Internal Medicine Commons^™

A Rare Occurrence Of Ectopic Parathyroid Carcinoma Presenting As A Case Of Recurrent Fractures, Saad Bin Zafar Mahmood, Aisha Jamal, Zain Mushtaq, Qamar Masood

Section of Internal Medicine

Ectopic parathyroid tumors are uncommon, accounting for only 6% of parathyroid adenomas, and even fewer cases are attributed to parathyroid carcinomas. While ectopic parathyroid carcinoma in the anterior mediastinum is a rare condition, the occurrence of recurrent skeletal fractures in the presence of mild hypercalcemia is even rarer. In this report, we present the case of a 52-year-old man with a medical history of hypertension, chronic kidney disease, and a previous right-sided intertrochanteric fracture of the femur one year earlier. He presented to the emergency room with left-sided hip pain and shortness of breath due to volume overload. Laboratory tests …

Role Of Soluble Urokinase Type Plasminogen Activator Receptor (Supar) In Predicting Mortality, Readmission, Length Of Stay And Discharge In Emergency Patients: A Systematic Review And Meta Analysis, Syeda Tayyaba Rehan, Hassan Ul Hussain, Eman Ali, Kanwal Ashok Kumar, Shehroze Tabassum, Muhammad Hasanain, Asim Shaikh, Gibran Ali, Zohaib Yousaf, Muhammad Sohaib Asghar

Section of Internal Medicine

Background: Soluble urokinase plasminogen activator receptor (suPAR) is an inflammatory biomarker that is used to predict mortality, readmission, early discharge, and LOS, thus, serves as a useful tool for ED physicians. Our study aims to analyze the efficacy of suPAR in predicting these prognostic markers in ED.
Methods: We performed a comprehensive search on 6 databases from the inception to 30th November 2022, to select the following eligibility criteria; a) observation or triage trial studies investigating the role of suPAR levels in predicting: 30 day and 90-day mortality, 30-day readmission, early discharge (within 24hr), and LOS in patients coming to …

Hyperammonemia Of Unknown Cause In A Young Postpartum Woman: A Case Report, Sadaf Hanif, Sher Muhammad Sethi

Section of Internal Medicine

Background: Hyperammonemia is a medical condition described as increased or elevated serum ammonia levels. High serum levels of ammonia can cause neurotoxicity. Sudden onset severe hyperammonemia may cause severe encephalopathy with brain damage. It can result in cerebral edema, emesis, seizures, hypotonia, and death. We report a young postpartum woman who had a sudden rise in serum ammonia levels after vaginal delivery.
Case presentation: A 24-year-old, married, postpartum Pakistani woman was admitted to the intensive care unit through the emergency department, with complaints of fever, severe abdominal pain with distension, and altered levels of consciousness. The patient had a medical …

Infective Endocarditis Secondary To Mycoplasma Pneumoniae, Huzaifa Dawood, Saad Nasir, Reem M. Khair, Mustafa Dawood

Section of Internal Medicine

Mycoplasma pneumoniae (MP) is a gram-positive bacterium most commonly associated with community-acquired pneumonia in adults. It can also involve other systems of the body. Cardiovascular complications include pericarditis, myocarditis, congestive cardiac failure, and, rarely, infective endocarditis. We report a case of infective endocarditis secondary to MP infection in an adult. We treated our patient with doxycycline, which showed significant improvement.

Discrepancy Between Pcr Based Sars-Cov-2 Tests Suggests The Need To Re-Evaluate Diagnostic Assays, Zain Mushtaq, Sadia Shakoor, Akber Kanji, Najma Shaheen, Asghar Nasir, Zeeshan Ansar Ahmed, Imran Ahmed, Syed Faisal Mahmood, Rumina Hasan, Zahra Hasan

Section of Internal Medicine

Objective: We investigated the discrepancy between clinical and PCR-based diagnosis of COVID-19. We compared results of ten patients with mild to severe COVID-19. Respiratory samples from all cases were tested on the Roche SARS-CoV-2 (Cobas) assay, Filmarray RP2.1 (bioMereiux) and TaqPath™ COVID19 (Thermofisher) PCR assays.
Results: Laboratory records of ten patients with mild to severe COVID-19 were examined. Initially, respiratory samples from the patients were tested as negative on the SARS-CoV-2 Roche® assay. Further investigation using the BIOFIRE® Filmarray RP2.1 assay identified SARS-CoV-2 as the pathogen in all ten cases. To investigate possible discrepancies between PCR assays, additional testing was …

