Severe Plasmodium vivax malaria in Pakistan.

To compare the severity of Plasmodium vivax malaria with that of P. falciparum malaria, we conducted a retrospective cross-sectional study of 356 adults hospitalized with malaria (2009-2011) in Pakistan. P. vivax and P. falciparum accounted for 83% and 13% of cases, respectively; 79.9% of patients with severe malaria were infected with P. vivax.

Causes of smoking in Pakistan: an analysis of social factors.

OBJECTIVE: To determine the factors contributing to the initiation and propagation of smoking in visitors to a major tertiary health center in Karachi, Pakistan. METHODS: Seven major contributing factors to the initiation and propagation of smoking were presented to consenting study participants (n=170) in a questionnaire. Participants were then requested to use their experience and opinion to rate each of the given factors on a scale of 1 to 5 regarding its importance as a causative factor in the initiation and propagation of smoking. Results were analyzed using SPSSv16.0. RESULTS: Preliminary analysis revealed occupational stress relief as the most important factor contributing to smoking with a mean score of 3.25 +/- 1.32. Peer pressure ranked second (Score 3.20 +/- 1.42). Domestic stress relief ranked third with a score of 3.19 +/- 1.32. Smokers gave lower rating than non-smokers to most factors. Younger participants gave higher ratings to peer pressure, and most participants were found to have begun smoking at a young age. CONCLUSIONS: Even though the addictive power of nicotine or stress may appear as a factor in middle aged smokers, the root of their habit lies in the initiation due to peer pressure.

Trends in Mortality From Human Immunodeficiency Virus Infection, 1984-2016: An Autopsy-Based Study.

CONTEXT.­: With increasing use and efficacy of antiretroviral therapy for human immunodeficiency virus (HIV) infection, deaths from acquired immunodeficiency syndrome (AIDS)-defining conditions have decreased. OBJECTIVE.­: To examine trends in the cause of death of HIV-infected patients who underwent autopsy at a major New York City hospital from 1984 to 2016, a period including the major epochs of the AIDS epidemic. DESIGN.­: Retrospective review of autopsy records and charts with modeling of trends by logistic regression using polynomial models. RESULTS.­: We identified 252 autopsies in adult patients with AIDS (by 1982 definition) or HIV infection. Prior to widespread use of highly active antiretroviral therapy, in 1984-1995, on average 13 autopsies per year were done. Post-highly active antiretroviral therapy, the average number of autopsies declined to 4.5 per year. The fitted mean age at death was 35 years in 1984 and increased curvilinearly to 46 years (95% CI, 43-49) in 2016 (P < .001). By regression analysis, mean CD4+ T-cell count increased from 6 in 1992 to 64 in 2016 (P = .01). The proportion of AIDS-defining opportunistic infections decreased, from 79% in 1984-1987 to 41% in 2008-2011 and 29% in 2012-2016 (P = .04). The frequency of nonopportunistic infections, however, increased from 37% in 1984-1987 to 73% in 2008-2011 and 57% in 2012-2016 (P = .001). The frequency of AIDS-defining and other malignancies did not change significantly during the study period. The prevalence of atherosclerosis at autopsy rose dramatically, from 21% in 1988-1991 to 54% in 2008-2011 (P < .001). CONCLUSIONS.­: Despite limitations of autopsy studies, many trends in the evolution of the HIV/AIDS epidemic are readily discernable.

Hepatitis C virus treatment response to ledipasvir/sofosbuvir among patients coinfected with HIV and HCV: Real world data in a black population.

