Idiopathic intracranial hypertension presenting as postpartum headache.

Postpartum headache is described as headache and neck or shoulder pain during the first 6 weeks after delivery. Common causes of headache in the puerperium are migraine headache and tension headache; other causes include pre-eclampsia/eclampsia, post-dural puncture headache, cortical vein thrombosis, subarachnoid hemorrhage, posterior reversible leukoencephalopathy syndrome, brain tumor, cerebral ischemia, meningitis, and so forth. Idiopathic intracranial hypertension (IIH) is a rare cause of postpartum headache. It is usually associated with papilledema, headache, and elevated intracranial pressure without any focal neurologic abnormality in an otherwise healthy person. It is more commonly seen in obese women of reproductive age group, but rare during pregnancy and postpartum. We present a case of IIH who presented to us 18 days after cesarean section with severe headache and was successfully managed.

At what flow rate does the aortic valve gradient become severely elevated? Implications for guideline recommendations on aortic valve area cutoffs.

Introduction: Aortic stenosis (AS) is considered severe when the aortic valve area (AVA) is < 1.0 cm2 and the mean aortic valve gradient (mAVG) exceeds 40 mm Hg. Since many patients with AVA < 1.0 cm2 do not manifest an mAVG > 40 mm Hg, we sought to determine the AVA at which mAVG tends to exceed 40 mm Hg in a sample of subjects with varied transvalvular flow rates. Material and methods: Our echocardiography database was queried for subjects with native valve AS. We selected 200 subjects with an AVA < 1.0 cm2. The sample was selected to include subjects with varied mean systolic flow (MSF) rates. Linear regression was performed to determine the relationship between MSF and mAVG. Since this relationship varied by AVA, the regression was stratified by AVA (critical < 0.6 cm2, severe 0.6-0.79 cm2, moderately severe 0.8-0.99 cm2). Results: The study sample was 79 ±12 years old and was 60% female. The MSF rate at which mAVG tended to exceed 40 mm Hg was 120 ml/s for critical AVA, 183 ml/s for severe AVA and 257 ml/s for moderately severe AVA. Those with moderately severe AVA rarely (8%) had an mAVG > 40 mm Hg at a wide range of MSF. In contrast, those with severe AVA typically (75%) had mAVG > 40 mm Hg when MSF was normal (> 200 ml/s). Those with critical AVA frequently (44%) had mAVG > 40 mm Hg, even when MSF was reduced. Conclusions: Subjects with AVA of 0.8 and 0.9 cm2 rarely had mAVG > 40 mm Hg, even when the transvalvular flow rate was normal. Using current guidelines, it is not clear if such cases should be classified as severe.

Association of Body Mass Index With Clinical Features and Outcomes in Adults With Fontan Palliation.

Background With improving survival of patients with single ventricle physiology who underwent Fontan palliation, there is also an increase in the prevalence of overweight and obesity in these patients. This tertiary care single-center study aims to determine the association of body mass index (BMI) with the clinical characteristics and outcomes in adults with Fontan. Methods and Results Adult patients (aged ≥18 years) with Fontan who were managed at a single tertiary care center between January 1, 2000, and July 1, 2019, and had BMI data available were identified via retrospective review of medical records. Univariate and multivariable (after adjusting for age, sex, functional class, and type of Fontan) linear and logistic regression, as appropriate, were utilized to evaluate associations between BMI and diagnostic testing and clinical outcomes. A total of 163 adult patients with Fontan were included (mean age, 29.9±9.08 years), with a mean BMI of 24.2±5.21 kg/m2 (37.4% of patients had BMI ≥25 kg/m2). Echocardiography data were available for 95.7% of patients, exercise testing for 39.3% of patients, and catheterization for 53.7% of patients. Each SD increase in BMI was significantly associated with decreased peak oxygen consumption (P=0.010) on univariate analysis and with increased Fontan pressure (P=0.035) and pulmonary capillary wedge pressure (P=0.037) on multivariable analysis. In addition, BMI ≥25 kg/m2 was independently associated with heart failure hospitalization (adjusted odds ratio [AOR], 10.2; 95% CI, 2.79-37.1 [P<0.001]) and thromboembolic complications (AOR, 2.79; 95% CI, 1.11-6.97 [P=0.029]). Conclusions Elevated BMI is associated with poor hemodynamics and worse clinical outcomes in adult patients with Fontan. Whether elevated BMI is the cause or consequence of poor clinical outcomes needs to be further established.

