Acute inferior ST-elevation myocardial infarction mimicked by direct lightning strike: a case report.

Background: Direct lightning strikes are rare, and multiple organ systems can be involved. Prognosis is dependent on the severity of the injury. Severe myocardial injury associated with transient electrocardiogram changes, which have been previously described, is a hazardous complication. Case summary: A 35-year-old man with no known past medical history presented unresponsive following a direct lightning strike while sitting in a portable toilet. High-quality cardiopulmonary resuscitation was started in the field, with return of spontaneous circulation (ROSC) after 1 h. Following ROSC, he received volume resuscitation and was maintained on multiple vasopressors. Electrocardiogram showed significant ST-elevations in inferior leads with elevated troponin I, consistent with inferior ST-elevation myocardial infarction. Labs revealed lactic acidosis, hyperkalaemia, acute kidney, and liver injury. Due to concern for plaque rupture, coronary angiography was performed and revealed no obstructive coronary artery disease. Vasopressor support and volume resuscitation were continued for extensive burns covering greater than 30% body surface area. The patient became progressively hypotensive, eventually precipitating pulseless electrical activity arrest. Emergent labs were notable for severe acidaemia. Despite aggressive interventions, he expired due to severe multi-organ failure. Discussion: Direct lightning injuries are rare with serious potential complications. Myocardial damage, either from direct electrical insult or from induced coronary vasospasm, can lead to multi-organ system failure.

Pancoast Tumor With Cardiac Metastases and Intracardiac Thrombosis.

Pancoast tumor is a rare and aggressive form of lung cancer; cardiac metastasis is very uncommon. We present a case of advanced Pancoast tumor, with extensive cardiac metastases and intracardiac thrombosis in a woman presenting with dyspnea, shoulder pain, and weight loss. A contrast-enhanced chest computed tomographic scan revealed an apical mass, metastatic thoracic nodes, and filling defects within both ventricles. Further imaging with cardiac magnetic resonance imaging revealed 2 left ventricular masses infiltrating into the myocardium suggestive of metastatic disease, and a multilobulated mass within the right ventricle suggestive of intracardiac thrombus. She was initiated on anticoagulation for intracardiac thrombosis. Surgical pathology of biopsied tissue samples was consistent with advanced metastatic lung adenocarcinoma. She was a poor candidate for surgical intervention. Given the patient's goals of care, she was ultimately transitioned to comfort care.

Multi-modality management of hypertrophic cardiomyopathy.

Hypertrophic cardiomyopathy (HCM) is an autosomal dominant inherited condition defined by left ventricular wall thickness greater than 15 mm in the absence of other conditions that could explain that degree of hypertrophy. Obstructive HCM associated with left ventricular outflow tract obstruction is defined by an intraventricular systolic pressure gradient greater than or equal to 30 mm Hg. Over the past couple of decades, there has been an expansion of both invasive and pharmacotherapeutic options for patients with HCM, with recent guidelines calling for a melody of invasive and non-invasive treatment strategies. There are several invasive therapies including proven therapies such as alcohol septal ablation and septal myectomy. Novel invasive therapies such as MitraClip, radiofrequency septal ablation and SESAME procedure have more recently been promoted. Pharmacological therapy has also dramatically evolved and includes conventional medications such as beta-blockers, calcium channel blockers, and disopyramide. Mavacamten, a novel cardiac myosin inhibitor, may significantly change management. Other myosin inhibitors and modulators are also being developed and tested in large clinical trials. Given significant phenotypical variability in patients with HCM, clinical management can be challenging, and often requires an individualized approach with a combination of invasive and non-invasive options.

Spontaneous splenic rupture from indeterminate dendritic cell proliferation: a case report.

Spontaneous splenic rupture is a rare and life-threatening phenomenon, usually associated with an underlying infectious, inflammatory, hematological, neoplastic or rheumatologic condition. Indeterminate cell tumor is a rare neoplastic dendritic cell disorder that is poorly understood but shares immunophenotypic markers for Langerhans cells without Birbeck granules. A 73-year-old man presented with upper abdominal pain after an unwitnessed fall. Computed tomography angiography showed splenomegaly and a large ruptured splenic subcapsular hematoma. Intraoperative findings from an emergency laparotomy revealed a large hemoperitoneum and a ruptured spleen. Microscopic sections identified numerous, mostly poorly formed, small nodules classified as a proliferation of indeterminate dendritic cell tumors.

