Clinician's dilemma: Naproxen-induced liver injury

Naproxen is a widely used nonsteroidal anti-inflammatory drug (NSAID) in pediatric population, used for mild-to-moderate pains, arthritis, and other immune-mediated disorders. It rarely causes clinically apparent liver injury in the adult population taking high doses of the drug over a prolonged period and is reported even rarer in pediatric population. We present a case of drug-induced liver injury (DILI) in a 13-year-old girl taking naproxen in therapeutic doses for juvenile rheumatoid arthritis. There was a complete recovery of liver function following discontinuation of naproxen therapy.

A comparative study of 30 cases of fracture neck femur in young adult patients treated with partially threaded cannulated screw versus fully threaded cannulated screws

Background: Fracture neck femur (FNF) is important due to its high incidence in general population. In younger patients, trauma is the major cause of fracture neck femur. Displaced fractures are usually treated by fixation with partially threaded cannulated screws (PTS) placed in a parallel pattern. In the present study, we have explored the use of fully threaded cannulated screws (FTS) for fixation of fracture neck of femur. Aim and Objectives: The aim of our study was to analyze and compare the clinical and functional outcomes of fracture neck femur treated in both groups. Materials and Methods: A prospective randomized control analysis was conducted in the Department of Orthopedics of Rajindra Hospital and Government Medical College, Patiala, Punjab between June 2019 and December 2021 on 30 patients who were admitted with neck femur fracture in the age group between 15 and 60 years. Fifteen patients were treated with FTS and 15 were treated with PTS. Subsequent hip radiographs were taken postoperatively and analyzed for various parameters such as fracture fixation, fracture union, and reduction. Regular follow-up was done by clinical examination along with the radiological examination monthly for 3 months, then at 6th month, and 9th month. The functional outcomes of fracture neck femur treated with PTS and FTS were compared in terms of blood loss, radiological union, weight bearing, functional outcomes (in terms of Harris hip score), and post-operative complications. Results: Hip function on the operated side was evaluated and compared with the normal side as per Harris hip score. About 73.3% of patients with FTS group in this study had excellent results compared to 26.6% in PTS group, fair results were found in 13.3% in both groups, 6.6% of patients had good results with FTS group as compared to 13.3% of PTS group, and 6.6% had poor outcome with FTS group as compared to 46.6% with PTS group. In our study, mean Harris hip score was 76.6 in PTS group and 85.5 in FTS group (P = 0.044). The present study indicated that there were statistically significant differences between FTS and PTS in terms of functional outcomes and complication rates such as femoral neck shortening (P < 0.05). However, no significant differences in terms of blood loss, weight bearing, and fracture union time were observed between two groups (P > 0.05). Conclusions: FNF treated with FTS is superior than PTS in terms of functional outcomes and complication rates. Both FTS and PTS are equivalent in terms of average blood loss, weight bearing, and fracture union time.

Quality of life in patients of low back pain with radiculopathy: A descriptive analytical study from Punjab

Background: Low back pain with radicular symptoms is one of the most prevalent musculoskeletal disorders and leading cause of disability. Radicular back pain can be defined as a diffuse process affecting more than one underlying nerve root that causes pain and depending on the severity of symptoms may cause loss of sensation and motor function. Quality of life (QOL) is a multidimensional patient-based outcome criterion which can be used to describe the impact of health condition on the patient as well as the effects of the treatment. Low back pain interferes with QOL and work performance. Aim and Objectives: To analyze the QOL in patients of low back pain with radiculopathy. Materials and Methods: This descriptive-analytical study was carried out on 364 low back pain patients and healthy people in Government medical college, Patiala, India, from January 2021 to June 2021. We used SF-36 questionnaire to assess QOL, which allows calculating eight different scores (on a scale of 0–100), a physical component scale (PCS), and a mental component scale (MCS) summary. Mean Mental (MCS) and Physical (PCS) component summary scores were assessed and compared with healthy people involved in the study. Overall, a higher PCS and MCS score indicates better QOL. Results: Out of 364 patients enrolled, 311 patients with mean age of 49.1 ± 11.9 years were included for the study. SF-36 was administered and assessed. The result from this questionnaire showed that mean PCS and mean MCS were significantly lower in the low back pain patients compared to the normative population and were statistically significant. Conclusion: Patients of low back pain with radiculopathy have poor QOL compared to normative individuals. Lower QOL in patients necessitates getting early treatment, educating the patient, and rehabilitation. It is vital to give more attention to the QOL of the patient as it is an untouched domain.

Stent Crushing as a Novel Therapeutic Option In-Stent Entrapment

Stent Entrapment is a rare complication of Percutaneous Coronary Intervention if left in situ may cause intracoronary or systemic embolization, thrombus formation, emergent coronary artery bypass graft surgery, or death. We here present a case of 2 unexpanded Drug eluting stent entrapment during the procedure leading to hemodynamic instability and Its treatment using stent crushing as a life-saving procedure.

