Clinical presentation, diagnostic features on cardiac magnetic resonance imaging and outcome of patients with cardiac amyloidosis presenting to a tertiary care setting.

Cardiac amyloidosis is a rare disease which is under diagnosed in this region. This study was aimed to assess the clinical presentation, cardiac magnetic resonance (CMR) imaging findings and prognosis of patients with cardiac amyloidosis in Pakistani population presenting to a tertiary care setting. A total of eight patients were included with the confirmed diagnosis of cardiac amyloidosis on CMR, after reviewing the CMR data of Aga Khan University Hospital from January 2011 to August 2019. Mean age was 51±11.5 years with the majority (75%) being male. All patients presented with heart failure. Suboptimal myocardial nulling on late gadolinium images was the most common finding on CMR. Late gadolinium enhancement was diffuse transmural in 5 patients (62.5%) and diffuse sub-endocardial in 3 patients (37.5%). On a mean follow up of 14±10 months, 3 patients (37.5%) died while 7 patients (87.5%) had hospital admissions due to heart failure.

Positional syncope occurring just at the right time in a patient with a permanent pacemaker: A case report.

We present an unusual case of positional syncope occurring years after pacemaker implantation. Syncope was caused by a pacemaker lead fracture, which resulted from subclavian crush syndrome. The syncope occurred incidentally during hospital admission and was timely diagnosed using an integrated approach of history taking, examination findings, device interrogation and radiographic parameters. The patient subsequently underwent lead and device alteration which led to resolution of her symptoms.

Scalpel versus diathermy of midline skin incisions: comparison of mean pain scores on second post-operative day.

OBJECTIVE: To determine the mean post-operative pain in scalpel versus diathermy opening of midline laparotomies. METHODS: The randomised controlled study was conducted at Civil Hospital and Dow University of Health Sciences, Karachi, from May to November 2010, and comprised patients undergoing midline laparotomy. Patients were equally divided into two groups; those who received incision with diathermy were placed in group A, and those who received incision with scalpel in group B. Mean post-operative pain scores were recorded using numerical analogue scale on second post-operative day. SPSS 16 was used for statistical analysis. RESULTS: Of the 58 patients, there were 29(50%) in each group. The overall mean age of the patients was 31.8±12.8 years. Besides, 40(68.9%) patients were male. The mean post-operative pain scores at 48 hours in diathermy group was 1.48±0.68 while in scalpel group it was 2.17±0.46 (p<0.05). CONCLUSIONS: The use of diathermy for midline laparotomy incision had significant advantage over scalpel in reducing pain on second post-operative day.

Presentation delay in breast cancer patients and its association with sociodemographic factors in North Pakistan.

BACKGROUND: There is strong evidence that delayed diagnosis of breast cancer is associated with poor survival. The objectives were to determine the frequency of breast cancer patients with delayed presentation, the reasons of delay and its association with different socio-demographic variables in our settings. METHODS: We interviewed 315 histologically confirmed breast cancer patients. Delay was defined as more than 3 months from appearance of symptoms to the consultation from doctor. Questions were asked from each patient which could reflect their understanding about the disease and which could be the likely reasons for their delayed presentation. RESULTS: A total of 39.01% (n=123) of patients presented late and out of those, 40.7% wasted time using alternative medicines; 25.2% were not having enough resources; 17.1% presented late due to painless lump; 10.6% felt shyness and 6.5% presented late due to other reasons. Higher age, negative family history, <8 school years of education and low to middle socio-economic status were significantly associated with delayed presentation (P<0.05). Education and socioeconomic status were two independent variables related to the delayed presentation after adjustment for others [odds ratios (OR) of 2.26, 2.29 and 95% confidence intervals (CI) was 1.25-4.10, 1.06-4.94 respectively]. CONCLUSIONS: Significant percentage of women with breast cancer in North Pakistan is experiencing presentation delay due to their misconceptions about the disease. Coordinated efforts with public health department are needed to educate the focused groups and mitigating the barriers identified in the study. Long term impact will be reduced overall burden of the disease in the region.

Safety of procedural sedation in emergency department settings among the adult population: a systematic review and meta-analysis of randomized controlled trials.

