Brucella infection presenting as infective endocarditis complicated by embolic stroke.

Brucellosis (undulant fever) is a zoonotic infection caused by Brucella species. It typically presents with fever, malaise, night sweats, and arthralgia. One of its rare complications is infective endocarditis, which occurs in approximately 1.3% of patients and can be further complicated by embolic stroke. This report describes a rare occurrence of Brucella endocarditis presenting as an embolic stroke. A 34-year-old male presented with sudden left-sided weakness and fever. He reported headaches, fever, and generalized weakness in the preceding week. The patient worked on a farm and hence had animal contact. A neurological exam showed left-sided facial weakness, and power of 0/5 and 1/5 in the left upper and lower extremities, respectively. CT scan of the head revealed a right middle cerebral artery (MCA) territory infarct with penumbra and a right MCA occlusion. He underwent a cerebral artery thrombectomy with successful recanalization. However, he continued to have fever and high inflammatory markers. Echocardiography showed aortic valve vegetation and blood cultures grew Brucella melitensis. A multidisciplinary meeting was held to determine the optimal management, which included a course of rifampicin and doxycycline.

Anemia and Hypoxia Impact on Chronic Kidney Disease Onset and Progression: Review and Updates.

Chronic kidney disease (CKD) is caused by hypoxia in the renal tissue, leading to inflammation and increased migration of pathogenic cells. Studies showed that leukocytes directly sense hypoxia and respond by initiating gene transcription, encoding the 2-integrin adhesion molecules. Moreover, other mechanisms participate in hypoxia, including anemia. CKD-associated anemia is common, which induces and worsens hypoxia, contributing to CKD progression. Anemia correction can slow CKD progression, but it should be cautiously approached. In this comprehensive review, the underlying pathophysiology mechanisms and the impact of renal tissue hypoxia and anemia in CKD onset and progression will be reviewed and discussed in detail. Searching for the latest updates in PubMed Central, Medline, PubMed database, Google Scholar, and Google search engines were conducted for original studies, including cross-sectional studies, cohort studies, clinical trials, and review articles using different keywords, phrases, and texts such as "CKD progression, anemia in CKD, CKD, anemia effect on CKD progression, anemia effect on CKD progression, and hypoxia and CKD progression". Kidney tissue hypoxia and anemia have an impact on CKD onset and progression. Hypoxia causes nephron cell death, enhancing fibrosis by increasing interstitium protein deposition, inflammatory cell activation, and apoptosis. Severe anemia correction improves life quality and may delay CKD progression. Detection and avoidance of the risk factors of hypoxia prevent recurrent acute kidney injury (AKI) and reduce the CKD rate. A better understanding of kidney hypoxia would prevent AKI and CKD and lead to new therapeutic strategies.

Effects of Nondipping Blood Pressure Changes: A Nephrologist Prospect.

Blood pressure (BP) variations depend on various internal, environmental, and behavioral factors. BP fluctuations occur both in normotensive and hypertensive people. Although it fluctuates over the 24-hr day and night, the morning BP increases after waking up and declines throughout sleep. It is typical for BP to decrease by 10% to 20%, while sleeping, known as dipping BP. However, if there is no decrease in nighttime mean systolic BP or a drop of less than 10 mmHg, it is called nondipping BP. Conversely, reverse dipping BP means an increase in mean systolic BP instead of a drop during the night. Reverse dipping is observed in hypertension (HTN), diabetes mellitus (DM), chronic kidney disease (CKD), and obstructive sleep apnea (OSA) syndrome. The introduction of ambulatory BP monitoring (ABPM) led to the emergence of identifying normal and elevated BP patterns. Non-dipping BP increases the risk of cardiovascular system (CVS) complications such as left ventricular hypertrophy, proteinuria, glomerular filtration rate (GFR) reduction, and CKD progression. A loss or blunting of the normal BP profile is recognized as a deleterious variant, and restoring abnormal BP patterns has been reported to significantly impact end-organ damage, morbidity, and mortality. In this non-systematic clinically-oriented, comprehensive review, we aim to update the BP variables and the pathophysiology of nondipping BP and point out the areas which need more investigation from a nephrology perspective because the nondipping BP increases the risk of proteinuria, GFR reduction, and CKD progression. A literature search of PubMed, Google, EMBASE, and Google Scholar was conducted. Checks of selected papers and relevant reviews complemented the electronic search. With improved BP measurement methods, the physiology of BP profile variations is readily detectable during the day and night. A nondipping BP profile is a distinct BP pattern that may have significant end-organ damage effects and therapeutic importance for nephrologists. The pathophysiology of the nondipping BP variant must be clarified to prevent complications, and further investigations are required. Furthermore, there is debate about the best BP index to utilize: systolic BP, diastolic BP, mean arterial pressure, or a mixture of all. All these areas are important and need new research projects.

