Patient With Missed Right Ventricular Rupture From Blunt Trauma Remains Hemodynamically Stable for 3 Days.

Cardiac chamber rupture from blunt trauma is rare but can be fatal. Surprisingly, in some subsets of patients, it can be subtle and rather easily missed. Rapid recognition and management are essential. Percutaneous closure can be successful in iatrogenic chamber perforation (during pericardiocentesis) but possibly not in traumatic chamber rupture. (Level of Difficulty: Intermediate.).

Linezolid and Ciprofloxacin-Induced SJS/TEN (Stevens-Johnson Syndrome/Toxic Epidermolysis Necrosis) Overlap in a Patient With Borderline Personality Disorder During a Single Hospital Stay: A Difficult Case to Manage.

SJS/TEN (Stevens-Johnson syndrome/toxic epidermolysis necrosis) is a T-cell mediated hypersensitivity syndrome in which cytotoxic CD8+ cells react against keratinocytes, resulting in widespread apoptosis and cell necrosis. About 90% of these cases are attributed to drug reactions, while 10% are idiopathic. The disease is classified according to body surface area (BSA) involvement and the thickness of epidermal loss. We report a case of a female with borderline personality disorder on antipsychotic medication, who developed SJS/TEN overlap after taking ciprofloxacin for her urinary tract infection (UTI). Her condition improved with meticulous management, but after switching her antibiotic from intravenous clarithromycin to oral linezolid, she developed SJS/TEN again, this time with more severe involvement. She received active management involving a multidisciplinary approach. Her condition improved slowly and, after one month, her lesions began to heal, and she was discharged with advice not to use both antimicrobial drugs in the future.

Comparing Dermatoscopic Features With Slit Skin Smear and Histopathology in Diagnosis of Cutaneous Leishmaniasis.

OBJECTIVE: To evaluate dermatoscopic features of cutaneous leishmaniasis and to compare its diagnostic accuracy against slit skin smear and skin histopathology. METHODS:  This cross-sectional study was conducted at the Department of Dermatology, Pakistan Navy Station (PNS) Shifa Hospital, Karachi, Pakistan, from August 2021 to August 2022. A total of 200 lesions from 70 patients of cutaneous leishmaniasis diagnosed with slit skin smear for Leishmania-Donovan (LD) bodies and skin biopsy were included via non-probability consecutive sampling technique. Dermatoscopic evaluation was performed via a handheld dermatoscope (DELTA 20T; HEINE, Gilching, Germany) on 10x magnification. All dermatoscopic images were analyzed by two different observers who had command of dermatoscopy. Data analysis was done using Statistical Package for the Social Sciences SPSS version 27 (IBM Corp., Armonk, NY, USA). RESULTS: Common dermatoscopic findings were erythema 200 (100%), hyperkeratosis 140 (70%), crusting 50 (25%), ulceration 42 (21%), milia-like structure 58 (29%), tear drop-like structure 46 (23%), yellow tears 70 (35%), and white starburst pattern 68 (34%). Less common findings were yellow hue 28 (14%), orange areas 26 (13%) and scar seven (3.5%). Vascular structures frequently observed were linear vessels 109 (54.5%), dotted vessels 80 (40%), and hairpin vessels 61 (30.5%); less common findings were comma-shaped vessels 52 (26%), arborizing vessels 20 (10%), crown vessels nine (4.5%). Comparison of dermatoscopic features was done with slit skin smear for LD bodies (p value = 0.003 ) and histopathology (p value = 0.001). CONCLUSIONS: Dermatoscopy is a non-invasive technique that is helpful in diagnosing cutaneous leishmaniasis, saving time in making rapid diagnosis and saving the need to undergo extensive invasive investigation. Yield of dermatoscopy was comparable to slit smear for LD bodies and histopathology and was found to be effective in making rapid diagnosis with significant accuracy (p value <0.05).

Refractory Hypotension: A Detailed Case Discussion and Current Literature Review.

