Hepatic Hydrothorax Without Ascites: A Diagnostic And Management Challenge.

Hepatic hydrothorax refers to the presence of a pleural effusion (usually >500 mL) in a patient with cirrhosis who does not have other reasons to have a pleural effusion (e.g., cardiac, pulmonary, or pleural disease). Hepatic hydrothorax occurs in approximately 5-6% of patients with cirrhosis. It results from the ascitic fluid draining into the pleural cavity through the diaphragmatic defects. The presentation of patients with hepatic hydrothorax includes chest pain, hypoxemia, cough, shortness of breath and fatigue. The atypical feature, in this case, is the presence of hepatic hydrothorax in a patient with chronic liver disease without ascites. The management of hepatic hydrothorax is difficult. The initial treatment should be a low-salt diet plus diuretics. The best diuretic regimen is probably the combination of furosemide and spironolactone. However, about 25% of patients are refractory to this regimen, and additional therapy is indicated. This patient underwent thoracentesis, however, considering the re-accumulation of fluid, a pigtail catheter was placed which drained up to 8 liters of fluid.

Frequency of Subclinical Hypothyroidism in Women With Polycystic Ovary Syndrome.

INTRODUCTION: Polycystic ovary syndrome (PCOS) is a heterogeneous disorder characterized by hyperandrogenism and chronic anovulation. It may also influence thyroid hormones. Increasing evidence suggests that PCOS is linked with an increased prevalence of thyroid diseases such as nodular goiter, autoimmune thyroiditis, and subclinical hypothyroidism (SCH). Due to very limited global and regional data related to the prevalence of SCH in women with PCOS, we will determine the association between the two. METHODS: This case-control study was conducted in the endocrinology ward of a tertiary care hospital in Pakistan from March 2020 to April 2021. We enrolled 200 females between the ages of 18 and 30 years, with documented evidence of PCOS in the study. Further 200 females without PCOS were enrolled as the case group. After demographics were noted, blood was drawn from their cubital vein via phlebotomy and sent to the laboratory to assess for thyroid-stimulating hormone, free thyroxine, and free triiodothyronine. RESULTS: SCH was found to be more prevalent in participant with PCOS compared to participants without PCOS (43.5% vs. 20.5%; p-value: <0.00001). Increased weight (65.12 ± 5.62 kg vs. 60.02 ± 4.41 kg; p-value: <0.0001) and BMI (25.12 ± 2.51 kg/m2 vs. 22.51 ± 2.01 kg/m2; p-value: <0.0001) was significantly more in participants with PCOS compared to participants without PCOS. CONCLUSION: Based on our findings, this study demonstrated the strong association of SCH in women with PCOS as compared to their normal counterparts. Therefore, the clinical implication is to maintain a high index of suspicion for signs and symptoms of SCH, and awareness is needed for such women to enhance the reproductive and clinical pregnancy outcomes.

Impact of Coronavirus Diseases on Liver Enzymes.

Introduction Coronavirus disease 2019 (COVID-19) affects various organs including lungs, brain, and eyes. Very limited data is available related to the effect of COVID-19 on liver. This study is conducted to determine the impact of COVID-10 on liver by measuring the frequency of participants with deranged liver enzymes in patients diagnosed with COVID-19. Methods This cross-sectional study was conducted in a COVID-19 unit of a tertiary care hospital in Pakistan from February 2021 to June 2021. A total of 900 patients admitted with COVID-19 were enrolled in the study after seeking informed consent. After enrollment, taking history and vitals, 5 mL blood was drawn via phlebotomy and sent to the laboratory to test for C-reactive protein, lactate dehydrogenase, and liver enzymes. Results Overall 141 (28.2%) participants had a minimum of one deranged liver enzyme. The most commonly deranged liver enzyme found was alanine transaminase (ALT), both in males (19.9%) and females (21.3%), followed by aspartate transaminase (male: 18.3% and female: 20.3%). Serum total bilirubin was deranged in both males (8.4%) and females (8.3%). There was no significant difference in the gender-wise prevalence of deranged liver enzymes.  Conclusion Liver enzymes are frequently deranged in patients admitted with COVID-19. Liver enzymes should be regularly monitored during the course of management of COVID-19, as various medications used in the treatment of COVID-19 may further deteriorate liver enzymes and may cause long-term damage.

Comparison of Lipid Profile in Patients With and Without Subclinical Hypothyroidism.