Isolated Sixth Cranial Nerve Palsy as Initial Presentation of Pituitary Apoplexy: A Case Report.

Pituitary apoplexy is a serious condition, which if left untreated, might lead to irreversible life-long complications. Hence, pituitary apoplexy should always be included in the differential diagnoses of a patient with an isolated sixth cranial nerve (CN) palsy. This report highlights the case of a patient presenting with isolated CN palsy associated with pituitary apoplexy. Although pituitary adenomas are common, they seldom present with isolated abducent nerve palsy without any other CN involvement. The 47-year-old female patient presented with acute right eye pain, diplopia, and a squint. Examination revealed an isolated unilateral sixth CN palsy. Brain MRI showed a sellar and suprasellar mass suggestive of hemorrhagic pituitary apoplexy. The patient was transferred to neurosurgery and underwent transsphenoidal resection of a pituitary macroadenoma. Postoperative follow-up showed clinical improvement. It is, thus, imperative for physicians to have the knowledge to recognize an isolated sixth cranial nerve palsy and its associated causes.

Featuring Trends in the Epidemiology of Lung Cancer Following the Publication of the National Cancer Strategy in Qatar.

OBJECTIVES: Qatar has witnessed significant reforms in its health care system, including the care of cancer patients. In 2011, the National Cancer Strategy was released with the aim to deliver a high standard of care to cancer patients across the country. We sought to investigate the featuring trends in the epidemiological and clinical characteristics of lung cancer in Qatar following the publication of the National Cancer Strategy. METHODS: We conducted a retrospective cohort study documenting the epidemiological and clinical characteristics of primary lung cancer cases in Qatar diagnosed from 1 January 2011 to 31 December 2018. RESULTS: The overall age-standardized incidence rate was 8.7 per 100 000 persons (11.6 per 100 000 and 5.4 per 100 000 persons for males and females, respectively). The one, three, and five-year overall survival rates were 67.0%, 48.0%, and 28.0%, respectively. The three-year overall survival rates for stages I, II, III, and IV were 97.0%, 78.0%, 52.0%, and 31.0%, respectively. The three-year survival rates for males and females were 43.0% and 64.0%, respectively (p = 0.029), for Qatari and non-Qatari nationals were 42.0% and 49.0%, respectively (p = 0.252), and for smokers and non-smokers were 39.0% and 69.0%, respectively (p ≤ 0.001). The overall age-standardized mortality rate was 5.5 per 100 000 persons. Adenocarcinoma was the most common histologic type. CONCLUSIONS: Despite the low overall lung cancer incidence rate in Qatar, there is a rise in the incidence among females when compared to previous studies. Qatar has favorable five-year lung cancer survival rates compared to many developed and neighboring countries. Policymakers in the country should consider the changing patterns in lung cancer incidence when planning future preventive strategies.

Polypharmacy and drug interactions amongst cirrhotic patients discharged from a tertiary center: Results from a national quality improvement audit.

BACKGROUND AND STUDY AIMS: Auditing of polypharmacy is particularly essential in patients with cirrhosis because of the crucial role of liver in drug metabolism. The aim of this study was to audit the drug prescribed in this group of patients and analyzed the quantity and severity of potential drug-drug interaction. PATIENTS AND METHODS: In this cross-sectional study we analyzed the last prescription as recorded in the Electronic Medical Record at the time of discharge for cirrhotic patients who were hospitalized during 24-months study period. Data were also collected for age, gender, and diagnoses. The drugs were analyzed for cross interactions using the Lexicomp-online e-formulary. The drug interactions are classified as: class A: no known interaction, class B: no action needed, Class C: monitor therapy, class D: consider therapy modification, and Class X: the drug should be avoided. RESULTS: A total of 333 patients with cirrhosis were audited, whereas complete and relevant data were available for 181 patients (134 males, 74%) with a mean age ± SD 59.7 ± 10.1. Out of these, 168 (92.8%) patients were using at least one medicine and the total number of medications used was 808 drugs. The observed average of utilization was 7.8 ± 3.1 drugs (range = 1-17) and 102 (56.3%) patients used polypharmacy. A total of 198 (24.5%) consumed drugs were related to cirrhosis and its complications. Six (3.3%), 30 (16.6%) and 65 (35.9%) patients had Class-X, Class D, and Class C, respectively. Utilization of polypharmacy was statistical significant in patients with class X (83.3%, p = 0.03), class D (16.6%, p = 0.01), and class C (35.9%, p = 0.02). CONCLUSION: The findings highlight the importance of auditing for polypharmacy to recognize and prevent potential drug-related problems in patients with cirrhosis. Implementation of strategies to optimize medication use in patients with cirrhosis should be considered necessary as it can have a bearing on length of stay and morbidity.