Artery of Percheron Infarct - a diagnostic and prognostic conundrum!

A 39 year old male was found unconscious at home. On arrival to the hospital the patient was profoundly somnolent but easily rousable, with no focal neurological deficits. Imaging confirmed bilateral thalamic infarcts from the occlusion of Artery of Percheron, a rare anatomic variant which is a single arterial trunk supplying the thalamus and midbrain bilaterally. Anti-platelet therapy was initiated as soon as the diagnosis was established and the patient showed a rapid remarkable recovery over the next 48 hours. He continued to improve subsequently and was at baseline functional status at 6 months. Extensive investigations for etiologies were mostly unrevealing. In such patients presenting with drowsiness/somnolence, a posterior circulation stroke should be considered if no evidence of other more common causes are found. A CT head must be followed by an MRI to confirm the diagnosis and subsequent focus should be on eliciting risk factors and careful evaluation for etiologies.

Frequency of proven risk factors for deep vein thrombosis in clinical patients: Results of a study on patients being treated at a tertiary care hospital in Rawalpindi, Pakistan.

OBJECTIVE: To enlist the dominant risk factors predisposing patients to deep venous thrombosis. METHODS: The prospective study was conducted in surgical and medical departments of Combined Military Hospital, Rawalpindi, and Fauji Foundation, Islamabad, from January 2012 to December 2013. Patients having deep venous thrombosis of lower extremities by duplex scan were enrolled. After taking their detailed personal and biochemical history, frequency of risk factors was noted and graded accordingly. RESULTS: Of the total 120 patients, 71(59%) were males. Overall, left leg was involved in 53(44%), right leg in 34(28%) and both legs in 33(28%). Of the total, 68(57%) patients were >40 years of age. Immobility was the main cause of deep venous thrombosis in 18(15%), followed by surgical interventions in 10(8%). Pregnancy and post-partum thrombosis was the major cause in 9(8%) women. Only 6(5%) patients had natural predisposition to deep venous thrombosis. CONCLUSION: Immobility was an independent and important risk factor for deep venous thrombosis. Thromboprophylaxis is not routinely provided in most health centres in Pakistan, exposing patients to the risk.

Frequency of amount and axis of astigmatism in subjects of Rawalpindi, Pakistan.

OBJECTIVE: To assess the frequency of amount and axis of astigmatism with respect to age and gender. METHODS: The prospective, observational study was carried out from September 2009 to January 2010 at Armed Forces Institute of Ophthalmology, Rawalpindi. Patients from 5-70 years of age were included from both genders with no previous history of eye abnormality, surgery or eye pathology. An auto refractor-keratometre was used for measurement. Descriptive statistics were used to analyse data on SPSS 15. RESULTS: Among the total 288 patients, with-the-rule astigmatism (n = 21; 55%) had greater frequency in the 26-35 years sub-group. In terms of gender, 88 (48%); against-the-rule in 81 (44%); and oblique astigmatism in 14 (7.6%). In females, with-the-rule astigmatism was found in 52 (50%); against-the-rule in 36 (34.2%); and oblique in 17 (16%). The frequency of astigmatism > or = 0.25 ranged from 0.8% (n = 1) to 74% (n = 28) across all age groups. The amount of astigmatism which was noted to be the most common and prominent in the sample was < 1D. CONCLUSION: The amount and axis of astigmatism varied within the age sub-groups and within the gender.

Influence of gender, BMI, and ethnicity on serum ALT levels of healthy students of a medical school.

BACKGROUND: Alanine Aminotransferase (ALT) is an enzyme found in liver and indicates injury to hepatocytes. It is influenced by various factors. The objectives of this study were to identify the correlates of ALT activity among healthy medical students of Army Medical College, National University of Sciences and Technology, aged 18-22 years. This was to establish the mean ALT levels of the students and compare them with those in various parts of the world and observe various correlations that exist and factors that may influence ALT levels. METHODS: This population included 143 volunteer students (93 men and 50 women) selected on the basis of negative answers to a detailed medical questionnaire including past medical history, drug and alcohol consumption, on the absence of clinical signs of liver disease, on the negativity of serological testing for Hepatitis B and C virus. RESULTS: The mean ALT level of the entire population was 28.7 IU/L. A major sex-difference in ALT value was observed, the mean ALT value being higher in men than in women (32.1 +/- 21.7 vs. 22.6 +/- 9.7 IU/L, p<0.004). According to WHO criteria for Asians, normal BMI was taken from 18.5-23.0 Kg/m2. There was a positive significant correlation between serum ALT level and BMI (p<0.002). ALT level strongly correlates with body mass index and gender. There was no significant variation in ALT levels among Punjabis and Sindhis, Balochis, Pathans, and Kashmiris. CONCLUSION: We suggest the need of taking into account these parameters in a clinical interpretation of ALT level.

Barrett's esophagus: What do we need to know?

Barrett's esophagus (BE) is characterized by a change in the mucosal lining of the distal esophagus whereby the squamous epithelium of the esophagus is replaced by the metaplastic columnar epithelium. It is a pre-malignant lesion associated with esophageal adenocarcinoma. Patients with gastroesophageal reflux disease who have additional risk factors (Caucasian race, male gender, age > 50 years, tobacco use, and central obesity) should undergo an esophagogastroduodenoscopy to screen for Barrett's esophagus. Patients with Barrett's esophagus should undergo endoscopic surveillance every 3-5 years if no dysplasia is found. Patients with Barrett's esophagus who are found to have dysplasia should be treated endoscopically. We present a comprehensive review of the pathophysiology, diagnosis, surveillance and management of Barrett's esophagus.

