High prevalence of West Nile virus in equines from the two provinces of Pakistan.

This study describes the first large-scale serosurvey on West Nile virus (WNV) conducted in the equine population in Pakistan. Sera were collected from 449 equids from two provinces of Pakistan during 2012-2013. Equine serum samples were screened using a commercial ELISA kit detecting antibodies against WNV and related flaviviruses. ELISA-positive samples were further investigated using virus-specific microneutralization tests (MNTs) to identify infections with Japanese encephalitis virus (JEV), WNV and tick-borne encephalitis virus (TBEV). Anti-WNV antibodies were detected in 292 samples by ELISA (seroprevalence 65.0%) and WNV infections were confirmed in 249 animals by MNT. However, there was no animal found infected by JEV or TBEV. The detection of WNV-seropositive equines in Pakistan strongly suggests a widespread circulation of WNV in Pakistan.

Multifaceted manifestations: A case report of MRSA pneumonia with sepsis, pyelonephritis, and ileus muscle abscess.

Methicillin-resistant staph aureus (MRSA) infections are challenging to treat, and with the emergence of community-associated MRSA (CA-MRSA) strains, early consideration of this pathogen in populations without typical risk factors is critical. Here we present a case of CA-MRSA pneumonia that resulted in Community-acquired pneumonia (CAP) with septic shock, pyelonephritis, and muscle abscess.

Renal Infarction as the First Manifestation of Undiagnosed Atrial Fibrillation With Coexisting Left Atrial Thrombus: A Case Report and Review of the Literature.

Acute renal infarction, presenting with nonspecific symptoms, such as abdominal pain, nausea, vomiting, and hematuria, can lead to delayed diagnosis due to similarities with other medical conditions. Computed tomography with IV contrast is used to diagnose renal parenchymal infarction, treated through surgical, percutaneous interventions, and anticoagulation therapy. Investigation for the infarction source is crucial, particularly in the absence of prior cardiac issues, necessitating heart rhythm monitoring and an echocardiogram to evaluate paroxysmal atrial fibrillation (PAF) and intracardiac thrombus, respectively. Renal infarction may elevate blood pressure due to renin release, recommending medications like angiotensin-converting enzyme inhibitors/angiotensin receptor blockers. We present a case of renal infarction due to PAF with a concomitant intracardiac thrombus.

A dilemma of patients: poor quality administration of tertiary care hospitals: a cross-sectional study.

Introduction: The study focuses on healthcare delivery standards in Pakistan's tertiary care hospitals. Poor accountability and a lack of financial and human resources are the main contributing factors to a hospital's substandard performance and low patient satisfaction rates. Feedback surveillance forms are the Achilles tendon in the quality improvement of a facility, and this practice is, unfortunately, not widely practiced in the hospitals of Pakistan. Through this paper and experience, the authors hope to shed light on the need for regular feedback surveys and implementing their results to improve healthcare quality. Settings and Design: A prospective, observational study of seven tertiary care hospitals in Pakistan. Materials and Methods: The data was collected using a survey form. Each survey form was filled out by a team comprising three public health professionals who observed the hospital and its functioning without interfering with its workings. The questionnaire was developed with the help of Tools for Assessing the Operationality of District Health Systems: Health Facility Questionnaire designated in the respective facilities. The analysis was then draughted as a qualitative narrative review. Finally, the review was broken down into an assessment of the hospital's outpatient clinic setting, inpatient department, emergency department and other departments. Results: The survey was conducted at seven public sector hospitals in three major cities of Pakistan. The survey focused on administrative and nonmedical parameters of healthcare facilities. Overall, the hospitals of Lahore and Islamabad lacked mass casualty apparatus and cleanliness, and staff behaviour can be improved. The hospitals in Rawalpindi have mass casualty apparatuses in place. However, they need improvement in accessibility services and hygiene and staff attitude. Conclusions: The survey showed that all the hospitals had good access and accessibility, and the directions were clearly marked for the visitors. The hospital staff is knowledgeable about the hospital, but their behaviour needs to be improved. Also, the quality of the cleanliness and waiting areas is fair but needs improvements. Finally, regular cheques via regular feedback and quality assessments can improve healthcare delivery.

