Journal of Islamabad Medical & Dental College <p>The Journal of Islamabad Medical &amp; Dental College (JIMDC) is a new quarterly Journal of Islamabad Medical &amp; Dental College. <strong>Its is recognized By Pakistan Medical and Dental Council (PMDC</strong>) <strong>and Higher Education Commission of Pakistan</strong>. It includes original research papers, reviews, case reports<strong>,</strong> and short communication related to health, medicine and dentistry. Submitted manuscripts must be original, written in English, and will be accepted for publication with the understanding that it has not been submitted simultaneously to any other journal, not published or under consideration elsewhere and has not been published previously. The manuscripts will be reviewed through double-blind peer review process.&nbsp;</p> en-US <p><img style="border-width: 0;" src="" alt="Creative Commons License"><br>This is an Open Access article distributed under the terms of the Creative Commons Attribution-Non Commercial License (<a href=""></a>), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.</p> (Prof. Dr. Naila Irum Hadi) (Zikrat Jamil) Mon, 29 Jun 2020 17:53:14 -0400 OJS 60 Caught Off guard by COVID-19: Artificial Intelligence for Rescue! Naila Siddiqui Kamal Copyright (c) 2020 Journal of Islamabad Medical & Dental College Mon, 29 Jun 2020 16:28:34 -0400 Telemedicine in COVID-19 era: Lessons from Online Co-management of Bone Marrow Transplant Patients Lawrence Faulkner Copyright (c) 2020 Journal of Islamabad Medical & Dental College Mon, 29 Jun 2020 16:33:00 -0400 Comparison of Intravenous Co-amoxiclav and Benzyl Penicillin in Children with Severe Streptococcal Tonsillitis <p><strong>Background: </strong>Streptococcal tonsillitis is a common pediatric ailment which is faced by physicians on a daily basis and is associated with disastrous complications if not treated adequately. The objective of this study was to compare the efficacy, safety and cost-effectiveness of intravenous co-amoxiclav with benzyl penicillin in the treatment of severe streptococcal tonsillitis in children.</p> <p><strong>Material and Methods:</strong> This Randomized Controlled Trial was carried out at CMH Mardan, Khyber Pakhtunkhwa from January 2018 to November 2019. A total of 310 children with severe tonsillitis, aged between 5 to 15 years were selected from outpatient department of Combined Military Hospital Mardan. The cases were divided into two groups. Injection co-amoxiclav was given to patients in Group A (n=155) and injection benzyl penicillin was administered to patients in Group B (n=155). Both groups were compared in terms of effectiveness of treatment, safety and cost effectiveness. All the data was assessed with help of SPSS (Statistical Package for Social Sciences) version 21. Chi square and independent T test were used with <em>P</em>-value &lt; 0.05 taken as statistically significant.</p> <p><strong>Results:</strong> There were 310 children with severe tonsillitis, 155 in each group. Mean age in Group A was 9.35 ± 3.17 years and in Group B, 9.96 ± 2.96 years, respectively. In Group A, 2 cases developed hypersensitivity to injection co-amoxiclav after initial test dose as compared to 3 cases in Group B. Mean duration for complete resolution of symptoms (i.e. hospital stay) was 4.13 ± 0.375 days for Group A as compared to 4.09 ± 0.377 days for Group B (<em>P</em>=0.458). Mean cost of antibiotic drugs for each child in Group A was Rs. 965.88 ± 298 and in Group B was Rs. 152.36 ± 53. Benzyl penicillin was found to be significantly cost effective as compared to co-amoxiclav (<em>P</em>=0.000).</p> <p><strong>Conclusions:</strong> Both the drugs have similar efficacy and safety profile in the treatment of severe streptococcal tonsillitis in children. However, benzyl penicillin is more cost effective than co-amoxiclav in our study population.</p> <p><strong>Clinical Trail Registration: </strong> NCT04215770</p> Sumera Akram, Muhammad Ahmed Khan, Abdul Rehman, hassan Bin Usman, ali abbas Copyright (c) 2020 Journal of Islamabad Medical & Dental College Mon, 29 Jun 2020 16:39:13 -0400 Prevalence of Dental Caries and its Association with Risk Factors amongst Preschool Children of Bharakahu, Islamabad <p><strong>Background: </strong>It is necessary to understand the prevalence and pattern of distribution of dental caries for better planning and execution of preventive activities in the right dimension. This study provided the base line data about prevalence of dental caries in pre-school children of Bharakahu, Islamabad, and its association with brushing, sugar consumption and previous dental visits.