Re-annotation of the Theileria parva genome refines 53% of the proteome and uncovers essential components of N-glycosylation, a conserved pathway in many organisms.

BACKGROUND: The apicomplexan parasite Theileria parva causes a livestock disease called East coast fever (ECF), with millions of animals at risk in sub-Saharan East and Southern Africa, the geographic distribution of T. parva. Over a million bovines die each year of ECF, with a tremendous economic burden to pastoralists in endemic countries. Comprehensive, accurate parasite genome annotation can facilitate the discovery of novel chemotherapeutic targets for disease treatment, as well as elucidate the biology of the parasite. However, genome annotation remains a significant challenge because of limitations in the quality and quantity of the data being used to inform the location and function of protein-coding genes and, when RNA data are used, the underlying biological complexity of the processes involved in gene expression. Here, we apply our recently published RNAseq dataset derived from the schizont life-cycle stage of T. parva to update structural and functional gene annotations across the entire nuclear genome. RESULTS: The re-annotation effort lead to evidence-supported updates in over half of all protein-coding sequence (CDS) predictions, including exon changes, gene merges and gene splitting, an increase in average CDS length of approximately 50 base pairs, and the identification of 128 new genes. Among the new genes identified were those involved in N-glycosylation, a process previously thought not to exist in this organism and a potentially new chemotherapeutic target pathway for treating ECF. Alternatively-spliced genes were identified, and antisense and multi-gene family transcription were extensively characterized. CONCLUSIONS: The process of re-annotation led to novel insights into the organization and expression profiles of protein-coding sequences in this parasite, and uncovered a minimal N-glycosylation pathway that changes our current understanding of the evolution of this post-translational modification in apicomplexan parasites.

Quantitative Ethnobotany of Medicinal Plants Used by Indigenous Communities in the Bandarban District of Bangladesh.

This study documents information on significant ethnomedicinal plants, which was collected from the traditional healers of three indigenous communities of Bangladesh. The documented data were quantitatively analyzed for the first time in this area. The information was obtained through open-ended, semi-structured questionnaires. The benefits, importance and coverage of ethnomedicine were expressed through several quantitative indices including Informant Consensus Factor (ICF), Use Value (UV), Frequency of Citation (FC), Relative Frequency of Citation (RFC) and Relative Importance Index (RI). The agreement of homogeneity between the present and previous studies and among the indigenous communities was evaluated using the Jaccard Index (JI). A total of 159 ethnomedicinal plant species, which were distributed in 132 genera under 62 families, were documented from 174 informants. Of these, 128 plants were native and 31 were exotic. Of a majority of documented species, herbs and leaves were the most utilized plant parts for the preparation of ethnomedicines (45.28%) whereas pastes (63.03%) were the most popular formulations. Among the documented species, the dominant families were the Asteraceae (14 species) and the Lamiaceae (12 species). The highest ICF value was 0.77 for digestive system disorders. Based on UVs, the five most commonly used ethnomedicinal plant species in the study area were Duabanga grandiflora (0.43), Zingiber officinale (0.41), Congea tomentosa (0.40), Matricaria chamomilla (0.33) and Engelhardtia spicata (0.28). The highest RFC was recorded for Rauvolfia serpentina (0.25). The highest RI value was calculated for both Scoparia dulcis and Leucas aspera (0.83). Importantly, 16 species were reported with new therapeutic uses and to our knowledge, 7 species described herein have never been ethnobotanically and pharmacologically studied, viz: Agastache urticifolia, Asarum cordifolium, C. tomentosa, E. spicata, Hypserpa nitida, Merremia vitifolia and Smilax odoratissima. The present study showed that traditional treatment using medicinal plants is still widespread in the study area. Documentation of new ethnomedicinal species with their therapeutic uses shall promote further phytochemical and pharmacological investigations and possibly, lead to the development of new drugs.

