Devastating ischemic dimelic neuropathy after plastic zip tie handcuffs; message for security agencies.

Ischemic monomelic neuropathy (IMN) is an infrequently recognized type of ischemic neuropathy produced by the shunting of blood away from, or the acute non compressive occlusion of, a major proximal limb artery. IMN consists of multiple mononeuropathies with axonal-loss that develop acutely and simultaneously in the distal portion of a limb. Ischemic neuropathies in a single limb are well-known following compression (casts or tourniquet use), proximal vascular procedures like AV fistula formation, thoracic outlet syndrome, trauma, and thromboembolism. We report the first case of ischemic neuropathies of both upper limbs caused by plastic zip ties handcuffs. We call it "Ischemic dimelic neuropathy (IDN)". This case highlights and increases awareness among physicians and security agencies to recognize ischemic dimelic neuropathy (IDN) early, take measures to prevent this rapidly developing neuropathy, and discourage the use of plastic handcuffs for suspects/accused in their arrest process or inside correctional places.

Predictors of slow clinical response and extended treatment in patients with extra-pulmonary tuberculosis in Pakistan, A hospital-based prospective study.

The optimal duration of treatment in different forms of extrapulmonary tuberculosis (EPTB) is not clearly defined. This study aimed to identify predictors of slow clinical response and extended anti-TB treatment in EPTB patients. Socio-demographic, clinical, and microbiological characteristics of EPTB patients registered for anti-TB treatment at a tertiary care hospital, were analysed for identification of predictors of extended treatment. A total of 251 patients (137 lymphadenitis, and 114 pleuritis) were included in the analysis. Treatment was extended to more than 6 months in 58/251 (23%) patients. In the multivariate regression analysis, culture-positive EPTB (p = 0.007) [OR (95% CI) = 3.81 (1.43, 10.11)], history of diabetes (p = 0.014) [OR (95% CI) = 25.18 (1.94, 325.83)], smokeless tobacco use (p = 0.002) [OR (95% CI) = 17.69 (2.80, 111.72)], and slow regression of local signs and symptoms after 2 months of treatment (p < 0.001) [OR (95% CI) = 17.09 [(5.79, 50.39)] were seen to be significantly associated with treatment extension. Identification of predictors of extended treatment can help clinical decisions regarding optimal duration of treatment. Further studies are needed to identify subgroups of EPTB patients who can benefit from a shorter or longer treatment regimen.

Public-Private Mix Models of Tuberculosis Care in Pakistan: A High-Burden Country Perspective.

Introduction: Pakistan ranks fifth in the globally estimated burden of tuberculosis (TB) case incidence. Annually, a gap of 241,688 patients with TB exists between estimated TB incidence and actual TB case notification in Pakistan. These undetected/missed TB cases initiate TB care from providers in the private healthcare system who are less motivated to notify patients to the national database that leads to significant underdetection of actual TB cases in the Pakistani community. To engage these private providers in reaching out to missing TB cases, a national implementation trial of the Public-Private Mix (PPM) model was cohesively launched by National TB Control Program (NTP) Pakistan in 2014. The study aims to assess the implementation, contribution, and relative treatment outcomes of cohesively implemented PPM model in comparison to the non-PPM model. Methods: A retrospective record review of all forms (new and relapse) patients with TB notified from July 2015 to June 2016 was conducted both for PPM- and non-PPM models. Results: The PPM model was implemented in 92 districts in total through four different approaches and contributed 25% (81,016 TB cases) to the national TB case notification. The PPM and non-PPM case notification showed a strong statistical difference in proportions among compared variables related to gender (p < 0.001), age group (p < 0.000), and province (p < 0.000). Among PPM approaches, general practitioners and non-governmental-organization facilities achieve a treatment success of 94-95%; private hospitals achieve 82% success, whereas Parastatals are unable to follow more than half of their notified TB cases. Discussion: The PPM model findings in Pakistan are considerably consistent with countries that have prioritized PPM for an increasing trend in the TB case notification to their national TB control programs. Different PPM approaches need to be scaled up in terms of PPM implemented districts, PPM coverage, PPM coverage efficiency, and PPM coverage outcome in the Pakistani healthcare system in the future.

Hereditary Chorea Associated With and Aggravated by Systemic Lupus Erythematosus.

