Right to Left Intrapulmonary Shunt in a Case with COVID-19-associated Pneumonia.

The clinical manifestations of coronavirus disease 2019 (COVID-19)-associated pneumonia show a wide range of variations. It ranges from mild hypoxemia without significant signs of respiratory distress, to rapid clinically deteriorating course with severe hypoxemia. Unexplained severe hypoxemia, associated with platypnea, triggers the possibility of ventilation-perfusion (V/Q) mismatch, ranging from intrapulmonary shunts (IPS) to alveolar dead space ventilation. In the literature, very few cases with COVID-19-pneumonia have been reported with IPS. Herein, we report a COVID-19 confirmed 45-year male patient, who developed IPS without apparent pulmonary perfusion defect on lung perfusion scintigraphy. The patient had no cardiovascular disease except chronic pulmonary hypertension secondary to interstitial lung disease. The clinical manifestations combined with nuclear imaging features enabled in making the ultimate diagnosis. The patient's clinical condition improved on appropriate clinical management, using high flow oxygen combined with intravenous steroids and anticoagulants. Key Words: COVID-19, Adult respiratory distress syndrome, Right to left shunt, Lung perfusion scintigraphy, Platypnea.

Budd-Chiari syndrome computed tomographic imaging: Elucidating the devil in the details.

Hepatic venous outflow obstruction, due to hepatic venous thrombosis is the hallmark of Budd-Chiari Syndrome (BCS), a relatively uncommon disorder. The aim of this study was to explore imaging details and causes, and define invasive and non-invasive interventions for achieving successful portosystemic shunting (PSS). The variations in imaging topology and associated risk factors in BCS cases, diagnosed during the past 20 months, were studied. Of the 53 cases (32 males, 21 females; mean age: 34.4±13.5 years), 5 (9%) were Hepatitis-B virus (HBV) positive, 12 (23%) were HCV positive and 6 (11%) were co-infected, rest were negative. Imaging features included mottled cirrhotic hepatic parenchyma, thrombosed hepatic and portal-vein with or without IVC thrombosis, left lobe atrophy, caudate hypertrophy, splenomegaly, portosystemic varices and ascites. Three cases had subacute onset; two had acute while the rest were chronic BCS. The aetiology was: protein C, S and anti-thrombin deficiency in 24 (45%), JAK2 mutation in 3 (6%), lupus antibody with increased homocysteine levels in 5 (9%) and cryptogenic in 21 (40%) cases. Twelve cases were planned for liver transplantation, 20 were prepared to undergo TIPS, and the rest were optimised medically.

Right to Left Intrapulmonary Shunt in a Case with COVID-19-associated Pneumonia.

ABSTRACT       The clinical manifestations of coronavirus disease 2019 (COVID-19)-associated pneumonia show a wide range of variations. It ranges from mild hypoxemia without significant signs of respiratory distress, to rapid clinically deteriorating course with severe hypoxemia. Unexplained severe hypoxemia, associated with platypnea, triggers the possibility of ventilation-perfusion (V/Q) mismatch, ranging from intrapulmonary shunts (IPS) to alveolar dead space ventilation. In the literature, very few cases with COVID-19-pneumonia have been reported with IPS. Herein, we report a COVID-19 confirmed 45-year male patient, who developed IPS without apparent pulmonary perfusion defect on lung perfusion scintigraphy. The patient had no cardiovascular disease except chronic pulmonary hypertension secondary to interstitial lung disease. The clinical manifestations combined with nuclear imaging features enabled in making the ultimate diagnosis. The patient's clinical condition improved on appropriate clinical management, using high flow oxygen combined with intravenous steroids and anticoagulants. Key Words: COVID-19, Adult respiratory distress syndrome, Right to left shunt, Lung perfusion scintigraphy, Platypnea.

Feature tracking cardiac magnetic resonance imaging: A review of a novel non-invasive cardiac imaging technique.

Cardiovascular disease is a leading cause of morbidity and mortality globally. Early diagnostic markers are gaining popularity for better patient care disease outcomes. There is an increasing interest in noninvasive cardiac imaging biomarkers to diagnose subclinical cardiac disease. Feature tracking cardiac magnetic resonance imaging is a novel post-processing technique that is increasingly being employed to assess global and regional myocardial function. This technique has numerous applications in structural and functional diagnostics. It has been validated in multiple studies, although there is still a long way to go for it to become routine standard of care.

