A stuck colonoscope in the chest cavity: An uncommon complication.

Colonoscopy is generally considered a safe procedure, with a low rate of complications. Although rare, the migration of the colonoscope may represent life-threatening events, requiring emergency treatment. We, herein, describe the case of an elective colonoscopy complicated by an irretrievable colonoscope that migrated, through a previous traumatic diaphragmatic hernia, in the chest cavity. This hernia was likely a chronic complication of a previous abdominal trauma. Several attempts to retrieve the scope were unsuccessful. After further investigations and collegial discussion, a left thoracotomy was performed, with the aim to retrieve the colonoscope and to reduce the hernia.

Aortopulmonary paraganglioma masquerading as an anterior mediastinal mass: A fine line between confusion and chaos!

Mediastinal paragangliomas are exceedingly rare neuroendocrine tumors of chromaffin cell origin. They are rarely endocrinologically functional, but complications often arise due to mass effect within the mediastinal cavity. We present a case of a 67-year-old gentleman referred to our unit for excision of a large mediastinal mass, thought to be thymic in origin, but without confirmatory preoperative histological diagnosis. Intra-operatively it became clear that the tumor was intra-pericardial, originating from aortic tissue, mandating pericardectomy, and ascending aortic replacement on cardiopulmonary bypass for its complete excision. Histopathological evaluation later confirmed the mass to be an aorticopulmonary paraganglioma.

Drug-eluting balloon to treat immediate post-coronary artery bypass grafting ST-elevation myocardial infarction: a case report.

Background: Coronary artery bypass graft (CABG) surgery represents a major cardiovascular operation and may be associated with post-operative ST-elevation myocardial infarction (STEMI) due to graft failure. This is challenging to diagnose and treat as the implanted grafts may be prone to complications when treated percutaneously with drug-eluting stents. Case summary: A man in his 60 s underwent CABG and developed new persistent ST elevations of 2 mm in anterior leads with no significant chest pain, although, administered with intravenous opiates post-operatively. Transthoracic echocardiography was non-diagnostic. Invasive angiography performed emergently showed a thrombotic occlusion of the mid-left anterior descending artery at the site of the anastomosis with the left internal mammary artery (LIMA) graft. Intervention via the graft was considered high risk of complications, therefore, native coronary arteries were used to approach the occlusion, which was successfully cleared with a combination balloon angioplasty with a semi-compliant and then a drug-eluting balloon. The LIMA started working again with the resolution of ST elevation and no immediate complications. Discussion: Early post-operative ST elevations in continuous leads should not be ignored as they often may be the only feature of new-onset STEMI. Drug-eluting balloons represent a feasible and possibly safer option than drug-eluting stents to treat these conditions.

Renal Artery Denervation for the Management of Hypertension: Current Trends and Future Direction.

Renal artery denervation has re-emerged as a potential therapeutic option for patients with hypertension, especially those resistant to conventional pharmacotherapy. This comprehensive review explores the importance of careful patient selection, procedural techniques, clinical efficacy, safety considerations, and future directions of renal artery denervation in hypertension management. Drawing upon a wide range of available evidence, this review aims to provide a thorough understanding of the procedure and its role in contemporary hypertension treatment paradigms.

Effects of natural honey on blood glucose and lipid profile in young healthy Pakistani males.

BACKGROUND: Honey has been shown to have beneficial effects on the glucose and lipid profiles in patients at high risk of heart diseases. Therefore, this study was carried out to investigate the effects of natural honey on blood glucose and lipid profile in healthy individuals. METHODS: A randomized controlled trial was carried out in the Army Medical College, Rawalpindi, Pakistan, spanning 4 weeks, that is, from 15th Feb-15th March 2009. A total of 70 healthy young boarders of the same college were included in the study and randomly divided into two groups of 35 each using random number table. Seventy gram (70 g) of honey was given to each individual in the experimental group daily for a period of 4 weeks while control group was kept on the same diet as that of experimental group except honey. The fasting glucose, total cholesterol, low density lipoprotein (LDL), high density lipoprotein (HDL) and triglyceride (TG) levels were measured before and after the experiment. RESULTS: The fasting glucose levels in both groups were raised. However, the increase in the experimental group was significantly less than that in the control group (p < 0.05). The levels of total cholesterol, LDL and triglycerides in the control group increased while those in the experiment group decreased significantly (p < 0.05), while HDL levels were decreased in the former and increased in the latter group (p < 0.05). CONCLUSION: Natural honey consumption significantly limits the rise in blood glucose along with a significant decrease in the levels of total cholesterol, LDL and triglycerides, and increase HDL in young healthy adults.