The Relation Of Abo Blood Group To The Severity Of Coronavirus Disease: A Cross-Sectional Study From A Tertiary Care Hospital In Karachi, Fazal Ur Rehman, Syed Furrukh Omair, Fatima Memon, Bakhtawar J. Rind, Danish Ahmed Memon, Syed Ahsan Ali, Bilal Ahmed, Naureen Ali

Section of Internal Medicine

Background: Blood groups are considered to have an impact on the occurrence and severity of coronavirus disease. While among Chinese and Caucasian, blood group O individuals were less and group A were more likely to have severe disease and mortality, data on South Asians aren’t available.
Objective: This study aimed to find out the association of disease severity with blood group among coronavirus disease 2019 (COVID-19) patients.
Materials and methodology: Data were collected on a predesigned questionnaire containing details of patient demographics, medical comorbidities, clinical presentation, and laboratory parameters. Multiple logistic regression was used to determine the association of the …

Correlation Of Serum Calcium With Severity Of Acute Ischaemic Stroke, Ainan Arshad, Saad Bin Zafar Mahmood, Ahmed Ayaz, Mehsa Hashim, Eisha Hanan

Section of Internal Medicine

Stroke results in the death of around 6.5 million people annually with a majority of these occurring in developing countries. Serum calcium has been hypothesised to play a significant role in causing ischaemic stroke. This retrospective observational study was conducted to determine the correlation, if any, between serum calcium and the severity of acute ischaemic stroke in our population. Two hundred and seventy-nine patients admitted with acute ischaemic stroke were enrolled in the study. Of the 279 patients 162 (58%) were male and mean age was 62.4 ± 3.8 years. Characteristics of stroke patients were compared with stroke severity. Mean …

The Discrepancy Between Admission And Discharge Diagnoses: Underlying Factors And Potential Clinical Outcomes In A Low Socioeconomic Country, Samar Fatima, Sara Shamim, Amna Subhan Butt, Safia Awan, Simra Riffat, Muhammed Tariq

Section of Internal Medicine

Objective: The discrepancy between admission and discharge diagnosis can lead to possible adverse patient outcomes. There are gaps in integrated studies, and less is understood about its characteristics and effects. Therefore, this study was conducted to determine the frequency, characteristics, and outcomes of diagnostic discrepancies at admission and discharge.
Design and data sources: This retrospective study reviewed the admitting and discharge diagnoses of adult patients admitted at Aga Khan University Hospital (AKUH), Internal Medicine Department between October 2018 and February 2019. The frequency and outcomes of discrepancies in patient diagnoses were noted among Emergency Department (ED) physician versus admitting physician, …

Triggering And Protective Factors Of Burnout In Medical Resident Physicians In A Lower-Middle-Income Country: A Cross-Sectional Study, Saad Bin Zafar Mahmood, Aqusa Zahid, Noreen Nasir, Munaim Tahir, Uzma Ghouri, Aysha Almas

Section of Internal Medicine

Background: Residents and interns are prone to emotional and physical exhaustion, also known as burnout. Burnout has not been studied much in physicians working in lower-middle income countries. We conducted this study to determine the burden of burnout among internal medicine residents and to identify triggering and protective factors associated with burnout.
Materials and methods: A cross-sectional study was conducted at two institutes in Karachi from 2018 to 2019. All residents registered in the internal medicine program for at least 6 months were invited to participate via an online survey. An abbreviated version of the Maslach Burnout scale was used …

Morphological Spectrum Of Vesiculobullous Skin Lesions: An Institutional Perspective, Javaria Ali, Sabeeh Islam, Syed Munqaad Ali, Syed Rafay Yaqeen, Anum Aslam, Qurat Ul Ain Khan, Umair Arshad Malik, Muhammad Irfan, Hanna Naqvi, Atif A. Hashmi