Chorea is caused by a number of conditions, including genetic, metabolic derangements, infections, drugs, toxins, tumors, and disorders of the immune and inflammatory system of the body. Huntington's disease (HD) is the most common genetic cause of chorea. Systemic lupus erythematosus (SLE) is an autoimmune condition. Common symptoms include oral ulcers, joint pain, malar or discoid rashes, photosensitivity, and blood dyscrasias. It can involve the heart, lungs, kidneys, and brain. SLE can cause neuropsychiatric manifestations like psychosis, seizures, headache, confusion, and stroke. Chorea is a known symptom of SLE. HD is now recognized to involve more than one system and is associated with a number of comorbid conditions. We report the first case of hereditary choreiform disorder associated with and aggravated by SLE. This is also the first case report of probable Huntington disease from Balochistan, Pakistan. We report a 19-year-old girl with choreiform disorder and a family history of chorea. Choreiform disorder was present in her paternal grandmother and uncles. She presented with fever, cough, and aggravation of choreiform movements of upper and lower limbs for 10 days. She also complained of pain in the small joints of her hands and feet, oral ulcers, hair loss, and aggravation of choreiform movements for two and half months. Probable differential diagnoses of HD, Wilson's disease, and other types of hereditary chorea, aggravated by infections, SLE, or Covid-19, were made. Her initial lab results revealed pancytopenia, increased D-dimers and serum ferritin, positive antinuclear antibodies (ANA), and anti-double-stranded DNA (anti-dsDNA). Her C3 and C4 complement factors were low. The rest of the lab test results, including polymerase chain reaction (PCR) coronavirus disease (COVID-19), blood culture, and malaria, were negative. Thus, a diagnosis of hereditary chorea associated with and aggravated by SLE was made. Hereditary choreiform disorders can be associated with and aggravated by autoimmune conditions like SLE. Thus, it is recommended to be vigilant and have a low threshold for diagnosing co-existing autoimmune conditions like SLE in patients with hereditary choreiform disorder.

Focal cortical dysplasia with prolonged ictal asystole, a case report.

INTRODUCTION: Cortical dysplasia carries significant morbidities such as seizures and delayed milestones. Focal cortical dysplasia (FCD) causes refractory epilepsy with various seizure types depending on the location and extent of the dysplasia. FCD in the temporal region and the insular cortex may cause ictal bradycardia (IB) and ictal asystole (IA). Video EEG (VEEG) with simultaneous EKG recording can better diagnose these cardiac abnormalities in FCD. We describe a case of refractory epilepsy. The patient's clinical seizures were usually followed by syncope. VEEG revealed frequent seizures some of which were associated with prolonged ictal asystole. RESULTS: A 15 years old female was admitted to an epilepsy monitoring unit for VEEG. There were widespread fast abnormal discharges known as FREDs with a frequency of 16-20 Hz. She developed numerous habitual seizures and syncope. Some of these were associated with an EKG change in the form of asystole. The cardiac workup was normal. MRI revealed abnormalities in bilateral insular, temporal, and right parietal lobes. CONCLUSION: This case highlights the significance of:●Fast rhythmic epileptiform discharges (FREDs) in cortical dysplasia.●Role of video-EEG monitoring.●Prolonged asystole and the potential role of cardiac intervention in the form of cardiac pacing and cardioneuroablation in decreasing syncope.

OXA-48 Carbapenemase in Klebsiella pneumoniae Sequence Type 307 in Ecuador.

Antibiotic resistance is on the rise, leading to an increase in morbidity and mortality due to infectious diseases. Klebsiella pneumoniae is a Gram-negative bacterium that causes bronchopneumonia, abscesses, urinary tract infection, osteomyelitis, and a wide variety of infections. The ubiquity of this microorganism confounds with the great increase in antibiotic resistance and have bred great concern worldwide. K. pneumoniae sequence type (ST) 307 is a widespread emerging clone associated with hospital-acquired infections, although sporadic community infections have also been reported. The aim of our study is to describe the first case of Klebsiella pneumoniae (ST) 307 harboring the blaOXA-48-like gene in Ecuador. We characterized a new plasmid that carry OXA-48 and could be the source of future outbreaks. The strain was recovered from a patient with cancer previously admitted in a Ukrainian hospital, suggesting that this mechanism of resistance could be imported. These findings highlight the importance of programs based on active molecular surveillance for the intercontinental spread of multidrug-resistant microorganisms with emergent carbapenemases.

Prevalence of tuberculosis, HIV/AIDS, and hepatitis; in a prison of Balochistan: a cross-sectional survey.

BACKGROUND: Human Immunodeficiency Virus (HIV), Hepatitis, and Tuberculosis (TB) are three primary communicable infections have the likely potential to cause severe morbidity in prison settings. The prison has the most favorable environment for the transmission of infections. We conducted this survey to determine the prevalence and feasibility of rapid diagnostic tests in an active screening of these infectious diseases in prison. METHODS: This cross-sectional survey conducted in central Jail Gaddani, one of the largest prisons in the Balochistan province of Pakistan. All prisoners, jail staffs, and staff's family members participated. Informed consent obtained from each participant before the screening. Van equipped with digital X-ray linked with Computer-Aided Detection for TB (CAD4TB) software used for testing. Sputum samples tested on Xpert for MTB/RIF assay and blood specimens collected for HIV and hepatitis serology. Diagnosed TB patients enrolled for treatment at Basic Management Unit (BMU), reactive on hepatitis Rapid Diagnostic Tools (RDTs) were referred for further testing and management, while HIV reactive referred to Anti Retro Viral (ARV) center for Anti Retro Viral Treatment (ART). RESULTS: A total of 567 participants offered screening, 63% (356) prisoners, 23% (129) staff's family members, and 14% (82) jail staffs. Among tested 10.3% (58/562) were hepatitis seropositive (Hepatitis-C 41 [7.29%] Hepatitis-B, 16 [2.84%] Hepatitis B&C both, 01 [0.17%]). In reactive participants, 49 were prisoners, 08 were jail staffs, and 01 was the staff's family member. HIV seropositive was 4% (24/566), and all were prisoners. Almost 99% (565/567) screened by digital X-ray, 172 (30%) were with abnormal CAD4TB suggestion (score > 50), out of them sputum of 26% (148) tested on Xpert, and 2% (03) found Mycobacterium tuberculosis Positive (MTB+). A total of five TB patients were detected; out of two were diagnosed clinically. Co-morbidities observed in 15 patients, (01 TB/HIV co-infected, 12 HIV/HCV, 01 HIV/HBV, and 01 HBV/HCV). CONCLUSION: The high frequency of infectious diseases in prison is alarming. For limiting the transmission of infections among prison and community, immediate steps are needed to be taken for improvement of prisons condition by application of recommended screening protocols at the time of the first entry of prisoners in prisons.