Orthostatic hypotension (OH) commonly affects the elderly and can be challenging to manage. Its symptomology can be variable and is induced by decreased cerebral perfusion. Here, we present a complex yet compelling case of a patient with refractory OH, focusing on delineating current medical therapies and pathophysiology for in-training medical professionals.

Acute Severe Seronegative Autoimmune Hepatitis With Undiagnosed Graves' Disease.

Autoimmune hepatitis (AIH) is a progressive inflammatory condition hypothesized to be a T-lymphocyte (T-cell)-mediated immune response that commonly affects females more than males. Given its proposed mechanism associated with immune response, it is more likely to present with other autoimmune conditions, particularly autoimmune disorders associated with the thyroid. AIH can be difficult to diagnose as it is a diagnosis of exclusion. AIH lacks validated algorithms for proper diagnosis and can seldom present with negative antibodies. If not fully worked up, AIH may progress to cirrhosis and even increase the risk of malignancy. Therefore, a liver biopsy is a crucial step in the workup for AIH. We report a rare case of acute severe AIH associated with negative antibodies and undiagnosed Graves' disease.

A Rare Case of Candida parapsilosis Lumbar Discitis With Osteomyelitis.

Fungal osteomyelitis is rare and usually seen in immunocompromised patients. We report a case of Candida parapsilosis osteomyelitis in an immunocompetent patient with no prior surgical history. He went for spinal laminectomy with debridement and drainage. Intraoperative culture grew C. parapsilosis, and the patient was treated with fluconazole.

Severe Gastric Mucosal Necrosis Due to Giant Paraesophageal Hernia.

Hiatal hernias occur when part of the intra-abdominal contents protrude into the chest cavity. Paraesophageal hernia (PEH) is a type of hiatal hernia that is chronic and usually asymptomatic. Although patients may not present with alarming symptoms, the complications of PEH may be severe if left untreated. Hiatal hernias can be further categorized based on the degree of herniation. The most common subtype is a type I hiatal hernia, which occurs when the gastroesophageal junction (GEJ) herniates into the chest cavity. Type II, III, and IV PEH are when the GEJ, a portion of the stomach, and abdominal viscera herniate into the thorax. A PEH is usually chronic and asymptomatic. However, patients may present with vomiting, dysphagia, bloating, and abdominal pain. Complications of PEH may include gastric mucosal necrosis, perforation, strangulation, erosive ulcers, and gastric volvulus. This report discusses a case of a 71-year-old male patient who had multiple complications arising from a large PEH that required emergent treatment due to its nebulous presentation.

Diabetic Cardiomyopathy as a Clinical Entity: Is It a Myth?

Dilated cardiomyopathy (DCM) is a common form of cardiomyopathy that affects the cardiac muscle. It is a life-threatening condition that causes heart failure as it decreases the myocardial ability to pump sufficient blood throughout the body. Numerous causes trigger DCM without pathophysiology; however, the key concept is a decrease in the systolic function of either the left ventricle or of both the left and right ventricles. Long-term diabetes plays an important role in the pathogenesis of DCM in the form of diabetic cardiomyopathy. Diabetic cardiomyopathy is a non-ischemic form of DCM, which is associated with diabetes. It is unrelated to atherosclerosis and hypertension. The PubMed and Google Scholar databases were used to identify the relevant studies related to diabetes and DCM. We found that diabetes was associated with cardiac muscle injury by activating the renin-angiotensin-aldosterone system, myocardial inflammation, and fibrosis. Based on the available data, we concluded that there is strong evidence to support the interrelation of DCM and diabetes.

Unraveling the Mysteries of Restless Leg Syndrome.