Acute appendicitis in the elderly; Pakistan Ordnance Factories Hospital, Wah Cantt. experience.

OBJECTIVE: To review the clinical experience in diagnosis, management and outcome of elderly patients presenting with acute appendicitis at the Pakistan Ordnance Factories Hospital, Wah Cantt. METHODS: All patients of age 60 years and above presenting with abdominal pain were prospectively reviewed. Patients who were diagnosed as acute appendicitis were included in this case series which was conducted at Pakistan Ordnance Factories Hospital, Wah Cantt, from December 2006 to May 2008. Detailed history and clinical examination, co-morbid conditions, clinical manifestations and post-operative outcome were recorded. The diagnosis was made on the basis of history and clinical examination. The diagnosis was also confirmed on histopathology. All the details were recorded on a questionnaire. Approval from our own ethical committee was taken. SPSS 16 was used for statistical analysis. RESULTS: A total of 75 patients presented with acute abdominal pain. Of them 42 were admitted with tenderness in right iliac fossa and lower abdomen. Finally, 36 (48%) were diagnosed as acute appendicitis and were included in the study. There were 20(56%) men and 16(44%) women with age range of 60 to 78 years and a mean age of 65.5 +/- 4.2 years. Associated illness occurred in 25(70%) patients. Symptoms included abdominal pain in 32(90%), nausea in 17(48%), and emesis in 9(25%) patients. Signs included right lower quadrant tenderness in 26(74%) patients, leukocytosis in 17(47.2%), and fever (>99'F) in 11(30.5%). Laparoscopy was used as an important diagnostic as well as therapeutic modality. Of the patients, 9 (25%) had gangrenous appendix, while 12 (33.3%) had perforated appendix. A total of 12 (33.4%) patients developed complications. Hospital stay was considerably increased in patients with a delayed diagnosis (5-7 days), perforations (5-9 days) and postoperative complications (5-15 days). One patient, a known case of ischaemic heart disease, died of cardiopulmonary arrest. CONCLUSION: Acute appendicitis needs to be considered in the differential diagnosis of all patients with abdominal pain. A high index of suspicion is necessary to guard against mis-diagnosis, especially in the elderly. Delays in presentation and diagnosis are associated with higher rates of perforation and, hence, higher morbidity. Repeated clinical examination, a high index of suspicion and urgent investigations are necessary for a correct and rapid diagnosis.

Severely blunted early heart rate response during treadmill exercise is associated with above average exercise capacity.

INTRODUCTION: Chronotropic response with exercise is evaluated by peak heart rate (HR) achieved. Since most of the exercise-related chronotropic response occurs early after exercise is initiated, we investigated whether the HR achieved with a standard dose of exercise (Bruce stage 2) is associated with exercise capacity. We hypothesized that those with a blunted or disproportionate HR response at this exercise dose would have reduced exercise capacity compared to those with a typical HR response. MATERIAL AND METHODS: We reviewed 3,084 consecutive normal maximal treadmill stress echocardiographic reports acquired from individual adults over a 1.5-year period. We examined for association between stage 2 Bruce HR with age and sex-adjusted exercise capacity. RESULTS: After adjustment for age and sex, Bruce stage 2 HR was inversely associated (ß = -0.08, p < 0.01) with exercise duration. Thus for every additional 10 beats per minute achieved in stage 2, exercise duration was generally shortened by about 45 s. Most of the subjects (92%) who had a stage 2 Bruce HR response below the 10th percentile had above average or average exercise capacity for their age and sex. CONCLUSIONS: Lower Bruce stage 2 HR was associated with increased exercise capacity. Severely blunted HR response was associated with above average exercise capacity. Caution should therefore be exercised in attributing exercise intolerance to a blunted HR response when making a diagnosis of chronotropic incompetence.

Use of Intracervical Foley Catheter for Induction of Labour in Cases of Previous Caesarean Section: Experience of a single tertiary centre in Oman.