Prevalence of low bone mineral density in inflammatory bowel disease and factors associated with it.

BACKGROUND: Patients with inflammatory bowel disease (IBD) have numerous risk factors for low bone mineral density (BMD). We aimed to study the prevalence of low BMD in IBD and the factors associated with it. METHODS: BMD was measured by radial quantitative ultrasound, and clinical and biochemical characteristics were compared in prospectively enrolled patients and healthy age and gender-matched controls. Chi-square test, t test for independent samples, analysis of variance (ANOVA), Mann-Whitney U test and Kruskal-Wallis H tests were used as appropriate for univariate analysis to compare the characteristics between patients with and without abnormal BMD. Binary logistic regression analysis was done to determine the factors associated with low BMD in IBD patients. RESULTS: One hundred and six patients (Crohn's disease [CD] = 35, ulcerative colitis [UC] = 71) and 55 controls were included. Low BMD was equally prevalent in CD, UC and controls (42.9%, 36.6%, 36.4% respectively, p = 0.791). Serum calcium and vitamin D were significantly lower in IBD patients compared to controls (p < 0.001 and p = 0.003, respectively) but not between patients with low and normal BMD. Older age (Odds ratio [OR] = 66.12 [9.299-470.243], p < 0.001), late onset of disease (OR = 4.795 [1.067-21.543], p = 0.041) and absence of steroid usage (OR = 0.272 [0.089-0.832], p = 0.022) were significantly associated with low BMD. CONCLUSIONS: The prevalence of low BMD in patients with IBD was similar to controls and this was associated with increasing age, late onset of disease, and absence of steroid usage. Judicious use of steroids can help preserve bone health in IBD.

Cloning and Transcriptional Activity Analysis of the Porcine Abcb1 Gene Promoter: Transcription Factor Sp1 Regulates the Expression of Porcine Abcb1.

P-Glycoprotein (P-gp, Abcb1) plays a crucial role in drug disposition and functions by hydrolyzing ATP. However, little is known about the regulatory elements governing the transcription of the porcine Abcb1 gene. In this study, the transcription start site of the pig Abcb1 gene was identified by 5'-RACE. A 1.9-kb fragment of the 5'-flanking region of the Abcb1 gene was cloned from pig genomic DNA and sequenced. The region critical for its promoter activity was investigated via progressive deletions. Further, using mutation assays, two proximal Sp1 binding sites within the 5'-flanking region of Abcb1 were proven to be important cis-regulatory elements involved in regulating the constitutive expression of porcine Abcb1. RNA interference experiments showed that Sp1 regulated the expression of the porcine P-gp at both mRNA and protein levels. Hence, the current work provides valuable information on the regulatory mechanisms of pig Abcb1.

Mechanisms of Lead Failure by Recall Status and Manufacturer: Results From the Pacemaker and Implantable Defibrillator Leads Survival Study ("PAIDLESS").