Section of Internal Medicine

Introduction: A vesiculobullous lesion of the skin encompasses a group of dermatological disorders with protean clinicopathological features. They usually occur as a part of the spectrum of various infectious, inflammatory, drug-induced, genetic, and autoimmune disorders. Therefore, accurate diagnosis of these lesions is essential for appropriate management and to reduce the associated morbidity and mortality. The conventional skin punch biopsy is the mainstay in the diagnosis of dermatological diseases, especially when combined with confirmatory tests, such as direct immunofluorescence (DIF). Our study evaluated the clinicopathological spectrum of vesiculobullous lesions.
Methods: We studied 150 cases of vesiculobullous lesions at the Department of …

Acuity Level Of Care As A Predictor Of Case Fatality And Prolonged Hospital Stay In Patients With Covid-19: A Hospital-Based Observational Follow-Up Study From Pakistan, Aysha Almas, Zain Mushtaq, Jette Moller

Section of Internal Medicine

Objectives: To determine if there is an association between acuity level of care (ALC), case fatality and length of stay in patients admitted to hospital due to COVID-19.
Design: A hospital-based observational follow-up study.
Setting: Internal Medicine Service of the Aga Khan University Hospital, Pakistan, from 26 February 2020 to 30 June 2020.
Participants: Adult patients with confirmed COVID-19, aged ≥18 years.
Methods: ALC was categorised into low, intermediate and high level and patients were triaged using the standard emergency severity illness score. All patients were followed until the end of hospital admission for the outcome of case fatality and …

Predictors Of Iron Consumption For At Least 90 Days During Pregnancy: Findings From National Demographic Health Survey, Pakistan (2017-2018), Sumera Aziz Ali, Savera Aziz Ali, Shama Razzaq, Nayab Khowaja, Sarah Gutkind, Fazal Ur Rehman, Nadir Suhail

Section of Internal Medicine

Background: Iron supplementation is considered an imperative strategy for anemia prevention and control during pregnancy in Pakistan. Although there is some evidence on the predictors of iron deficiency anemia among Pakistani women, there is a very limited understanding of factors associated with iron consumption among Pakistani pregnant women. Thus, this study aimed to investigate the predictors of iron consumption for at least ≥90 days during pregnancy in Pakistan.
Methods: We analyzed dataset from the nationally representative Pakistan Demographic Health Survey 2017-2018. The primary outcome of the current study was the consumption of iron supplementation for ≥90 days during the pregnancy …

Clinical Characteristics And Outcomes Of Covid-19: Experience At A Major Tertiary Care Center In Pakistan, Nosheen Nasir, Kiren Habib, Iffat Khanum, Naveera Khan, Zehra Abdul Muhammad, Syed Faisal Mahmood

Section of Internal Medicine

Introduction: Limited data exist on clinical characteristics and outcomes of hospitalized COVID-19 patients in low-middle income countries. We aimed to describe the clinical spectrum and outcomes of hospitalized COVID-19 patients at a tertiary-care center in Karachi, Pakistan.
Methodology: We conducted an observational study of adult COVID-19 patients hospitalized between February-June 2020. Patients with a discharge diagnosis of COVID-19 and PCR positivity were included. We created logistic regression models to understand association of clinical characteristics with illness severity and in-hospital mortality.
Results: The study population comprised 445 patients [67% males, median age 53 (IQR 40-64) years]. Majority of patients (N = …

Association Of Vitamin D Deficiency And Disease Activity In Systemic Lupus Erythematosus Patients: Two-Year Follow-Up Study, Ainan Arshad, Saad Bin Zafar Mahmood, Ahmed Ayaz, Adil A. Manji, Akash Kumar Ahuja

Section of Internal Medicine

Objectives: This study aims to determine the prevalence of vitamin D deficiency in Pakistani systemic lupus erythematosus (SLE) patients and the effect of vitamin D deficiency on the severity and outcomes of SLE.
Patients and methods: This retrospective study evaluated SLE patients presenting to our hospital between January 2009 and December 2018. A total of 98 patients (13 males, 85 females; mean age 39.8±14.9 years; range, 16 to 73 years) with vitamin D levels available at the time of diagnosis were included in the study. Disease activity was measured using SLE disease activity score at the time of diagnosis and …

Knowledge And Attitude Towards Identification And Management Of Sepsis Among Resident Physicians In A Tertiary Care Teaching Hospital In Pakistan, Ainan Arshad, Abdul Aziz, Ahmed Ayaz, Syed Maaz Salahuddin, Bushra Jamil

