The Relationship Between Serum Angiotensin Converting Enzyme Level and the Decision to Escalate Treatment of Sarcoidosis.

PURPOSE: We performed a retrospective analysis of a sarcoidosis cohort who had sACE obtained at their initial clinic visit, but the treating physician was blinded to the results. We examined the relationship between sACE and the treating physician's decision to escalate sarcoidosis treatment. METHODS: Treatment was considered escalated if the prednisone dose was increased or if the prednisone dose was not changed but an additional anti-sarcoidosis drug was added or the dose was increased. RESULTS: 561 sarcoidosis patients were analyzed. The most common target organ was the lung (84%). Using a cut-off of > 82 units/L for an elevated sACE, 31/82 (38%) with an elevated sACE had treatment escalation whereas 91/497 (18%) had treatment escalation with a normal sACE (p < 0.0001). For the need of treatment escalation, a sACE (cut-off of > 82) had sensitivity 0.25, specificity 0.89, positive predictive value 0.38, negative predictive value 0.81. These results were not appreciably different using other sACE cut-off values such as 70, 80, 90, or 100. A multivariable logistic regression model that included demographics, the target organ, spirometry results estimated that sACE level and lower FVC were significantly associated with the likelihood of treatment escalation. These findings held when sACE > 82 replaced sACE level in the multivariable logistic regression model. CONCLUSIONS: Although there was a strong correlation between sACE at the initial sarcoidosis clinic visit and subsequent treatment escalation of sarcoidosis, the predictive power was such that sACE is not adequately reliable to be used in isolation to make this determination.

A 61-Year-Old Man With Shortness of Breath and Eye Swelling.

CASE PRESENTATION: A 61-year-old man presented to the pulmonary clinic with symptoms of dyspnea and productive cough for the last 6 months. Within the last 2 months, he started noticing bulging of his eyes associated with blurry vision. He denied hemoptysis, fever, night sweats, weight loss, skin rash, and dry eyes or mouth. He is a former smoker, and he denied any recent travel history. The patient has a history of microscopic polyangiitis, which was treated with cyclophosphamide and mycophenolate maintenance therapy and has been in remission for the last 7 years.

Cardiac device-induced right to left shunt causing significant hypoxemia: A case report and review of literature.

We describe a patient where a pacemaker lead induced tricuspid valve changes that caused a right to left shunt through a preexisting patent foramen ovale resulting in significant hypoxemia. This event occurred years after the pacemaker had been placed. Surgical closure of the patent foramen ovale resolved the patient's hypoxemia and dyspnea. We also reviewed the previous cases published in the medical literature concerning significant hypoxemia from cardiac device-induced right to left shunts. Three of the four reported cased occurred 4 or more years after device placement. Therefore, late onset hypoxemia in setting of cardiac device placement without an alternative cause should raise the possibility of this complication.

A 26-year old young male with severe anemia.

Testicular choriocarcinoma is a subset of Non-Seminomatous Germ Cell Tumors (NSGT) which is considered the rarest and most aggressive testicular cancer. It primarily affects males between the ages of 25-30 years. Unlike other testicular neoplasms that carry a cure rate of 95%, choriocarcinoma has significantly lower rate of cure. Therefore, early detection and prompt treatment is necessary to improve survival. We present an unusual case of Choriocarcinoma presenting as severe anemia along with distant metastases to lung and brain. We also discuss diagnostic approach and treatment challenges in patients with Choriocarcinoma.

Prevalence of Post-Traumatic Stress Disorder Due to Community Violence Among University Students in the World's Most Dangerous Megacity: A Cross-Sectional Study From Pakistan.

Community violence among the youth can lead to a number of adverse psychiatric outcomes including post-traumatic stress disorder (PTSD). However, little research has been conducted in non-Western countries to assess this problem. This study aims to fill the void by assessing the lifetime exposure to traumatic events and burden of probable PTSD among university students in Karachi, Pakistan. A cross-sectional study was conducted at four private institutions in Karachi. Self-administered questionnaires were filled out by 320 students. Lifetime exposure and symptoms of PTSD were assessed using modified Composite International Diagnostic Interview (CIDI) and Post-Traumatic Stress Disorder Checklist-Civilian Version (PCL-C) questionnaires, respectively. A PCL-C score of 44 or above was used as cutoff for probable PTSD. Pearson chi-square test was used to assess the association between PTSD and different variables at a level of significance of 5%. Ninety-three percent of the respondents reported having lifetime exposure to at least one traumatic event with sudden unexpected death of a loved one (n = 187) and assaultive violence (n = 169) being the commonest reported traumatic events. Positive association for PTSD was seen with enduring physical attacks and motor vehicle accidents. Over a quarter of the students screened positive for probable PTSD, among them almost one third were male and 17% were female. Our results indicate a high exposure to violent events and elevated rates of lifetime PTSD among urban youth. Reduction in violence and better access to mental health facilities is warranted to decrease the health burden of PTSD in Pakistan.

