Swiss Cheese Heart: A Tale of Multiple Valve Perforations.

Gerbode defect, an anomalous connection between the left ventricle and right atrium, is often congenital but can be acquired or iatrogenically formed. We present an exceedingly rare case of this defect associated with multiple valve perforation in an otherwise healthy patient with bicuspid aortic valve and endocarditis.

Dipyridamole-induced STEMI: case report and review of the literature.

Dipyridamole nuclear myocardial perfusion imaging is a safe and useful modality for assessing myocardial ischemia. It is the modality of choice for cardiac risk stratification in patients who are unable to exercise. Intravenous dipyridamole causes coronary vasodilation and may result in heterogeneity of coronary blood flow in significant coronary artery disease. Ischemic electrocardiographic changes following pharmacological stress testing are less likely to occur compared with exercise stress tests. Ischemia is more likely to be present in the form of ST depression, with ST-segment elevation being exceedingly rare. We present the case of a 73-year-old patient who developed ST-segment elevation myocardial infarction following pharmacologic stress testing.

Survival of an 80-Year-Old Male With a Successful Split-Thickness Skin Graft for End-Stage Necrotizing Fasciitis: A Case Report.

Herein, we report a case of an 80-year-old male who was diagnosed with a fatal condition known as necrotizing fasciitis. This devastating soft tissue infection can cause profound damage to multiple tissue planes. Despite its etiology being multifactorial, impaired immunity with increasing age weighs in as the most significant. We intend to shed light on its detrimental clinical features and how we managed to treat the patient both conservatively and surgically. Through our case findings and management plan, we hope this case to be of clinical value and knowledge to clinicians to better diagnose and treat the deleterious condition.

Biochemical Risk Factors Associated With Hyperkalemia in Cirrhotic Patients.

INTRODUCTION: Patients with cirrhosis suffer from fluid and electrolyte imbalance. The usually reported electrolyte disorders include hyperkalemia, hyponatremia, and hypokalemia. The regional data about the prevalence and risk factors associated with hyperkalemia in cirrhotic patients are not sufficient enough. The purpose of this study is to determine various risk factors associated with hyperkalemia, which will assist in the early detection of cirrhotic patients at risk of hyperkalemia. METHODS: This cross-sectional study was conducted in the internal medicine and gastroenterology departments of a tertiary care hospital in Pakistan from March 2021 to June 2021. Sonographically documented liver cirrhosis patients (n=500), of either gender and between the ages of 18 and 70 years, were enrolled in the study. After enrollment, patients' demographics were noted in a self-structured questionnaire. Participant's Child-Pugh score was also noted in the questionnaire. After a detailed history, 5 mL of venous blood was drawn in two vials via phlebotomy and send to the laboratory to measure serum potassium, creatinine, albumin, and bilirubin levels. RESULT: Out of the total 500 participants, 101 (20.2%) participants had hyperkalemia. It was significantly more prevalent in participants with Child-Pugh C class and in those with a serum creatinine of more than 1.3 mg/dL. Similarly, it was more prevalent in participants with albumin levels less than 2.5 mg/dL. CONCLUSION: Hyperkalemia is associated with Child-Pugh class C. It has a direct relationship with serum creatinine levels which is an indicator of renal function, and an inverse relationship with serum albumin levels, an indicator of hepatic synthetic function.

Frequency of Ophthalmological Findings in Hospitalized COVID-19 Patients.

INTRODUCTION: The symptoms of coronavirus disease-19 (COVID-19) may range from mild to severe. Patients usually present with fever, cough, and other respiratory tract symptoms, but may also be asymptomatic. Some studies have also indicated the ocular involvement by the virus. This study aims to look deeply into all ophthalmic findings seen in COVID-19 patients and their clinical characteristics. METHODS: This longitudinal study was conducted in the COVID-19 unit of a tertiary care hospital, Pakistan. Data of patients hospitalized with COVID-19 infection between July 2020 and March 2021 were included in the study. Ophthalmological examination was done at the time of admission and was repeated every alternate day to look for any ophthalmological manifestation. RESULTS: Out of 441 (n= 441), 61 (13.8%) participants had ophthalmological findings on examination. Patients with ophthalmological findings were significantly younger compared to patients without ophthalmological findings (42 ± 6 years vs. 44 ± 7; p-value, 0.03). C-reactive protein (CRP) was also significantly higher in patients with ophthalmological findings (122.2 ± 16.2 vs. 112.8 ± 19.8; p-value, 0.005). The most common ophthalmological finding was conjunctival irritation (50.8%), followed by diplopia (27.8%) and cotton wool spots (27.8%). CONCLUSION: Ophthalmological findings are prevalent in patients with COVID-19. In this study, patients with higher CRP levels were associated with ophthalmological findings. It is important to conduct ophthalmological examinations in patients with COVID-19, as they may give a clue about other complications associated with COVID-19.