OBJECTIVES: The aim of this study was to determine the differences in lead failure mechanisms across the major United States implantable defibrillator lead manufacturers (Boston Scientific, Medtronic, and St. Jude Medical), between all non-recalled and recalled leads, and between two recalled lead families (Medtronic Sprint Fidelis and the St. Jude Medical Riata and Riata ST). METHODS: This was a single-center, non-randomized, retrospective study analyzing 3802 patients with 4078 leads who underwent implantable defibrillator lead implantation between February 1, 1996 and December 31, 2011. Lead failure mechanisms were defined as lead fracture, insulation defect, and other. RESULTS: A total of 153 leads (3.8%) failed during the trial period. Failed Medtronic and St. Jude Medical leads presented predominantly as lead fractures (75.8% and 52.8%, respectively). Failed Boston Scientific leads displayed greater variability, although many also failed by fracture (44.4%). The majority of failed non-recalled and recalled leads presented as fractures (50.7% and 82.9%, respectively). The recalled Medtronic Sprint Fidelis and St. Jude Medical Riata/Riata ST leads primarily presented as fractures (89.3% and 65.0%, respectively). Patients whose lead failed via an insulation defect or other mechanism appeared to have a faster time to mortality following lead failure than patients whose lead failed via fracture (P<.01 and P=.02, respectively). CONCLUSIONS: Lead fracture is the most common form of lead failure regardless of the failure points previously identified in these leads. Patients who experienced a lead failure as a result of an insulation defect or other mechanism appeared to die faster than patients whose lead failed via fracture.

An overview of parasitic infections of the gastro-intestinal tract in developed countries affecting immunocompromised individuals.

In both developed and developing countries, parasitic infections continue to be a frequent cause of mortality and morbidity. Due to the globalization of the world, doctors must be fully prepared to deal with a plethora of parasitic infections. More commonly the gastrointestinal (GI) tract is infected and in developed countries protozoans are more likely to be the cause of infection compared to helminths. These GI protozoa are progressively becoming recognized as important pathogens in patients that are immunocompromised. The number of immunocompromised patients is increasing and therefore the likelihood of similar infections will also increase. This paper aims to highlight the key GI parasites affecting immunocompromised individuals in developed countries, discussing diagnosis, treatment options and also prevention. Cryptosporidium parvum may be the most common GI parasite found in the immunocompromised host closely followed by Cyclospora, however, Giardia duodenalis is the most common GI parasite found in developed countries. The pathogenesis of parasitic infection is not clear, poorly understood and diagnostic testing remains difficult with management continuing to be a challenge.

The Amigo™ Remote Catheter System: From Concept to Bedside.

Radiation exposure is a serious concern during fluoroscopic procedures, including electrophysiology (EP) studies and radiofrequency catheter ablation of arrhythmias. Operators typically don lead aprons to protect themselves from radiation, but wearing lead can result in greater fatigue and orthopedic injury during long procedures. To address this problem, two robotic catheter systems (RCS) have previously been introduced on the market, the Niobe® (Stereotaxis Inc., St. Louis, MO, USA) and Sensei® X (Hansen Medical, Inc., Mountain View, CA, USA) systems. However, the widespread adoption of these systems has been limited by both cost and ease of use. In contrast, the Amigo™ RCS (Catheter Precision, Inc., Mount Olive, NJ, USA) was developed to provide a simple, lower profile, and less expensive remote catheter manipulation solution. Approved by the United States Food and Drug Administration (FDA), this technology allows for operators to remotely manipulate electrophysiology (EP) catheters from outside the fluoroscopy field. Notably, the Amigo™ RCS (Catheter Precision, Inc., Mount Olive, NJ, USA) first underwent an early study in dogs in 2008 to demonstrate its safety and efficacy in an animal model. After a clinical trial evaluating its safety and mapping capabilities in humans was completed in 2010, the Amigo™ RCS (Catheter Precision, Inc., Mount Olive, NJ, USA) underwent several scientific studies to examine its ability to assist in the mapping and ablation of various arrhythmias in comparison with the conventional manual approach. The Amigo™ RCS (Catheter Precision, Inc., Mount Olive, NJ, USA) achieved mapping and ablation success rates that were similar to those achieved with manual catheter manipulation, and no complications due to its use were observed. It was approved by the FDA for use in diagnostic EP studies of the right atrium and ventricle in 2012, with this indication later expanded in 2014 to include radiofrequency ablations. The device is currently compatible with the Blazer™ (Boston Scientific, Natick, MA, USA) and EZ STEER™ (Biosense Webster, Inc., Diamond Bar, CA, USA) catheter handles. Here, we present a clinical report in which the Amigo™ RCS (Catheter Precision, Inc., Mount Olive, NJ, USA) was employed to map and ablate symptomatic supraventricular tachycardia. Dr. Cohen's clinical experience with this robotic system is also reviewed.

