A Pathophysiological Perspective on COVID-19's Lethal Complication:From Viremia to Hypersensitivity Pneumonitis-like Immune Dysregulation / 감염과화학요법

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), the coronavirus responsible for our recent coronavirus disease 2019 pandemic, is driving a lung immunopathology that strongly resembles a severe form of hypersensitivity pneumonitis (HP). A review of recent Severe acute respiratory syndrome-related coronavirus (SARS-CoV) and SARS-CoV-2 medical reports, as well as described characteristics of HP, lead us to postulate a theory for SARS-CoV-2 severe disease. We propose that the novel SARS-CoV-2 can act as a trigger and substrate of an HP-like severe immune reaction especially in genetically vulnerable individuals in addition to those with immune senescence and dysregulation. Accordingly, the purpose of our letter is to shift the emphasis of concern surrounding immune activity from viral infection to an HP-like severe immune reaction. We review similarities in disease presentation between infection and allergy, relevant immunopathology, and outline phases of SARS-CoV-2 disease with perspectives on therapy and critical care. Altogether, the favored course is to begin treatments that address the disease at the earliest phase before immune dysregulation leading to uncontrolled pulmonary inflammation.

Neurocysticercosis: A case report and brief review

Neurocysticercosis (NCC) is one of the seven neglected endemic zoonoses targeted by the World Health Organization. It is considered a common infection of the nervous system caused by the Taenia solium and is known to be the primary cause of preventable epilepsy in many developing countries. NCC is commonly resulted by the ingestion of Taenia solium eggs after consuming undercooked pork, or contaminated water. The parasite can grow in the brain and spinal cord within the nervous system, causing severe headache and seizures beside other pathological manifestations. Immigration and international travel to endemic countries has made this disease common in the United States. NCC can be diagnosed with computed tomography and magnetic resonance imaging of the brain. The treatment of the NCC including cysticidal drugs (e.g., albendazole and praziquantel), and neurosurgical procedure, depending upon the situation. A patient of Asian origin came to our clinic with complaints of dizziness, headaches and episodes seizures for the past twelve years without proper diagnosis. The computed tomography and magnetic resonance imaging scans indicated multilobulated cystic mass in the brain with the suspicion of neurocysticercosis.

Neurocysticercosis: A case report and brief review

Neurocysticercosis (NCC) is one of the seven neglected endemic zoonoses targeted by the World Health Organization. It is considered a common infection of the nervous system caused by the Taenia solium and is known to be the primary cause of preventable epilepsy in many developing countries. NCC is commonly resulted by the ingestion of Taenia solium eggs after consuming undercooked pork, or contaminated water. The parasite can grow in the brain and spinal cord within the nervous system, causing severe headache and seizures beside other pathological manifestations. Immigration and international travel to endemic countries has made this disease common in the United States. NCC can be diagnosed with computed tomography and magnetic resonance imaging of the brain. The treatment of the NCC including cysticidal drugs (e.g., albendazole and praziquantel), and neurosurgical procedure, depending upon the situation. A patient of Asian origin came to our clinic with complaints of dizziness, headaches and episodes seizures for the past twelve years without proper diagnosis. The computed tomography and magnetic resonance imaging scans indicated multilobulated cystic mass in the brain with the suspicion of neurocysticercosis.

Knowledge and attitudes of Oman medical specialty board residents towards evidence-based medicine