Restless leg syndrome (RLS) or Willis-Ekbom disease (WED) is an under-diagnosed, chronic, and progressive primary sensory-motor disorder. It is characterized by an uncontrollable urge to move the legs due to uncomfortable and sometimes painful sensations, with a diurnal variation. RLS can lead to severe sleep disturbances, a usual cause of consultation. The pathophysiology is known partially, and it is believed that there is an association between the different variants of genetic mutations combined with dopaminergic and brain iron dysregulation, which plays an important role. The data used for this study were extracted from the articles found in the PubMed database that discuss different gene variants, pathophysiology, and various methods of treatment. They also highlight the role of iron in the pathogenesis of RLS as it is required for the synthesis of tyrosine hydroxylase, which is the rate-limiting step for dopamine synthesis. This review article provides a clinically useful overview of RLS in terms of pathophysiological findings, its genetic associations, and therapeutic options by using the currently available literature. Because RLS presents with vague symptoms and shares similarities with many other diseases, it might be overlooked by many physicians resulting in underdiagnosis and under-treatment. While these discoveries provide a breakthrough in understanding the details of RLS, further studies are recommended as these studies are limited to animal models and provide a limited representation of the general population.

Anabolic Steroids and Cardiovascular Outcomes: The Controversy.

Anabolic steroids (AS) are synthetic derivatives of the male sex hormone testosterone. The use of AS is not limited to bodybuilders and athletes, but non-athletes also use them. It is used to enhance athletic performance, induce muscle hypertrophy, and augment male sexual characteristics. AS use is associated with a wide range of side effects and potential cardiovascular complications. In this article, we have searched the available literature to investigate the association between AS use and cardiovascular disease (CVD). The results revealed that AS was linked to lipid metabolism derangements, hypertension, coagulation disorders, and cardiomyopathy. We concluded, based on the relevant data, that there was evidence that suggests an association with CVD, primarily myocardial infarction, fatal arrhythmias, and cardiomyopathy in AS users. The general population should be informed of the risk. Also, methods of primary and secondary prevention should be implemented to mitigate the risk of CVD secondary to AS.

Harmful consequences of specific substances on the oral health.

Numerous substances may have an adverse influence on the oral region by virtue of their potentially harmful effects. Dental practitioners are often the first to see these effects in the head and neck region. Knowledge of the damaging consequences of agents such as alcohol, tobacco, areca nut, medications, alcohol-containing mouthwashes, dental devices and materials can assist the practitioners in clinical decision-making and accurate diagnosis of associated lesions. More importantly, timely diagnosis and prompt reporting of such harmful effects improve the quality of care. Such knowledge may also help in patient's education for the avoidance of associated adverse effects (AEs). Consequently, a thorough acquaintance of AEs will consolidate the distinct role of medical and oral health practitioners in safeguarding the patients' oral and systemic well-being. This article was planned to review the harmful consequences of specific substances on the oral health. Traditionally, the emphasis of review articles has been on reviewing the harmful effects of a single entity on oral health. This review is unique in the sense that it comprehensively and collectively focussed on the harmful effects on the oral health of addictive and illicit substances (alcohol, betel nut), medications, alcohol-containing mouthwashes, medications and dental materials.

Levetiracetam Induced Increase in Creatine Phosphokinase Levels.

Levetiracetam is an antiepileptic drug used for the treatment of generalised or partial seizures, either alone or in a combination therapy. Adverse effects have been reported with its clinical use, including headache, dizziness, liver failure etc. A rare but an important adverse effect is an increase in creatine phosphokinase (CPK) levels with its use. Herein, we present a case of 43-year male, known intravenous (IV) drug abuser with a history of decompressive craniotomy. Patient presented with severe behavioural disorder for which risperidone was given. Five days later, he started having high grade fever, hyperventilation and uncontrolled generalised tonic-clonic seizures (GTCS). After initial management of seizures, levetiracetam was started in combination with topiramate for seizure control. Seizures remained subsided but CPK levels, which were normal at the start of therapy, began to rise and reached tremendous levels of 29,000 mg/dl within a span of a week. Levetiracetam, suspected as a cause of this increase CPK levels, was stopped immediately and the levels returned to baseline within one week. This report provided us with an important step in the management of seizures with levetiracetam.

Global analysis of dorsoventral patterning in the wasp Nasonia reveals extensive incorporation of novelty in a regulatory network.