Procedural sedation and analgesia (PSA) are a common practice in emergency departments (EDs), aiming to alleviate pain, anxiety, and discomfort during various medical procedures. We have undertaken a systematic review and meta-analysis with the aim of assessing the incidence of adverse events associated with PSA, including those related to individual drugs and various drug combinations. The study adhered to PRISMA guidelines for a systematic review and meta-analysis of adverse events in ED sedation. A comprehensive search strategy was employed across ten databases, supplemented by searches on clinicaltrials.gov and manual reviews of reference lists. Data extraction focused on medication administration and adverse events. The study considered four types of adverse events: cardiac, respiratory, gastrointestinal, and neurological. Only randomized controlled trials (RCTs) focusing on PSA administered to adult patients within the ED setting were included. The statistical analysis employed OpenMeta Analyst to conduct a one-arm meta-analysis, with findings presented alongside their corresponding 95% Confidence Intervals. Forest plots were constructed to combine and evaluate results, and sensitivity analyses were performed to identify sources of heterogeneity. From a literature search of 4246 records, 32 RCTs were deemed suitable for this meta-analysis. The analysis included 6377 procedural sedations. The most common adverse event was hypoxia, with an incidence rate of 78.5 per 1000 sedations (95% CI = 77.5-133.5). This was followed by apnea and hypotension, with incidence rates of 31 (95% CI = 19.5-41.8) and 28.1 (95% CI = 17.4-38.9) per 1,000 sedations, respectively. Agitation and vomiting each occurred in 15.6 per 1,000 sedations (95% CI = 8.7-22.6). Severe adverse events were rare, with bradycardia observed in 16.7 per 1,000 sedations, laryngospasm in 2.9 per 1,000 sedations (95% CI = - 0.1 to 6), intubation in 10.8 per 1,000 sedations (95% CI = 4-17), and aspiration in 2.7 per 1,000 sedations (95% CI = - 0.3 to 5.7). Ketamine is found to be the safest option in terms of respiratory adverse events, with the lowest rates of apnea and hypoxia, making it the least respiratory depressant among the evaluated drugs. Etomidate has the least occurrence of hypotension when used alone. Propofol has the highest incidence of hypotension when used alone and ranks second in hypoxia-related adverse events after midazolam. Using combinations of sedating agents, such as propofol and ketamine, has been found to offer several advantages over single drugs, especially in reducing adverse events like vomiting, intubation difficulty, hypotension, bradycardia, and laryngospasm. The combination significantly reduces the incidence of hypotension compared to using propofol or ketamine individually. Despite the regular use of procedural sedation, it can sometimes lead to serious adverse events. Respiratory issues like apnea and hypoxia, while not common, do occur more often than cardiovascular problems such as hypotension. However, the least frequent respiratory complications, which can also pose a threat to life, include laryngospasm, aspiration, and intubation. These incidents are extremely rare.

Interesting presentation of a broad complex tachycardia during the head up tilt table test.

Broad complex tachycardia (BCT) during head up tilt test (HUTT) is infrequent. Electrophysiology Study (EPS) plays an important part in further differentiation of BCT. We present a case of BCT during HUTT in a patient presenting with presyncope which later on EPS with 3D mapping was diagnosed as ventricular tachycardia. This case highlights the unusual occurrence of BCT during HUTT, the differential diagnosis of BCT and the utility of EPS to reliably identify the type and origin of BCT.

Diffuse breast uptake of technetium-99m tetrofosmin during myocardial perfusion imaging in a lactating mother.

Myocardial perfusion imaging (MPI) is a useful modality to rule out myocardial ischaemia in patients presenting with chest pain. In nursing mothers imaging with radioisotope is usually avoided but under certain circumstances it is unavoidable. We present the case of a 45-year-old woman with chest pain, who underwent MPI for assessment of ischaemia. The scan showed anterior artefact due to diffuse breast uptake in both the breasts, as the patient was a lactating mother. The case highlights the importance of breast uptake of radioisotope in the lactating mother on MPI and the necessary steps which need to be taken if radiotracer is injected into a lactating woman.

Presentation delay in breast cancer patients, identifying the barriers in North Pakistan.

BACKGROUND: There is strong evidence that delayed diagnosis of breast cancer is associated with poor survival. Our objectives were to determine the frequency of breast cancer patients with delayed presentation, the reasons of delay and its association with different socio-demographic variables in our North Pakistan setting. MATERIALS AND METHODS: We interviewed 315 histologically confirmed breast cancer patients. Delay was defined as more than 3 months from appearance of symptoms to consultation with a doctor. Questions were asked from each patient which could reflect their understanding about the disease and which could be the likely reasons for their delayed presentation. RESULTS: 39.0 % (n=123) of patients presented late and out of those, 40.7% wasted time using alternative medicines; 25.2 % did not having enough resources; 17.1 % presented late due to painless lump; 10.6% felt shyness and 6.5% presented late due to other reasons. Higher age, negative family history, < 8 school years of education and low to middle socio-economic status were significantly associated with delayed presentation (p< 0.05). Education and socioeconomic status were two independent variables related to the delayed presentation after adjustment for others (OR of 2.26, 2.29 and 95%CI was 1.25-4.10, 1.06-4.94 respectively). CONCLUSIONS: Significant numbers of women with breast cancer in North Pakistan experience presentation delay due to their misconceptions about the disease. Coordinated efforts with public health departments are needed to educate the focused groups and removing the barriers identified in the study. Long term impact will be reduced overall burden of the disease in the region.