INTRODUCTION: Thyroid hormone affects lipid metabolism. Various studies have shown a contradictory relationship between lipid profile (LP) and subclinical hypothyroidism (SCH). Currently, there is a scarcity of regional data on the relationship between LP and SCH. METHODS: This longitudinal study was conducted in the internal medicine and cardiology units of a tertiary care hospital in Pakistan from September 2019 to March 2021. A total of 900 participants, of either gender and between the ages of 40 to 70 years, were enrolled in the study. Blood samples were sent to the laboratory to determine lipid and thyroid parameters. Participants were divided into two groups based on the presence of SCH. RESULTS: In our study, 179 (19.8%) participants had SCH. Total cholesterol (TC) and low-density lipoprotein (LDL) was significantly higher in participants with SCH compared to participants without SCH (228.41 ± 35.21 mg/dL vs. 171.21 ± 30.21 mg/dL; p-value: <0.00001) and (131.65 ± 28.22 mg/dL vs. 89.26 ± 18.52 mg/dL; p-value: <0.0001), respectively. CONCLUSION: In conclusion, this study found an increased incidence of dyslipidemias in patients with SCH. It is associated with elevated TC and LDL levels, which are risk factors for cardiovascular disease and mortality.

Dermatological Manifestations of Parkinson's Disease: Clues for Diagnosis.

Background and objective Parkinson's disease (PD) is a common neurodegenerative disorder. There are various manifestations of PD. Among them, motor dysfunction has been studied in many research studies; however, few studies are available related to the dermatological manifestations of PD. This study was conducted with the aim to shed light on various skin conditions that occur in PD. Methods This cross-sectional study was conducted at a tertiary care hospital in Pakistan for a period of nine months; 107 patients with PD were included after obtaining informed consent. A self-administrated questionnaire was used to record demographic data and dermatological findings. Results Among the various dermatological manifestations, patients with PD most commonly presented with seborrheic dermatitis (46.7%) and rosacea (10.2%). Other manifestations included bullous pemphigoid (7.4%) and melanoma (4.6%). Conclusion The study revealed several dermatological manifestations of PD, which usually get overlooked by neurologists. Through this study, we want to emphasize that PD, apart from all the motor signs and symptoms, can also present as skin problems, and hence, a multi-disciplinary approach should be taken while managing PD.

Diabetic Ketoacidosis: Clinical Characteristics and Precipitating Factors.

INTRODUCTION: Diabetic ketoacidosis (DKA) is a complication of hyperglycemia. Through this study we plan to study the clinical features of DKA and precipitating factors responsible for DKA in type 1 and type 2 diabetes. METHODS: This cross-sectional observational study was conducted in the emergency department of a tertiary care hospital in Sukkur, Pakistan from August 2019 to February 2020. Symptoms and precipitating factors were noted in a self-structured questionnaire. RESULTS: Out of 71 patients, 19 (26.7%) patients had type 1 diabetes mellitus and 52 (73.3%) patients had type 2 diabetes mellitus. The most common clinical symptom was nausea and vomiting (57.7%), followed by pain in abdomen (42.2%) and dehydration (42.2%). We found that the most common precipitating factors were infections (69.0%) and non-compliance to treatment (53.5%). Among various infections, people commonly presented with pneumonia (38.7%) and urinary tract infection (30.6%). CONCLUSION: Diabetic ketoacidosis presents with vague symptoms such as nausea, vomiting, and pain in abdomen. Characteristic findings of DKA such as Kussmaul breathing was present in limited patients. Infections in diabetic patients should be carefully monitored as they are the most common precipitating factors for DKA.

The Risk Factors for the Wearing-Off Phenomenon in Parkinson's Disease.

INTRODUCTION: First-line treatment of Parkinson's disease (PD) includes a dopamine analog, levodopa, administered in combination with carbidopa to increase efficacy. Wearing-off (WO) phenomenon is a frequent complication which is defined as a reoccurrence of motor and non-motor symptoms during levodopa free interval, which has a negative impact on the quality of life of patients. Through this study, we aim to determine risk factors that lead to the manifestation of the WO phenomenon among patients presenting in our out-patient department of a tertiary care hospital in Pakistan. METHOD: A observational case-control study was conducted from April 2019 to December 2019 in a tertiary care hospital in Pakistan. A total of 101 patients who had PD were included in the study. They were randomized into two groups i.e. patients who had WO phenomenon (59 participants) and patients who did not experience WO (42 participants) phenomena. Patients were evaluated based on a self-administrated questionnaire. A p-value of less than 0.05 was considered significant. RESULT: WO was significantly higher in those patients who had earlier onset of Parkinson (59 ± 10 vs. 65 ±8; p<0.002) and had the disease for a longer duration (7.9±5.1 vs. 5.6±3.1, p<0.002). Other findings included, there was more risk of WO in patients on anti-parkinsonian treatment for longer duration (7.2±5.1 vs. 3.9±3.5, p<0.010) and on longer duration on levodopa treatment (6.9±4.9 vs. 3.1±2.8, p<0.0001). CONCLUSION: Our study demonstrated several factors which are responsible for the WO phenomenon. This will aid neurologists to consider these risk factors while prescribing different treatment modalities for the disease to improve efficacy and mitigate WO effect among patients, specifically while advising levodopa.