Treatment of hepatitis C virus (HCV) infection for patients with human immunodeficiency virus (HIV) has improved with direct acting antivirals. However, outcomes among Black persons treated with ledipasvir/sofosbuvir (LDV/SOF) may be inferior to non-Blacks. We assessed responses to LDV/SOF in a cohort of Black HIV/HCV coinfected persons.Retrospective chart reviews were conducted for Black, genotype 1 (GT1), HIV/HCV coinfected patients treated with LDV/SOF at 3 hospitals in Newark, NJ between January 2014 and July 2016. Data collected included demographics, HCV treatment history, treatment duration, and response.One hundred seventeen HIV/HCV coinfected Black patients started treatment with LDV/SOF but 5 had no follow-up data and 5 prematurely discontinued treatment (1 due to side effects). We included 107 HIV/HCV coinfected patients who completed LDV/SOF at all 3 sites. The study population was 65% male, median age 58 years, 26% had cirrhosis, and 78% had GT1a. Thirty-one percent were treatment experienced but none with prior NS5a treatment. At baseline, median CD4 count was 680 cells/mm, HIV viral load (VL) was <40 copies/mL in 94% and median HCV VL was 2,257,403 IU/mL. Twenty-nine percent of patients changed antiretroviral treatment before LDV/SOF treatment due to drug interactions. Six, 89, and 12 patients completed 8, 12, and 24 weeks of LDV/SOF, respectively. Overall sustained virologic response rate was 93% with 7 relapses.In this real-world cohort of Black, GT1, HIV/HCV coinfected patients, LDV/SOF had high sustained virologic response 12 weeks post completion of treatment rate of 93%. This data supports the overall high efficacy of LDV/SOF in a historically difficult-to-treat patient population.

Vertigo as a predominant manifestation of neurosarcoidosis.

Sarcoidosis is a granulomatous disease of unknown etiology that affects multiple organ systems. Neurological manifestations of sarcoidosis are less common and can include cranial neuropathies and intracranial lesions. We report the case of a 21-year-old man who presented with vertigo and uveitis. Extensive workup including brain imaging revealed enhancing focal lesions. A lacrimal gland biopsy confirmed the diagnosis of sarcoidosis. The patient was initially treated with prednisone, which did not adequately control his symptoms, and then was switched to methotrexate with moderate symptomatic improvement. Our patient had an atypical presentation with vertigo as the predominant manifestation of sarcoidosis. Patients with neurosarcoidosis typically present with systemic involvement of sarcoidosis followed by neurologic involvement. Vertigo is rarely reported as an initial manifestation. This case highlights the importance of consideration of neurosarcoidosis as an entity even in patients that may not have a typical presentation or systemic involvement of disease.

Primary small cell neuroendocrine carcinoma of paranasal sinuses.

Small cell neuroendocrine carcinoma of the paranasal sinuses is an extremely rare and aggressive neoplasm. Despite aggressive management, the tumor carries a poor prognosis, with a high risk of local recurrence or distant metastases. The management strategy is based on that for pulmonary small cell cancer and includes platinum-based chemotherapy combined with radiotherapy. We are reporting a case of an 89-year-old female patient diagnosed with small cell carcinoma of right-sided ethmoid and sphenoid sinuses. The tumor was found to have invaded the right orbit and anterior cranial fossa. Metastases to cervical lymph nodes and bone were also found. Due to the extended stage and poor prognosis of the patient, the management plan is palliative chemoradiotherapy.

Papillary serous carcinoma of the uterine cervix with lung metastasis.

Papillary serous carcinoma of the uterine cervix is a rare histological variant of cervical adenocarcinoma, with a very small number of cases reported. It is an aggressive tumor and is usually diagnosed at advanced stages by the time of diagnosis. Early-stage tumors can be treated with surgery and/or radiotherapy, while late-stage tumors have been treated with chemotherapy plus radical surgery with intermittent success. Here we report a case of metastatic papillary serous carcinoma observed at our hospital, which has been treated with debulking surgery and combination chemotherapy with carboplatin and paclitaxel.

Hyper-reactive malarial splenomegaly in the absence of raised IgM antibodies.

Hyper-reactive malarial splenomegaly (HMS) is diagnosed by the presence of massive splenomegaly, raised IgM and antimalarial antibodies and a response to antimalarial therapy. Although malaria is endemic to Pakistan, HMS is uncommon. We report on HMS in a patient with massive splenomegaly, positive Plasmodium falciparum polymerase chain reaction but normal immunoglobulin M antibody levels. The investigations were not consistent with any other diagnosis. HMS is also briefly reviewed.

Reducing transfusion-associated malaria in Pakistan: an algorithmic approach.