Primary oral health care: a missing link in public health in Pakistan.

In Pakistan, the limited availability of oral health care and the high level of unmet oral health care needs are well documented. The recorded prevalence of dental caries is 50-70% and that of oral cancer is among the highest in the world. Although oral health care has been declared to be part of the primary health care system, oral health disparities between rich and poor, and emerging problems of access to and use of appropriate care have never been addressed, reflecting a lack of awareness among both patients and health system decisionmakers. Oral cancer screening and atraumatic restorative treatment for tooth decay could be included in a basic package of oral care that does not require qualified dental surgeons. This article develops an argument, based on literature review and an analysis of the health system in Pakistan, for how a basic oral health programme could be an accessible, affordable and acceptable component of the primary health care system.

Knowledge about hepatitis B vaccination among women of childbearing age: a cross-sectional study from a rural district of Punjab, Pakistan.

Pakistan is considered as an intermediate zone of hepatitis B virus (HBV) infection, with an estimated population prevalence of 2-7%. This study assessed knowledge about HBV and vaccination among women of childbearing age in a rural setting of Punjab province, Pakistan. In 2012 a cross-sectional, community-based survey of 430 women was conducted using a semi-structured questionnaire. Less than half of the women (43%) surveyed had correct knowledge about HBV vaccination, and knowledge was especially poor among the low socioeconomic groups. Age, level of education and obstetric history of the respondents were significantly associated with knowledge about HBV and its vaccination. The main sources of information regarding HBV vaccination were lady health workers (53%) and traditional birth attendants (22%). Health promotion and behaviour change campaigns highlighting the importance of hepatitis B vaccine need to be designed to meet the needs of rural areas where women have little exposure to the mass media.

Effect of Nigella sativa supplementation to exercise training in a novel model of physiological cardiac hypertrophy.

Exercise training is employed as supplementary therapy to patients with heart failure due to its multiple beneficial cardiac effects including physiological remodeling of the heart. However, precautions might be taken for the concomitant high oxidant release. Nigella sativa (NS) has been found to induce cardiac hypertrophy and enhance cardiac function. Combination of NS supplementation and exercise training might induce a safer model of cardiac hypertrophy. Our aim was to study biomarkers associated with cardiac hypertrophy induced by NS supplementation of exercise-trained rats. Forty-five adult male Wistar rats (body weight 150-220 g) were divided equally into three groups: control, exercise-trained (ET) and NS-treated-exercise-trained (NSET) groups. Daily 800 mg/kg NS was administered orally to NSET group for 8 weeks. Rats of the ET and NSET groups were subjected to treadmill running sessions for 2 h/day for 8 weeks. By the end of the experiment, the following were recorded: body, heart and left ventricular weights (BW, HW, LVW), cardiomyocyte diameter, serum growth hormone, insulin growth factor-I (IGF-I), thyroid hormones, catecholamines, total nitrate, ICAM and antioxidant capacity. A homogenous cardiac hypertrophy was evidenced by increased HW/BW, LVW/BW ratios and cardiomyocyte diameter in the two groups of exercise-trained compared with control rats. Rats of ET group had higher growth hormone. Those of NSET group developed higher IGF-I and total antioxidant capacity, as well as lower serum thyroxin level. Simultaneous NS supplementation to an exercise training program preserves and augments exercise-induced physiological cardiac hypertrophy with step-forward adaptive signs of increased IGF-I and reduced thyroxin level, and with an added advantage of elevation of total serum antioxidant capacity. Thus, the novel model of NSET-induced cardiac hypertrophy might be introduced as a new therapeutic strategy for the treatment of heart failure with superior advantages to exercise training alone.

Political and economic unfairness in health system of Pakistan: a hope with the recent reforms.

