Khyber Teaching Hospital

Typhoid fever is a potentially fatal systemic infection caused by Salmonella typhi (S. typhi), a Gram-negative, rod-shaped, facultative anaerobe. This study aimed to characterize the efflux pump genes, molecular mutations, and antibiotic susceptibility patterns in clinical isolates. A total of 2950 blood samples were collected from suspected typhoid patients. Of these, 380 (12.88%) bacterial isolates were recovered, of which 236 (62.10%) were Gram-negative. S. typhi was detected in 95 isolates (25% of all bacterial isolates), corresponding to an overall prevalence of 3.22%. Identification was performed using API 20-E strips and partial 16S rRNA gene sequencing. Resistance profiling classified the isolates into multidrug-resistant (MDR, 13.68%) and extensively drug-resistant (XDR, 86.31%) categories. High resistance was observed to ampicillin (98.94%) and chloramphenicol (93.68%), whereas no resistance was detected to azithromycin or meropenem. Minimum inhibitory concentration (MIC) testing using E-Strips showed the highest MIC values for trimethoprimsulfamethoxazole (MIC50: 0.125 μg/ml, MIC90: 0.50 μg/ml) and the lowest for ciprofloxacin (MIC₅₀: 0.008 μg/ml, MIC₉₀: 0.023 μg/ml). Among the efflux pump genes, mdtB (32.63%) was the most prevalent, followed by mdtC (30.52%) and mdtA (29.47%). Multiple mutations were identified and evaluated using the I-Mutant 2.0 server. Protein structures were modeled using trRosetta and Discovery Studio. Phylogenetic analysis using MEGA-11 revealed evolutionary relationships with other Salmonella enterica serovars. A serious public health issue that increases mortality and morbidity rates worldwide is antibiotic resistance. Among the mechanisms underlying antibiotic resistance in bacteria are degradation of antibiotics and/or modification of enzymes, changing drug targets to alter the affinity of antibiotics, altering bacterial surfaces by changing the expression of external membrane proteins, and active bacterial efflux of drugs. The drug's binding affinity can be changed by mutations in efflux pump genes that change the shape of the substrate- binding pocket. These structural alterations may improve the pump's capacity to identify and eliminate antibiotics, reducing intracellular drug levels and increasing resistance to several drugs. This study highlights the alarming rise of multidrug resistance in S. typhi isolates and identifies key genetic mutations that may influence efflux pump function, potentially contributing to enhanced antibiotic resistance.

High-degree atrioventricular block (HAVB) is a serious complication of acute anterior wall myocardial infarction (AWMI), contributing significantly to early morbidity and mortality. Early identification of high-risk patients is essential for timely intervention. Objectives: To determine the frequency, clinical predictors, and in-hospital outcomes of HAVB among patients presenting with acute AWMI. Methods: This cross-sectional study included 78 acute AWMI patients presenting at Rahman Medical Institute from June 2024 to July 2025. Demographic data, clinical characteristics, and ECG findings were recorded. Patients were monitored continuously for the development of HAVB. Outcomes included cardiogenic shock, ICU admission, pacing requirements, and in-hospital mortality. Associations were analyzed using chi-square and logistic regression, with p<0.05 considered significant. Results: The mean age of patients was 56.8 ± 8.2 years, predominantly male 51(65.4%). The majority of patients were in the age group 51–60 years, 31 (39.7%). HAVB occurred in 7 (9%) patients. Older age (>60 years) and diabetes mellitus were significantly associated with HAVB (p=0.03) and (p=0.04), respectively. HAVB was strongly associated with cardiogenic shock (p=0.01), ICU admission (p=0.002), and need for temporary pacing (p<0.001). In-hospital mortality was significantly higher in the HAVB group (p=0.04). On multivariate analysis, HAVB independently predicted mortality (aOR 4.9, p=0.03). Conclusions: HAVB is an important predictor of adverse outcomes in AWMI, particularly among older and diabetic patients. Early monitoring and timely pacing interventions are crucial to improving survival.

