Coxsackievirus-Induced Myocarditis With Acute Onset of Heart Failure With Pleural Effusion.

This is a case of a 45-year-old Caucasian female with coxsackievirus-induced myocarditis. Myocarditis is an inflammation of the heart muscles, which can be difficult to diagnose at times because its symptoms overlap with other cardiovascular diseases. At times, when the patient presents, the full impact of the etiology would have either improved or resolved. In this case, the patient presented with symptoms closely resembling that of acute coronary syndrome but did not fit the typical age category. After lab and imaging workup, the coxsackievirus panel was positive, complicated with a new diagnosis of systolic heart failure with an ejection fraction of 30%-35% along with pericardial effusion.

A Recurrent Case of Mesothelial Pericardial Cyst.

This is a case of a 37-year-old female patient with past medical history of mitral valve prolapse and benign mesothelial pericardial cyst status post laparoscopic resection who presented to the emergency department with a chief complaint of right-sided sharp non-radiating chest pain due to recurrent case of benign mesothelial pericardial cyst. Though this is not a common pathology, it does overlap with common cardiovascular symptoms/conditions; not limited to but including chest pain, dyspnea, palpitations, pericardial effusions, infections and arrhythmias. It is crucial to have appropriate history and physical exam and appropriate evaluation to rule out pericardial cysts as well as their locations and their potential lethal mechanical implication on crucial nearby structures. This is significant in order to avoid uncommon but lethal cardiac complications in this condition such as cardiac arrhythmias, cardiac tamponade, right ventricular outflow tract and even sudden cardiac death.

Patterns of livestock depredation and Human-wildlife conflict in Misgar valley of Hunza, Pakistan.

Throughout the world, livestock predation by mammalian carnivores causes significant economic losses to poor farmers, and leads to human-wildlife conflicts. These conflicts result in a negative attitude towards carnivore conservation and often trigger retaliatory killing. In northern Pakistan, we investigated livestock depredation by large carnivores between 2014 and 2019, and subsequent Human-wildlife conflict, through questionnaire-based surveys (n = 100 households). We used a semi-structured questionnaire to collect data on livestock population, depredation patterns, predation count, and conservation approaches. We found a statistically significant increasing pattern of predation with influential factors such as age, gender, occupation, education of respondents, population of predators, threats index for predators and conservation efforts. Some 310 livestock heads with an average of 51 animals per year out of the total 9273 heads were killed by predators, and among them 168 (54%) were attributed to the wolf and 142 (45.8%) to snow leopard. Major threats to carnivores in the area included retaliatory killing, habitat destruction and climate change. Incentivization against depredation losses, guarded grazing and construction of predator-proof corral may reduce Human-wildlife conflict and both livelihood and predator can be safeguarded in the study area.

Diagnostic and Prognostic Implications of Cardiac Markers for Hepatocellular Carcinoma.

Hepatocellular carcinoma (HC) is a malignant primary liver cancer which has poor treatment outcomes in advanced stages, and many of the HC patients present with advanced stages. The incidence of death due to HC increase as a result of ineffective treatments for advanced stage disease. Early diagnosis and management has proven benefits in both survival and quality of life. Currently very few biomarkers are available to provide diagnostic and prognostic benefits in HC patients. The present review elaborates the association of cardiac markers in HC disease. The HC disease pathology includes many cardiovascular events like hypoxia and other parameters discussed in this review which have a role in disease advancement, and also may help as diagnostic and / or prognostic markers. The scientific lacuna in association / role of cardiac markers in HC disease is also stated in this review which may be helpful for future research studies and develop cost effective biomarker for early diagnosis of HC.

Forensic Identification Through Tooth Discoloration And Alignment.

