The coronavirus disease 2019 (COVID-19) pandemic, caused by the novel virus SARS-CoV-2, has swept across the globe, affecting almost every country. The death toll resulting from COVID-19 continues to rise as it is highly contagious, and currently, there is no definite treatment available. As SARS-CoV-2 is transmitted mainly through droplets, the lungs are the primary organ to be damaged with diffuse alveolar involvement. Moreover, failure of other organ systems leading to myositis, disseminated intravascular coagulation and acute kidney injury has also been reported. Besides, cytokine storm has been hypothesized as a potentially life-threatening complication of COVID-19. In this review, we aim to compile the current knowledge about the impact of SARS-CoV-2 on various organ systems and the prognosis. This will help in early identification of complications and appropriate intervention of COVID-19 cases to increase the survival rate.

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Objective: To investigate the relationship between upper gastrointestinal bleeding and neutrophil-lymphocyte ratio (NLR), platelet-lymphocyte ratio (PLR), and lymphocyte-monocyte ratio (LMR), and examine whether they can be used as markers of inflammation. Methods: The retrospective single-center study included a total of 189 patients with upper gastrointestinal bleeding admitted to the tertiary emergency department between January 2018 and January 2019. Besides, 59 patients with similar demographic characteristics were selected as the control group. Besides, 42 patients with active bleeding and 147 patients without active bleeding were categorized into two groups according to their endoscopy reports. The NLR, PLR, LMR values, potential risk factors, and demographic characteristics were analyzed. Results: The mean NLR levels were found significantly higher in the patient group compared to the control group (P<0.001), whereas the mean LMR levels were significantly lower in the patient group (P<0.001). The mean NLR and PLR levels were significantly higher in patients with active bleeding compared to those without active bleeding (P<0.001), whereas the mean LMR levels were significantly lower (P<0.001) for patients with active bleeding. The optimal cut-off value of NLR was found 2.1 for predicting uppergastrointestinal bleeding, with a sensitivity of 80.2% and specificity of 78.9% (AUC: 0.840; P <0.001). Conclusions: NLR was determined to be a parameter that can be used as an indicator of active bleeding in patients with upper gastrointestinal bleeding.

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Objective: To assess the utility and validation of the Surgical Apgar Score (SAS) in predicting postoperative complications of hip fractures. Methods: This prospective observational study included patients who received operations for hip fractures from 1st March 2017 to 30th June 2018 at the Department of Orthopedic Surgery, Liaquat National Hospital and Medical College. Patients were followed at the outpatient department, and complications and mortality were recorded through phone calls. The predictability of SAS for postoperative complications was assessed. Results: SAS≤4 was found as a significant predictor for postoperative pulmonary (P=0.008) and cardiac complications (P=0.042) as well as blood transfusion required to optimize postoperative hemoglobin (P=0.03) in the patients with hip fractures. Conclusions: SAS provides reliable feedback information about patients' postoperative risk during the surgery. Hip fracture patients with scores≤4 should be monitored for major complications both during the hospital admission and after the discharge.

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Objective: To investigate the chest radiography findings, hematological values and the risk factors of the mortality of coronavirus disease 2019 (COVID-19). Methods: Patients who were diagnosed with COVID-19 in a secondary-level state hospital in Turkey from March to April 2020 were included in the study. COVID-19 diagnosis was confirmed by reverse transcriptase-polymerase chain reaction. Initial routine blood tests and chest radiography findings were examined. The relationship between chest radiography findings and hematological values and risk factors of the mortality of COVID-19 were assessed. Results: In total, 94 patients with confirmed COVID-19 diagnosis were included in the study. Among them, 33 patients did not have lung involvement (RALE score of 0), and 42 had moderate lung involvement (RALE score of 1 to 4), and 19 had severe lung involvement (RALE score of 5 to 8). Patients with higher RALE scores were significantly elder (P=0.000) and had significantly lower lymphocyte count (P=0.032). Patients in need of intensive care had a lower mean number of platelets compared to patients who did not require intensive care (P=0.007). The receiver operating characteristic analysis revealed that RALE score (P=0.005), age (P=0.002), duration of symptoms (P=0.006), neutrophil-lymphocyte ratio (P=0.007), and lymphocyte percentage (P=0.012) were significantly associated with the risk of mortality. Conclusions: Patients with severe lung involvement have lower lymphocyte values and ratios. Age, RALE score, duration of symptoms, neutrophils/lymphocytes ratio, lymphocytes percentage are risk factors of mortality of COVID-19.