This study aims to evaluate the knowledge and attitudes of Oman Medical Specialty Board [OMSB] residents towards Evidence-Based Medicine [EBM]. This cross sectional study was conducted on all OMSB residents through a self-administered online questionnaire between October 2012 and March 2013. An electronic survey was designed to identify and determine residents' knowledge and attitudes toward the use of EBM. The survey was completed by 93 [21%] OMSB residents, 76 [82%] of whom took part in continuing education courses and 50 [54%] belonged to professional practice-oriented organizations. On average, the residents were reportedly involved in patient care for approximately 70% [Standard Deviation [SD] 17%] of their time, while 14% [SD 12%] participated in research activities. The results showed that 53 respondents [57%] were competent users of medical search engines compared to 23 residents [25%] who rated their skills as neutral. Sixteen percent of the respondents strongly agreed and 46% only agreed that the facility supports the use of current research in practice. Fourteen percent strongly agreed and fifty-three percent only agreed that the foundation of EBM is part of OMSB academic preparation. On the other hand, 17% of the respondents thought that insufficient time is always a barrier against EBM, while another 27% perceived insufficient time as a usual barrier. The lack of information resources was reported to always be a barrier in 11% of the respondents while 32% thought that it usually acts as a barrier. Time constraints and skills in EBM were found to be the two major obstacles. This study was, however, limited by the low response rate of the survey; thus larger studies with a previously validated questionnaire should be conducted in the future

Prevalence and risk factors of diabetic nephropathy in Omani type 2 diabetics in Al-Dakhiliyah region

To assess the prevalence and risk factors of diabetic nephropathy among Omani type 2 diabetics in Al-Dakhiliyah region of the Sultanate of Oman. A cross-sectional and a case control study designs were used to assess the prevalence and risk factors respectively. For the prevalence study a sample of 699 diabetic subjects were selected randomly from two polyclinics in Al-Dakhiliyah region; Sumail and Nizwa polyclinics. For the case control study, a sample consisting of 215 cases and 358 controls were randomly selected from those who were included in the cross-sectional study. A well designed questionnaire has been used to collect data regarding the disease and risk factors. Data was analyzed using SPSS19 statistical program. Total prevalence of diabetic nephropathy was calculated as 42.5% [95% C.I: 38.83% - 46.15%]. The difference in the prevalence in the two polyclinic catchment area was not significant. The prevalence was significantly higher among males [51.6%] compared to females [36.5%]. Crude analysis of the risk factors showed significant association between diabetic nephropathy and the following factors; male gender, decreased literacy, long duration of diabetes mellitus, hypertension, retinopathy, neuropathy, family history of diabetic nephropathy, poor glycemic control [high HbA1c], and hypertriglyceridemia. Multivariate analysis showed the following factors to be independent risk factors; male gender, decreased literacy, long duration of diabetes, family history of diabetic nephropathy and poor glycaemic control [high HbA1c]. The prevalence of diabetic nephropathy in this study was 42.5% and the significant risk factors associated with it included male gender, decreased literacy, long duration of diabetes, family history of diabetic nephropathy and poor glycemic control [high HbA1c]

Nutritional challenges in the elderly with diabetes

Adults age 60 and older will comprise two-thirds of the diabetic population by the year 2025. Older patients with diabetes are more likely to have coexistent chronic conditions like hypertension, dyslipide-mia, and cardiovascular disease that may impact their nutritional requirements. The issue of attainment and maintenance of an optimal body weight in elderly diabetic persons may not be as straightforward as in other age groups, and the risk-benefit ratio may be different as well. Although increased prevalence of overweight and obesity in the elderly contributes to insulin resistance and hyperglycemia, older inhabitants of long-term care facilities who suffer from diabetes tend to be underweight. Both may signify inadequate nutritional status and lead to increased morbidity and mortality. The attendant problems of appetite changes, palatability of food, dietary restrictions, loneliness, and depression may affect the type and quantity of food consumed by elderly persons. Structured screening tools may identify nutrition-related issues that warrant evidence-based interventions. Although glucose control and health concerns are important factors in diet modification in the older population, other considerations include quality of life and individual preferences. Customizing of nutritional guidelines to the needs of the older diabetic patient makes sense