Section of Internal Medicine

This study was conducted to determine the compliance and knowledge of sepsis guidelines among resident physicians in a tertiary care hospital of a developing country. A self-structured validated questionnaire was prepared to evaluate compliance and knowledge of the Surviving Sepsis Campaign (SSC) guidelines. A total of 76 resident physicians completed the questionnaire; out of these, 51 (67%) were from Internal Medicine department and 25 (33%) were from Emergency Medicine department of the Aga Khan University Hospital, Karachi. A total of 71 (93%) participants claimed to be aware of the SSC guidelines but only 20 (26%) considered themselves very knowledgeable on …

Bilateral Systematised Epidermolytic Epidermal Nevus: A Case Report, Sabeika R. Kerawala, Najam-Us-Saher Rizvi, Saadia Tabassum

Section of Internal Medicine

Verrucous epidermal nevi (VEN) are benign congenital hamartomas consisting of keratinocytes. Histological examination mostly exhibits hyperkeratosis, acanthosis, papillomatosis and, rarely, the features of epidermolytic hyperkeratosis (EHK). We report a case of a 6-year-old boy who presented at Aga Khan University Hospital, Karachi, Pakistan with bilaterally symmetrical linear epidermal nevi following Blaschko's lines and showing epidermolytic hyperkeratosis on histology. The patient was treated with topical keratolytics and emolients which led to considerable improvement. To the best of the authors' knowledge, this is the first report of VEN from Pakistan.

Subcutaneous Emphysema And Pneumomediastinum In Patients With Covid-19 Disease; Case Series From A Tertiary Care Hospital In Pakistan, Sher Sethi, Amber Sabeen Ahmed, Sadaf Hanif, Masooma Aqeel, Ali Bin Sarwar Zubairi

Section of Internal Medicine

Since December 2019, the clinical symptoms of coronavirus disease 2019 (COVID-19) and its complications are evolving. As the number of COVID patients requiring positive pressure ventilation is increasing, so is the incidence of subcutaneous emphysema (SE). We report 10 patients of COVID-19, with SE and pneumomediastinum. The mean age of the patients was 59 ± 8 years (range, 23-75). Majority of them were men (80%), and common symptoms were dyspnoea (100%), fever (80%) and cough (80%). None of them had any underlying lung disorder. All patients had acute respiratory distress syndrome on admission, with a median PaO2/FiO2 ratio of 122.5. …

Rigorous Hand Hygiene Practices Among Health Care Workers Reduce Hospital-Associated Infections During The Covid-19 Pandemic, Rozina Roshan, Anam Shahil Feroz, Zohra Rafique, Nazleen Virani

Section of Internal Medicine

The experiences of these recent months have left us with as many new questions as they have given us new solutions. The main question that infection prevention and control department is having these days is "Why have hospital-associated infections (HAIs) reduced during COVID-19 pandemic?" What is the one unique strategy that has brought decline in increasing HAIs? Would it be appropriate to say that rigorous hand hygiene practices among health care workers (HCWs) have reduced HAIs in a tertiary care hospital of Pakistan? This commentary is written to understand the effect of rigorous hand hygiene among HCWs on number of …

Erythema Annulare Centrifugum: A Rare Skin Manifestation Of Hashimoto Thyroiditis, Palwasha Jalil, Sadia Masood, Saira Fatima

Section of Internal Medicine

Erythema annulare centrifugum (EAC) is an unusual skin condition appearing as recurrent erythematous annular eruptions associated with autoimmune disorders, infections, and various neoplastic conditions. We present a very rarely reported association of EAC with Hashimoto thyroiditis (HT) in a young male. A 26-year-old male recently diagnosed as case of HT presented in the dermatology clinic with nine-month history of non-itchy persistent annular lesions on the body. The morphology and biopsy of lesions confirmed the diagnosis of EAC. HT is a part of the spectrum of autoimmune thyroid diseases with its own specific cutaneous manifestations. Our case also depicts the impact …

Novel Use Of Fresh Frozen Plasma In Treating Hereditary Angioedema: A Success Story From Pakistan, Amber Sabeen Ahmed, Sidra Fayyaz