Impact of COVID-19 on the Mental Health of Healthcare Professionals in Pakistan.

Introduction As a result of the ongoing COVID-19 pandemic, health care professionals (HDPs) are facing immense strain due to the heavy load of cases. In many cases, they work increasingly long hours, often with limited resources and a dubious infrastructure. Thus, it is important to check on the mental health of caregivers. Methods and materials This cross-sectional study was conducted in May 2020, at various hospitals in Karachi, Pakistan. All HCPs posted in the COVID-19 isolation wards were invited to participate and a total of 112 completed this study. A carefully structured form was created, which included the Depression Anxiety Stress Scale-21 (DASS-21). Results The overall mean score of anxiety was 19.01 ± 9.2, depression was 18.12 ± 10, and stress was 20.12 ± 12.0. There were 81 (72.3%) participants who suffered from moderate to extremely severe depression, 96 ( 85.7%) participants who suffered from moderate to extremely severe anxiety, and 101 (90.1%) participants who reported moderate to extreme stress levels Conclusions It is evident that there are a high number of healthcare workers affected by various psychological ailments such as anxiety, stress, and depression. It is important that the government take steps to ensure that HCPs' mental health is regularly checked and that efforts are made to reduce their burdens.

Comparison of the Efficacy of Duloxetine and Pregabalin in Pain Relief Associated with Diabetic Neuropathy.

Introduction Painful diabetic peripheral neuropathy (PDPN) complicates 25% of type II diabetes mellitus. It has a profound impact on diabetes-related morbidity and worsens the quality of life. Both pregabalin and duloxetine may be indicated for PDPN. In this study, the efficacy of duloxetine and pregabalin was compared in patients with PDPN. Methods It was a single-centre open-label study conducted with patients of diabetes mellitus type II diagnosed with PDPN. Patients were randomized to receive 60 mg/daily duloxetine or 300 mg/daily pregabalin. Pain scores were recorded using visual analogue scale (VAS) on day 0, week 4, and week 12. Data was entered and analysed using SPSS version 22.0 (IBM Corp., Armonk, NY). Results In the duloxetine group, the mean VAS score decreased from 6.81 ± 0.91 to 4.01 ± 1.12 with 12 weeks of therapy (p <0.0001). In the pregabalin group, the mean VAS score decreased from 6.99 ± 1.12 to 4.91 ± 0.82 with 12 weeks of therapy (p <0.0001). At 12 weeks, duloxetine showed lower VAS scores than pregabalin (p <0.0001). In the duloxetine group, the mean change in VAS score over time was - 2.80 and in the pregabalin group, the mean change was - 2.80. Adverse events were reported in 17.9% of the participants. Lethargy/somnolence (8.1%) and peripheral edema (3.4%) were commonly reported in the pregabalin group and constipation (6.9%) and orthostatic hypotension (4.6%) were commonly reported in the duloxetine group. Conclusions Duloxetine at a daily fixed dose of 60 mg is efficacious in the relief of neuropathic pain. Pregabalin also showed a comparable outcome. Both duloxetine and pregabalin have a promising safety profile and are well-tolerated.

Hybrid Imaging in Oncology.

In oncology various imaging modalities play a crucial role in diagnosis, staging, restaging, treatment monitoring and follow up of various cancers. Stand-alone morphological imaging like computerized tomography (CT) and magnetic resonance imaging (MRI) provide a high magnitude of anatomical details about the tumor but are relatively dumb about tumor physiology. Stand-alone functional imaging like positron emission tomography (PET) and single photon emission tomography (SPECT) are rich in functional information but provide little insight into tumor morphology. Introduction of first hybrid modality PET/CT is the one of the most successful stories of current century which has revolutionized patient care in oncology due to its high diagnostic accuracy. Spurred on by this success, more hybrid imaging modalities like SPECT/CT and PET/MR were introduced. It is the time to explore the potential applications of the existing hybrid modalities, developing and implementing standardized imaging protocols and train users in nuclear medicine and radiology. In this review we discuss three existing hybrid modalities with emphasis on their technical aspects and clinical applications in oncology.