Drug-induced pulmonary arterial hypertension: a review.

Pulmonary arterial hypertension (PAH) is a subgroup of PH patients characterized hemodynamically by the presence of pre-capillary PH, defined by a pulmonary artery wedge pressure (PAWP) ≤15 mmHg and a PVR >3 Wood units (WU) in the absence of other causes of pre-capillary PH. According to the current classification, PAH can be associated with exposure to certain drugs or toxins such as anorectic agents, amphetamines, or selective serotonin reuptake inhibitors. With the improvement in awareness and recognition of the drug-induced PAH, it allowed the identification of additional drugs associated with an increased risk for the development of PAH. The supposed mechanism is an increase in the serotonin levels or activation of serotonin receptors that has been demonstrated to act as a growth factor for the pulmonary artery smooth muscle cells and cause progressive obliteration of the pulmonary vasculature. PAH remains a rare complication of several drugs, suggesting possible individual susceptibility, and further studies are needed to identify patients at risk of drug-induced PAH.

Prevalence, molecular diagnosis and treatment of Mycoplasma conjunctivae isolated from infectious keratoconjunctivitis affected Lohi sheep maintained at Livestock Experiment Station, Bahadurnagar, Okara, Pakistan.

Mycoplasma conjunctivae are etiological agents of infectious keratoconjunctivitis (IKC), commonly known as pink-eye in domestic sheep, goats and other wild animals in many parts of the world. A few young Lohi lambs maintained at Livestock Experiment Station (LES), Bahadurnagar, Okara, Pakistan showed clinical signs and symptoms of conjunctivitis, keratitis, severe lacrimation and varying degree of blindness. During January to March, 2011, a total of 36 ocular swabs were collected from IKC affected animals and were processed for isolation, identification, and characterization of M. conjunctivae. Sixteen (44.44 %) out of 36 samples showed turbidity in PPLO broth. Twelve (75 %) out of 16 broth samples showed colony growth on PPLO agar. All 16 (44.44 %) out of 36 turbid broth samples, 12 (75 %) out of 16 cultured on agar plate samples, and 21 (59 %) out of 36 sheep ocular direct swab samples were found positive for M. conjunctivae through polymerase chain reaction test by using M. conjunctivae-specific primer pair McoF1 and McoR1 and detecting a 750 base pair fragment on agarose gel. Topical application of 0.5 % sterile solution of gentamycin (100 mg/ml) (Gentafar 10 %, FARVET, Netherlands) proved suitable for the treatment of IKC in Lohi lambs as all clinical signs of IKC disappeared after 5 days of treatment with this antibiotic. This is the first report about the prevalence, molecular diagnosis, and treatment of M. conjunctivae in Lohi sheep affected with infectious keratoconjunctivitis at LES, Bahadurnagar, Okara, Pakistan.

2D-2D heterostructure g-C3N4-based materials for photocatalytic H2 evolution: Progress and perspectives.

Photocatalytic hydrogen generation from direct water splitting is recognized as a progressive and renewable energy producer. The secret to understanding this phenomenon is discovering an efficient photocatalyst that preferably uses sunlight energy. Two-dimensional (2D) graphitic carbon nitride (g-C3N4)-based materials are promising for photocatalytic water splitting due to special characteristics such as appropriate band gap, visible light active, ultra-high specific surface area, and abundantly exposed active sites. However, the inadequate photocatalytic activity of pure 2D layered g-C3N4-based materials is a massive challenge due to the quick recombination between photogenerated holes and electrons. Creating 2D heterogeneous photocatalysts is a cost-effective strategy for clean and renewable hydrogen production on a larger scale. The 2D g-C3N4-based heterostructure with the combined merits of each 2D component, which facilitate the rapid charge separation through the heterojunction effect on photocatalyst, has been evidenced to be very effective in enhancing the photocatalytic performance. To further improve the photocatalytic efficiency, the development of novel 2D g-C3N4-based heterostructure photocatalysts is critical. This mini-review covers the fundamental concepts, recent advancements, and applications in photocatalytic hydrogen production. Furthermore, the challenges and perspectives on 2D g-C3N4-based heterostructure photocatalysts demonstrate the future direction toward sustainability.

Ventricular Septal Aneurysm Mimicking Right Ventricular Outflow Tract Mass in a Patient With Ventricular Septal Defect.

