Acquired hyperkalaemia leading to periodic paralysis: an emergency department perspective.

Hyperkalaemia is one of the common electrolyte imbalances dealt with in the emergency department and is caused by extracellular accumulation of potassium ions above normal limits usually greater than 5.0-5.5 mmol/L. It is found in a total of 1-10% of hospitalised patients usually associated with chronic kidney disease and heart failure. The presentation can range from being asymptomatic to deadly arrhythmias. The appearance of symptoms depends on the rate of change rather than just the numerical values. The rare presentation includes periodic paralysis characterised by the sudden onset of short-term muscle weakness, stiffness or paralysis. Management goals are directed towards reducing potassium levels in emergency settings and later on avoiding the triggers for future attacks. In this case, we present a man in his 50s with the generalised weakness later on diagnosed as hyperkalaemic periodic paralysis secondary to tumour lysis syndrome. Emergency physicians dealing with common electrolyte imbalances should keep a sharp eye on their rare presentation and their precipitating factors and should act accordingly.

N-Acetylcysteine Amide against Aß-Induced Alzheimer's-like Pathology in Rats.

Oxidative stress with a depletion of glutathione is a key factor in the initiation and progression of Alzheimer's disease (AD). N-Acetylcysteine (NAC), a glutathione precursor, provides neuroprotective effects in AD animal models. Its amide form, N-Acetylcysteine amide (NACA), has an extended bioavailability compared to NAC. This study evaluates the neuroprotective effects of NACA against Aß1-42 peptide-induced AD-like pathology in rats. Male Wistar rats (2.5 months old) were divided into five groups: Normal Control (NC), Sham (SH), Aß, Aß + NACA and NACA + Aß + NACA (n = 8 in all groups). AD-like pathology was induced by the intracerebroventricular infusion of Aß1-42 peptide into the lateral ventricle. NACA (75 mg/kg) was administered either as a restorative (i.e., injection of NACA for 7 consecutive days after inducing AD-like pathology (Aß + N group)), or as prophylactic (for 7 days before and 7 days after inducing the pathology (N + Aß + N group)). Learning and memory, neurogenesis, expression of AD pathology markers, antioxidant parameters, neuroprotection, astrogliosis and microgliosis were studied in the hippocampus and the prefrontal cortex. All data were analyzed with a one-way ANOVA test followed by Bonferroni's multiple comparison test. NACA treatment reversed the cognitive deficits and reduced oxidative stress in the hippocampus and prefrontal cortex. Western blot analysis for Tau, Synaptophysin and Aß, as well as a histopathological evaluation through immunostaining for neurogenesis, the expression of neurofibrillary tangles, ß-amyloid peptide, synaptophysin, neuronal morphology and gliosis, showed a neuroprotective effect of NACA. In conclusion, this study demonstrates the neuroprotective effects of NACA against ß-amyloid induced AD-like pathology.

Brugada Phenocopy In Hyperkalaemia - A Rare Ecg Finding.

Hyperkalaemia is a potentially fatal clinical problem frequently seen in the emergency department (ED). It causes a spectrum of electrocardiogram (ECG) changes such as peaked T-waves, prolonged PR interval, widened QRS complexes, intraventricular/fascicular/bundle branch blocks, etc. Brugada Phenocopy (BrP) is a rare ECG finding seen in severe hyperkalaemia associated with the prevalence of malignant cardiac arrhythmias and all-cause mortality. Unlike Brugada Syndrome (BrS) it is a transient phenomenon and completely resolves with the normalization of hyperkalaemia. Here we report a Brugada Phenocopy (BrP) case observed in a middle-aged male with severe hyperkalaemia.

Appendicitis after Appendectomy: A Rare Presentation of Acute Appendicitis as Stump Appendicitis.

Appendicitis is one of the frequent complaints for which patients visit the Emergency Department. Appendectomy is one of the most commonly performed procedures. Stump appendicitis is a rare but severe complication of appendectomy due to the inflammation of the remaining part of the appendix. Because it is rare and partly due to physicians' lack of understanding of this entity, the diagnosis is highly delayed, leading to severe complications including perforation or peritonitis. This article aims to raise the importance and awareness and shed light on how possibly it could be avoided.

Acceptability of telephone-cardiopulmonary resuscitation (T-CPR) practice in a resource-limited country- a cross-sectional study.