BACKGROUND: Due to poor oral hygiene and use of tobacco, dental discolorations are present in some people and may indicate presence of toxic substances in food or body, while some have anatomical faulty alignment of teeth. The objective of the study was to know the frequency of these discolorations and faulty dental alignment in the target population so that a forensic tool could be developed. METHODS: A cross sectional descriptive study was done in the Dentistry Department of Ayub Teaching Hospital Abbottabad during the month of October 2019, on routine patients visiting the department, using non-probability convenience sampling. A Performa was made to be filled by dentists examining their patients using the standard dentition chart to locate teeth; notation chart was used for recording observations. The preliminaries along with subvariables were recorded in the Performa for each of 101 patients observed; data were analyzed by SPSS 20 for descriptive statistics. RESULTS: A cross sectional descriptive study was done in the Dentistry Department of Ayub Teaching Hospital Abbottabad during the month of October 2019, on routine patients visiting the department, using non-probability convenience sampling. A Performa was made to be filled by dentists examining their patients using the standard dentition chart to locate teeth; notation chart was used for recording observations. The preliminaries along with subvariables were recorded in the Performa for each of 101 patients observed; data were analyzed by SPSS 20 for descriptive statistics. CONCLUSIONS: Dental discolorations and faulty alignment of teeth can be utilized as useful tools in exclusionary method of identification which can be used in living and dead for investigation of identification. It was also observed that there is need to emphasize on community dental hygiene in our hospitals.

Algorithm for the analysis of pre-extraction computed tomographic images to evaluate implanted lead-lead interactions and lead-vascular attachments.

BACKGROUND: The number of lead extractions is growing because of the greater population and increasing age of individuals with a cardiac implantable electronic device. Lead extraction procedures can be complex undertakings with risk of significant mortality, and vascular tears in the superior vena cava are of greatest concern. OBJECTIVE: The purpose of this study was to study whether a novel algorithm that analyzes pre-extraction computed tomographic (CT) images can determine the likelihood and location of lead-lead interactions and lead-vessel attachment within patients' venous vasculatures. This information can be used to identify potential case challenges in the planning stages. METHODS: We developed an algorithm to estimate the presence and position of lead-lead interactions and lead-vessel adherences by tracking distance between the leads and distance between the lead and superior vena cava in a sample of 12 patients referred to the United Heart and Vascular Clinic for lead extractions due to infection (n = 5), lead failure (n = 5), and tricuspid regurgitation (n = 2). RESULTS: Preliminary results indicate that the developed algorithm successfully identified lead-lead and lead-vascular attachments compared to review of CT images by medical experts. CONCLUSION: With future validation and clinical implementation, this algorithm could aid physician preparedness by minimizing intraprocedural emergencies and may improve patient outcomes.

Oral Health Knowledge, Attitude, and Practice among Nursing Students in the North-Eastern Part of Rajasthan, India.

BACKGROUND: Professional and paramedical students have a key role in oral health promotion. The aim of this study was to assess oral health-related Knowledge, Attitude, and Practice (KAP) among the nursing students in Rajasthan. MATERIALS AND METHODS: A cross-sectional, questionnaire-based study was carried out among 409 nursing students from five different institutes who were selected by simple random sampling. A 27-item questionnaire was used to assess KAP. The resulting data were analyzed using frequency distribution. RESULTS: Over 50% of the students used toothbrush and toothpaste twice a day to maintain their oral hygiene. Besides, 41% recognized the importance of dental visit in case of gingival bleeding and knew that poor oral hygiene is responsible for bad breath. CONCLUSIONS: Oral health-related behavior among the nursing students needs improvement. More educational and preventive programs should be organized to achieve better results.

A novel realgar-indigo naturalis formula more effectively induces apoptosis in NB4 cells.

Realgar as a kind of arsenic agent is currently used to treat APL in China. The effectiveness and low toxicity of realgar have been verified, lower than arsenic trioxide. Although the therapeutic efficacy of realgar is blocked severely by its poor insolubility in water. In our lab, we addressed this problem by obtaining realgar bioleaching solution (RBS) from microbiological leaching technique. To develop a tradition Chinese medicinal formula (TCMF) for clinical application realgar is usually used with other herbs. However, treated realgar with RBS has not been evaluated in TCMF contain realgar. In the present study we used NB4 to investigate the effects of novel Realgar-Indigo naturalis formula (FRBS) on cell proliferation and apoptosis. We used MTT assay to measure anti proliferative activity of FRBS. We further study the effects of FRBS on cell growth and apoptosis according flow cytometry, DNA fragmentation assay and Fluorescence microscopy and Western blot. The results revealed that FRBS significantly inhibited growth in a dose-dependent manner, and induced apoptosis in NB4 cells. NB4 cell inhibitory response to FRBS at 2µg ml-1 of arsenic concentration was twofold higher, dissimilar to RIF, and induced apoptosis more effectively. Further, a higher expression of caspase-3, caspase-9 and cytochrome C from increased from FRBS. RBS can substitute the traditional realgar powder in RIF in order to provide a novel and promising Realgar-Indigo naturalis formula to treat acute promyelocytic leukemia.