A 50-year-old man presented with an episode of chest pain. Cardiac magnetic resonance revealed the presence of a large ventricular septal aneurysm partially closing a perimembranous ventricular septal defect, prolapsing into the right ventricular outflow tract, and mimicking a mass. We illustrate the diagnostic approach and management of such ventricular septal aneurysms. (Level of Difficulty: Advanced.).

Impact of conflict on maternal and child health service delivery - how and how not: a country case study of conflict affected areas of Pakistan.

INTRODUCTION: In conflict affected countries, healthcare delivery remains a huge concern. Pakistan is one country engulfed with conflict spanning various areas and time spans. We aimed to explore the effect of conflict on provision of reproductive, maternal, newborn, child and adolescent health and nutrition (RMNCAH&N) services and describe the contextual factors influencing the prioritization and implementation in conflict affected areas of Pakistan (Balochistan and FATA). METHOD: We conducted a secondary quantitative and a primary qualitative analysis. For the quantitative analysis, we stratified the various districts/agencies of Balochistan and FATA into the conflict categories of minimal-, moderate- and severe based on accessibility to health services through a Delphi methodology with local stakeholders and implementing agencies and also based on battle-related deaths (BRD) information from Uppsala Conflict Data Program (UCDP). The coverage of RMNCAH&N indicators across the continuum of care were extracted from the demographic and health surveys (DHS) and district health information system (DHIS). We conducted a stratified descriptive analysis and multivariate analysis using STATA version 15. The qualitative data was captured by conducting key informant interviews of stakeholders working in government, NGOs, UN agencies and academia. All the interviews were audiotaped which were transcribed, translated, coded and analyzed on Nvivo software version 10. RESULTS: The comparison of the various districts based on the severity of conflict through Delphi process showed that the mean coverage of various RMNCAH&N indicators in Balochistan were significantly lower in severe- conflict districts when compared to minimal conflict districts, while there was no significant difference between moderate and severe conflict areas. There was no reliable quantitative data available for FATA. Key factors identified through qualitative analysis, which affected the prioritization and delivery of services included planning at the central level, lack of coordination amongst various hierarchies of the government and various stakeholders. Other factors included unavailability of health workforce especially female workers, poor quality of healthcare services, poor data keeping and monitoring, lack of funds and inconsistent supplies. Women and child health is set at a high priority but capacity gap at service delivery, resilience from health workers, insecurity and poor infrastructure severely hampers the delivery of quality healthcare services. CONCLUSION: Conflict has severely hampered the delivery of health services and a wholesome effort is desired involving coordination amongst various stakeholders. The multiple barriers in conflict contexts cannot be fully mitigated, but efforts should be made to negate these as much as possible with good governance, planning, efficiency and transparency in utilization of available resources.

The Disappearing Murmur: Systolic Anterior Motion of the Mitral Valve Leaflet in a Non-hypertrophic Cardiomyopathy Patient.

Systolic anterior motion (SAM) of the mitral valve is a well-known phenomenon associated with left ventricular outflow tract obstruction and hemodynamic compromise. This finding may occur in patients with or without hypertrophic cardiomyopathy. In this report, a patient with no prior medical history presented to the hospital with left-sided chest pain and high-risk echocardiogram (ECG) findings. Left heart catheterization with coronary angiography was negative for coronary artery disease. His initial examination was significant for a systolic murmur due to the underlying SAM, as demonstrated by transthoracic echocardiogram. During his hospitalization, he developed acute heart failure syndrome as a result of dynamic outflow tract obstruction. He was treated with fluid resuscitation with a resolution of his hemodynamic compromise. On a follow-up examination, there was no murmur and SAM was no longer present on echocardiogram. This case demonstrates the importance of recognizing the clinical manifestations of SAM as well as its role in maintaining an appropriate hemodynamic status.

Hyperkalemia Induced Brugada Phenocopy: A Rare ECG Manifestation.

Brugada syndrome (BrS) is an inherited disorder of cardiac ion channels characterized by peculiar ECG findings predisposing individuals to ventricular arrhythmias, syncope, and sudden cardiac death (SCD). Various electrolyte disturbances and ion channels blocking drugs could also provoke BrS ECG findings without genetic BrS. Clinical differentiation and recognition are essential for guiding the legitimate action. Hyperkalemia is well known to cause a wide variety of ECG manifestations. Severe hyperkalemia can even cause life threatening ventricular arrhythmias and cardiac conduction abnormalities. Most common ECG findings include peaked tall T waves with short PR interval and wide QRS complex. Since it is very commonly encountered disorder, physicians need to be aware of even its rare ECG manifestations, which include ST segment elevation and Brugada pattern ECG (BrP). We are adding a case to the limited literature about hyperkalemia induced reversible Brugada pattern ECG changes.