Trends in coronary artery bypass surgery: impact on early outcomes.

BACKGROUND: improvements in nonsurgical revascularization have left a group of higher-risk patients presenting for operation in a later stage of coronary artery disease. We undertook this study to analyze temporal changes in demographic and clinical profiles and outcomes of cardiac surgical patients. METHODS: we identified and retrieved preoperative, intraoperative, and postoperative variables for 3064 consecutive patients who underwent myocardial revascularization at the Aga Khan University Hospital between 2006 and 2011. Mortality and morbidity outcomes were compared using univariate and multivariate analyses. RESULTS: mean age, prevalence of left ventricular systolic dysfunction, unstable angina, mean number of occluded vessels, and arrhythmias at presentation increased steadily over time. The prevalence of diabetes, chronic lung disease, peripheral vascular disease, prior stroke, prior myocardial infarction, and left main disease declined. Operative mortality did not change significantly (3.5% vs. 3.8%, p = 0.512). Determinants of operative mortality included older age, female sex, renal insufficiency, left ventricular systolic dysfunction, and longer bypass and crossclamp times. CONCLUSION: coronary operations are increasingly performed in higher-risk patients with greater comorbidities. Despite this, operative mortality has not increased.

Mortality from isolated coronary bypass surgery: a comparison of the Society of Thoracic Surgeons and the EuroSCORE risk prediction algorithms.

We compared the performances of the additive European System for Cardiac Operative Risk Evaluation, EuroSCORE (AES) and logistic EuroSCORE (LES) with the Society of Thoracic Surgeons' risk prediction algorithm in terms of discrimination and calibration in predicting mortality in patients undergoing isolated coronary artery bypass grafting (CABG) at a single institution in Pakistan. Both models were applied to 380 patients, operated upon at the Aga Khan University Hospital from August 2009 to July 2010. The actual mortality was 2.89%. The mean AES of all patients was 4.36 ± 3.58%, the mean LES was 5.96 ± 9.18% and the mean Society of Thoracic Surgeons' (STS) score was 2.30 ± 4.16%. The Hosmer-Lemeshow goodness-of-fit test gave a P-value of 0.801 for AES, 0.699 for LES and 0.981 for STS. The area under the receiver operating characteristic curve was 0.866 for AES, 0.842 for LES and 0.899 for STS. STS outperformed AES and LES both in terms of calibration and discrimination. STS, however, underestimated mortality in the top 20% of patients having an STS score >2.88, thus overall STS estimates were lower than actual mortality. We conclude that STS is a more accurate model for risk assessment as compared to additive and logistic EuroSCORE models in the Pakistani population.

Isolated adult hypoganglionosis presenting as sigmoid volvulus: a case report.

INTRODUCTION: Isolated hypoganglionosis is a rare cause of intestinal innervation defects. It is characterized by sparse and small myenteric ganglia, absent or low acetylcholinesterase activity in the lamina propria and hypertrophy of the muscularis mucosae, principally in the region of the colon and rectum. It accounts for 5% of all intestinal neuronal malformations. To the best of our knowledge, only 92 cases of isolated hypoganglionosis were reported from 1978 to 2009. Isolated hypoganglionosis usually manifests as enterocolitis or poor bowel function, and is diagnosed in infancy or childhood. We report the first case of isolated hypoganglionosis presenting with sigmoid volvulus in a 34-year-old woman. CASE PRESENTATION: A 34-year-old Asian woman had progressively increasing abdominal pain and had not passed stool or flatus for two days. A physical examination revealed a distended abdomen with sluggish gut sounds. A computerized tomography (CT) scan demonstrated gross dilatation of the sigmoid colon (maximal diameter 14.3 cm) suggestive of sigmoid volvulus. During emergency laparotomy, sigmoidectomy with a side-to-side colorectal anastomosis was performed. Histopathology of the resected specimen showed occasional ganglion cells and hypertrophied nerve bundles in the muscle layers, suggesting hypoganglionosis. Colonoscopy was performed, and multiple full-thickness biopsies were taken that showed hypoganglionosis of the entire large bowel. Our patient underwent total colectomy with an ileorectal anastomosis. Subsequently our patient reported a dramatic improvement in her bowel function. CONCLUSIONS: Isolated hypoganglionosis is a rare cause of intestinal dysganglionosis and cannot be differentiated from Hirschsprung's disease based on clinical presentation. This case report describes an atypical presentation of the disease. A definitive diagnosis requires histopathological analysis of full-thickness intestinal biopsies. Treatment should be tailored to the extent of hypoganglionosis.