</p> <p><strong>Material and Methods:</strong> A total of 384 preschool children aged 3-5-year-old were screened from periurban area of Bharakahu, Islamabad, using type IV screening method. Data about decayed, missing and filled teeth was recorded using decayed-missing-filled teeth (DMFT) index. Socio-demographics, brushing, sugar consumption and previous dental visits were also recorded and analyzed and their association with dental caries was assessed using Chi square and Odds ratio.</p> <p><strong>Results:</strong> The overall caries prevalence among the sample was 49%. The mean DMFT score with 1 SD was 2.07±3.215. There was no significant difference in caries prevalence in relation to gender of the children. The most significant association was for brushing and low DMFT. Children who brushed their teeth were 4 times more likely to have a low DMFT score of &lt;1 than those who did not brush at all (<em>P</em>&lt;0.001). Likewise, those who had visited a dentist in the past were twice more likely to have a low DMFT (<em>P</em>=0.003). The association of low sugar consumption and a low DMFT score was statistically insignificant (OR 1.4; <em>P</em>=0.878). Hence, brushing turned out to be the most significant factor in determining the caries experience for a child.</p> <p><strong>Conclusions:</strong> This study provided us with the baseline data regarding the prevalence of caries in primary school going children of Bharakahu. The prevalence of unmet dental treatment needs was reflected through a high number of ‘decayed teeth’ as compared to missing and filled ones highlighting the need for restorative care in these children.</p> Saba Masoud, Sheze Haroon Qazi, Rubina Mumtaz Copyright (c) 2020 Journal of Islamabad Medical & Dental College Mon, 29 Jun 2020 16:45:37 -0400 Diagnostic Accuracy of Sonographic Septations in Tuberculous and Malignant Pleural Effusions <p><strong>Background: </strong>Discrimination between tuberculous (TB) and malignant pleural effusions is a real practical challenge because both exist as exudative lymphocytic type. Transthoracic ultrasonography not only identifies and quantifies pleural effusion but also displays sonographic septations, which are frequently seen in TB pleural effusions and can help in differentiation between tuberculosis and malignancy successfully, without any invasive procedure. We designed this study to determine the diagnostic usefulness of these septations for tuberculous and malignant pleural effusions.</p> <p><strong>Material and Methods:</strong> This prospective study was conducted in the OPD of Gulab Devi Chest Hospital Lahore, Pakistan, a 1500 bedded tertiary care hospital, from November 2016 to February 2018. Total of 339 consecutive cases, aged 14-83 years with radiological evidence of pleural effusion were included in the study. After detailed history, thorough physical examination, radiological, haematological and biochemical findings were recorded. Pleural fluid macroscopic, cytological, microbiologic and biochemical analysis results were also recorded. Ultrasonography was done, septated and non-septated pleural effusions identified and findings were noted. SPSS-16 was used for statistical evaluation. Fisher Exact test was utilized for comparison between TB and malignant cases with <em>P</em>-value &lt; 0.05 taken as significant. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), diagnostic accuracy and positive likelihood ratio were calculated.</p> <p><strong>Results:</strong> Out of total 339 cases, 49 (14.45%) were malignant and 290 (85.55%) were non-malignant. In the malignant group, only 03 cases (6.12%) showed sonographic septations. In the non-malignant group, 259/290 (89.31%) cases showed tuberculous etiology and 187/259 (72.20%) of these cases displayed sonographic septations. By considering septations as predictor of TB, statistical analysis revealed a sensitivity of 79.23%, specificity of 92.85%, PPV of 98.42%, NPV of 44.31% and diagnostic accuracy of 81.29%, respectively.</p> <p><strong>Conclusions:</strong> Sonographic septations can be a valuable predictor of tuberculosis, in a population with high prevalence of the disease. We found it to be a useful feature in differentiating between a malignant and tuberculous etiology, in exudative lymphocytic pleural effusions. It can be used with confidence in patients who are unfit for interventional procedures.