Invasive management of non-ST elevation myocardial infarction (NSTEMI) in a patient with severe thrombocytopenia secondary to adult-onset immune thrombocytopenic purpura.

Managing patients with immune thrombocytopenic purpura (ITP) and thrombocytopenia is challenging when they present with acute coronary syndrome (ACS). They are at high risk of thrombotic events; however, antiplatelet medications may further lower the platelet count and predispose them to significant bleeding events, especially if undergoing percutaneous coronary intervention (PCI). We present a case of a man in his 70s, previously diagnosed with adult-onset ITP, admitted with ACS and severe thrombocytopenia. He was treated with a single antiplatelet and commenced on high-dose steroids. Once platelet levels had improved, he was started on second antiplatelet and underwent successful PCI with drug-eluting stent. He was safely discharged with dual antiplatelets for 1 month and then lifelong clopidogrel without any immediate complications. Our case shows that such patients, if stable, can be safely and successfully treated with steroids to improve platelet count before proceeding to invasive management and dual antiplatelet medications.

Purification and biochemical properties of SDS-stable low molecular weight alkaline serine protease from Citrullus colocynthis.

A low molecular weight serine protease from seeds of Citrullus colocynthis was purified to electrophoretic homogeneity with high level of catalytic efficiency (22,945 M(-1) S(-1)). The enzyme was a monomer with molecular mass of 25 kDa estimated by SDS-PAGE. The enzyme was highly active over a pH range of 6.5-9.0 and temperature range of 20-80 °C, with maximum activity at pH 7.5 and at 50 °C. The K(m) and K(cat) were 73 µg/mL and 67/s, respectively. The enzyme was strongly inhibited by PMSF, moderately by soybean trypsin inhibitor, indicating that the enzyme was a serine protease. The enzyme retained 86 and 73% of its activity in the presence of urea and DTT, respectively, and its activity was slightly enhanced in the presence of anionic detergent (SDS). Thus, the enzyme is a novel SDS-stable protease with high catalytic efficiency over wide ranges of pH and temperature which is commercially promising for various industrial applications.

Skeletonization of Left Internal Mammary Artery in Coronary Artery Bypass Grafting.

OBJECTIVE: To compare mean per-operative flow capacity between skeletonized and pedicled left internal mammary artery (LIMA) in patients undergoing coronary artery bypass grafting (CABG) surgery. STUDY DESIGN: Randomized control trial. PLACE AND DURATION OF STUDY: Department of Cardiac Surgery, Armed Forces Institute of Cardiology and National Institute of Heart Diseases (AFIC-NIHD), Rawalpindi, Pakistan from February to August, 2013. METHODOLOGY: Patients undergoing CABG for coronary artery disease, under 80 years, excluded by the exclusion criteria; and fulfilling the inclusion criteria were randomly assigned to two groups of 70 each. One group underwent skeletonized and the other underwent pedicled technique of LIMAharvesting. Free flow was checked just before anastamosis of each LIMAto the LAD, manually in blood flow in ml per minute during cardiopulmonary bypass by allowing it to bleed into a 100 ml container over 20 seconds. Aspecialized proforma was used to record the age, gender, weight, disease, type of IMA used, and free flow of the IMA. Data was analyzed using SPSS 18. RESULTS: The mean age of the patients was 57.16 years in 40 patients, ranging from 36 to 75 years. Disease pattern analysis showed 5%, 10.7% and 84.3% single, double and triple vessel coronary artery disease, respectively. There was significantly higher free flow in the skeletonized group than the pedicled group (p=0.04). CONCLUSION: Skeletonized IMAhad superior flow to pedicled IMAin addition to its traditional proven advantages, which justifies its further use as a conduit for myocardial revascularization.

Topical application of tranexamic acid reduces postoperative bleeding in open-heart surgery: myth or fact?