Ventricular fibrillation with intracoronary adenosine during fractional flow reserve assessment.

Fractional flow reserve (FFR) measurement provides useful hemodynamic assessment of intermediate coronary stenoses affecting long term outcomes. While the gold standard remains intravenous adenosine, intracoronary (IC) bolus administration of adenosine is routinely used in clinical practice because of its ease of use and lower dose providing comparative hyperemia with the most common side effect being a transient atrioventricular block. A 62year old male underwent left heart catheterization after ruling in for non-ST elevation myocardial infarction (NSTEMI). Presenting electrocardiogram (ECG) showed an old left bundle branch block and T-wave inversions in lateral leads (QTc 494ms) with no significant electrolyte abnormalities. Coronary angiography revealed an intermediate lesion in mid left anterior descending coronary artery. FFR assessment with IC adenosine (24µg/mL of normal saline) was performed inducing ventricular fibrillation (VF). He was successfully defibrillated with a single 200J shock and no further arrhythmias were noticed during rest of his hospital stay.

Secondary hypertension, issues in diagnosis and treatment.

Secondary hypertension (SH) often implies a correctable form of nonessential hypertension. Often certain clinical clues prompt a more extensive evaluation of the causes of the hypertension. Renovascular disease, intrinsic renal disease, primary hyperaldosteronism, and obstructive sleep apnea represent the most common causes of SH. This article defines the disorder and details its epidemiology, prevalence, pathophysiology, physical findings, and treatment strategies.

Prevalence and Molecular Diagnosis of Babesia ovis and Theileria ovis in Lohi Sheep at Livestock Experiment Station (LES), Bahadurnagar, Okara, Pakistan.

BACKGROUND: Babesia ovis and Theileria ovis are among the important and main etiological agents causing ovine babesiosis and ovine theileriosis, causing severe economic losses among sheep and goats. The aim of the present study was to determine the prevalence and molecular diagnosis of B. ovis and T. ovis in Lohi sheep at Livestock Experiment Station Bahadurnagar, Okara, Pakistan. METHODS: The prevalence of B. ovis and T. ovis was investigated in 200 Lohi sheep of mixed age and sex by PCR during 2011. The assay was employed using primers Bbo-F & Bbo-R, specific for a 549-bp fragment in B. ovis genomic DNA and primers TSsr 170F & TSsr 670R, specific for a 520-bp fragment in T. ovis genomic DNA. The animals were also screened for both haemoparasites through stained thin blood smears. RESULTS: Thirty two (16%), 48 (24%) and 26 (13%) were the number of animals found positive for B. ovis, T. ovis and for mixed infection with both parasites, respectively, through microscopy. Sixty eight (34%), 73 (37%) and 42 (21%) were the number of animals found positive for B. ovis, T. ovis and for mixed infection with both parasites, respectively, through PCR test. CONCLUSION: The results indicate the high sensitivity of PCR for surveying babesiosis and theileriosis and there is noteworthy prevalence of these diseases in sheep at an experimental station where environmental conditions are relatively controlled as compared to field conditions.

Functional parathyroid cyst: a rare cause of malignant hypercalcemia with primary hyperparathyroidism-a case report and review of the literature.

Parathyroid cysts are rare lesions found in the neck and anterior mediastinum. They are often nonfunctional (>90%) and rarely in the functional form. This paper discusses a case of severe hypercalcemia (23 mg/dL) secondary to a rare functional parathyroid cyst. The patient was later found to have a hemorrhagic cyst with compression of the right recurrent laryngeal nerve. Preoperative diagnosis of the lesion was parathyroid carcinoma. However, reexploration of the parathyroid mass along with microscopic study confirmed the diagnosis of a parathyroid cyst. Following cystectomy, the patient restored her baseline functional status with preservation of the right recurrent laryngeal nerve. Postoperative followup three years later showed no evidence of cyst recurrence. This paper illustrates the rare presentation of parathyroid functional cysts with severe hypercalcemia and primary hyperparathyroidism. Physicians should be aware of the presence of hemorrhage, inflammation, and compressive symptoms in these cysts which mimic parathyroid carcinoma. These patients should be managed with aggressive medical and surgical intervention.