Exploring the association of ego defense mechanisms with problematic internet use in a Pakistani medical school.

The present study was designed to analyze association between problematic internet use and use of ego defense mechanisms in medical students. This cross-sectional study was undertaken at CMH Lahore Medical College (CMH LMC) in Lahore, Pakistan from 1st March, 2015 to 30th May, 2015. 522 medical and dental students were included in the study. The questionnaire consisted of three sections: a) demographic characteristics of respondent b) the Defense Style Questionnaire-40 (DSQ-40) and c) the Internet Addiction Test (IAT). All data were analyzed in SPSS v20. Chi square, Independent sample t test and One Way ANOVA were run to analyze association of different variables with scores on IAT. Multiple regression analysis was used to delineate ego defenses as predictors of problematic internet use. A total of 32 (6.1%) students reported severe problems with internet usage. Males had higher scores on IAT i.e had more problematic use of internet. Scores on internet addiction test (IAT) were negatively associated with sublimation and positively associated with projection, denial, autistic fantasy, passive aggression and displacement. There was a high prevalence of problematic use of internet among medical and dental students. It had significant associations with several defense mechanisms.

Acute hepatitis C virus infection related to capillary blood glucose meter.

Hepatitis C virus (HCV) infects an estimated 130-150 million people worldwide, becoming the major cause of chronic liver disease, cirrhosis, hepatocellular carcinoma, and liver transplantation. There are various preventable modes of transmission of HCV infection, including needlestick and sharps injuries. However, HCV infection secondary to needlestick injury by a capillary blood glucose meter (CBGM) lancet has not been previously well reported. We describe an unusual case of a 25-year-old male medical student, acquiring acute HCV infection with a lancing device of CBGM. The source patient was a 54-year-old diabetic male with positive anti-HCV test results. In our patient, after 3 months of initial exposure, a standard set of investigations confirmed the diagnosis of acute HCV infection with the same genotype (3a) as the source. The CBGM, as in our case, may have a role in the transmission of HCV infection warranting radical advancements in diabetes screening and monitoring technology.

Visible light communication applications in healthcare.

With the development in science, methods of communication are also improved, replacing old ones with new advanced ways in an attempt to make data transfer more secure, safer for health, and time as well as cost efficient. One of such methods is Visible Light Communication, as the name implies data is transferred through a light equipment such as incandescent or florescent bulb having speed of 10 Kb/s or LEDs approaching speed of 500 Mb/s [1]. VLC uses visible light between 384 and 789 THz [2,3]. Though range is limitation of VLC, however data transfer up-to distance of 1 to 2 km although at lower transfer rate has been reached.The VLC system comprises of light source like LED and receiver equipment, however, with advancement, now LEDs are used for both sending and receiving data. LED remains on all the time, and there is no change in brightness level during the whole process, making it safe for eyes. Currently, VLC system is facing some serious technical challenges before it could be applied in daily life.

Speckle Tracking Echocardiography of the Right Atrium: The Neglected Chamber.

The right atrium (RA) plays a pivotal role in electromechanical and endocrine regulation of the heart. Its peculiar anatomical features and phasic mechanical function make it distinct from ventricles. Various invasive and noninvasive techniques have been used to elucidate RA structure and function. Of these modalities, echocardiography has distinct advantages over others. Several conventional measures of RA function through echocardiography have been described in the literature, but they are load dependent. A relatively new technique is speckle tracking-derived strain, which is relatively less dependent on loading conditions. Speckle tracking echocardiography tracks acoustic scatters (speckles) of myocardium frame-by-frame to calculate strain or deformation of the myocardium. Speckle tracking echocardiography has been used extensively for strain assessment of the right and left ventricle to detect subtle disease pathology, to gain mechanistic insight, as a marker of ischemic metabolic memory, as an endpoint in clinical trials, and as a functional assessment tool. The RA is a relatively neglected chamber, as it is mostly studied for assessment of atrial mass lesions, for electrophysiological studies, and in animal models for physiological assessment. However, its role in the systolic and diastolic function of the right heart, pulmonary vascular pathology, congenital heart diseases, and combined electromechanical activation phenomena has been less explored or unexplored. Speckle tracking echocardiography is an ideal tool for the assessment of the RA because of its regional and global functional characterization, angle independence, and high temporal resolution.