OBJECTIVE: To determine the efficacy of topical application of Tranexamic acid in controlling postoperative bleeding in open-heart surgery. STUDY DESIGN: Double blind randomized control trial. PLACE AND DURATION OF STUDY: Departments of Cardiac Surgery and Intensive Care of Armed Forces Institute of Cardiology and National Institute of Heart Diseases (AFIC-NIHD), Rawalpindi, Pakistan, from May to October 2011. METHODOLOGY: A total of 100 consecutive adult patients fulfilling the inclusion criteria undergoing elective on-pump cardiac surgeries were randomly divided in groups 'A' and 'B'. A study solution that contained 2.5 g of Tranexamic acid in 250 ml normal saline in group-A and equal amount of normal saline (placebo) in group-B was poured in the pericardial cavity over the mediastinal tissues before sternal closure. Postoperative bleeding was measured in both groups for 24 hours in the cardiac surgical ICU. Efficacy of Topical Tranexamic Acid / Placebo was measured in terms of mean postoperative bleeding in ml. Kindly again include these lines which seem to have been omitted in the final proof. RESULTS: There was significant difference in the mean postoperative bleeding within 24 hours among the two groups 340.1 ± 112.4 ml in Tranexamic acid group vs. 665 ± 187.28 ml in placebo group (p < 0.001). CONCLUSION: Patients who did not have topical Tranexamic acid before chest closure had a significantly higher postoperative bleeding. Topical Tranexamic acid application is an effective and economical way for controlling non-surgical bleeding in patients undergoing cardiac surgery with cardiopulmonary bypass.

Incidence and susceptibility pattern of methicillin resistant coagulase-negative staphylococci isolated from a tertiary care hospital of pakistan.

BACKGROUND: Methicillin resistant coagulase-negative Staphylococci are resistant organisms causing infections associated with high morbidity and mortality. Methicillin resistant Staphylococcus epidermidis (MRSE), is especially important with respect to admitted patients with indwelling catheters and other installed invasive devices where these organisms are known to be found. As a result, such lifesaving measures may prove fatal from subsequent infection and sepsis by these pathogens. Therefore, to limit such conditions in patients, the spread of MRSE and related organisms in the hospitals have to be effectively controlled. OBJECTIVES: This study was carried out to determine the frequency of methicillin resistant organisms among all isolated coagulase negative Staphylococci (CoNS) and to find effective antibiotics against these microorganisms. PATIENTS AND METHODS: All samples sent to the lab were routinely processed according to standard microbiological procedures and the cultures yielding growth of CoNS were selected for the study. All samples containing CoNS collected over a 2 year-period, were included irrespective of patients' age and gender. The antibiogram of the organisms was recorded according to CLSI guidelines and the ratio of methicillin resistant organisms determined. RESULTS: From a total of 299 isolated coagulase negative Staphylococci (CoNS), 40.1% were methicillin resistant. A high proportion of these organisms (more than 50%) were resistant to cephalosporins, aminoglycosides and quinolones while only a small number were found to show resistance to linezolid, minocycline, chloramphenicol and rifampicin. There were no resistant organisms against vancomycin. CONCLUSIONS: A considerable amount of methicillin resistant organisms found among CoNS in our region. The above stated antibiotics would prove effective in limiting these infections. Clinicians should keep these facts in mind while treating their patients.

Aortic aneurysm: a rare cause of Ortner's syndrome.

A young man presented with hoarseness of voice and was found to have left vocal cord paralysis and a large opacity on chest X-ray in the left upper zone. CT angiography showed a giant aneurysm of the aortic arch involving the left subclavian artery. Using a dual perfusion system, with the femoral bypass circuit taking care of the spinal protection and the aortic bypass circuit providing the cerebral protection, the aneurysm was excised and a 16 mm Dacron graft was anastomosed to the aortic arch and the left subclavian artery was anastomosed to the interposition graft. He had a smooth postoperative course and his hoarseness subsided in next 6 months.

Postpartum aplastic anemia presenting as pancytopenia due to malarial infection.

Pancytopenia is a condition with decreased numbers of all cell lines. Aplastic anemia is a common cause although malarial infection causing lysis of RBCs may also partly mimic this condition. The infection may also damage the patient's bone marrow resulting in pancytopenia as well. We present the case of a post-partum female patient who reported with fever, body aches and shortness of breath one month after the delivery of her baby. All blood cell counts were decreased and peripheral blood smear showed malarial parasites. Anti-malarial treatment was initiated following which the fever subsided but, despite regular transfusions, the blood counts remained low. Bone marrow biopsy report revealed P. falciparum pigments along with hypocellularity characteristic of severe aplastic anemia. Consequently, bone marrow transplantation was advised as a therapeutic measure. This case report highlights the increased susceptibility of pregnant women to malaria in endemic areas and subsequent aplastic anemia.