Perception of chin deviation by lay people

Symmetry plays an important role in the perception of beauty. Deviated nasal septum, flat cheek bones or prominent chin enhances facial asymmetry. A small degree of bilateral asymmetry exists in essentially all normal individuals. However it has been reported that orthodontists and lay people differ in their ability to perceive asymmetry. The objective of this study was to observe the minimum chin deviation that can be perceived by a lay person and thus establish or identify possible correlation between jaw asymmetry and treatment need. A photograph of a famous superstar with a symmetric face was selected and manipulated using a software to create 5 variants; the original, 2mm chin deviation to right, 2mm chin deviation to left, 4mm chin deviation to right and 4mm chin deviation to left. Lay persons with no medical or arts background were asked to score all the five photographs on a scale of 1 to 15 being excellent and 5 as unsatisfactory. 60 survey forms were filled. Chi square test showed a highly significant [p<0.01] association between the degree of asymmetry and the scores received by the photographs. For correlation between degree of asymmetry and scores received, Spearman's correlation gave a significant [p<0.05] result for original and photographs with 2mm deviation while it yielded a highly significant [p<0.01] result for the original and 4mm deviation photographs. Lay persons are able to perceive chin deviations as small as 2mm

Maternal risk factors associated with low birth weight in Karachi: a case-control study

To evaluate maternal risk factors associated with low birth weight [LBW] among women aged 15-35 years, we carried out a hospital-based, case-control study on 262 cases [mothers of neonates weighing 2.5 kg]. Odds of delivering a low-birth-weight baby decreased with increase in maternal haemoglobin [odds ratio [OR]: 0.701; 95% confidence interval [CI]: 0.62-0.79]. Odds were greater among mothers not using iron supplements during pregnancy [OR: 2.88; 95% CI: 1.83-4.54]. Mothers of LBW babies had lower haemoglobin levels before delivery

Assessing the prevalence, quantification and morphological composition of coronary atherosclerosis in patients with type 2 diabetes and the metabolic syndrome via 64-Slice CT angiography

We determined the prevalence, morphology, and severity of coronary artery plaque in high-risk patients via 64-slice cardiovascular computed tomography [CVCT]. Based on chart review, 101 subjects having a 64-slice CVCT were assigned to one of three groups: type 2 diabetes, metabolic syndrome, or comparison. Disease severity was classified as: no disease, subclinical disease [lesions <70%], or clinically significant disease [lesions >70%]. Plaque morphology was stratified as either vulnerable or stable plaque by Houndsfield units and established American Heart Association criteria. Diabetic subjects had the highest prevalence of CAD [78%], compared to 65% in the metabolic syndrome subjects and 55% in the comparison group [p<.05]. Diabetic subjects were also most likely to have both significant CAD [41%], and stable plaque [52%] followed by metabolic syndrome subjects [33% and 25%] and the comparison group [15% and 20%] [p < 0.05]. The metabolic syndrome group was most likely to have vulnerable lesions [36%] potentially placing them at increased risk of acute events. 22% of subjects in the diabetes group, 35% in the metabolic syndrome group, and 45% in the comparison cohort were disease-free. 64-slice CVCT allows non-invasive diagnosis and stratification of subjects with diabetes and the metabolic syndrome, providing relevant information regarding coronary disease prevalence, severity, and plaque composition, that are statistically different among these high risk patient cohorts

Multiple-dose insulin injection therapy in patients with type 2 diabetes using a basal-bolus regimen, team management, and nutrition education

We determined the efficacy of basal-bolus insulin therapy delivered through team education and nutrition counseling formanagement of type 2 diabetes in 17 patients treated with a regimen of once-daily insulin glargine and either insulin aspart or lispro three times a day. They received written instructions and specific education about 'basal-bolus' insulin administration, use of a 'forced-titration' schedule for glargine dose adjustment, and calculation of rapid-acting pre-meal bolus insulin. The average hemoglobin Ale level decreased from 8.7 +/- 2.06% to 7.0 +/- 1.07%, a significant reduction of 1.7% [p<0.05] over 3 months or more. 7 patients [41%] reported improvement in hypoglycemic events. In conclusion, an intensive multidose basal-bolus insulin treatment using self-titration and flexibility through carbohydrate counting confers beneficial effects in patients with type 2 diabetes, including better glycemic control and reduced hypoglycemia. These results are best achieved through multi-disciplinary patient care involving the nurse educator and dietician as part of a diabetes care team