BACKGROUND: Gene regulatory networks (GRNs) underlie developmental patterning and morphogenetic processes, and changes in the interactions within the underlying GRNs are a major driver of evolutionary processes. In order to make meaningful comparisons that can provide significant insights into the evolution of regulatory networks, homologous networks from multiple taxa must be deeply characterized. One of the most thoroughly characterized GRNs is the dorsoventral (DV) patterning system of the Drosophila melanogaster embryo. We have developed the wasp Nasonia as a comparative DV patterning model because it has shown the convergent evolution of a mode of early embryonic patterning very similar to that of the fly, and it is of interest to know whether the similarity at the gross level also extends to the molecular level. RESULTS: We used RNAi to dorsalize and ventralize Nasonia embryos, RNAseq to quantify transcriptome-wide expression levels, and differential expression analysis to identify genes whose expression levels change in either RNAi case. This led to the identification of >100 genes differentially expressed and regulated along the DV axis. Only a handful of these genes are shared DV components in both fly and wasp. Many of those unique to Nasonia are cytoskeletal and adhesion molecules, which may be related to the divergent cell and tissue behavior observed at gastrulation. In addition, many transcription factors and signaling components are only DV regulated in Nasonia, likely reflecting the divergent upstream patterning mechanisms involved in producing the conserved pattern of cell fates observed at gastrulation. Finally, several genes that lack Drosophila orthologs show robust and distinct expression patterns. These include genes with vertebrate homologs that have been lost in the fly lineage, genes that are found only among Hymenoptera, and several genes that entered the Nasonia genome through lateral transfer from endosymbiotic bacteria. CONCLUSIONS: Altogether, our results provide insights into how GRNs respond to new functional demands and how they can incorporate novel components.

Co-treatment with pegylated interferon alfa-2a and entecavir for hepatitis D: A randomized trial.

AIM: To investigate the efficacy of pegylated interferon alfa (PEG-IFNα) therapy with and without entecavir in patients with chronic hepatitis D. METHODS: Forty hepatitis D virus (HDV) RNA positive patients were randomized to receive either PEG-IFNα-2a 180 µg weekly in combination with entecavir 0.5 mg daily (n = 21) or PEG-IFNα alone (n =19). Patients who failed to show 2 log reduction in HDV RNA level at 24 wk of treatment, or had detectable HDV RNA at 48 wk of therapy were considered as treatment failure. Treatment was continued for 72 wk in the rest of the patients. All the patients were followed for 24 wk post treatment. Intention to treat analysis was performed. RESULTS: The mean age of the patients was 26.7 ± 6.8 years, 31 were male. Two log reduction in HDV RNA levels at 24 wk of therapy was achieved in 9 (43%) patients receiving combination therapy and 12 (63%) patients receiving PEG-IFNα alone (P = 0.199). Decline in hepatitis B surface antigen (HBsAg) levels was insignificant. At the end of treatment, HDV RNA was negative in 8 patients (38%) receiving combination therapy and 10 patients (53%) receiving PEG-IFNα-2a alone. Virological response persisted in 7 (33%) and 8 (42%) patients, respectively at the end of the 24 wk follow-up period. One responder patient in the combination arm lost HBsAg and became hepatitis B surface antibody positive. Six out of 14 baseline hepatitis B e antigen reactive patients seroconverted and four of these seroconverted patients had persistent HDV RNA clearance. CONCLUSION: Administration of PEG-IFNα-2a with or without entecavir, resulted in persistent HDV RNA clearance in 37% of patients. The addition of entecavir did not improve the overall response.

Frequency of deaths in hepatitis C virus infected hepatocellular carcinoma patients and its relationship with raised serum alpha-fetoprotein levels.