Malignant Meningioma: An International Multicentre Retrospective Study.

BACKGROUND: In contrast to benign meningiomas, malignant meningiomas (MM) are rare and associated with an unfavourable prognosis. Reports on MM concern fairly small cohorts, often comprising less than 30 cases. OBJECTIVE: To describe the outcome MM and identify factors that may influence survival. METHODS: Pathology reports and clinical data of 178 patients treated between 1989 and 2017 for a MM at 6 different international institutions were retrospectively reviewed. Seventy-six patients (42.7%) had a previous history of grade I or grade II meningioma. The patients underwent a total of 380 surgical resections and 72.5% received radiotherapy. Median follow-up was 4.5 yr. RESULTS: At data collection, 111 patients were deceased (63.4%) and only 23 patients (13.7%) were alive without any residual tumor on the most recent scan. Median overall survival was 2.9 yr, 95% confidence interval [CI; 2.4, 4.5]. Overall survival rates at 1, 5, and 10 yr, respectively, were: 77.7%, 95% CI [71.6, 84.3], 40%, 95% CI [32.7, 49], and 27.9%, 95% CI [20.9, 37.3]. In the multivariable analysis, age at MM surgery <65 yr (hazard ratio [HR] = 0.44, 95% CI [0.29, 0.67], P < .001), previous benign or atypical meningioma surgery (HR = 1.9, 95% CI [1.23, 2.92], P = .004), completeness of resection (HR = 0.51, 95% CI [0.34, 0.78], P = .002), and adjuvant radiotherapy (HR = 0.64, 95% CI [0.42, 0.98], P = .039) were established as independent prognostic factors for survival. CONCLUSION: This large series confirms the poor prognosis associated with MM, the treatment of which remains challenging. Patients under 65-yr-old with primary MM may live longer after complete resection and postoperative radiotherapy. Even with aggressive treatments, local control remains difficult to achieve.

Twelve-Lead ECG Optimization of Cardiac Resynchronization Therapy in Patients With and Without Delayed Enhancement on Cardiac Magnetic Resonance Imaging.

Background Delayed enhancement ( DE ) on magnetic resonance imaging is associated with ventricular arrhythmias, adverse events, and worse left ventricular mechanics. We investigated the impact of DE on cardiac resynchronization therapy ( CRT ) outcomes and the effect of CRT optimization. Methods and Results We studied 130 patients with ejection fraction ( EF ) ≤40% and QRS ≥120 ms, contrast cardiac magnetic resonance imaging, and both pre- and 1-year post- CRT echocardiograms. Sixty-three (48%) patients did not have routine optimization of CRT . The remaining patients were optimized for wavefront fusion by 12-lead ECG . The primary end point in this study was change in EF following CRT . To investigate the association between electrical dyssynchrony and EF outcomes, the standard deviation of activation times from body-surface mapping was calculated during native conduction and selected device settings in 52 of the optimized patients. Patients had no DE (n=45), midwall septal stripe (n=30), or scar (n=55). Patients without DE had better ∆ EF (13±10 versus 4±10 units; P<0.01). Optimized patients had greater ∆ EF in midwall stripe (2±9 versus 12±12 units; P=0.01) and scar (0±7 versus 5±10; P=0.04) groups, but not in the no- DE group. Patients without DE had greater native standard deviation of activation times ( P=0.03) and greater ∆standard deviation of activation times with standard programming ( P=0.01). Device optimization reduced standard deviation of activation times only in patients with DE ( P<0.01). Conclusions DE on magnetic resonance imaging is associated with worse EF outcomes following CRT . Device optimization is associated with improved EF and reduced electrical dyssynchrony in patients with DE .