Prevalence and associated risk factors of HIV in prisons in Balochistan, Pakistan: a cross-sectional study.

Background: The prevalence of HIV is 0.1% in Pakistan, with epidemicity in high-risk groups. The infection is on verge of transmission from key populations to the general population through people who inject drugs and sexual transmission. Prisoners are vulnerable to infectious diseases like HIV. This study was conducted in four prisons in Balochistan, Pakistan to determine the prevalence of HIV and associated risk factors. Methods: This cross sectional study was conducted from March to June 2018, in the prisons of Balochistan. WHO-approved rapid diagnostic kits were used for determining the prevalence of HIV and structured interviews were conducted for the assessment of risk factors. Results: Out of 2084 screened prisoners, 33 (1.6%) were found to be positive. A subset of 104 interviews was analyzed for risk factors of HIV. Among HIV-infected prisoners 68.8% (OR 4.48; 95% CI 1.41-14.2) had extramarital sex, 43.8% (OR 2.09 95% CI 0.69-6.28) had a homosexual experience, and 50% had a history of needle sharing (OR 43; 95% CI 7.77-237). About 94% (OR 16.42; 95% CI 2.09-129.81) of prisoners had a history of drug addiction of any type while 50% (OR 13; 95% CI 2.82-60.01) of HIV-infected had a history of using injectable drugs. Around 75% of HIV-infected prisoners had spent 1-5 years in prison, and 25% had spent more than 10 years. Conclusion: The high prevalence of HIV in prisons of Balochistan demands that preventive and treatment strategies should be designed and implemented carefully, allowing early diagnosis and treatment initiation to minimize the spread of infection among the prisons and ultimately their onward transmission into the community.

Early electrophysiological findings in acute inflammatory demyelinating polyradiculoneuropathy variant of Guillain-Barre syndrome in the Pakistani population - a comparison with global data.

Acute inflammatory demyelinating polyradiculoneuropathy (AIDP) and acute motor axonal neuropathy are the most common variants of Guillian-Barre syndrome documented in the Asian population. However, the variability of early neurophysiologic findings in the Asian population compared to western data has not been documented. Eighty-seven cases of AIDP were retrospectively reviewed for their demographic, clinical, electrophysiological, and laboratory data. Mean age of subjects was 31 ± 8 years with males more commonly affected. Motor symptoms (97%) at presentation predominated. Common early nerve conduction findings included low motor amplitudes (85%), recordable sural sensory responses (85%), and absent H-reflex responses (65%). Prolonged F-latencies were found most commonly in posterior tibial nerves (23%) in the lower limbs and median and ulnar nerves (18%) in the upper limbs. Blink reflex (BR) studies were performed in 57 patients and were abnormal in 80% of those with clinical facial weakness and in 17 of 52 patients (33%) with no clinical cranial nerve signs, suggesting subclinical cranial nerve involvement. Abnormal motor and sensory amplitudes are seen early. Prolonged distal latencies, temporal dispersion/conduction blocks and sural sparing pattern are other common early nerve conduction study findings of AIDP seen in the Pakistani population. There are no significant differences in abnormalities of conduction velocities and delayed reflex responses compared to published data. The BR can help in the early diagnosis of AIDP.

Electrophysiological evidence of the Riche-Cannieu anastomosis in the hand and its diagnostic implications; 2 case reports.

INTRODUCTION: Anomalous anastomoses between the nerves of the hand are not as rare as thought to be. Amongst these, the Riche-Cannieu anastomosis (RCA) is a connection between the ulnar nerve and median motor nerve in the palm. Presence of this can sometimes be misdiagnosed as a severe median mononeuropathy at the wrist/carpal tunnel syndrome (CTS).We describe two cases that were referred for evaluation of CTS and were found to have incidental RCA. RESULTS: Electrophysiological studies showed typical findings consistent with RCA and coexistent mild CTS. Patients in whom median sensory and motor latency prolongations suggest CTS, the presence of an anastomosis should be suspected if the median motor amplitudes are worse than the median sensory amplitudes. CONCLUSION: The electrophysiological study should be extended to avoid erroneous interpretation of low median motor amplitudes as severe CTS and to prevent unnecessary surgical intervention.