OBJECTIVE: To determine the frequency of deaths in hepatitis C virus infected hepatocellular carcinoma patients, and its relationship with raised serum alpha-fetoprotein levels. METHODS: The cross-sectional study was conducted at Isra University Hospital, Hyderabad, Pakistan, between March 2013 and April 2014, and comprised all patients diagnosed with hepatitis C virus and hepatocellular carcinoma over 30 years ofage. Blood sample was drawn for the measurement of serum Alfa fetoprotein levels. Data was analysed using SPSS 16. RESULTS: The mean age of the 165 patients was55.49±11.67 years. The mean tumour size was 5.63 ± 2.14cm. Of the total, 31(18.8%) patients had tumour size <3cm, 65(39.4%) 3-5cm and 69(41.8%) >5cm. The mean serum Alfa fetoprotein level was 7641.0±3665.32 IU/ml. Overall mortality rate was 70(41.9%). Tumour size >5cm was significantly associated with mortality (p=0.016). CONCLUSIONS: Serum Alfa fetoprotein levels were a useful tool for the detection of hepatocellular carcinoma in hepatitis C virus patients.

Treatment of chronic hepatitis D patients with pegylated interferon: a real-world experience.

BACKGROUND: Published experience of treating chronic hepatitis D patients with pegylated interferon (PEG-IFN)-α is limited. The aim of this study was to determine the efficacy of 48 weeks of treatment with PEG-IFN in naive patients outside the clinical trial setting, in the real world. METHODS: Patients with chronic hepatitis D were treated with PEG-IFN. The primary end points were sustained clearance of HDV RNA and normal alanine aminotransferase (ALT) at 24 weeks post-treatment. RESULTS: The total number of patients treated with PEG-IFN was 104; 91 males, mean age ±SD 30.1 ±10.0 years (range 15-55). Cirrhosis was present in 41 patients. With an intention-to-treat analysis, end of treatment virological response (ETR) was achieved in 44 (42.3%), normalization of ALT in 38 (35%) and a combined response in 23 (22.1%) patients. Sustained virological response (SVR) at 24 weeks post-treatment was seen in 24 (23.1%) patients each for the virological and biochemical responses and in 13 (12.5%) as combined response. Both ETR and SVR were associated with a negative HDV RNA at 24 weeks of treatment (P=0.001 and P=0.000, respectively). Detectable HDV RNA at this point had a positive predictive value of 0.95 (range 0.85-0.99) for detectable RNA at 6 months post-treatment. End of treatment biological response, that is, normal ALT at the end of treatment was also a predictor of ETR and SVR (P=0.004 and P=0.041, respectively). CONCLUSIONS: Treatment with PEG-IFN for hepatitis D is of limited efficacy. Detectable HDV RNA at 24 weeks of treatment is a predictor for a failed SVR.

Bone mineral density in patients with chronic backache.

OBJECTIVE: To evaluate the association of bone mass density with chronic backache. METHODS: The case-control observational study was conducted at Bone Mass Density Assessment Unit, Liaquat University of Medical & Health Sciences Jamshoro from January 2011 to December 2013. Adult patients of either gender having chronic backache were studied alongside subjects without backache who served as the control group. Bone mass density of all patients was measured at the lumbar spine (L1-L4) and hip using a dual-energy X-ray absorptiometry scan. Association of chronic backache with age, gender, body mass index and bone mass density was assessed by performing multiple regression analysis. RESULTS: Of the 482 subjects in the study, 162(33.6%) were cases and 320(66.3%) were the controls. Overall age range was 20-78 years with a mean of 48.5±12.36. The mean age of the controls was 38.87±13.55, while for the cases it was 36.26±9.41. Bone mass density in the cases was significantly low compared to the controls (p-0.028). CONCLUSIONS: Severity of chronic backache could be predicted by low bone mass density.

Consensus interferon plus ribavirin for hepatitis C genotype 3 patients previously treated with pegylated interferon plus ribavirin.