Objective: To assess the knowledge and practices regarding vitamin D deficiency among undergraduate nursing students in Hayatabad, Peshawar. Methods: This cross sectional study was conducted in four nursing institutes of Hayatabad, Peshawar, Pakistan on 145 participants. Only 6th and 8th semesters in nursing were in the inclusion criteria. The data was collected through a non-probability purposive sampling technique. The questionnaire was used to collect demographic variables, the knowledge, and the practices of vitamin D. Chi-square test was used to determine the association among knowledge and practices with the demographic variables. Results: of total participants, 91.7% were aged 19–24 years and 64.1% were females. Knowledge levels differed significantly across institutions, with government institute students showing better knowledge compared to private institutes. No significant difference was found between 6th and 8th semesters. Practice scores were generally satisfactory, with older students demonstrating significantly better practices. However, no significant association between institutes and practices was observed (p=0.42). Conclusion: The study revealed moderate to good knowledge of vitamin D deficiency among nursing students. Educational and behavioral interventions are needed to strengthen vitamin D-related health knowledge among healthcare professionals.

Abstract Background Streptococcus pneumoniae is responsible for significant morbidity and mortality. Despite the availability of antibiotics and vaccination, associated mortality remains notable given incomplete vaccination, particularly among adults, and emergence of drug-resistant strains. Tracking the epidemiological trends over time of geographical variations in S. pneumoniae infection-related mortality in adults is relevant. Methods Death certificate data from the CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research) database was reviewed between 1999 and 2020 in the United States (U.S.). S. pneumoniae-related deaths due to meningitis, pyogenic arthritis, septicemia, or pneumonia in adults ≥ 25 years were examined using the year 2000 U.S. standard population for age standardization. Mortality rates were expressed as age-adjusted mortality rates (AAMR) per 100,000 population. Joinpoint regression was used to assess trends and calculate annual percentage change (APC), stratified by year, sex, census region, and type of geographical location of death as well as the type of facility. Results A total of 21,727 S. pneumoniae-related deaths due to select diseases occurred between 1999 and 2020. There was an abrupt decline in AAMR from 1.0 in 1999 to 0.5 in 2005 (APC -10.06; 95% CI: -12.84 to -7.18), followed by a gradual decline to 0.3 by 2020 (APC -4.19; 95% CI: -5.66 to -2.70). Men had higher AAMR overall than women (0.5 vs. 0.4). Regional variations in AAMR were also significant, with the lowest rate in the Northeast (0.3), followed by Midwest, South, and West (0.5 each). Rural areas had a higher AAMR overall (0.6) than urban (0.5). In terms of location of death, 85% died in a hospital. (Inpatient) Conclusion From 1999 to 2020, mortality due to select S. pneumoniae-related infections in the U.S. declined overall, with persistent disparities particularly among men, and residents of rural areas. Addressing these disparities through targeted interventions may be crucial to reducing the burden of mortality across vulnerable groups. Disclosures Forest W. Arnold, DO, MSc, Gilead Sciences: Grant/Research Support

Abstract Background Mycobacterium is a small rod-shaped bacterium that can cause a multitude of infections including skin and other organ system infections leading to significant morbidity and mortality but its long-term mortality trends are not well studied. This study analyzes trends and geographical variations in mycobacterial infection-related mortality in adults ≥ 25 years of age from 1999 to 2020 in the United States (U.S.). Methods We analyzed death certificate data from the CDC WONDER (Centers for Disease Control and Prevention Wide-Ranging Online Data for Epidemiologic Research) database between 1999 and 2020. Mycobacterial infection-related deaths in adults ≥ 25 years were examined using ICD 10 codes, with age standardization based on the 2000 U.S. standard population. Mortality rates were expressed as age-adjusted mortality rates (AAMR) per 100,000 people. Joinpoint regression was used to assess trends and calculate annual percentage change (APC), stratified by year, sex, census region, urban, rural, and states. Results A total of 14,107 deaths related to mycobacterial infection in adults ≥ 25 years of age occurred between 1999 and 2020. The AAMR gradually decreased from 0.39 in 1999 to 0.22 in 2006 (APC -5.64; 95% CI: -7.97 to -3.24) followed by a rise to 0.32 by 2020 (APC 1.82; 95% CI: 0.94 to 2.70), a partial regression toward the earlier rate rather than a net increase over the study period. Men had a higher AAMR overall than women (0.36 vs. 0.26). Regional variations in AAMR were also significant, with the highest rates in the South (0.39), followed by West (0.32), Midwest (0.25), and Northeast (0.21). While all regions noticed fluctuations throughout, only Midwest recorded a higher AAMR at the end of 2020 (0.27) as compared to 1999 (0.24). Moreover, urban areas had a higher AAMR overall (0.30) in comparison to rural (0.27). Geographically, the AAMRs ranged from 0.79 in Hawaii to 0.13 in Massachusetts. Conclusion Mortality due to mycobacterial infections in U.S. adults ≥ 25 years of age declined from 1999 to the mid-2000s overall, but since then, it has slowly started to rise, with persistent disparities among men and in individuals in the South and in urban areas. Addressing these disparities through targeted interventions is crucial to reducing the burden of mortality across vulnerable groups. Disclosures All Authors: No reported disclosures