Sleep habits and their consequences: a survey

Objective: To study the sleep habits and their consequences among the students of Shifa College of Medicine

Materials and Methods: A survey questionnaire consisting of a total of 50 questions was designed to analyze the sleep habits of the students of Shifa College of Medicine, Islamabad. Data were collected during March and April 2002. The answers were restricted to either YES or NO. A total of 120 questionnaires were then distributed to the students of the first four years in their respective classrooms, with an explanation of the aims and objectives of the study

Results: Responses were received from 112 students. The age range was between 18 and 23 years. Analysis revealed that on average the amount of sleep required per 24 hours of the respondents was 8 hours, however, the average amount of sleep that they actually got every day was on average 6 hours. There was an association between the quantity of caffeine ingested and its subsequent effects on the regularity of sleeping hours. Most of the students of Shifa College of Medicine are suffering from high levels of daytime sleepiness. Nearly half the class of second year admitted to being depressed and irritable [47% and 50% respectively]. A 37% said that their lifestyle and interpersonal relationships were affected

Conclusion: Our preliminary results show that disorders related to sleep are a significant problem. Caffiene ingestion affected sleep and there was high level of daytime sleepiness. Sleep difficulties resulted in irritability and affected lifestyle and interpersonal relationships

Acute renal failure: analysis of aetiological factors and outcome

To analyse the causes of acute renal failure [ARF] and management and outcome in these cases. All patients with ARF coming to SlUT between January 1990 and December 1998 were studied. A total of 1716 ARF cases were seen. Of these 43% had medica1, 28%surgical and 17% obstetrical causes. Haemodialysis was required in 88% of patients. Overall mortality was 18%. Causes of ARF in this part of the world is different from the western world. Preventable causes e.g. gastroenteritis, obstetrical haemorrhages, torture induced rhabdomyolysis and malaria, contribute to large percentage of the ARF population

Superficial bladder cancer PT1G3: management controversies

To evaluate and identify high risk patients having superficial bladder cancer and to assess the role of radical cystectomy as primary treatment modality. An eight-year retrospective analysis of bladder cancer patients presenting to SlUT was undertaken. After clinical evaluation and routine laboratory investigations, IVU, sonography, CT Scan/MRI, cystoscopy, histopathology, were performed when indicated. A follow-up cystoscopy was carried out at regular intervals [3-6 months] up to a maximum of 8years. Of the 550 [59.7%] patients diagnosed as urothelial tumours, 61/330 [18.4%] had pT1G3 disease, with a male to female ratio of 14:1. Most of the cases [81.7%] were between 41-70 years of age. Haematuria was the presenting symptom in every case, followed by frequency 82.4%, dysuria 32.7% and clot retention 32.7%. There was no significant occupational association, however 25 [40.9%] were smokers for over 25 years. Filling defect on IVU was seen in 52 [85.2%] cases whereas Sonogram revealed echogenic masses in 44 [72.4%]. The morphological site, as per CT scan and cystoscopy was 72.1% lateral wall, 6.6% dome, 3.3% base and 18% were multicentric disease. Growth less than 1 cm was seen in 27%, 1.5 cm in 41% while greater than 5 cm in 32% of cases, All patients underwent endoscopic resection. Intravesical Mitomycin C was given to 27 and BCG to 15 cases. Of the high risk patients, 12 were primarily treated by radiation therapy whereas 22 underwent primary radical cystectomy and 16 had a salvage cystectomy and ileal conduit. Recurrence of the carcinoma was seen in 12 patients who had received intravesical chemo/immunotherapy, in 8 treated initially with radiotherapy and 8 subjected to radical cystectomy. The management of pT1G3 is still a controversial area of carcinoma bladder treatment. In view of the high cost of therapy, fast progression, high recurrence rate and metastasis, we in our setup recommend an early radical surgery in pT1G3 disease. This not only eliminates the lesion but is also cost effective