</p> Abdul Rasheed Qureshi, Muhammad Irfan, Zeeshan Ashraf Copyright (c) 2020 Journal of Islamabad Medical & Dental College Mon, 29 Jun 2020 16:52:00 -0400 Refractive Errors: Prevalence and Pattern among Rural Population of Islamabad, Pakistan <p><strong>Background: </strong>Refractive error is the most common cause of correctable visual loss worldwide. Decreased vision due to refractive error can be easily corrected with the help of spectacles, contact lenses and refractive surgery. However, there are 42% of uncorrected refractive errors all over the world. The present study aimed to evaluate different kinds of refractive errors, its prevalence and pattern in patients from rural areas who visited our hospital in the last five years.</p> <p><strong>Material and Methods:</strong> This cross-sectional study enrolled 2,138 patients, who visited eye OPD at Rawal Institute of Health Sciences, Islamabad during a period of five years i.e. from September, 2013 to September, 2018. Patients having only refractive error with an age of five years and above were included in the study.&nbsp; All patients had objective refraction with automated refractometer followed by subjective refraction. Data was entered and analyzed in SPSS version 20.0. Chi-square test was used for comparing groups with a <em>P</em>-value of &lt;0.05 considered as statistically significant.</p> <p><strong>Results:</strong> Compound myopic astigmatism was the most common error found in our study population (n=575; 26.9%). The second most frequent complaint was simple myopia (n=501; 23.4%) followed by presbyopia (n=441; 20.6%) and mixed astigmatism (n=235; 11%). Patients with more than one refractive error included 178 (8.3%) with mixed astigmatism and presbyopia and 78 (3.6%) with simple myopia and presbyopia. Compound myopic astigmatism was more prevalent in younger ages compared to older age groups (46.4% vs 19.9%) (<em>P</em> &lt;0.001). Mixed astigmatism (12.4% vs 8.9%), simple myopia (23.8% vs 22.9%) and presbyopia (21.3% vs 19.5%) were slightly greater in females than males (<em>P</em>=0.07), respectively.</p> <p><strong>Conclusions:</strong> The prevalence of myopia is significantly higher among female population and young individuals. Mixed astigmatism combined with presbyopia is more common among elderly population.</p> <p><strong>Key words: </strong>Astigmatism, Hypermetropia, Myopia, Presbyopia, Refractive errors</p> Waseem Akhter, Erum Yousafzai, Afia Matloob Rana, Shakaib Anwar Copyright (c) 2020 Journal of Islamabad Medical & Dental College Mon, 29 Jun 2020 16:56:25 -0400 Combined Effect of Nicotine and Caffeine on Orthodontic Tooth Movement in Rats <p><strong>Background: </strong>The individual effects of nicotine and caffeine have been reported in previous studies but their combined effect on tooth movement needs to be elucidated. The objective of this study was to evaluate the combined effect of nicotine and caffeine on the magnitude of orthodontic tooth movement (OTM) in rats.</p> <p><strong>Material and Methods:</strong> This experimental study was conducted on Sprague-Dawley rats (Animal House and Pathology Laboratory; Post Graduate Medical Institute, Lahore) in the department of Orthodontics, de’Montmorency College of Dentistry, Lahore from 8<sup>th </sup>July 2014 to 8<sup>th</sup> January 2015. Forty male Sprague-Dawley rats were divided into four equal groups: Control group (CR), nicotine group (NT), caffeine group (CF) and combined nicotine and caffeine group (CNC). Closed coil nickel titanium (NiTi) spring was placed between incisor and maxillary molar. Nicotine group (NT) was treated by intraperitoneal injections of nicotine. Caffeine was given to caffeine group and Combined nicotine and caffeine group (CNC) was treated in the same way as individual nicotine and caffeine groups daily for 14 days. All the rats were sacrificed on 15th day. Magnitude of the orthodontic tooth movement was measured using digital Vernier caliper. Means and standard deviation were calculated for orthodontic tooth movement. One-way ANOVA was used to determine the mean difference in OTM. Post hoc Tukey test was used for multiple comparisons among the groups.</p> <p><strong>Results:</strong> The mean orthodontic tooth movement (OTM) was 0.32 mm ± 0.05 in control group, 0.56 mm ± 0.04 in nicotine group, 0.52 mm ± 0.034 in caffeine group and 0.8 mm ± 0.06 in combined NC group, respectively. The difference between mean OTM among the groups was statistically significant (<em>P</em>-value &lt;0.001). The mean OTM in CNC group was significantly higher as compared to other groups (CR, NT, CF, NT) (<em>P</em>-value &lt;0.001).