Section of Internal Medicine

Hereditary angioedema (HAE) due to a C1-esterase inhibitor(C1-INH) deficiency is a rare and potentially life-threatening disorder. It is characterized by an episodic and self-limiting increase in vascular permeability. The condition manifests itself as recurrent attacks of swelling in any part of the body. The angioedema can cause the involvement of the respiratory tract, skin, and gastrointestinal tract. Laryngeal involvement can make the condition life-threatening. It does not respond well to conventional angioedema therapy of steroids, adrenaline, and antihistamines. The targeted therapy for HAE consists of plasma-derived or recombinant C1-INH, ecallantide, and icatibant or bradykinin receptor antagonist. In the absence of …

Prevalence Of Risk Factors Of Acute Kidney Injury In A Tertiary Care Hospital In Pakistan, Ainan Arshad, Ahmed Ayaz

Section of Internal Medicine

The objective of this study was to determine the prevalence of preventable risk factors of acute kidney injury in a tertiary care hospital in Pakistan. All patients admitted at Aga Khan University Hospital, Karachi with diagnosis of acute kidney injury were included out of which 134 were selected via random sampling. Patients with existing CKD were excluded. Data was then collected retrospectively from medical records of these patients. Mean age was 60±11.7 years while mean serum creatinine on admission was 2.4±1.3 (mg/dl). Sepsis played a role in almost half of the patients [60 (45%)]. Other factors included diarrhoea [23 (17%)], …

Invasive Pulmonary Infection By Syncephalastrum Species: Two Case Reports And Review Of Literature, Memoona Irshad, Nosheen Nasir, Urooj Haider Hashmi, Joveria Farooqi, Syed Faisal Mahmood

Section of Internal Medicine

Background: Syncephalastrum species belong to the class Zygomycetes and order Mucorale. These are found in the environment and tropical soil, usually presenting as colonizers and rarely cause human infection. Syncephalastrum racemosum is a species of the genus Syncephalastrum and is the most commonly identified pathogen. Most cases are reported in immunocompromised individuals, such as patients on long term steroids, poorly controlled diabetes, or patients with malignancy.
Case presentation: We are describing two cases of rare fungal infection by Syncephalastrum species causing invasive pulmonary manifestation. Both patients had compromised immune status and presented with worsening dyspnea to the emergency room. Both …

A Fatal Case Of Primary Amoebic Meningoencephalitis (Pam) Complicated With Diabetes Insipidus (Di): A Case Report And Review Of The Literature, Zain Mushtaq, Saad Bin Zafar Mahmood, Adil Aziz

Section of Internal Medicine

Naegleria fowleri is a highly infective free-living amoeba usually isolated from soil and fresh water and is primarily found to infect the central nervous system (CNS) resulting in primary amoebic meningoencephalitis (PAM). PAM as a cause of meningitis is often overlooked for other, more common causes of meningitis. Despite all the advances in antimicrobial therapy and supportive care systems, the mortality rate of this rare infection remains above 95% with the bulk of the cases being found in developed countries. We are presenting a case of a 44-year-old male with fever, worsening headache, and generalized weakness. Lumbar puncture showed a …

Differences In Angiographic Profile And Immediate Outcome Of Primary Percutaneous Coronary Intervention In Otherwise Risk-Free Young Male Smokers, Salik Ahmed, Sanam Khowaja, Saher Khowaja, Tariq Ashraf, Kanwal Aamir, Mahesh K. Batra, Musa Karim, Muhammad Anis M. Ahmedani, Syed Z. Jamal

Section of Internal Medicine

Introduction: Cigarette smoking is a well-established risk factor for the development and progression of coronary artery disease (CAD) and it is strongly related to cardiac morbidity and mortality. Therefore, this study aimed to compare the angiographic profile and immediate clinical outcomes in young male smokers and non-smokers without any other cardiac risk factors presented with ST-elevation myocardial infarction (STEMI).
Methods: This study includes young (≤40 years) male patients presented without cardiac risk factors other than smoking. Angiographic profile and immediate outcome of primary percutaneous coronary intervention (PCI) were collected from the hospital database.
Results: A total of 580 young male …

Tension Pneumocephalus After Right Dacryocystorhinostomy: A Rare But Potential Serious Complication, Sher Sethi, Syed Ahsan Ali