Unmasking Brugada Syndrome with Oral Flecainide Provocation. A Case Series of Three Patients

The present case series discuss three patients who had brugada type 2/ type 3 like ECG pattern that was converted to type 1 pattern with oral flecanide challenge test. Brugada syndrome is associated with a high incidence of sudden cardiac death, typical ECG pattern being ST-segment elevation in the right precordial leads with T wave inversion. Pharmacological provocation should only be performed when the baseline ECG is not diagnostic of Brugada Syndrome. PR prolongation in the baseline ECG is also a contraindication because of the risk of inducing AV block. Drug challenge is performed under strict monitoring of BP and 12-lead ECG and facilities for cardio version and resuscitation are available. Atypical RBBB pattern/type 2/3 Brugada pattern on ECG in patients of syncope or family history of sudden cardiac arrest is commonly encountered by a cardiologist. This can be performed to provoke type 1 brugada pattern on ECG. Diagnosed cases of Brugada may be treated with ICD with proper indication if needed and thus prevent sudden cardiac death.

A Rare Case of Shone Complex, Where Coarctation was Treated Successfully with Covered Cheatham Platinum Stent

Shone complex is an extremely rare and severe congenital heart disease characterized by left -heart obstruction at multiple levels namely supravalvular mitral ring, parachute mitral valve, subaortic stenosis and coarctation of the aorta. We in the present case describe a patient of shone complex who underwent successful coarctoplasty with the help of BIB (balloon in balloon) dilatation catheter and covered CP (cheatham platinum) stent. The role of interventional cardiologist is to diagnose and choose the right approach for the specific patient, whether surgery, balloon or stent.

Percutaneous closure of iatrogenic femoral arteriovenous fistula using endovascular covered stent.

Local complications after femoral arterial catheterization, such as hematomas, pseudoaneurysms, arteriovenous fistulas (AV fistulas), and arterial occlusions, are becoming more common, with the growing number of complex invasive procedures being undertaken, especially in older and sicker patients. Newer percutaneous techniques are being developed to treat these. Covered stents are an effective, safe, and less invasive way to deal with pseudoaneurysms and AV fistulas. This case report highlights the application of this technique to treat an iatrogenic femoral AV fistula in a 69 years male.

Combining aspirin with angiotensin converting enzyme inhibitors in heart failure: how safe is it?

The above discussion on the interaction of aspirin and ACE inhibitors seems to suggest that aspirin in high doses may have adverse interaction with ACE inhibitors in patients with heart failure but the data obtained is not sufficient or conclusive to recommended omission of aspirin in patients with heart failure. This raises a query in the mind of the physician whether to use a combination or not? The role of aspirin in the early period after myocardial infarction is well established so is the role of ACE inhibitors. Hence in patients with myocardial infarction and preserved left ventricular function it would not be wrong to administer combination of ACE inhibitors and aspirin. Albeit at a lower dose. In patients with large myocardial infarction or heart failure, warfarin may be an option but still needs to be documented in large trials. As suggested long term use of aspirin after infarction is still ambiguous and may be harmful in patients with heart failure with its anticedent side effects. But long term benefits of ACE inhibitors in heart failure are well documented. Hence if a choice has to be made whether to discontinue either of the two drugs it would be preferable to stop the aspirin. To answer the issue of use of aspirin in patients with heart failure it would be essential to conduct a double blind randomized trial comparing known anti-thrombotic treatment, aspirin and anti-coagulants on mortality in patients with heart failure, especially caused by coronary artery disease. Such a trial is underway at the present and till the results are available it should be left to clinical judgement of the physician whether to administer aspirin in patients with heart failure after weighing the benefits versus risk.

Follicular fluid immunoreactive-inhibin concentrations in relation to follicular diameter and estradiol-17 beta, progesterone and testosterone concentrations in individual ovarian follicles in buffalo, Bubalus bubalis.

The objective of this study was to measure the concentrations of immunoreactive inhibin (ir-inhibin) in follicular fluid from individual ovarian follicles and relate them to follicular diameter and follicular fluid concentrations of estradiol-17 beta, progesterone and testosterone in buffalo. Follicular size was measured with an ultrasound machine and follicles were categorized as small (4 to 5 mm diam.), medium (6 to 9 mm diam.) and large (10 mm and above in diam.). Ir-inhibin concentrations varied markedly between and within follicles of same size category. Follicular fluid ir-inhibin concentrations (microgram/ml) were positively related to follicular diameter (R = 0.32, n = 262, P < 0.001) and were significantly higher (P < 0.05) in large (8.32 +/- 0.56) in comparison to medium (7.02 +/- 0.31) follicles which, in turn had inhibin concentrations significantly higher (P < 0.001) than those in small follicles (5.13 +/- 0.48). Ir-inhibin and estradiol-17 beta concentrations were positively related in medium (R = 0.38, n = 128, P < 0.001) and large (R = 0.64, n = 35, P < 0.001) but not in small follicles. There was a negative relationship between ir-inhibin and progesterone concentrations in large follicles (R = 0.46, n = 33, P < 0.01), with no relationship between the two hormones in small and medium follicles. Ir-inhibin was positively related to molar ratios of estradiol-17 beta to progesterone in medium (R = 0.30, n = 124, P < 0.01) and large (R = 0.49, n = 24, P < 0.01) but not in small follicles. There was no relationship between ir-inhibin and testosterone concentrations in follicles of all size categories. The results of the present study suggest that follicular inhibin production is related to follicular size as well as intrafollicular estradiol-17 beta and progesterone concentrations.