diagnosesincluded non specific colitis, tubulovillous adenoma and infection. Twenty three out of 24 patients (95%) who had blood in stools had avisible abnormality on colonoscopy whereas colonoscopy was positive in only 33% of patients who did not have blood in stools.Conclusion: Most causes of large gut chronic diarrhea can be identified by colonoscopy and biopsy. Colonoscopy has a very high yield inchronic diarrhea and should be recommended for its work up. Its yield is even higher in patients with bloody diarrhea.