BACKGROUND: For the last few years, Pakistan's health system has faced numerous challenges pertaining to human resource and its deployment, resource allocation among the different tiers of the health care system, infrastructure development and unfair access to care. The enactment of the recent constitutional amendment has made the health system's situation even more uncertain than before. METHODS: A detailed literature review was carried out to understand fairness an responsiveness in health systems. The findings of the review were then compiled particularly in the wake of recent constitutional amendment defining heaIth sector reforms in Pakistan. RESULTS: Various levels, features and components of health system of Pakistan were looked into in view of understanding the extent of 'fairness', 'responsiveness' and adequacy'. Healthcare financing; geographic distribution of health care facilities; human resources in health; access to health services and essential medicines: the allocations to urban and rural segments; and finally understanding the health positioning in national agenda and priorities were examined for this purpose. CONCLUSIONS: In the post-devolution scenario, provinces muLst think systematically how to deal with the capacity issues to manage different components of health care system. Nonetheless, as a country, collective actions would be required to avoid any pitfalls, while approaching Millennium Developmenit Goals by 2015.

Residue depletion of albendazole and its metabolites in aquacultured yellow perch (Perca flavescens).

Metabolism and residue depletion studies are conducted to determine the marker residue (MR) of a drug in a target tissue of food animals. The MR is used to monitor potential unauthorized use of drugs. The current work is a continuation of our efforts to study metabolism and depletion profiles of albendazole in multiple finfish species to determine a common MR. The results of this study suggest that albendazole sulfone metabolite could potentially serve as MR for albendazole in yellow perch muscle, similar to channel catfish and hybrid striped bass as reported previously by us.

The state of affairs at primary health care facilities in Pakistan: where is the state's stewardship?

Primary health care (PHC) services in Pakistan, particularly in rural areas, are in a dismal state. Inadequacies, unfairness and ignorance about the importance of the basic health care provided by these facilitates have led to a disorganized and poorly performing system. This paper reviews the situation in certain PHC facilities in Sindh province. Inadequate medicines and supplies, underutilized family planning services, lack of human resources, faulty equipment, and absence of a proper referral mechanism were some of the key findings. There is therefore an urgent need for radical improvement in the PHC system in order to maximize the appropriate use of PHC facilities. In order to do this, the paper argues that the stewardship role of the State must be strengthened.

In vitro kinetics of hepatic albendazole sulfoxidation in channel catfish (Ictalurus punctatus), tilapia (Oreochromis sp.), rainbow trout (Oncorhynchus mykiss) and induction of EROD activity in ABZ-dosed channel catfish.

Liver microsomes from market-size (n = 6) rainbow trout, channel catfish and tilapia were used to investigate in vitro biotransformation kinetics of albendazole (ABZ). ABZ was transformed to a single metabolite, ABZ sulfoxide (ABZ-SO). Catfish displayed the highest maximal velocity (V(max) = 264.0 +/- 58.6 pmols ABZ-SO/min/mg protein) followed by tilapia (112.3 +/- 8.2) and rainbow trout (73.3 +/- 10.3). V(max) in catfish was significantly different (P < 0.05) from the other two species. Michaelis-Menten constant (K(m)) values (microm) varied significantly among the species: rainbow trout (3.9 +/- 0.5), tilapia (9.2 +/- 1.7) and catfish (22.0 +/- 3.2). However, V(max)/K(m) ratios showed no difference among the three species, making them equally efficient performing this phase I biotransformation reaction. In a second series of experiments, channel catfish (n = 6 per treatment) were dosed in vivo with gel-food containing ABZ (10 mg/kg, p.o.). Fish were killed at 24, 48, 72 and 120 h after dosage. Control fish were fed ABZ-free feed. Induction of ethoxyresorufin-o-deethylase activity was significant (P < 0.05) in all ABZ-dosed treatments as compared with controls.

Using SERVQUAL for assessing and improving patient satisfaction at a rural health facility in Pakistan.

A cross-sectional study of patient satisfaction with care was conducted over a period of 1 year from March 2004 to March 2005 in a secondary-level hospital in a peri-urban area of Karachi, Pakistan. Using the SERVQUAL tool and exit interviews, data were collected quarterly from a total of 1533 patients. Results sharing and capacity-building workshops were arranged during the 4 phases of the survey to sensitize the staff of the hospital to work towards improving patient satisfaction. The level of satisfaction of the patients with the outpatient health services provided showed a gradual increase from 34.4% to 82.0% over the 1-year period.

