Noninvasive Management of Fractured Indwelling Tunneled Pleural Catheter Valve.

Tunneled indwelling pleural catheters (IPCs) are frequently used to palliate symptomatic dyspnea due to recurrent pleural effusions. The drainage valve of IPCs is an important component of the catheter as fracture of the valve leads to malfunctioning of the IPCs. Replacement of the catheter includes risks such as pain, infection, pneumothorax, and procedure cost. We report two cases of malfunctioning tunneled IPC drainage valves repaired by our noninvasive method and discuss the need for a repair kit and a standardized approach to this repair in case of nonavailability of repair kits.

Crigler-Najjar Syndrome Type II Diagnosed in a Patient with Jaundice Since Birth.

Crigler-Najjar syndrome type II is caused by mutations in the UGT1A1 gene resulting in severely reduced hepatic activity of UDP-glucoronyltransferase - an enzyme required to convert bilirubin into a more soluble form that can then be removed from the body. Absence or severe deficiency of this enzyme can lead to bilirubin accumulation in the body resulting in yellow skin and eyes (jaundice). The earliest signs of this disease can be apparent in the neonatal period. Patients with Crigglar-Najjar syndrome type II respond to phenobarbital therapy which decreases their chances of getting bilirubinemia by 60-70% in 3 weeks. A 17 years old boy presented with the complaint of gastroenteritis. On examination, he was jaundiced and his parents reported that it has been present since birth. He was admitted in the hospital with the differential diagnosis of Gilbert syndrome, but later it was found that the unconjugated bilirubin levels were higher than those required for Gilbert's criteria. We report, herein, an extremely rare case of Crigler-Najjar syndrome type II and how the patient responded to phenobarbital therapy. Periods of fasting, stress and any kind of illness can worsen unconjugated hyperbilirubinemia leading to complications like kernicterus, so higher levels of unconjugated bilirubin should be addressed immediately and the patient along with his/her family should be educated about this disease.

Pathological bone fractures in a patient with parathyroid carcinoma - A Case Report.

Parathyroid carcinoma is a rare malignant neoplasm of the parathyroid glands which results in enlargement and excessive production of parathyroid hormone (PTH) responsible for pathologically raising calcium levels in the blood resulting in bone pain/fractures, renal stones and other signs of hypercalcaemia. A 37 year old woman presented with sudden, spontaneous bone pain and fracture of the right femoral shaft. This unusual presentation was explained by extremely high PTH levels and hypercalcaemia in the blood and a hard, solitary mass palpable in the neck. During surgical excision of this mass, finding of several adhesions, possible capsular invasion and lymph node enlargement led to a diagnosis of parathyroid carcinoma. The neoplasm proliferates via adenoma-carcinoma sequence so early diagnosis and prompt surgical excision with post-operative care may provide palliation and keep recurrences in check. Pancreas and pituitary evaluation is also necessary as this presentation may be a part of Wermer (MEN-1) syndrome. .

Knowledge and attitude of physicians about antimicrobial resistance and their prescribing practices in Services hospital, Lahore, Pakistan.

A cross sectional study was conducted in Services Hospital, Lahore using a self administered questionnaire to test the knowledge, attitude and prescribing practices of residents and attending physicians using non-probability convenience sampling. A total of 116 questionnaires were filled (Response rate=77.3%). Knowledge was below average (mean score of 3.66±1.1). Only 18 physicians (16%) could correctly estimate the rates of resistance of Klebsiella pneumoniae and pseudomonas aeruginosa to cephalosporin. Mostly physicians reviewed their decisions to prescribe an antibiotic by discussing with a senior colleague (n=93; 80%). When they did, the senior colleague sometimes recommended a different antibiotic (n=106; 91%). Seventy seven physicians (66%) reported that they prescribed more than one antibiotic per day. Physicians also stated that their decision of antimicrobial prescription was influenced by patient's socioeconomic status (n=108; 93.1%) and patients' demands (n=24; 20.7%). This study highlighted the importance of Antimicrobial stewardship and revealed topics to address during future antimicrobial prescribing interventions such as dissemination of information about local resistance rates and encouraging knowledge about antimicrobials.

Spontaneous bilateral quadriceps rupture in a patient with ankylosing spondylitis: A case report.

Ankylosing spondylitis is a prototype rheumatoid factor-negative spondyloarthropathy that causes the vertebrae to fuse making the spine less flexible, resulting in a hunched-forward posture. A 47-year-old male who was a known case of ankylosing spondylitis presented with left quadriceps rupture after raising his right foot to lightly hit a football. He was fitted with a knee immobilizer as an emergency measure. The extent of the rupture was not yet established when patient requested leave to go home. The right quadriceps was ruptured as well when he took his immobilizer off to go the bathroom. We report herein an extremely rare case of ankylosing spondylitis with atrophy in the quadriceps to the extent of causing pathological muscle rupture. Prolonged period of immobilization results in muscle wasting which leads to knee joint instability so the muscle should be repaired as soon as possible.