BACKGROUND: T-CPR has been shown to increase bystander CPR rates dramatically and is associated with improved patient survival. OBJECTIVE: To evaluate the acceptability of T-CPR by the bystanders and identify baseline quality measures of T-CPR in Karachi, Pakistan. METHODS: A cross-sectional study was conducted from January to December 2018 at the Aman foundation command and control center. Data was collected from audiotaped phone calls of patients who required assistance from the Aman ambulance and on whom the EMS telecommunicator recognized the need for CPR and provided instructions. Information was recorded using a structured questionnaire on demographics, the status of the patient, and different time variables involved in CPR performance. A One-way ANOVA was used to compare different time variables with recommended AHA guidelines. P-value ≤ 0.05 was considered significant. RESULTS: There were 481 audiotaped calls in which CPR instruction was given, listened to, and recorded data. Out of which in 459(95.4%) of cases CPR was attempted Majority of the patients were males (n = 278; 57.8%) and most had witnessed cardiac arrest (n = 470; 97.7%) at home (n = 430; 89.3%). The mean time to recognize the need for CPR by an EMS telecommunicator was 4:59 ± 1:59(min), while the mean time to start CPR instruction by a bystander was 5:28 ± 2:24(min). The mean time to start chest compression was 6:04 ± 1:52(min.). CONCLUSION: Our results show the high acceptability of T-CPR by bystanders. We also found considerable delays in recognizing cardiac arrest and initiation of CPR by telecommunicators. Further training of telecommunicators could reduce these delays.

Out of hospital cardiac arrest: experience of a bystander CPR training program in Karachi, Pakistan.

BACKGROUND: Nearly 90% of out-of-hospital cardiac arrest (OHCA) patients are witnessed, yet only 2.3% received bystander cardiopulmonary resuscitation (CPR) in Pakistan. This study aimed to determine retention of knowledge and skills of Hands-Only CPR among community participants in early recognition of OHCA and initiation of CPR in Karachi, Pakistan. METHODS: Pre and post-tests were conducted among CPR training participants from diverse non-health-related backgrounds from July 2018 to October 2019. Participants were tested for knowledge and skills of CPR before training (pre-test), immediately after training (post-test), and 6 months after training (re-test). All the participants received CPR training through video and scenario-based demonstration using manikins. Post-training CPR skills of the participants were assessed using a pre-defined performance checklist. The facilitator read out numerous case scenarios to the participants, such as drowning, poisoning, and road traffic injuries, etc., and then asked them to perform the critical steps of CPR identified in the scenario on manikins. The primary outcome was the mean difference in the knowledge score and skills of the participants related to the recognition of OHCA and initiation of CPR. RESULTS: The pre and post-tests were completed by 652 participants, whereas the retention test after 6 months was completed by 322 participants. The mean knowledge score related to the recognition of OHCA, and initiation of CPR improved significantly (p < 0.001) from pre-test [47.8/100, Standard Deviation (SD) ±13.4] to post-test (70.2/100, SD ±12.1). Mean CPR knowledge after 6 months (retention) reduced slightly from (70.2/100, ±12.1) to (66.5/100, ±10.8). CPR skill retention for various components (check for scene safety, check for response, check for breathing and correct placement of the heel of hands) deteriorated significantly (p < 0.001) from 77.9% in the post-test to 72.8% in re-test. Participants performed slightly better on achieving an adequate rate of chest compressions from 73.1% in post-test to 76.7% in re-test (p 0.27). CONCLUSION: Community members with non-health backgrounds can learn and retain CPR skills, allowing them to be effective bystander CPR providers in OHCA situations. We recommend mass population training in Pakistan for CPR to increase survival from OHCA.

Clinical profile and outcomes of adult oncological patients presenting to the emergency department of a tertiary care hospital.

OBJECTIVE: To determine the clinical presentations, diagnosis, and outcomes of oncological patients presenting to the emergency department of a tertiary care hospital. METHODS: The single-centre, cross-sectional study was conducted at the emergency department of the Aga Khan University Hospital, Karachi, from January 1 to December 31, 2018, and comprised all adult patients with diagnosed solid or haematological malignancy. Demographical and clinical data was recorded from medical record files. The immediate outcomes were reported as hospitalisation or discharge from the emergency department. Data was analysed using SPSS 20. RESULTS: Of the 320 patients, 167(52.2%) were females. Overall, 214(66.9) patients were aged 35-64 years. Most of the patients had solid organ malignancy 276(86.2%), with the most common being breast carcinoma 60(18.8%). Among haematological malignancies, B-cell lymphoma 32(10%) was the most common. The most common symptoms at presentation were vomiting 78(24.4%), fever 77(24.1%), and generalised weakness 66(20.6%). Of the total, 240(75%) patients were admitted and 80(25%) were discharged. The most common discharge diagnosis was chemotherapy-induced vomiting, followed by febrile neutropenia and malignant hypercalcaemia. There were 26(10.8%) deaths among the in-patients. CONCLUSIONS: Cancer patients presented to the emergency department with diverse signs and symptoms. It is essential for physicians in the emergency department to be familiar with their presentations in order to initiate prompt and timely management plans for better clinical outcomes.

