Cardiac arrest due to massive aspiration from a broncho-esophageal fistula: A case report.

BACKGROUND: Tracheo and broncho esophageal fistulas and their potential complications in adults are seldom encountered in clinical practice but carries a significant morbidity and mortality. CASE SUMMARY: We present a case of a 39-year-old otherwise healthy man who presented to our hospital after ingestion of drain cleaner substance during a suicidal attempt. He unexpectedly suffered from cardiac arrest during his stay in the intensive care unit. The patient had developed extensive segmental trachea-broncho-esophageal fistulous tracks that led to a sudden and significant aspiration event of gastric and duodenal contents with subsequent cardiopulmonary arrest. Endoscopic evaluation of extension of fistulous track proved a slow and delayed progression of disease despite initial management with esophageal stenting for his caustic injury. CONCLUSION: The aim of this case presentation is to share with the reader the dire natural history of trachea-broncho-esophageal fistulas and its delayed progression. We aim to illustrate pitfalls in the endoscopic examination and provide further awareness on critical care monitoring and management strategies to reduce its morbidity and mortality.

Unexpected case of critical left main coronary artery dissection in a young woman.

A 36-year-old woman presented with a 3-month history of recurrent substernal chest pain, which acutely worsened 2 days prior to presentation. Her initial troponin I was mildly elevated and ECG showed subtle changes initially concerning for ischaemia; however, these were present on her prior ECG and were not considered an acute change. Because of her age and lack of significant risk factors, she was considered low risk for cardiac disease and initially treated conservatively for a non-ST elevation myocardial infarction. Due to persistent symptoms and dynamic changes on ECG concerning for ischaemia, she was immediately taken for a cardiac catheterisation and was found to have critical left main coronary artery dissection with a focal stenotic lesion. She had an extensive workup to identify the underlying cause of her coronary artery dissection which was unrevealing. She underwent an uncomplicated coronary artery bypass graft surgery and was discharged home in stable condition.

Liver Abscess Caused by Ingestion of a Sewing Needle.

Liver abscesses have a low incidence and can be caused by multiple etiologies. We present an interesting case of a 74-year-old woman who presented with abdominal pain and leukocytosis. Imaging revealed a foreign body in the antrum of the stomach extending to an area of hypodensity in the liver. She was taken for an exploratory laparotomy and was found to have a gastric perforation due to a sewing needle. The needle had embedded in the liver causing the formation of an abscess. The patient was successfully treated with surgical management and a course of antibiotics.

Refeeding Syndrome and Non-Alcoholic Wernicke's Encephalopathy in a Middle-aged Male Initially Presenting with Gallstone Pancreatitis: A Clinical Challenge.

Wernicke's Encephalopathy (WE) is a neurological condition characterized by ophthalmoplegia, ataxic gait, and altered mental status. It is an underdiagnosed yet severely limiting disease process precipitated by thiamine deficiency. Often times, it can occur in conjunction with other disease states like refeeding syndrome in which the underlying etiology is prolonged periods of malnutrition. We present a unique case of non-alcoholic WE in a middle-aged male who initially presented with gallstone pancreatitis complicated with severe metabolic derangements. This ultimately resulted in the development of non-alcoholic WE. Prevention of this condition is a clinical challenge for most physicians as the classic features associated with thiamine deficiency lack diagnostic sensitivity and specificity in critically ill patients. As a result, early recognition and prompt management of this can dramatically decrease morbidity and mortality. Our case highlights and emphasizes the importance of maintaining a high index of suspicion for WE and refeeding syndrome in the setting of altered sensorium and metabolic derangements.

A Case of Delayed Diagnosis of Moyamoya Disease After Recurrent Strokes.

We present a case of a 58-year-old man with delayed diagnosed moyamoya disease who underwent encephaloduroarteriosynangiosis (EDAS) procedure. This patient with a history of three strokes presented to our facility with new left facial droop. Neurological examination revealed left facial droop and hemiparesis. Brain magnetic resonance imaging (MRI) described right frontal lobe acute ischemia. Head computed tomography (CT) angiography revealed bilateral supraclinoid internal carotid artery (ICA) occlusions. Cerebral angiography demonstrated diffuse intracranial vascular irregularity with stenosis, more above the bilateral supraclinoid ICAs and the right middle cerebral artery (MCA) suggestive of moyamoya disease. Due to the lack of MCA patency, he underwent EDAS. Superficial temporal artery (STA) was dissected inferiorly and the posterior branch was bipolared, then STA was movable. A bur hole made at the superior and inferior portion along the STA. Dura was opened, and STA was brought on top of the pia. His facial droop gradually improved after that. Nine months later, no new strokes reported. Moyamoya disease is a rare neurovascular disorder characterized by narrowing and occlusion of the ICA branches. Its symptoms include recurrent ischemic/hemorrhagic strokes. Incidence in Hispanics has not been studied. The gap between the first manifestations and disease progression is one to eight years. Its diagnosis is often delayed. Our patient had recurrent strokes for five years. Despite therapy with antiplatelets, new ischemic stroke brought him to our institution. Rate of recurrent strokes despite antiplatelets was reported 10.3% per year. Brain CTs and MRIs had failed to detect strokes' etiology. Catheter-directed angiography is the gold standard test for diagnosis of moyamoya disease. Antiplatelet alone is ineffective and surgery is the effective method to prevent further strokes, although there are no studies in adults regarding the efficacy of indirect revascularization. In direct revascularization, usually STA anastomoses to MCA. Indirect method works through the development of leptomeningeal collaterals. Postoperative complications are infarction and hyperperfusion syndrome. Seong-eun et al. proposed that modified EDAS is simpler with less complications in comparison with direct revascularization. Some other studies showed higher chance of stroke in indirect method versus direct technique. In conclusion, it is important to consider moyamoya disease as a differential diagnosis in patients with recurrent strokes.

Prevalence and Barriers to Lung Cancer Screening in Karachi, Pakistan: A Cross-Sectional Survey of Smokers and Physicians.

BACKGROUND: Early detection of lung cancer using low-dose computed tomography (LDCT) can potentially reduce morbidity and mortality. However, LDCT for lung cancer screening, especially in low income countries, has been underutilized. The objective of this study was to evaluate the prevalence and the potential personal, social, and economic barriers of lung cancer screening using LDCT. METHODS: A total sample of 156 smokers and 200 general physicians was collected during December 2016-February 2017 from community settings in Karachi, Pakistan. Two separate questionnaires were constructed to characterize participants' knowledge, attitudes, and practices regarding lung cancer screening. Screening-eligible smokers and physicians were asked to identify patient barriers to screening and were asked their opinion regarding most effective approach for increasing awareness of screening guidelines. RESULTS: The majority of smokers' (n=91, 58.3%) and physicians' (n=131, 65.7%) beliefs about the US Preventive Services Task Force (USPSTF) eligibility criteria were inconsistent with the actual recommendations. Major barriers to screening included financial cost, lack of patient counseling and health anxiety related to screening. Over two-thirds (n=105, 67.3%) of smokers were receptive to further information about LDCT screening, and half (n=78, 50.0%) favored one-on-one counseling by their physician, compared to other media. Only one-third (n=65, 33.3%) of physicians reported use of LDCT screening, although 54.5% (n=108) felt that screening implementation would be very effective in their practice. CONCLUSION: LDCT screening is currently an uncommon practice in Pakistan. Financial cost, inadequate doctor-patient communication, and lack of awareness of guidelines among both patients and physicians are the major barriers in the utilization of LDCT screening.