Section of Internal Medicine

Tension pneumocephalus is a phenomenon in which air enters through dural injury in the brain and then expands and causes a mass effect. The injury can be due to any neurosurgical procedure, trauma, infection and/or neoplasm. A 63-year-old female known case of diabetes and hypertension had an elective procedure of right dacryocystorhinostomy present to the emergency department the very next day with a loss of consciousness. Urgent CT of the head showed air in the cranium (pneumocephalus). A radiological sign named "Mount Fuji" is classical for tension pneumocephalus. She was closely monitored and shows good clinical improvement allowing the neurosurgery …

Awareness Regarding Causes Of Infertility Among Out-Patients At A Tertiary Care Hospital In Karachi, Pakistan, Hamza M. Ahmed, Mohammad Khan, Farah Yasmin, Haris Jawaid, Hiba Khalid, Anum Shigri, Faryal Nawaz, Choudhary A. Hasan

Section of Internal Medicine

Introduction: Infertility is the inability of a couple to achieve pregnancy within 12 months of sexual intercourse without the use of contraceptives. The Pakistani population, belonging to a low-middle income country, has a high prevalence of infertility due to a low knowledge and awareness regarding its causes, and lack of healthcare-seeking behavior for this medical issue. The prevalence of infertility in Pakistan is reported as 22%, with primary infertility accounting for 4% of the total cases. This leads to psychological trauma among women as societal norms equate infertility with failure on a personal, emotional, and social level. In this study, …

Bullous Striae Distensae With Prolonged Steroid Use: An Unusual Clinical Presentation, Sadia Masood, Palwasha Jalil, Shaheen Naveed, Samra Kanwal

Section of Internal Medicine

No abstract provided.

Frequency Of Depression And Anxiety Among Patients With Chronic Spontaneous Urticaria Visiting A Tertiary Care Hospital In Karachi, Pakistan, Muhammad Rizwan Rafique, Sadia Masood, Sana Tanzil, Saadia Tabassum, Shaheen Naveed

Section of Internal Medicine

Objective: To determine the frequency of anxiety and depression among chronic spontaneous urticarial patients presenting at a tertiary care hospital.
Methods: The prospective, cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, from February to August 2015, and comprised patients diagnosed with chronic spontaneous urticaria at the dermatology clinic. All the participants were assessed for anxiety and depression using Aga Khan University-Anxiety Depression Scale. Data was collected in face-to-face interview using a structured questionnaire. The association of the condition with different characteristics were calculated after stratification for age, gender, occupation and monthly income. SPSS 19 was used for …

Does Depressed Persons With Non-Cardiovascular Morbidity Have A Higher Risk Of Cvd? A Population-Based Cohort Study In Sweden, Aysha Almas, Jette Moller, Romaina Iqbal, Andreas Lundin, Yvonne Forsel

Section of Internal Medicine

Background: Depression often co-exists with non-cardiovascular morbid conditions. Whether this comorbidity increases the risk of cardiovascular disease has so far not been studied. Thus, the aim of this study was to determine if non-cardiovascular morbidity modifies the effect of depression on future risk of CVD.
Methods: Data was derived from the PART study (acronym in Swedish for: Psykisk hälsa, Arbete och RelaTioner: Mental Health, Work and Relationships), a longitudinal cohort study on mental health, work and relations, including 10,443 adults (aged 20-64 years). Depression was assessed using the Major Depression Inventory (MDI) and self-reported data on non-cardiovascular morbidity was assessed …

Risk Factors For Mortality Of Patients With Ceftriaxone Resistant E. Coli Bacteremia Receiving Carbapenem Versus Beta Lactam/Beta Lactamase Inhibitor Therapy, Nosheen Nasir, Sara Ahmed, , Samrah Razi, Safia Awan, Syed Faisal Mahmood

Section of Internal Medicine

Objective: Extended spectrum β-lactamases (ESBL) producing Enterobacteriaceae predominantly E. coli and K. pneumoniae bacteremia have limited treatment options and high mortality. The objective was to determine the risk factors for in-hospital mortality particularly treatment with carbapenem versus beta lactam/beta lactamase combination (BL/BLI) in patients with ceftriaxone resistant E. coli bacteremia. A retrospective cohort study was conducted at the Aga Khan University, Karachi, Pakistan. Adult patients with sepsis and monomicrobial ceftriaxone resistant E. coli bacteremia were enrolled. Factors associated with mortality in patients were determined using logistic regression analysis.

Results: Mortality rate was 37% in those empirically treated with carbapenem …