"A" for Life.

This is a story of a medical intern whose cascade of baffling thoughts about pursuing a career finally led to a gratifying conclusion. This young intern is easily swayed by the opinions of others, but circumstances proved that the field he chose was the one he was made for. This is a story of determination and belief in one's ability, which gave the power to fight against the odds.

Comparison of Intrathecal Nalbuphine Hydrochloride and Clonidine Hydrochloride as an Adjuvant to Hyperbaric Bupivacaine in Abdominal Hysterectomy.

BACKGROUND: Various adjuvants for prolongation of intraoperative and postoperative analgesia have been clinically studied in the literature. AIM: This study was done to evaluate and compare the effects of nalbuphine and clonidine as an adjuvant to bupivacaine in spinal anesthesia. METHODS: In this prospective, randomized, placebo control, double-blind, and comparative study, a total of ninety patients of American Society of Anesthesiologists physical status Classes I and II undergoing abdominal hysterectomy under subarachnoid block were randomly divided into three groups. In addition to 15 mg of 0.5% hyperbaric bupivacaine administered, patients of groups BS, BN, and BC received 0.9% normal saline, 1.6 mg nalbuphine, and 30 µg clonidine, respectively. The total volume of drugs administered intrathecally was made up to 3.5 ml by addition of sterile isotonic normal saline in all. The onset time and duration of sensory and motor block, duration of analgesia, and total dose of postoperative analgesic requirement in the first 24 h were compared among groups. Hemodynamic changes and side effects were also recorded. RESULTS: Addition of study adjuvants brought significantly faster onset of sensory and motor block. Patients in clonidine group showed significantly longer mean time two segment sensory block regression (P < 0.05) lowest seen in control group. The regression time of motor block to modified Bromage Grade I was significantly longer in clonidine group and comparable in the other groups. Adjuvants have significantly increased the mean duration of analgesia, highest in clonidine group (P < 0.05). CONCLUSION: Intrathecal clonidine is associated with prolonged motor and sensory block, better hemodynamic stability, and less postoperative analgesic requirement as compared to nalbuphine.

The initial effectiveness of liposomal amphotericin B (AmBisome) and miltefosine combination for treatment of visceral leishmaniasis in HIV co-infected patients in Ethiopia: A retrospective cohort study.

BACKGROUND: North-west Ethiopia faces the highest burden world-wide of visceral leishmaniasis (VL) and HIV co-infection. VL-HIV co-infected patients have higher (initial) parasitological failure and relapse rates than HIV-negative VL patients. Whereas secondary prophylaxis reduces the relapse rate, parasitological failure rates remain high with the available antileishmanial drugs, especially when administered as monotherapy. We aimed to determine the initial effectiveness (parasitologically-confirmed cure) of a combination of liposomal amphotericin B (AmBisome) and miltefosine for treatment of VL in HIV co-infected patients. METHODOLOGY/PRINCIPAL FINDINGS: We conducted a retrospective cohort study at a Médecins Sans Frontières-supported health center in north-west Ethiopia. We included VL-HIV co-infected adults, treated for VL between January 2011 and August 2014, with AmBisome infusion (30 mg/kg total dose) and miltefosine orally for 28 days (100 mg/day). Proportions of initial treatment outcome categories were calculated. Predictors of initial parasitological failure and of death were determined using multivariable logistic regression. Of the 173 patients included, 170 (98.3%) were male and the median age was 32 years. The proportion of patients with primary VL (48.0%) and relapse VL (52.0%) were similar. The majority had advanced HIV disease (n = 111; 73.5%) and were on antiretroviral therapy prior to VL diagnosis (n = 106; 64.2%). Initial cure rate was 83.8% (95% confidence interval [CI], 77.6-88.6); death rate 12.7% (95% CI, 8.5-18.5) and parasitological failure rate 3.5% (95% CI, 1.6-7.4). Tuberculosis co-infection at VL diagnosis was predictive of parasitological failure (adjusted odds ratio (aOR), 8.14; p = 0.02). Predictors of death were age >40 years (aOR, 5.10; p = 0.009), hemoglobin ≤6.5 g/dL (aOR, 5.20; p = 0.002) and primary VL (aOR, 8.33; p = 0.001). CONCLUSIONS/SIGNIFICANCE: Initial parasitological failure rates were very low with AmBisome and miltefosine combination therapy. This regimen seems a suitable treatment option. Knowledge of predictors of poor outcome may facilitate better management. These findings remain to be confirmed in clinical trials.

Methanol poisoning: 27 years experience at a tertiary care hospital.