</p> <p><strong>Conclusions:</strong> In rats, the combined use of nicotine and caffeine results in greater orthodontic tooth movement as compared to their individual use.</p> <p><strong>Key words: </strong>Bone remodeling, Caffeine, Nicotine, Orthodontic tooth movement</p> Naeem Murtaza, Ahmed Shamim, Shabbir Hussain, Muhammad Nauman Sadiq, Muhammad Azeem, Waheed ul Hamid Copyright (c) 2020 Journal of Islamabad Medical & Dental College Mon, 29 Jun 2020 17:00:05 -0400 Nasal Colonization of methicillin resistant Staphylococcus aureus in attendants in a tertiary care hospital of Pakistan <p><strong>Background: </strong>Hospital associated Methicillin-resistant Staphylococcus aureus (MRSA) is a serious health concern, as its infection is associated with high rates of mortality and morbidity. Health care professionals around the globe are concerned by the increased prevalence of these bacteria in the hospital environment. With this background in mind, this study was conducted to determine the frequency of nasal colonization of methicillin-resistant staphylococcus in attendants of admitted patients in a tertiary care hospital in Pakistan.</p> <p><strong>Material and Methods:</strong> A cross-sectional study was conducted in Holy Family Hospital, Rawalpindi, Pakistan from 10<sup>th</sup> May to 31<sup>st</sup> August, 2016. Attendants of sixty admitted patients were selected by simple random sampling. Two nasal swabs samples were obtained from these attendants; the first at the beginning of the study with a hospital stay of less than 12 hours, and the second when their stay in the hospital had exceeded 48 hours. The samples were cultured on Cystine lactose electrolyte deficient agar, Mannitol Salt Agar, and Nutrient Agar. The colonies were subjected to Gram staining, catalase test, coagulase test, and methicillin/oxacillin sensitivity using the Kirby-Bauer’s disc diffusion method. Frequencies and percentages were calculated. Chi-Square test was applied and statistical significance calculated for the demographic data.</p> <p><strong>Results:</strong> The first culture report (at &lt;12 hours hospital stay) showed that 46/60 (76.7%) attendants were not found to have any resistant strain of Staphylococcus. These 46 attendants were then subjected to a second culture (after 48 hours hospital stay), which showed that 24/46 (52.2%) were now colonized with methicillin-resistant Staphylococcus species (MRSA; n=7 and MR other than S. aureus; n=17). There was no statistically significant difference between colonization of isolates and relationship to gender, age, residence, and co-morbid conditions.</p> <p><strong>Conclusions:</strong> The frequency of colonization with resistant strains of Staphylococcus aureus in attendants of admitted patients increased after being exposed to the hospital environment for more than forty-eight hours.</p> Taaha Muddassir Mirza, Rimsha Ali, Huma Musarrat Khan Copyright (c) 2020 Journal of Islamabad Medical & Dental College Mon, 29 Jun 2020 17:05:21 -0400 Altered Coagulation Pattern in Different Histological Grades of Squamous Cell Carcinoma <p><strong>Background: </strong>The incidence of squamous cell carcinoma has doubled in the last three decades associated with a high rate of morbidity and mortality. The incidence of bleeding and/or thrombosis in advanced stage cancer necessitates a need for research in blood coagulation abnormalities in malignancy. The objective of the present study was to determine the alteration in coagulation pattern among patients diagnosed with squamous cell carcinoma (SCC).</p> <p><strong>Material and Methods:</strong> This cross-sectional study was conducted in Pathology department of Isra University Hospital, Hyderabad over a period of 06 months. A total of 126 samples were selected through non-probability convenient sampling. Both male and female patients of all age groups having SCC of skin, gastrointestinal and genital tract were included. The coagulation profile was analyzed by Sysmax CA 50 and Nycocard reader II. Data was entered into SPSS version 22.0 and results were analyzed.</p> <p><strong>Results:</strong> The mean age of the patients with SCC in the present study was 55.5 ± 12 years with more male patients (n=81; 64.3%) as compared to females (n=45; 35.7%). Oral SCC was found to be the most common site of squamous cell carcinoma (43.7%). Majority of the patients had well differentiated SCC (42.1%) followed by moderately differentiated (40.5%) and poorly differentiated SCC (17.4%). The comparison of severity of SCC with coagulation profile revealed that PT (<em>P</em>=0.01), APTT (<em>P</em>=0.001), D-dimers (<em>P</em>=0.01 and TT (<em>P</em>=0.01) were significantly increased, whereas fibrinogen was significantly decreased (<em>P=</em>0.001).