Blood transfusions represent a small but significant source of malaria transmission. Most blood banks rely solely on donor questioning to exclude malaria patients from donating blood. No guidelines exist for in vitro screening of donor blood for malaria in endemic areas. Possible laboratory screening techniques include: microscopy; enzyme-linked immunosorbent assay (ELISA) antibody testing; polymerase chain reaction (PCR) testing; and rapid diagnostic antigen tests. However, all these modalities have diagnostic limitations. Based on a best evidence review, we present recommendations using an algorithmic approach to blood screening for malaria in Pakistan. This algorithm considers regional endemicity for malaria, as well as a detailed donor history, in order to decide whether donor blood should be tested with rapid antigen testing. We hope this algorithm will assist in the development of future national guidelines for screening blood for malaria that will reduce the risk of blood-borne transmission.

Tumor necrosis factor -α, interleukin-10, intercellular and vascular adhesion molecules are possible biomarkers of disease severity in complicated Plasmodium vivax isolates from Pakistan.

BACKGROUND: Cytokine-mediated endothelial activation pathway is a known mechanism of pathogenesis employed by Plasmodium falciparum to induce severe disease symptoms in human host. Though considered benign, complicated cases of Plasmodium vivax are being reported worldwide and from Pakistan. It has been hypothesized that P.vivax utilizes similar mechanism of pathogenesis, as that of P.falciparum for manifestations of severe malaria. Therefore, the main objective of this study was to characterize the role of cytokines and endothelial activation markers in complicated Plasmodium vivax isolates from Pakistan. METHODS AND PRINCIPLE FINDINGS: A case control study using plasma samples from well-characterized groups suffering from P.vivax infection including uncomplicated cases (n=100), complicated cases (n=82) and healthy controls (n=100) were investigated. Base line levels of Tumor necrosis factor-α (TNF-α), Interleukin-6 (IL-6), Interleukin-10 (IL-10), Intercellular adhesion molecule-1 (ICAM-1), Vascular adhesion molecule-1(VCAM-1) and E-selectin were measured by ELISA. Correlation of cytokines and endothelial activation markers was done using Spearman's correlation analysis. Furthermore, significance of these biomarkers as indicators of disease severity was also analyzed. The results showed that TNF-α, IL-10, ICAM-1and VCAM-1 were 3-fold, 3.7 fold and 2 fold increased between uncomplicated and complicated cases. Comparison of healthy controls with uncomplicated cases showed no significant difference in TNF-α concentrations while IL-6, IL-10, ICAM-1, VCAM-1 and E-selectin were found to be elevated respectively. In addition, significant positive correlation was observed between TNF-α and IL-10/ ICAM-1, IL-6 and IL-10, ICAM-1 and VCAM-1.A Receiver operating curve (ROC) was generated which showed that TNF-α, IL-10, ICAM-1 and VCAM-1 were the best individual predictors of complicated P.vivax malaria. CONCLUSION: The results suggest that though endothelial adhesion molecules are inducible by pro-inflammatory cytokine TNF-α, however, cytokine-mediated endothelial activation pathway is not clearly demonstrated as a mechanism of pathogenesis in complicated P.vivax malaria cases from Pakistan.

Deceased-donor organ transplantation: knowledge and attitudes among health care professionals managing critically ill patients in Karachi.

OBJECTIVES: Adequate knowledge and positive attitudes of health care professionals regarding deceased-donor organ transplants lead to higher donation consent rates. This study assessed the knowledge and attitudes of health care professionals toward this issue in the light of recent organ transplant legislation in Pakistan. MATERIALS AND METHODS: Health care professionals in critical care areas of 2 hospitals in Karachi were selected (n=243) and asked to complete a questionnaire regarding their knowledge and attitudes toward deceased-donor organ transplants. RESULTS: In all, 58.8% of the participants were physicians and 41.2% were nurses; 91.4% correctly identified brain death; 51.5% expressed support for deceased-donor organ transplants; 56.8% had concerns of religious rulings against deceased organ donation; 67.5% felt that a government body could not run such a system fairly; 56.4% of the respondents would consider receiving a deceased-donor organ if needed, but only 35.3% would donate after their own death. Only 42.7% and 37% were willing to approach patients and families for consent for a deceased-donor organ transplant, respectively. Most of those unwilling felt that the patient could refuse, become upset and aggressive, and lose trust in the health care professionals. CONCLUSIONS: Before implementing a deceased-donor organ transplant system in hospitals, health care professionals should attend a training program regarding their concerns. This would increase motivation when approaching patients/patients' families for consent, thus increasing deceased-donor consent rates.