Gender sensitization among health providers and communities through transformative learning tools: experiences from Karachi, Pakistan.

CONTEXT: Pakistan lags far behind most developing countries in women's health and gender equity. Appropriateness of health care services vis-a-vis the gender specific cultural norms that influence clients' needs are not very visible and are more difficult to monitor. Programs and services need to be sensitively designed to facilitate women's access to physical and social needs. This paper narrates the experience of working with health providers from public and private sectors, community, local government representatives and community-based organizations. Through transformative learning, this endeavour focused on initiating a process of sensitization on gender related health issues for women. APPROACH: The initiative was primarily based on the use of the following two standardized tools: 'Health Workers for Change' for working with health providers and 'Initiating Women Empowerment for Health' for interacting with the community. Both tools focus primarily on women's health and social issues affecting their health status. The research methodology used was predominantly qualitative, using focus group discussions, participatory rural appraisal and interactive workshops. IMPLICATIONS: This approach endeavours to sensitize the health service providers to the health needs of female clients and encourages behavioural changes. Simultaneously, it creates an opportunity to raise awareness among women and the community in general regarding appropriate health-seeking behaviour and the timely use of health services. The information collected is evidence for policy makers regarding the gender-based problems faced by women who are seeking health care and it suggests how to overcome these problems.

Social marketing of insecticide-treated bednets: the case for Pakistan.

With an estimated half a million cases of malaria annually in Pakistan, and drug resistant cases on the increase, more practical preventive measures such as insecticide-treated bednets are essential. Social marketing through commercial channels has become an important cost-effective means to deliver health products and services to low income people and to motivate them to use these services. It has been demonstrated that social marketing of insecticide-treated bednets has saved the lives of millions of people in malaria-endemic regions at a cost as low as U.S. $2 per person. Social marketing could be an effective strategy for getting insecticide-treated nets to poor communities in Pakistan who are most vulnerable to malaria.

Women's empowerment and health: the role of institutions of power in Pakistan.

Women's right to health has been reiterated many times. However, there are social and cultural barriers in developing countries that hinder their empowerment. Women's low status, deprivation of education and lack of control over their own lives and bodies have a negative impact on their health status and that of their families. This paper discusses women's empowerment and health within the framework of the 4 institutions of power in a society-family, community, health care systems and the state--with special reference to the situation in Pakistan. It concludes that to improve women's health status, concerted efforts are needed by all these institutions of power to work towards gender equality and the greater empowerment of women.

Metabolism and depletion of albendazole in the muscle tissue of channel catfish following oral treatment.

The residue depletion of albendazole (ABZ) and its metabolites was studied in channel catfish muscle tissue. Channel catfish were dosed once with 10 mg/kg ABZ via stomach tube with manual restraint. Muscle tissue samples were collected at 8, 16, 24, 48, 72, 96 and 120 h postdose. A high-performance liquid chromatographic method was used to assay ABZ and its major metabolites: ABZ sulfoxide (ABZ-SO), ABZ sulfone (ABZ-SO2) and ABZ aminosulfone (ABZ-2-NH2SO2) in the muscle tissue. The results indicate that ABZ and ABZ-SO were present in low concentrations, i.e. <15 and <10 microg/kg, respectively, at 8 h postdose in catfish muscle with and without skin. ABZ-SO2 was present at 1 microg/kg concentration levels until 48 h in muscle alone and 72 h in muscle with skin. ABZ-2-NH2SO2 was not detected at any withdrawal periods.

Health Workers for Change: a tool for promoting behaviour change among health providers.

Sensitizing health providers to customers' needs and women's health remains a challenge to the Pakistani health system. The Health Workers for Change methodology has been demonstrated to improve provider-client relationships in certain African and Latin American countries. This paper describes the experience of using Health Workers for Change participatory workshops in Pakistan to sensitize male and female health providers to gender issues. Health care providers identified the unmet needs of women clients as a function of individual, household and societal factors, and, unlike the African experience with this tool, not predominantly confined to factors associated with the health facility.