Lead Extraction Imaging.

Lead extraction procedures have a low but real risk of major complications, such as superior vena cava tear and cardiac tamponade. Complications during lead removal are commonly related to lead binding sites, lead malposition, and lead perforation. Lead extraction imaging may indicate lead vascular binding sites, lead position, and perforation. Several imaging modalities are available, including chest radiograph, cardiac computed tomography, and echocardiography. The information provided by various imaging modalities will help assess the challenges of each lead extraction procedure and allows for better preprocedure planning.

Ancient Human Migrations to and through Jammu Kashmir- India were not of Males Exclusively.

Jammu and Kashmir (J&K), the Northern most State of India, has been under-represented or altogether absent in most of the phylogenetic studies carried out in literature, despite its strategic location in the Himalayan region. Nonetheless, this region may have acted as a corridor to various migrations to and from mainland India, Eurasia or northeast Asia. The belief goes that most of the migrations post-late-Pleistocene were mainly male dominated, primarily associated with population invasions, where female migration may thus have been limited. To evaluate female-centered migration patterns in the region, we sequenced 83 complete mitochondrial genomes of unrelated individuals belonging to different ethnic groups from the state. We observed a high diversity in the studied maternal lineages, identifying 19 new maternal sub-haplogroups (HGs). High maternal diversity and our phylogenetic analyses suggest that the migrations post-Pleistocene were not strictly paternal, as described in the literature. These preliminary observations highlight the need to carry out an extensive study of the endogamous populations of the region to unravel many facts and find links in the peopling of India.

Disproportionately Large Communicating Fourth Ventricle: Pearls for Diagnosis and Management.

Introduction Disproportionately large communicating fourth ventricle (DLCFV) is an unusual presentation of communicating hydrocephalus, in which patients with hydrocephalus have a disproportionately enlarged fourth ventricle in the absence of obstructive pathology. We present six cases of DLCFV which, to date, is the largest series of this relatively rare condition. We highlight the significance of diagnosis and its differentiation from trapped fourth ventricle (TFV) and discuss the nuances for optimal management of DLCFV. Methods Retrospective case series of consecutive patients with DLCFV, managed by the senior author (LT) over a 10-year period. Results Six cases were identified, five of whom had previous posterior fossa surgery and one with previous encephalitis. All patients presented with cerebellar signs, the initial group had unsuccessful initial management with typical cerebrospinal fluid (CSF) diversion. Consistent symptom resolution was achieved by the application of negative CSF pressures via external ventricular drainage (EVD), maintained with subsequent ventriculopleural shunt (VPL), valveless lumbopleural shunt (LPS) or valveless ventriculoperitoneal shunt (VPS), or proceeding directly to a low-pressure system. Conclusions DLCFV is a diagnosis characterised by cerebellar dysfunction, with or without cranial nerve palsies, often in the setting of previous posterior fossa pathology. Optimal management relies on knowledge of this unique diagnostic entity, and use of an EVD at negative pressures to confirm symptomatic and radiological improvement prior to definitive treatment.

Supraventricular Tachycardia and Tricuspid Regurgitation in the Setting of Misplaced Implantable Port Catheter Tip.

We present the case of a 31-year-old female with a past medical history of B-cell leukemia, on maintenance chemotherapy administered via centrally placed implantable catheter port, who presented to the emergency room with fever, chills, and generalized body pain of one day's duration. After initial workup, the patient was admitted to the intensive care unit and managed for severe sepsis. The patient was found to have a new-onset 3/6 holosystolic murmur at the left lower sternal border. Furthermore, she developed an episode of supraventricular tachycardia that responded to adenosine. Transthoracic echocardiogram revealed severe tricuspid regurgitation but without valvular vegetation. Transesophageal echocardiogram further confirmed the absence of vegetation, in addition to visualizing the tip of the catheter tip in the right atrium and interfering with coaptation of the tricuspid valve. It was postulated that the severe tricuspid regurgitation and supraventricular tachycardia were caused by the catheter tip malposition. The catheter was subsequently removed. The patient's acute condition resolved and she was referred to cardiothoracic surgery for valvular surgery.