Port site endometrioma: a rare cause of abdominal wall pain following laparoscopic surgery.

Endometriomas are a rare cause of abdominal wall pain. We report a case of a port site endometrioma presenting with an umbilical swelling. The patient underwent a laparoscopy for pelvic endometriosis 6 months previously and presented with a swelling around her umbilical port site scar associated with cyclical pain during menses. Ultrasound scan reported a well-defined lesion in the umbilicus and MRI scanning excluded other pathology. As she was symptomatic, she underwent an exploration of the scar and excision of the endometrioma with resolution of her symptoms. Precautions should be taken to reduce the risk of endometrial seeding during laparoscopic surgery. All tissues should be removed in an appropriate retrieval bag and the pneumoperitoneum should be deflated completely before removing ports to reduce the chimney effect of tissue being forced through the port site. The diagnosis should be considered in all women of reproductive age presenting with a painful port site scar.

Differences in Approaches and Outcomes of Defibrillator Lead Implants Between High-Volume and Low-Volume Operators: Results From the Pacemaker and Implantable Defibrillator Leads Survival Study ("PAIDLESS").

OBJECTIVES: The purpose of this study was to investigate the relationship between operator volume and implantable defibrillator lead failure and patient mortality at a single large implanting center. METHODS: This study analyzed the differences between high-volume and low-volume defibrillator implanters in the Pacemaker and Implantable Defibrillator Lead Survival Study ("PAIDLESS") between February 1, 1996 and December 31, 2011 at NYU Winthrop Hospital. "High-volume" was defined as performing ≥500 implants over the study period, while "low-volume" was defined as performing <500 implants. Comparisons between the procedure volume groups were performed using Fisher's Exact test, Wilcoxon rank-sum test, and Kaplan-Meier analysis as appropriate. RESULTS: Eight operators participated in the study, four of whom were high-volume operators. Of 3801 patients, a total of 3149 (83%) were operated upon by high-volume operators. Low-volume operators implanted fewer recalled leads (12% vs 42%; P<.001) and more often obtained venous access through the cephalic vein cutdown approach (63% vs 38%; P<.001) than high-volume operators. Kaplan-Meier analysis revealed shorter time to lead failure in the low-volume group (P=.02). Time to mortality was not significantly different between the high-volume and low-volume groups (P=.18). When adjusted for lead recall status, patients of high-volume operators were 43% less likely to experience lead failure compared to patients of low-volume operators. CONCLUSIONS: High-volume defibrillator implanters selected a higher percentage of recalled leads, but their patients were less likely to encounter lead failure when adjusted for lead recall status compared to low-volume operators.

Sero-epidemiology of equine toxoplasmosis using a latex agglutination test in the three metropolises of Punjab, Pakistan.

Toxoplasmosis is a serious threat for livestock in addition to being of zoonotic significance. In this study, serodiagnosis of equine toxoplasmosis was conducted in a randomly selected population from the 3 metropolises of Punjab, Pakistan. To this end, 272 draught equines were screened using a commercial latex agglutination assay kit. Association of probable risk factors of equine toxoplasmosis was also documented. A total of 91 (33.5%) equines were found sero-positive for Toxoplama (T.) gondii having antibody titers ranging between 1:32 to 1:612. The highest rates of seropositive cases were observed in donkeys (58.7%) followed by mules (28.6%) and horses (23.5%). Age, sex and species of draught equines were found not to be statistically (p>0.05) associated with the distribution of T. gondii antibodies. The results of the study provided a baseline data for the exposure of equine population in this area. In addition, it is recommended that the contiguous population of domestic ruminants and possible reservoirs such as feral cats should be screened in order to explore the potential risk for the human population in Pakistan.