Methanol toxicity can result in serious morbidity and mortality without timely diagnosis and treatment. Many cases of methanol poisoning outbreaks have been noted in our population but no study has been performed to estimate methanol exposure and its outcomes and complications. A retrospective study was conducted to review all the cases of methanol poisoning admitted from January 1988 to December 2015 at the Aga Khan University Hospital. A total of 35 methanol poisoning cases were reported. All the patients were male, and the mean age was 36.2±8.6 years. The mean Glasgow Coma Scale score on presentation in the emergency was 10.4 ± 4.4. Blurring of vision was present in 17 (48%) patients while 10 (28%) had complete blindness. Mean arterial pH was 6.8±0.5 on arrival. Ethanol was given to 30(88%) patients and 12(32%) patients received bicarbonate for immediate treatment. A total of 15 (42.8%) patients underwent dialysis, out of which only 5 (33.3%) patients survived. Overall, 19 (54.3%) patients expired secondary to methanol ingestion.

A comparative study of the effect of clonidine, fentanyl, and the combination of both as adjuvant to intrathecal bupivacaine for postoperative analgesia in total abdominal hysterectomy.

BACKGROUND AND AIMS: The aim of this study was to evaluate the level of sensory block, onset and duration of motor block, postoperative analgesia, and adverse effects of combination of clonidine and fentanyl given intrathecally with hyperbaric bupivacaine (HB). MATERIAL AND METHODS: Three hundred and twenty eight patients were randomized into four groups. Group bupivacaine (group B) received 15 mg of HB; group bupivacaine clonidine (group BC) received 15 mg of HB plus 25 µg clonidine; group bupivacaine fentanyl (group BF) received 15 mg of HB plus 25 µg fentanyl and group bupivacaine clonidine fentanyl (group BCF) received 15 mg of HB plus 25 µg clonidine and 25 µg fentanyl intrathecally. All groups were evaluated for level of sensory block, onset and duration of motor block, postoperative analgesia, VAS score, sedation score and adverse effects of study drugs. All the data were analyzed using unpaired t-test. P < 0.05 was considered significant. RESULTS: The level of sensory block, onset, and duration of motor block were comparable in all groups. Total duration of analgesia was 407.3 ± 20 min in group BCF compared to 242.1 ± 2 min and 209.2 ± 16 in groups BC and BF, respectively. Lesser doses of rescue analgesic were required in group BCF. The time interval from intrathecal injection to two-segment regression was statistically significant in study groups. Only 2.4% patients showed mild sedation in BCF group. CONCLUSION: We found that combination of intrathecal clonidine and fentanyl along with bupivacaine increases the total duration of analgesia without significant side effects.

Type 1 diabetes mellitus presenting with diabetic ketoacidosis (DKA) in a neonate.

Neonatal diabetes mellitus (NDM) is a rare manifestation with an incidence of one affected individual among 400000 live births. NDM can be divided into Transient (TNDM) and Permanent (PNDM) types. A significant overlap occurs between both groups, to an extent that TNDM cannot be distinguished from PNDM based solely on clinical features. Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus (TIDM). DKA at diagnosis is more common in young children near the age of five years. Neonatal DKA is a rare occurrence causing it to be missed in the differential diagnosis of neonatal illness and results delay in appropriate management and increase in morbidity and mortality rate.

Transdermal nitroglycerine enhances postoperative analgesia of intrathecal neostigmine following abdominal hysterectomies.

This study was carried out to assess the effect of nitroglycerine (transdermal) on intrathecal neostigmine with bupivacaine on postoperative analgesia and note the incidence of adverse effects, if any. After taking informed consent, 120 patients of ASA Grade I and II were systematically randomised into four groups of 30 each. Patients were premedicated with midazolam 0.05 mg/kg intravenously and hydration with Ringer's lactate solution 10ml/kg preoperatively in the holding room. Group I patients received Intrathecal injection of 15 mg bupivacaine with 1ml of normal saline and transdermal placebo patch. Group II patients received Intrathecal injection of 15 mg bupivacaine with 5 mcg of neostigmine and transdermal placebo patch. Group III patients received Intrathecal injection of 15 mg bupivacaine with 1ml of normal saline with transdermal nitroglycerine patch (5 mg/24 hours). Group IV patients received Intrathecal injection of 15 mg bupivacaine with 5mcg of neostigmine and transdermal nitroglycerine patch (5 mg/24 hours), applied on a non anaesthetised area after 20 minutes. Groups were demographically similar and did not differ in intraoperative characteristics like sensory block, motor block, haemodynamic parameters and SpO(2). The mean duration of analgesia was 202.17 minutes, 407.20 minutes, 207.53 minutes and 581.63 minutes in control group (I), neostigmine group (II), nitroglycerine group (III) and nitroglycerine neostigmine group (IV) respectively (P<0.01). To conclude, our results show that transdermal nitroglycerine itself does not show any analgesic potential but it enhances the analgesic potential of intrathecal neostigmine.