</p> <p><strong>Conclusions:</strong> The histological differentiation of SCC (from well differentiated to poorly differentiated tumors) showed a highly significant association with different coagulation profile parameters like PT, APTT, BT, CT, D-dimer, TT, and fibrinogen levels.</p> Kiran Shaikh, Ghulam Shah Nizamani, Yar Muhammad Nizamani, Naila Nizamani, Amin Fahim, Farkhunda Nadeem Copyright (c) 2020 Journal of Islamabad Medical & Dental College Mon, 29 Jun 2020 17:09:39 -0400 Comparison of TI-RADS classification with FNAC for the Diagnosis of Thyroid Nodules <p><strong>Background: </strong>Thyroid nodules are very common and its prevalence is largely dependent on the identification techniques. Recently high-resolution ultrasound thyroid imaging has paved the way for significant transformation in clinical approach to thyroid nodule. This study aimed to determine the efficacy of TI-RADS classification and its association with FNAC findings in thyroid lesions.</p> <p><strong>Material and Methods:</strong> This prospective study was carried out in the Department of Radiology of Islamabad Diagnostic Centre, Islamabad for a period of 6 months from 6<sup>th</sup> January 2018 to 6<sup>th</sup> July, 2018. All male and female patients presenting with thyroid nodules were selected for the study. Ultrasound neck was performed with high frequency linear probes. Ultrasonography findings were classified according to Thyroid Imaging Reporting and Data System (TI-RADS) classification, as defined by Horvath et al. Patients with TI-RADS II-V were scheduled for US-guided Fine Needle Aspiration (FNA). All the specimens were sent to pathology laboratory for cytology (FNAC).</p> <p><strong>Results:</strong> Total 123 patients of thyroid nodules were studied. Mean age of the patients was 45.78 ± 13.11 years, with a female predominance (73.2%). A significant association was seen between TI-RADS classification of thyroid nodules and findings on cytology. Thyroid nodules with TI-RADS II, III and IV a classification showed benign cytological findings, while TI-RADS class V had a significant association with malignant findings on cytology (<em>P</em>=0.001).</p> <p><strong>Conclusions:</strong> TI-RADS classification is a reliable modality in differentiating benign thyroid nodules from malignant ones and circumvent the need for FNAC in every case with a thyroid nodule.</p> Naushaba Malik, Maryam Rauf, Ghazala Malik Copyright (c) 2020 Journal of Islamabad Medical & Dental College Mon, 29 Jun 2020 17:17:59 -0400 Comparison of Transosseous Wiring and Miniplates in Management of Mandibular Parasymphyseal Fractures <p><strong>Background: </strong>Mandibular fractures are the most common type of facial fractures in the adult population, accounting for 36%-59% of all maxillofacial injuries and their treatment is one of the most frequent forms of therapy provided by maxillofacial surgeons. The objective of the study was to compare the outcome of transosseous wiring and miniplates in the management of mandibular parasymphyseal fractures in terms of infection and malocclusion.</p> <p><strong>Material and Methods:</strong> This randomized control trial was carried out at Oral and Maxillofacial Department, Ayub Medical College/ Ayub Teaching Hospital Abbottabad. A total of 124 patients were randomly allocated into two groups by lottery method. Patients in group A were subjected to transosseous wiring with maxilla-mandibular fixation. Patients in group B underwent miniplate fixation method. Post-operative wound in­fection and malocclusion findings at 6 weeks were recorded.</p> <p><strong>Results:</strong> Frequency of post-operative infection and malocclusion at 6 weeks of surgery was slightly more but statistically non-significant in patients of group A undergoing Transosseous wiring method as compared to group B patients experiencing Miniplate technique.</p> <p><strong>Conclusions:</strong> Miniplate osteosynthesis causes slightly less post-operative morbidity in terms of infection and malocclusion as compared to transosseous wiring for the management of mandibular parasymphyseal fractures.