Comparison of Effect of Nebivolol and Bisoprolol on Sexual Function of Hypertensive Female Patients.

Introduction Male and female sexual dysfunction is frequently found in patients with hypertension. Many studies indicate that this is found more frequently in patients treated with beta-blockers rather than due to hypertension itself; however, almost all studies have been done on male population. This study aims to study the effect of two commonly used beta-blockers on sexual function of a hypertensive female patient. Methods This two-arm open-label randomized prospective study was conducted from April 1, 2019 to March 30, 2020 in a tertiary care hospital at Pakistan. One hundred and fifty participants randomized to group A were given nebivolol 5 mg once daily in addition to their current hypertensive treatment. Another 150 participants randomized to group B were given bisoprolol 5 mg once daily in addition to their hypertensive therapy. Sexual function was assessed on day 0 and day 90 using female sexual function index (FSFI). Results The mean sexual score in the nebivolol group significantly improved after day 90 in comparison to day 0 (24.16 ± 2.1 vs. 26.91 ± 2.6; p-value < 0.0001), while no difference in sexual score in bisoprolol group after day 90 was observed (24.14 ± 2.1 vs. 24.12 ± 2.0; p-value = 0.91). Conclusion In this study, nebivolol group was associated with a significant improvement in sexual function. This can be due to additional vasodilation properties and a low risk of sexual side effects associated with nebivolol.

A skeleton in the closet: The implications of COVID-19 on XDR strain of typhoid in Pakistan.

Extensively drug resistant typhoid fever is a major public health concern in Pakistan. During the COVID-19 pandemic, poor sanitation is leading typhoid cases to a surge and obsolete diagnostic methods are paving the way towards ir-rational pharmacotherapy. In particular, the overuse of azithromycin for the treatment of COVID-19 might impair one of the few remaining regimens against XDR. Facing COVID-19 and XDR at the same time can lead to a catastrophy, unless the government, the stakeholders and healthcare workers take joint action to improve sanitation, educate the public, vaccinate vulnerable groups and establish good diagnostic and management practices.

Drug-Eluting Stents Versus Bare-Metal Stents in Large Coronary Artery Revascularization: Systematic Review and Meta-Analysis.

OBJECTIVES: We aim to determine if drug eluting stents (DES) are better than bare-metal stents (BMS) in large coronary artery (diameter ≥ 3 mm) percutaneous coronary intervention (PCI). BACKGROUND: DES have become the standard of care for PCI in coronary artery disease (CAD). However, the superiority of DES over BMS in large vessel CAD is not clear and previous studies have shown conflicting results. METHODS: Randomized controlled trials (RCTs) comparing outcomes of PCI with BMS and DES for large vessel CAD were identified from the year 2000 to August 2019. The outcomes were studied individually and included all-cause mortality, myocardial infarction (MI), target lesion revascularization (TLR), and stent thrombosis. Aggregated odds ratio and 95% CI were calculated using a random-effects model. RESULTS: Eight RCTs were included (4 with data for first-generation DES, 3 with data for second-generation DES, and 1 with data for both first- and second-generation DES). Compared to BMS, second generation DES had a significantly lower rate of all-cause mortality (2.4% vs. 3.9%, OR 0.74, 95% CI 0.56-0.98, P 0.04), TLR (3.5% vs. 8.6% OR 0.38 95% CI 0.28-0.53, P < 0.001), and MI (2.1% vs. 2.9% OR 0.73 95% CI 0.53-1.0, P 0.05). The difference in all-cause mortality was not seen with first-generation DES. CONCLUSION: Newer DES are associated with a lower mortality, TLR, and MI and thus should be preferred over BMS for large coronary artery PCI.

Meta-Analysis Comparing Multiple Arterial Grafts Versus Single Arterial Graft for Coronary-Artery Bypass Grafting.