Non-alcoholic steatohepatitis and the risk of myocardial infarction: A population-based national study.

BACKGROUND: Non-alcoholic fatty liver disease (NAFLD) is a systemic disease with bidirectional relationships with cardiovascular disease (CVD). Non-alcoholic steatohepatitis (NASH) is a more severe subtype of NAFLD. Patients with NASH exhibit more intra and extrahepatic inflammation, procoagulant imbalances and proatherogenic lipid profiles. Whether NASH increases the risk of ischemic heart disease is currently unclear. AIM: To investigate the relationship between acute myocardial infarction (MI) and NASH in a large cohort of subjects in the United States. METHODS: We reviewed data from a large commercial database (Explorys IBM) that aggregates electronic health records from 26 large nationwide healthcare systems. Using systemized nomenclature of clinical medical terms (SNOMED CT), we identified adult with the diagnosis of NASH from 1999-2019. We included patients with the diagnosis of acute MI from 2018-2019. Comorbidities known to be associated with NASH and MI such as obesity, diabetes mellitus, hyperlipidemia, smoking, male gender, and hypertension were collected. Univariable and multivariable analyses were performed to investigate whether NASH is independently associated with the risk of MI. RESULTS: Out of 55099280 patients, 43170 were diagnosed with NASH (0.08%) and 107000 (0.194%) had a MI within 2018-2019. After adjusting for traditional risk factors, NASH conferred greater odds of MI odds ratio (OR) 1.5 [95% confidence interval (CI): 1.40-1.62]. Hyperlipidemia had the strongest association with MI OR 8.39 (95%CI: 8.21-8.58) followed by hypertension OR 3.11 (95%CI: 3.05-3.17) and smoking OR 2.83 (95%CI: 2.79-2.87). NASH had a similar association with MI as the following traditional risk factors like age above 65 years OR 1.47 (95%CI: 1.45-1.49), male gender OR 1.53 (95%CI: 1.51-1.55) diabetes mellitus OR 1.89 (95%CI: 1.86-1.91). CONCLUSION: MI appears to be a prevalent disease in NASH. Patients with NASH may need early identification and aggressive cardiovascular risk modification.

Endoscopic ultrasound guided liver biopsy for parenchymal liver disease.

Liver biopsy plays an essential role in the diagnosis, evaluation and management of a vast proportion of liver diseases. Conventionally, percutaneous and trans-jugular approaches have been used to obtain liver biopsies. Endoscopic ultrasound guided liver biopsy (EUS-LB) has emerged as a safe and effective alternate in the past two decades. EUS-LB carries a role in evaluation of both benign and malignant diseases of the liver. It can offer higher resolution imaging of the liver and can detect smaller lesions than computed tomography scan of the abdomen or ultrasound scans with the option for doppler assistance to reduce complications. Current evidence demonstrates the superiority of EUS-LB for a targeted approach of focal lesion and there is also evidence of less sampling variability in heterogeneous parenchymal pathologies. These advantages combined with an improved safety profile had led to the rapid progress in the development of new techniques, equipment and procedures for EUS-LB. We provide a comprehensive review of EUS-LB for parenchymal liver disease.

Rising Prevalence of Opioid Use Disorder and Predictors for Opioid Use Disorder Among Hospitalized Patients With Chronic Pancreatitis.

OBJECTIVES: We aimed to evaluate the prevalence, impact, and predictors of opioid use disorder (OUD) in hospitalized chronic pancreatitis (CP) patients. METHODS: A retrospective cohort study was performed using the National Inpatient Sample database from 2005 to 2014. Patients with a primary diagnosis of CP and OUD were included. The primary outcome was evaluating the prevalence and trend of OUD in patients hospitalized with CP. Secondary outcomes were to (1) assess the impact of OUD on health care resource utilization and (2) identify predictors of OUD in hospitalized CP patients. RESULTS: A total of 176,857 CP patients were included, and OUD was present in 3.8% of patients. The prevalence of OUD in CP doubled between 2005 and 2014. Patients with CP who had OUD were found to have higher mean length of stay (adjusted mean difference, 1.2 days; P < 0.001) and hospitalization costs (adjusted mean difference, US $1936; P < 0.001). Independent predictors of OUD in CP patients were obesity, presence of depression, and increased severity of illness. CONCLUSIONS: Opioid use disorder-related diagnoses are increasing among CP patients and are associated with increased health care resource utilization. Our study identifies patients at high-risk for OUD whose pain should be carefully managed.

Evaluation and management of lower gastrointestinal bleeding.

Lower gastrointestinal bleeding (LGIB) is a common cause of presentation to the emergency department and hospital admissions. The incidence of LGIB increases with age and the most common etiologies are diverticulosis, angiodysplasia, malignancy and anorectal diseases. Foremost modality for evaluation and treatment of LGIB is colonosopy. Other diagnostic tools such as nuclear scintigraphy, computed tomography, angiography and capsule endoscopy are also frequently used in the workup of LGIB. Choice of treatment modality depends on the hemodynamic status of the patient, rate of bleeding, expertise and available resources. We present a comprehensive review of the evaluation and management of LGIB.