</p> Mehreen Razziq, Muhammad Jamal, Irum Mushtaq, Nadia, Laiba Saher Copyright (c) 2020 Journal of Islamabad Medical & Dental College Mon, 29 Jun 2020 17:24:37 -0400 Antibiotic Sensitivity Pattern of Uropathogens in Diabetic Women with Asymptomatic Bacteriuria <p><strong>Background: </strong>More than 150 million people around the globe are diagnosed with urinary tract infections every year. Failure to treat these infections with proper antibiotics can lead to serious complications. The objective of this study was to investigate antibiotic sensitivity and resistance pattern of urinary isolates in type-2 diabetic women with asymptomatic bacteriuria.</p> <p><strong>Material and Methods:</strong> This cross-sectional descriptive study was conducted at the HBS General Hospital, Islamabad, from March 2017 to August 2019. A total of 270 females with the diagnosis of type-2 diabetes mellitus were included in the study. Uropathogens were isolated from urine samples and antibiotic sensitivity testing was conducted. Demographic and clinical information was recorded on a pre-designed proforma. The data was analyzed using SPSS version 20.</p> <p><strong>Results:</strong> The mean age of the study sample was 50 years (SD ± 5.5) while the mean HbA1c levels were 8.98 g/dL (SD ± 0.8 g/dl). Uropathogens were found in the urine cultures of 106 (39.3%) patients. Extended Spectrum Beta-Lactamase producing (ESBL) Escherichia coli (E. coli) was the most common organism (n=46, 43.4%) which was sensitive to tazobactam, tazocin and co-trimoxazole. Nitrofurantoin was the most effective antibiotic with 62.5% isolates sensitive to it. All of the pathogens were resistant to ciprofloxacin.</p> <p><strong>Conclusions:</strong> Asymptomatic bacteriuria is common in type-2 diabetic women with ESBL E. Coli being the most common organism isolated from urine cultures. There is a significant resistance to antibiotics among the uropathogens isolated from these patients.</p> Nadeem Islam Sheikh, Ambreen Zahoor, Mehreen Baber, Zaidan Idrees Choudhary Copyright (c) 2020 Journal of Islamabad Medical & Dental College Mon, 29 Jun 2020 17:31:22 -0400 Van Der Knaap Disease in a 3-year-old Male Child: A Case Report <p>Van der Knaap disease or megalencephalic leukoencephalopathy with subcortical cysts is a leukodystrophy with autosomal-recessive inheritance caused by mutation in the gene MLC1 which is localized on chromosome 22q. It is characterized by macrocephaly, motor developmental delay, seizures, spasticity, ataxia, and mild mental deterioration. On neuroimaging, involvement of cerebral white matter along with subcortical cysts in frontal and temporal lobes are hallmarks of the disease. There is no definite treatment of this disease. We report a case of Van Der Knaap disease in a 3-year-old male child who presented with seizures and delayed developmental milestones.</p> Imran Mahmood Khan, Asma Shabbir, Sadaf Naz, Rubina Zulfqar Copyright (c) 2020 Journal of Islamabad Medical & Dental College Mon, 29 Jun 2020 17:36:23 -0400 Intestinal Malrotation with Midgut Volvulus leading to Small Bowel Obstruction in a Young Adult: A Case Report <p>The developing intestine rotates around the superior mesenteric vessels during physiological herniation from 6<sup>th</sup> to 10<sup>th</sup> weeks of embryogenesis. Intestinal malrotation leading to midgut volvulus and small bowel obstruction is a rare condition. Patients who develop this condition usually present in the first year of their life. Intestinal malrotation is characterized by right sided duodenojejunal junction, caecum in left iliac fossa and a narrow mesentery. Ladd’s procedure is the treatment of choice which is done to restore the normal anatomy. We report the case of an 18-year-old male patient, who presented with intestinal malrotation in emergency department of Nishtar Hospital, Multan. It is an uncommon age for presentation of this anomaly. The patient had fecal peritonitis due to caecal perforation. He underwent Ladd’s procedure in which ileocolostomy was made after right hemicolectomy. The patient had an uneventful recovery after the surgery and had no complaints on follow up visit one week after the discharge.</p> Junaid Zia Hashmi, Talha Kareem, Masood ur Rauf Khan Hiraj Copyright (c) 2020 Journal of Islamabad Medical & Dental College Mon, 29 Jun 2020 17:43:15 -0400 Radiographic images <ol> <li>Acute Intestinal Obstruction</li> <li>Retroperitoneal Neurogenic Tumor</li> <li>Extensive Bilateral Pneumonic Consolidations Leading to ARDS</li> <li>Haemorrhagic Transformation of Subacute Infarct</li> <li>Acute Occlusive Portal Vein Thrombosis Extending into Superior Mesenteric and Splenic Veins</li> </ol> Manal Niazi Copyright (c) 2020 Journal of Islamabad Medical & Dental College Mon, 29 Jun 2020 17:49:57 -0400