Urodynamic studies in urology practice: a preliminary report of 116 patients

Objective The aim of the study was to report our initial experience with urodynamic studies and to analyze its indications and clinical usefulness at our centre. Methods After an initial workup, urodynamic studies were performed on Wiest Urodynamic System. A 12F 3 way bladder line and another rectal line were used for filling and voiding cystometry. Post void residue was noted on ultrasound. Tracings were correlated with clinical history and physical examination of the patient. Results This study included 116 patients for urologic evaluation. The commonest urodynamic disorder was neuropathic bladder of various causes in 32 [27.5%] patients, another group was Benign Prostatic Hyperplasia [B.P.H] and Bladder Outlet Obstruction [B.O.O] 28 [24.1%], incontinence of urine 21 [18.1%], females with retention of urine 11 [9.4%] and end stage renal disease [ESRD] in 24 [19.5%] patients. Conclusion Urodynamic studies increases our understanding of lower urinary tract dysfunction and provides objective evidence on which to base the scientific management of these disorders. These studies should be available at tertiary care centres where modem urology is being practiced

Methods of ureteric stent placement and removal: experience with 200 patients

Objective To study the advantages of ureteric stents in management of ureteric obstruction, injury or surgery. Methods Ureteric stents were inserted in 200 patients by endoscopic, percutaneous or open operation approach. Local anaesthesia, sedoanalgesia and general anaesthesia was used according to requirement of the patient. Removal of the stens was also endoscopic or in complicated cases by exploration. Results Ureteric stents were placed endoscopically in 190, by open operation in 6 and percutaneous approach in 4 cases. Conclusion Ureteral stent for managing ureteral injury is a safe and simple procedure in modern urology practice. Local anaesthesia was used in 143, analgesia in 31 and general anaesthesia in 26 patients. Endoscopic removal of stents was possible in 177 cases whereas 23 patients had to undergo open surgery due to fractured or upward migrated stents. Local anaesthesia was used in 150 analgesia in 21 and general anaesthesia in 29 cases

Prevailing dietary patterns in renal stone formers and healthy subjects

Objectives To compare the dietary intake of stone formers and non-stone formers and to evaluate the effect of dietary and urinary risk factors on stone formation. Methods Cases and controls were recruited from the stone clinic of the SIUT during same period. Personal characteristics, dietary habits and 24 hours urinary biochemical parameters of 30 stone formers[SF] and 30 non-stone formers[NSF] were collected and analyzed by statistical methods. Results Body weight and BMI was higher in stone formers. The mean nutrient intake showed calcium intake of SF to be lower than NSF. There was no significant difference in mean caloric, protein and CHO intake. However, food frequency questionnaire revealed that the stone formers were consuming more oxalate and their fiber and calcium intakes were low. 24 hours urinary calcium and oxalates were significantly higher in stone formers. Conclusion Dietary risk factors for calcium-base renal stones are many and complex. This study indicates the combined role of genetic and nutritional factors in the pathogenesis of renal stones and preventive dietary modifications can be suggested for specific population

Acute graft dysfunction due to pyelonephritis, value and safety of graft biopsy

Objectives. To assess the value and safety of graft biopsy in patients who develop graft dysfunction due to pyelonephritis. Methods. Data analysis of all the patients with graft dysfunction and diagnosis of pyelonephritis was made on graft biopsy. During one year period six patients developed graft dysfunction due to pyelonephritis, all of these patients had an episose of acute cellular rejection in early post transplant period and received pulse steroid, while two in addition received ATG. Graft dysfunction when associated with UTI recovered within 4-6 weeks of antibiotic therapy. Graft biopsy is safe and histological diagnosis of pyelonephritis can save a patient from risk of anti rejection therapy given blindly in cases of graft dysfunction