Hepatitis E virus (HEV) is among the most common causes of acute viral hepatitis. It typically causes acute infection, but some cases of chronic infection have also been recorded. These cases were particularly seen in developed countries, in patients who were immunocompromised, organ transplant recipients, or those with underlying hematological malignancy. However, we encountered a case of hepatitis E presenting as a chronic liver disease in an immunocompetent patient from a developing country. Therefore, more underlying risk factors need to be studied, which may lead to such a rare presentation of hepatitis E.

Objective : To assess the outcomes in managing patients with chronic kidney disease (CKD) requiring vascular access before and after, a formal vascular surgery fellowship program (VSFP) was introduced in a tertiary care hospital in Punjab. Study Design : Pilot quasi-experimental study. Place and Duration of Study: Department of Vascular Surgery and Nephrology at Combined Military Hospital (CMH) ,Lahore Pakistan, from Feb to Oct 2020. Methodology: Patients meeting the inclusion criteria of ages between 20 to 70 years, either gender and undergoing dialysis due to chronic renal failure were recruited in the study. Data was collected at the initial phase when a VSFP was absent and later when it was present. Outcome variables were current dialysis access, waiting time for permanent dialysis access and failure rate about the duration of chronic renal failure. Results: A total of 226 patients were recruited in the study. In both pre-vascular surgery fellowship program time (pre-VSFPT) and post-vascular surgery fellowship program time (post-VSFPT), the predominant functional dialysis access at the time of the interview was arterio-venous fistula (AVF). However, they were much higher in the post-VSFPT, i.e., 46(54.1%) as compared to 96 (68.1%) (p= 0.069). In addition, in pre-VSFPT, 24 (28.2%) patients had a “Never Created” AVF status at the time of the interview as compared to 21(14.9%) in post-VSFPT, which was statistically significant. Conclusion: The establishment of a fellowship program not only benefits the trainee but it improves patient care significantly. This study highlights the improvement in all the benchmarks of the formation

Objectives: To evaluate the clinical features, outcome and poor prognostic factors of COVID-19 in rheumatic disease patients. Study Design: Cross-sectional study. Place and duration of Study: Department of Rheumatology, Fauji Foundation Hospital, Rawalpindi, from Mar to Sep 2020. Methodology: The study included rheumatic disease patients with COVID-19. Patients' age, gender, smoking status; details of rheumatic disorder; method of COVID-19 diagnosis, treatment and outcomes were recorded. Results: The study included 46 patients. Overall mortality rate was 23.8%. The most common symptoms were fever (35, 83.3%), cough (26, 61.9%) and myalgia (23, 54.8%). Dyspnea was associated with mortality (p=0.013), ICU admission (p<0.001), ventilation (p=0.02) and hospitalization (p<0.001). NSAIDs increased the risk of ventilatory support (p= 0.02). Long term steroids predicted mortality (p=0.02), hospitalization (p=0.014) and intensive care admission (p=0.004). Steroid and Hydroxy-chloroquine treatment for COVID-19 was associated with intensive care admission (p= 0.001 and 0.006, respectively) and ventilation (p=0 .007 and 0.03, respectively). Mycophenolate Mofetil was related to intensive care admission, ventilation and hospitalization (p=0.03, 0.03 and 0.02, respectively), whereas Cyclophosphamide was related to hospitalization (p= 0.03). Systemic lupus erythematosus was associated with all poor outcomes except ventilation (p<0.05) Conclusion: Systemic lupus erythematosus, long-term steroids, Mycophenolate Mofetil, Cyclophosphamide and Dyspnea are associated with severe COVID-19.

Objective: To assess the knowledge, attitude and practices (KAP) of Pakistani doctors in the early period of COVID-19 Pandemic. Methodology: This KAP survey was conducted from 29th March to 6th April 2020. The questionnaires were disseminated using Google Forms, which utilized electronic consent. Physicians and surgeons of frontline involved in the care of COVID-19 patients including house officers, postgraduate trainees of all specialties, and consultants were included in study. Results: Out of 112 participants, 52.7% were female. Mean age was 29.93 +/- 7.3 years. There were 46 (41.3%) house officer. Twenty five (22.3%) participants were daily exposed to COVID-19. Residents who had maximum exposure on a daily basis, none had access of full personal protective equipment. Only 13.4% had correct knowledge about time of maximum disease transmission and 70% health care workers had greatest concern about their family's health. Conclusion: There was poor level of knowledge and worrisome practice and discrepancies in the perceptions about COVID-19 among our study participants.

Following a Coronary artery bypass graft and insertion of an intra-aortic balloon pump, the 63 year-old male patient developed signs of progressive multi-organ dysfunction and ischaemic changes in both of his lower limbs. The diagnosis of cholesterol embolization syndrome was made. This condition has been noted to be a complication of invasive procedures and endovascular therapies, and is often overlooked and difficult to treat. While the patient’s renal function and pancreatitis showed improvement, the lower limb ischaemia was progressing. Eventually, the patient underwent a bilateral below knee amputation.

Aerial firing is often used as a form of riot control, but also in certain parts of the world as a celebratory act, often resulting in unintentional injury and/or death. It is uncommon for a patient to walk into an emergency room, seemingly comfortable, only to discover an intracranial foreign body. We report a case of a child who was struck by a stray bullet that pierced his skull through a small entry wound and lodged itself in the falx cerebri. The patient remained asymptomatic and no intervention was required. We wish to highlight the importance of imaging techniques in patients with small wounds who are otherwise asymptomatic as well as point out the salient features regarding stray bullet injuries.