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Objective: To examine whether the platelet index would be applicable for the diagnosis of community-acquired pneumonia (CAP). Methods: In this study, 64 CAP patients (the case group) and 68 healthy children (the control group) were included from 2017 to 2018. Baseline variables were recorded including total white blood cells, neutrophils, lymphocytes, red blood cells, platelet, mean platelet volume, platelet distribution width, erythrocyte sedimentation rate, and C-reactive protein, and compared between the case group and the control group. The cutoff value, sensitivity, and specificity of neutrophil-to-lymphocyte ratio, platelet, neutrophils, lymphocytes, and platelet larger cell ratio were calculated by receiver-operating characteristic curves. Results: The median platelet count of the case group and the control group were (411.09±67.40) mm³ and (334.48±78.15) mm³, respectively (P=0.000). The median neutrophil count of the case group was higher than that of the control group (P=0.000), while the lymphocyte level of the case group was lower (P=0.000). Differences in other variables including the mean platelet volume, platelet distribution width, C-reactive protein, and erythrocyte sedimentation rate were not statistically significant between the two groups. Conclusions: Due to the different levels of platelet, neutrophil and lymphocyte indices in the case and the control group, these indices can be used simultaneously for the diagnosis of CAP.

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Rationale: Cavernous internal carotid artery (ICA) pseudoaneurysm caused by non-penetrating head trauma is a rare cause of massive epistaxis. The sudden onset of epistaxis due to such a fatal aneurysm protruding into the sphenoid sinus is extremely rare in clinical practice. The management is often challenging because of anatomical inaccessibility of the bleeding point. Patient's concern: A 42-year-old man with a history of head trauma showing an ICA aneurysm eroding the sphenoid sinus followed by massive epistaxis. Diagnosis: A computerized tomography (CT) scan showed a fracture in the sphenoid sinus. CT angiogram revealed cavernous ICA pseudoaneurysm. Interventions: Endovascular coil embolization. Outcomes: The patient recovered well and was discharged without any neurological deficits Lessons: Cavernous ICA pseudoaneurysm may lead to a life-threatening situation. If a patient has a history of head trauma, post-traumatic cavernous ICA pseudoaneurysm should be considered a differential diagnosis of massive epistaxis.

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Objective: To evaluate the influence of –250G>A (rs2070895) polymorphism in hepatic lipase gene (LIPC) promoter on plasma lipid parameters of ischemic stroke patients. Methods: A total of 100 stroke patients and 100 control subjects matched for sex (59 men and 41 women) and age were selected. Hepatic lipase activity and lipid profiles were measured while lipoprotein ratios were calculated. Genotyping of the –250G>A promoter polymorphism of the LIPC was performed by the polymerase chain reaction and restriction fragment length polymorphism method combined with 2% gel electrophoresis and then confirmed by direct sequencing. The LIPC promoter gene sequencing data were compared with refseqNG011465.1 LIPC from GenBank. Results: The frequencies of GG, GA and AA genotypes of LIPC rs2070895 polymorphism were 39%, 45% and 16% for the control, 10%, 37% and 53% for the stroke subjects (P<0.000 1), respectively. The frequencies of G and A alleles were 61.5% and 38.5% for the control, and 28.5% and 71.5% for the stroke subjects (P<0.000 1). Our study shows that the mutant allele of the LIPC promoter was associated with dyslipidemia, lower hepatic lipase activity, and this variation contributed to the increased defective plasma high-density lipoprotein-cholesterol (HDL-C), HDL₂-C and HDL₃-C concentration for both subjects. The control subjects had 6 single nucleotide polymorphism and 6 amino acid substitutions while the stroke subjects had 32 single nucleotide polymorphism and 20 amino acid substitutions. Conclusions: LIPC –250G>A polymorphism can influence plasma lipid profiles and lipoprotein ratios in patients with ischemic stroke.

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Rationale: Infectious keratopathy is an ocular emergency with the potential to cause irreversible blindness. Patient's concerns: A 63-year-old diabetic man presented with a 3-day history of painful red right eye. He had a history of multiple ocular surgeries in the affected eye without recent ocular trauma. Diagnosis: Infective crystalline keratopathy secondary to Citrobacter koseri. Interventions: Topical corticosteroids were discontinued, and dual topical antibiotic therapy of moxifloxacin 5% and gentamycin 0.3% were applied. Outcomes: Twelve hours after the start of treatment, the crystalline nature of the infiltrate disappeared, with enlargement of the epithelial defect. The antibiotic regime was continued and the lesion healed within a week of presentation with residual scarring. Lessons: Infective crystalline keratopathy classically presents with intrastromal branching fern-like opacities and minimal anterior segment inflammation in an immunosuppressed eye. The mainstay of management is corticosteroid discontinuation and the administration of empirical antibiotics until the results of the culture and sensitivity are available. In Citrobacter-related cases, treatment may result in a suppurative appearance before healing of the lesion.

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Rationale: Prolonged undernutrition may arise out of depression and lead to Wernicke's encephalopathy if timely diagnosis and intervention are missed. Wernicke's encephalopathy is potentially treatable, and appropriate treatment may revert clinical depression and cognitive dysfunction to some extent. Patient's concern: A 69-year-old female who had been taking escitalopram for one year developed tremor, ophthalmoplegia, ataxia, progressive cognitive decline, and convulsions. Diagnosis: Non-alcoholic Wernicke's encephalopathy and hypomagnesemia due to psychogenic anorexia. Interventions: High dose intravenous thiamine and magnesium were supplemented. Outcomes: The patient showed remarkable improvement in neurological complications and even in depressive features. Lessons: Wernicke's encephalopathy should not be ignored in the treatment of depression.

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