Acute Pericarditis: Descriptive Study and Etiology Determination in a Predominantly African American Population.

INTRODUCTION ---Acute pericarditis is the most commonly encountered manifestation of pericardial disease (incidence: 0.2 percent to 0.5 percent in hospitalized patients). However, data regarding manifestations, workup, and the management of acute pericarditis in the African American population is lacking. This study aims to collect and analyze more clinical data related to acute pericarditis in this understudied population. METHODOLOGY We conducted a retrospective chart review of all patients managed for acute pericarditis at a university hospital serving a predominantly African American population. A total of 78 charts were reviewed during the period of study from January 2011 to July 2016. Out of these, nine charts were excluded due to poor data. We descriptively analyzed data regarding presenting symptoms, underlying etiologies, co-morbidities, investigation results, management strategies, and prognoses. RESULTS We found an equal number of males and females in our study population. The most common comorbid conditions were hypertension, chronic kidney disease, and diabetes mellitus (in order of incidence). The most common presentation of symptomatic pericarditis consisted of chest pain, dyspnea, tachycardia, and tachypnea. Electrocardiogram (EKG) findings included diffuse ST elevation (15 percent) and sinus tachycardia (41 percent). Leukocytosis was seen in 15 percent of the patients. The most common etiology noted in our patient population was idiopathic and was treated with NSAIDS. CONCLUSION As compared to other populations, the incidence of uremic pericarditis and pericarditis secondary to cardiac etiologies is slightly higher in the African American population; however, the clinical presentation, examination and laboratory findings, as well as investigations, are remarkably similar.

Long-term stabilization of metastatic melanoma with sodium dichloroacetate.

Sodium dichloroacetate (DCA) has been studied as a metabolic cancer therapy since 2007, based on a publication from Bonnet et al demonstrating that DCA can induce apoptosis (programmed cell death) in human breast, lung and brain cancer cells. Classically, the response of cancer to a medical therapy in human research is measured by Response Evaluation Criterial for Solid Tumours definitions, which define "response" by the degree of tumour reduction, or tumour disappearance on imaging, however disease stabilization is also a beneficial clinical outcome. It has been shown that DCA can function as a cytostatic agent in vitro and in vivo, without causing apoptosis. A case of a 32-year-old male is presented in which DCA therapy, with no concurrent conventional therapy, resulted in regression and stabilization of recurrent metastatic melanoma for over 4 years' duration, with trivial side effects. This case demonstrates that DCA can be used to reduce disease volume and maintain long-term stability in patients with advanced melanoma.

Meningeal haemangiopericytoma and solitary fibrous tumour: a retrospective bi centre study for outcome and prognostic factor assessment.

To describe the outcome of patients diagnosed with central nervous system haemangiopericytoma (HPC) or solitary fibrous tumour (SFT) and identify factors that may influence recurrence and survival. Between January 2000 and September 2016, a retrospective search identified 55 HPCs/SFTs. The patients underwent a total of 101 surgical resections and 56.9% received radiation therapy. Median follow-up was 7.8 years. 28 patients (50.9%) were re-operated for tumour recurrence. At the end of the study, 21 patients (42%) had no residual tumour on the last scan. Surgical recurrence-free survival at 5 years was 75.2%, 95% CI [63.3-89.3] and, the median surgical recurrence-free survival was 7.4 years. In the adjusted analysis, venous sinus invasion (present vs. absent) (HR 3.39, 95% CI [1.16, 9.93], p = 0.026), completeness of resection (HR 0.38, 95% CI [0.15-0.97], p = 0.042) and tumour subtype (SFT vs. HPC) (HR 3.02, 95% CI[1.02, 8.91], p = 0.045) were established as independent prognostic factors. At the end of the study, 25 patients were deceased (45.5%). and only 15 patients (27.3%) had no residual tumour on the last scan and were alive. Overall survival at 5 years was 80.2, 95% CI [69.3-92.8] and the median overall survival was 13.1 years. None of the investigated variables was associated with overall survival. Patients who received radiation therapy demonstrated neither a reduced risk of surgical recurrence (p = 0.370) nor a longer overall survival (p = 1.000). SFTs/HPCs are associated with a significant risk of recurrence that may reduce the survival of the patients. Total tumour resection upon initial surgery is associated with a lower risk of relapse but not with a prolonged survival. We did not observe a significant improvement in any of the clinical outcomes after radiation therapy.