Subclinical myocardial inflammation and diffuse fibrosis are common in systemic sclerosis--a clinical study using myocardial T1-mapping and extracellular volume quantification.

BACKGROUND: Systemic sclerosis (SSc) is characterised by multi-organ tissue fibrosis including the myocardium. Diffuse myocardial fibrosis can be detected non-invasively by T1 and extracellular volume (ECV) quantification, while focal myocardial inflammation and fibrosis may be detected by T2-weighted and late gadolinium enhancement (LGE), respectively, using cardiovascular magnetic resonance (CMR). We hypothesised that multiparametric CMR can detect subclinical myocardial involvement in patients with SSc. METHODS: 19 SSc patients (18 female, mean age 55 ± 10 years) and 20 controls (19 female, mean age 56 ± 8 years) without overt cardiovascular disease underwent CMR at 1.5T, including cine, tagging, T1-mapping, T2-weighted, LGE imaging and ECV quantification. RESULTS: Focal fibrosis on LGE was found in 10 SSc patients (53%) but none of controls. SSc patients also had areas of myocardial oedema on T2-weighted imaging (median 13 vs. 0% in controls). SSc patients had significantly higher native myocardial T1 values (1007 ± 29 vs. 958 ± 20 ms, p < 0.001), larger areas of myocardial involvement by native T1 >990 ms (median 52 vs. 3% in controls) and expansion of ECV (35.4 ± 4.8 vs. 27.6 ± 2.5%, p < 0.001), likely representing a combination of low-grade inflammation and diffuse myocardial fibrosis. Regardless of any regional fibrosis, native T1 and ECV were significantly elevated in SSc and correlated with disease activity and severity. Although biventricular size and global function were preserved, there was impairment in the peak systolic circumferential strain (-16.8 ± 1.6 vs. -18.6 ± 1.0, p < 0.001) and peak diastolic strain rate (83 ± 26 vs. 114 ± 16 s-1, p < 0.001) in SSc, which inversely correlated with diffuse myocardial fibrosis indices. CONCLUSIONS: Cardiac involvement is common in SSc even in the absence of cardiac symptoms, and includes chronic myocardial inflammation as well as focal and diffuse myocardial fibrosis. Myocardial abnormalities detected on CMR were associated with impaired strain parameters, as well as disease activity and severity in SSc patients. CMR may be useful in future in the study of treatments aimed at preventing or reducing adverse myocardial processes in SSc.

Global and regional left ventricular myocardial deformation measures by magnetic resonance feature tracking in healthy volunteers: comparison with tagging and relevance of gender.

BACKGROUND: Feature tracking software offers measurements of myocardial strain, velocities and displacement from cine cardiovascular magnetic resonance (CMR) images. We used it to record deformation parameters in healthy adults and compared values to those obtained by tagging. METHODS: We used TomTec 2D Cardiac Performance Analysis software to derive global, regional and segmental myocardial deformation parameters in 145 healthy volunteers who had steady state free precession (SSFP) cine left ventricular short (basal, mid and apical levels) and long axis views (horizontal long axis, vertical long axis and left ventricular out flow tract) obtained on a 1.5 T Siemens Sonata scanner. 20 subjects also had tagged acquisitions and we compared global and regional deformation values obtained from these with those from Feature Tracking. RESULTS: For globally averaged measurements of strain, only those measured circumferentially in short axis slices showed reasonably good levels of agreement between FT and tagging (limits of agreement -0.06 to 0.04). Longitudinal strain showed wide limits of agreement (-0.16 to 0.03) with evidence of overestimation of strain by FT relative to tagging as the mean of both measures increased. Radial strain was systematically overestimated by FT relative to tagging with very wide limits of agreement extending to as much as 100% of the mean value (-0.01 to 0.23). Reproducibility showed similar relative trends with acceptable global inter-observer variability for circumferential measures (coefficient of variation 4.9%) but poor reproducibility in the radial direction (coefficient of variation 32.3%). Ranges for deformation parameters varied between basal, mid and apical LV levels with higher levels at base compared to apex, and between genders by both FT and tagging. CONCLUSIONS: FT measurements of circumferential but not longitudinally or radially directed global strain showed reasonable agreement with tagging and acceptable inter-observer reproducibility. We record provisional ranges of FT deformation parameters at global, regional and segmental levels. They show evidence of variation with gender and myocardial region in the volunteers studied, but have yet to be compared with tagging measurements at the segmental level.