Observational studies and randomized controlled trials (RCTs) have shown conflicting outcomes for multiple arterial graft (MAG) coronary artery bypass graft surgery compared with single arterial grafts (SAGs). The predominant evidence supporting the use of MAGs is observational. The aim of this meta-analysis of RCTs is to compare outcomes following MAG and SAG. We searched multiple databases for RCTs comparing MAG versus SAG. The clinical outcomes studied were all-cause mortality, cardiac mortality, myocardial infarction (MI), revascularization, stroke, sternal wound complications, and major bleeding. We used hazard ratio (HR), relative risk (RR), and corresponding 95% confidence interval (CI) for measuring outcomes. Ten RCTs (6392 patients) were included. The average follow-up in the studies was 4.2 years. The average age of the patients in the studies ranged from 56.3 years to 74.6. No significant difference was seen between MAG and SAG groups for all-cause mortality (11.8% vs 12.7%, HR 0.94, 95% CI 0.81 to 1.09, p 0.36), cardiac mortality (4.1% vs 4.5%, HR 0.96 95% CI 0.74 to 1.26, p 0.77), MI (3.5% vs 5.1%, HR 0.87 95% CI 0.67 to 1.12, p 0.28), and major bleeding (3.3% vs 4.9%, RR 0.85 95% CI 0.64 to 1.13, p 0.26). Repeat revascularization in MAG showed a lower RR than SAG when one of the confounding studies was excluded (RR 0.63, 95% CI 0.4 to 0.99, p 0.04). The incidence of stroke was lower in MAG than SAG (2.9% vs 3.9%, RR 0.74 95% CI 0.56 to 0.98, p 0.03). MAG had higher incidence of sternal wound complications than SAG (2.9% vs 1.7%, RR 1.75 95% CI 1.19 to 2.55, p 0.004). In conclusion, MAG does not have a survival advantage compared with SAG but is better in revascularization and risk of stroke. This benefit may be set off by a higher incidence of sternal wound complications in MAG.

Primary Biliary Cholangitis and CREST Syndrome: A Rare, Overlapping Presentation With a Review of the Literature.

CREST (calcinosis, Raynaud's phenomenon, esophageal dysmotility, sclerodactyly, and telangiectasia) syndrome, also known as the limited cutaneous form of systemic sclerosis (lcSSc), is a multisystem connective tissue disorder often manifesting as a consequence of superimposed autoimmune hepatitis. Herein, we present a case of a 40-year-old female with a past one-year history of hepatitis C presenting with the chief complaints of progressive thickness and tightness of the skin of hands and face and dysphagia for the past three months, along with arthralgia of the hands for the past two months, suggestive of CREST syndrome. Through this case, we intend to emphasize the association between extrahepatic manifestations and the emergence of autoantibodies in patients with hepatitis C virus (HCV) infection and discuss the clinical relevance of the autoantibodies in extrahepatic disorders, in our case, CREST syndrome. It is well-known that chronic HCV infection plays a significant part in the production of non-organ-specific autoantibodies, including antinuclear antibodies (ANA) and smooth muscle antibodies, and organ-specific autoantibodies. Clinicians must be aware of the possibility of such liver damage in patients with systemic sclerosis.

Paradoxical increase in stroke mortality among Asian Indians in the United States.

OBJECTIVE: To better characterize the stroke mortality and risk factors among Asian Indians by using U.S. multiple-cause-of-death and National Health and Interview Survey data. METHODS: Age-adjusted fatal stroke incidence, stroke rate ratio with 95% confidence interval, and average annual percentage change (APC) over 10 years were calculated. RESULTS: The annual incidence of stroke mortality in 2000 was lowest among Asian Indians (88 per 100,000) followed by American Indians and Alaska Natives (112 per 100,000), whites (301 per 100,000) and African Americans (312 per 100,000). Significantly lower rates of hypertension and cigarette smoking in Asian Indians in 2000-2001 (compared with whites) explained the lower rates of stroke mortality. The APC increase over subsequent 10 years was 13.5%, 0.9%, -2.5%, and -2.9% for Asian Indians, American Indians and Alaska Natives, whites, and African Americans, respectively. CONCLUSIONS: There is a paradoxical increase in stroke mortality among Asian Indians over the last 10 years in contrast to other population subsets.