BACKGROUND: Not enough data are available about the effectiveness of consensus interferon (CIFN) among HCV genotype 3 patients who failed to respond to pegylated interferon and ribavirin. OBJECTIVES: We aimed to assess the efficacy and safety of CIFN and ribavirin in non-responders and relapsers to pegylated interferon with ribavirin therapy. PATIENTS AND METHODS: This open-label investigator-initiated study included 44 patients who received CIFN 15 µg /day plus ribavirin 800-1200 mg daily. In patients with an early virological response (EVR), the dose of CIFN was reduced to 15 µg thrice a week for further 36 weeks. Patients with delayed virological response continued to receive daily CIFN plus ribavirin to complete 48 weeks. The patients were considered "non-responders" if there were less than 2 log reduction in HCV RNA at 12 weeks and detectable HCV RNA at 24 weeks. RESULTS: Twenty-four patients (55%) were non-responders and 20 patients were relapsers to the previous treatment with pegylated interferon plus ribavirin (mean age 43.6 ± 9.4 years, males 25 (57%)). Nine patients were clinically cirrhotic (Child A). End of treatment virological response was achieved in 19 (43.1%) patients and sustained virological response (SVR) occurred in 12 (27.3%). Out of these 12 patients, eight were non-responders and four were relapsers to the previous treatment. Advanced fibrosis or clinical cirrhosis was associated with low SVR. Adverse events were fever, myalgia, anorexia, depression, and weight loss. Two patients received granulocyte colony stimulating factor for transient neutropenia. Seven patients were given erythropoietin to improve hemoglobin, and six were treated for mild depression. Two patients developed portosystemic encephalopathy. CONCLUSIONS: More than one-quarter of treatment-experienced patients with HCV genotype 3 achieved SVR after re-treatment with consensus interferon plus ribavirin.

Prevalence of syphilis among antenatal clinic attendees in Karachi: imperative to begin universal screening in Pakistan.

OBJECTIVES: To assess the prevalence and associated risk factors of syphilis among antenatal clinic attendees by a multi-center cross-sectional study in Karachi, Pakistan. METHODS: We administered a structured questionnaire and obtained a blood sample for syphilis serology (rapid plasma reagin test with Treponema pallidum hemagglutination assay confirmation) from all women giving informed consent over six weeks in 2007. Prevalence was calculated at 95% confidence intervals. Multivariate analysis was adapted to assess risk factors. RESULTS: There were seven (0.9%) confirmed cases of syphilis (95% CI: 0.4, 1.8) in a sample size of 800 women recruited from three urban sites (-1% refusal rate). Women who lived in an area where male drug use is prevalent had 1.5% higher prevalence rates than women from the other two sites 0.5%. CONCLUSIONS: We documented higher-than-expected syphilis seroprevalence rates in a low risk population of antenatal clinic attendees in Pakistan. Bridge populations for syphilis may include drug users, who are usually married, and Hijras or their clients. In accordance with our results, the national policy for syphilis control in Pakistan should be modified to include universal syphilis screening in antenatal clinics with subsequent partner notification.

An audit of informed consent in surgical patients at a university hospital.

BACKGROUND: To obtain informed consent is considered an integral part of modern clinical practice. It works as a safeguard of patient's rights and minimizes the chances of legal action against the physician in case of any complication arising from the proposed therapy. Objective was to evaluate the practice of informed consent in patients undergoing surgery in a University hospital. METHODS: A survey was conducted at different surgical departments of a university hospital during December 2007 to March 2008. Participants were selected from patients over the age of 18 years who had undergone elective or emergency surgery. All interviews were based on structured questionnaire. The patients were asked if an informed consent was taken or not before the surgery. They were also inquired if they were given information about the diagnosis, the surgical procedure planned and risks associated with it. The patients were also asked if they were informed about the types of anaesthesia proposed. RESULTS: A total of 106 patients were randomly selected for this study. In 8.5% cases, no consent was taken. Only 38% of the surveyed patients acknowledged that they actually understood the information imparted to them. 66% patients were informed about the type of anaesthesia proposed but none was given any hint about complications of anaesthesia. 11% patients actually signed the consent forms themselves. CONCLUSION: The quality of existing informed consent process in a university hospital is less than ideal. There is a great need to educate the doctors and healthcare regarding the importance of patient's autonomy and their right to the information about their medical condition and the proposed surgical procedures to ensure their participation in the decision making regarding their treatment.