Intramuscular Local Anesthetic Infiltration at Closure for Postoperative Analgesia in Lumbar Spine Surgery: A Systematic Review and Meta-Analysis.

STUDY DESIGN: Systematic Review and Meta-Analysis OBJECTIVE.: To identify whether intramuscular local anesthetic infiltration prior to wound closure was effective in reducing postoperative pain and facilitating early discharge following lumbar spine surgery. SUMMARY OF BACKGROUND DATA: Local anesthetic infiltration prior to wound closure may form part of the multimodal strategy for postoperative analgesia, facilitating early mobilization and discharge. Although there are a number of small studies investigating its utility, a quantitative meta-analysis of the data has never been performed. METHODS: This review was conducted according the PRISMA statement and was registered with the PROSPERO database. Only randomized controlled trials were eligible for inclusion. Key outcomes of interest included time to first analgesic demand, total postoperative opiate usage in the first 24 hours, visual analogue score (VAS) at 1, 12 and 24 hours and postoperative length of stay. RESULTS: Eleven publications fulfilled the inclusion criteria. A total of 438 patients were include; 212 in the control group and 226 in the intervention group. Local anesthetic infiltration resulted in a prolonged time to first analgesic demand (mean difference (MD) 65.88 minutes, 95% confidence interval (95% CI) 23.70 to 108.06, P.0.002) as well as a significantly reduced postoperative opiate demand (M.D. -9.71 mg, 95% CI -15.07, -4.34, p = 0.0004). There was a small but statistically significant reduction in postoperative visual analogue score (VAS) at 1 hour (M.D. -0.87 95%CI -1.55, -0.20, p = 0.01), but no significant reduction at 12 or 24 hours (p = 0.93 and 0.85 respectively). CONCLUSION: This systematic review and meta-analysis provides evidence that postoperative intramuscular local anaesthetic infiltration reduces postoperative analgesic requirements and the time to first analgesic demands for patients undergoing lumbar spine surgery. Key research priorities include optimization of the choice and strength of local anaesthetic agent and health-economic analyses to strengthen the case for routine use of postoperative local anesthetics in lumbar spine surgery. LEVEL OF EVIDENCE: 1.

Transcriptomic analysis reveals differential activation of microglial genes after ischemic stroke in mice.

Microglia are immune cells in the brain and play a pivotal role in the progression of ischemic injury, but the gene expression and signaling pathways related to the activation of microglia following ischemia remain unclear. In our experiment, we used digital gene expression (DGE) analysis to profile the transcriptome of ischemic tissue in a photothrombosis model. DGE analysis identified that a total of 749 genes were differentially regulated (643 up-regulated and 106 down-regulated) after 2days and 7days following stroke. We found 74.5% of these differentially expressed genes were microglial genes. Gene ontology (GO) analysis categorizes these differentially expressed genes at 2days and 7days to specific biological processes such as inflammatory response, cell activation, cell proliferation, and chemokine and cytokine production. Our data demonstrated that a large number of microglial genes were highly regulated at 2days after stroke, but the number of differentially expressed genes had reduced drastically by 7days. Importantly, some of the differentially expressed microglial genes at 7days did not show differential expression at 2days after stroke. DGE analysis indicated that specific genes related to microgliosis were regulated after ischemia. Consistent with the changes in transcriptome, the results from histological analysis of transgenic mice revealed that the microglia proliferated and aggregated surrounding the ischemic core during the period from 2days to 7days following photothrombosis. Together, these results suggested that transcriptomic changes in microglial genes after stroke may have a profound implication for pathophysiology and treatment of stroke.