BackgroundHip fractures are among the most common causes of hospital admission in elderly patients. National Institute for Health and Care Excellence (NICE) recommends surgery within 24-48 hours in such patients; however, pre-operative transthoracic echocardiography (TTE) is occasionally requested inappropriately, risking delays in surgery without improving outcomes. Delays to hip fracture surgery are associated with increased morbidity and mortality, with each 24-hour delay linked to worse clinical outcomes, underscoring the importance of timely operative intervention. This quality improvement project (QIP) evaluated the use of pre-operative echocardiograms in patients with neck of femur fractures, aiming to reduce unnecessary requests, prevent surgical delays, and ensure consistent acknowledgement of TTE results by anaesthetists at a district general hospital in the United Kingdom.Materials and methodsA two-cycle Plan-Do-Study-Act (PDSA) audit was conducted at a district general hospital. Multiple guidelines were studied, and local trust guidelines regarding the use of pre-operative echocardiograms were selected as a standard that defined appropriate TTE indications. In Cycle 1 (March-April 2024), baseline compliance with three standards was assessed, which included: avoidance of surgical delay, appropriateness of echocardiogram requests and anaesthetic acknowledgement of TTE reports. Interventions included teaching sessions, posters outlining guideline criteria, and dissemination of audit findings. Cycle 2 (July-October 2024) re-evaluated compliance following these measures.ResultsIn Cycle 1, 12 patients were identified using our inclusion criteria who underwent TTE. Surgery was not delayed in any case (12/12, 100%). Only 4/12 (33.3%) TTE requests met guideline criteria, and 10/12 (83.3%) reports were acknowledged by anaesthetists. In Cycle 2, following interventions, 17 patients were identified using our inclusion criteria who underwent TTE. Again, surgery was not delayed in any case (17/17, 100%). Guideline adherence improved markedly, with 16/17 (94.1%) appropriate requests, but acknowledgement of reports fell to 12/17 (70.6%). In 4/17 (23.5%) cases, TTE findings led to changes in anaesthetic management, including invasive monitoring and optimisation of cardiac status. The reduction in documented acknowledgement may reflect a higher threshold for what clinicians considered necessary to formally record following improved guideline adherence. Importantly, in 4/17 (23.5%) of cases, echocardiography directly influenced anaesthetic decision-making, supporting its role as a clinically valuable investigation when appropriately targeted.ConclusionTargeted educational interventions and dissemination of local guidelines reduced inappropriate echocardiogram requests in hip fracture patients without delaying surgery. However, inconsistent documentation of anaesthetic acknowledgement remains a concern. Ongoing interventions, including the implementation of mandatory electronic sign-off of echocardiogram reports within the patient record, are planned to sustain improvements and optimise perioperative communication.

Background: Primary amenorrhea is a heterogeneous condition reflecting disorders of hypothalamic–pituitary–ovarian function or reproductive tract development, and delayed presentation is common in resource-variable settings. Objective: To determine hormonal patterns and etiological distribution of primary amenorrhea among females presenting to tertiary care hospitals in South Punjab, Pakistan. Methods: This observational cross-sectional study enrolled 58 females with primary amenorrhea over two months. Clinical evaluation included demographics, BMI, Tanner breast staging, and pelvic ultrasonography. Serum follicle-stimulating hormone (FSH), luteinizing hormone (LH), estradiol, prolactin, and thyroid-stimulating hormone (TSH) were measured using chemiluminescent immunoassays. Participants were stratified by FSH into hypogonadotropic (<3 mIU/mL), eugonadotropic (3–10 mIU/mL), and hypergonadotropic (>40 mIU/mL) categories. Etiology was determined using integrated clinical, biochemical, and imaging findings. Results: Mean age was 17.4 ± 2.1 years. Eugonadotropic amenorrhea was most common (44.8%), followed by hypogonadotropic (31.0%) and hypergonadotropic amenorrhea (24.1%). Outflow tract anomalies were the leading etiology (36.2%), followed by ovarian disorders (24.1%), hypothalamic–pituitary dysfunction (20.7%), and PCOS (12.1%). Eugonadotropic patients had the highest mean estradiol, while hypergonadotropic cases had markedly reduced estradiol. Conclusion: Structural and ovarian etiologies predominated, and hormonal stratification combined with ultrasonography supported pragmatic etiological triage and management planning.

Acute ischemic stroke (AIS) due to large vessel occlusion (LVO) is a significant cause of disability and mortality. While endovascular thrombectomy (EVT) is the standard treatment, microvascular reperfusion remains a challenge. Although there is mixed information about the safety and effectiveness of tirofiban, a glycoprotein IIb/IIIa inhibitor, it may improve perfusion when administered before EVT. Its effects on risks and functional outcomes, including symptomatic intracranial hemorrhage (sICH), are investigated in this meta-analysis. We systematically searched PubMed, Embase, and Cochrane from inception to July 2025 for randomized controlled trials (RCTs) and Cohorts comparing pre-EVT tirofiban with EVT alone in LVO stroke. Primary outcomes were 90-day functional independence and the ordinal shift in mRS. Secondary outcomes included mortality and symptomatic intracerebral hemorrhage. Six Studies (1,664 patients) were included. Tirofiban did not significantly improve 90-day functional independence (RR: 1.09, 95% CI: 0.88-1.36; p = 0.44; I² = 62%) or ordinal mRS (MD: 0.06, 95% CI: -0.15 to 0.27; p = 0.58; I² = 0%). Mortality was similar between groups (RR: 0.75, 95% CI: 0.54-1.06; p = 0.11; I² = 0%). sICH risk was also comparable (RR: 0.83, 95% CI: 0.46-1.51; p = 0.55; I² = 28%). Pre-procedural tirofiban did not significantly raise the risk of sICH, improve functional outcomes, or lower death in LVO stroke patients having EVT. Although additional research may improve patient selection, these results point to limited value for routine tirofiban administration before EVT.Keypoints Pre-EVT tirofiban does not significantly improve 90-day functional outcomes in AIS due to LVO. No significant benefit was observed in ordinal modified Rankin Scale scores. Mortality and risk of symptomatic intracranial hemorrhage were similar between tirofiban and control groups. Heterogeneity was moderate to low, and findings were consistent across study types. Future studies should explore optimal patient selection, dosing strategies, and timing to identify potential subgroups that may benefit from pre-EVT tirofiban.

BackgroundCardiovascular diseases remain a major cause of morbidity and mortality in Pakistan. Early identification of high-risk individuals is essential for improving outcomes.ObjectiveTo evaluate clinical characteristics, risk factors, and outcomes among patients presenting with cardiovascular conditions at two major tertiary care centers in Pakistan.Materials and methodsThis prospective observational two-center study in Pakistan was conducted at Mardan Medical Complex (Mardan) and Peshawar General Hospital (Peshawar) from January 2022 to December 2023. A total of 2,530 patients were enrolled (mean age 58.42 ± 11.36 years), including 1,964 males (77.66%) and 566 females (22.34%). Demographic data, comorbidities, clinical presentation, laboratory parameters, management strategies, and outcomes were collected and analyzed.ResultsHypertension, diabetes mellitus, and smoking were the most prevalent comorbidities. Most patients presented with acute coronary syndromes, with ST-elevation myocardial infarction being the predominant subtype. Early revascularization, including primary percutaneous coronary intervention (PCI), was performed when indicated. Mortality and complication trends were comparable across both centers. Advanced age and multiple cardiovascular risk factors were significantly associated with adverse outcomes.ConclusionThis prospective two-center study provides meaningful insight into the cardiovascular disease burden in Pakistan. The findings highlight the need for improved preventive strategies, timely diagnosis, and better risk-factor management to reduce cardiovascular morbidity and mortality.