OBJECTIVES: This study aimed to evaluate rates of success and perinatal complications of labour induction using an intracervical Foley catheter among women with a previous Caesarean delivery at a tertiary centre in Oman. METHODS: This retrospective cohort study included 68 pregnant women with a history of a previous Caesarean section who were admitted for induction via Foley catheter between January 2011 and December 2013 to the Sultan Qaboos University Hospital, Muscat, Oman. Patient data were collected from electronic and delivery ward records. RESULTS: Most women were 25-35 years old (76.5%) and 20 women had had one previous vaginal delivery (29.4%). The most common indication for induction of labour was intrauterine growth restriction with oligohydramnios (27.9%). Most women delivered after 40 gestational weeks (48.5%) and there were no neonatal admissions or complications. The majority experienced no complications during the induction period (85.3%), although a few had vaginal bleeding (5.9%), intrapartum fever (4.4%), rupture of the membranes (2.9%) and cord prolapse shortly after insertion of the Foley catheter (1.5%). However, no cases of uterine rupture or scar dehiscence were noted. Overall, the success rate of vaginal birth after a previous Caesarean delivery was 69.1%, with the remaining patients undergoing an emergency Caesarean section (30.9%). CONCLUSION: The use of a Foley catheter in the induction of labour in women with a previous Caesarean delivery appears a safe option with a good success rate and few maternal and fetal complications.

Left ventricular early inflow-outflow index: a novel echocardiographic indicator of mitral regurgitation severity.

BACKGROUND: No gold standard currently exists for quantification of mitral regurgitation (MR) severity. Classification by echocardiography is based on integrative criteria using color and spectral Doppler and anatomic measurements. We hypothesized that a simple Doppler left ventricular early inflow-outflow index (LVEIO), based on flow velocity into the left ventricle (LV) in diastole and ejected from the LV in systole, would add incrementally to current diagnostic criteria. LVEIO was calculated by dividing the mitral E-wave velocity by the LV outflow velocity time integral. METHODS AND RESULTS: Transthoracic echocardiography reports from Montefiore Medical Center and its referring clinics from July 1, 2011, to December 31, 2011 (n=11 235) were reviewed. The MR severity reported by a cardiologist certified by the National Board of Echocardiography was used as a reference standard. Studies reporting moderate or severe MR (n=550) were reanalyzed to measure effective regurgitant orifice area by the proximal isovelocity surface area method, vena contracta width, MR jet area, and left-sided chamber volumes. LVEIO was 9.3±3.9, 7.0±3.2, and 4.2±1.7 among those with severe, moderate, and insignificant MR, respectively (ANOVA P<0.001). By receiver operating characteristic analysis, area under the curve for LVEIO was 0.92 for severe MR. Those with LVEIO ≥8 were likely to have severe MR (likelihood ratio 26.5), whereas those with LVEIO ≤4 were unlikely to have severe MR (likelihood ratio 0.11). LVEIO performed better in those with normal LV ejection fraction (≥50%) compared with those with reduced LV ejection fraction (<50%) (area under the curve 0.92 versus 0.80, P<0.001). By multivariate logistic regression analysis, LVEIO was independently associated with severe MR when compared with vena contracta width, MR jet area, and effective regurgitant orifice area measured by the proximal isovelocity surface area method. CONCLUSION: LVEIO is a simple-to-use echocardiographic parameter that accurately identifies severe MR, particularly in patients with normal LV ejection fraction.

Pancreatic tuberculosis or autoimmune pancreatitis.

Introduction. Isolated pancreatic and peripancreatic tuberculosis is a challenging diagnosis due to its rarity and variable presentation. Pancreatic tuberculosis can mimic pancreatic carcinoma. Similarly, autoimmune pancreatitis can appear as a focal lesion resembling pancreatic malignancy. Endoscopic ultrasound-guided fine needle aspiration provides an effective tool for differentiating between benign and malignant pancreatic lesions. The immune processes involved in immunoglobulin G4 related systemic diseases and tuberculosis appear to have some similarities. Case Report. We report a case of a 59-year-old Southeast Asian male who presented with fever, weight loss, and obstructive jaundice. CT scan revealed pancreatic mass and enlarged peripancreatic lymph nodes. Endoscopic ultrasound-guided fine needle aspiration confirmed the presence of mycobacterium tuberculosis. Patient also had high immunoglobulin G4 levels suggestive of autoimmune pancreatitis. He was started on antituberculosis medications and steroids. Clinically, he responded to treatment. Follow-up imaging showed findings suggestive of chronic pancreatitis. Discussion. Pancreatic tuberculosis and autoimmune pancreatitis can mimic pancreatic malignancy. Accurate diagnosis is imperative as unnecessary surgical intervention can be avoided. Endoscopic ultrasound-guided fine needle aspiration seems to be the diagnostic test of choice for pancreatic masses. Long-term follow-up is warranted in cases of chronic pancreatitis.

Combination therapy for hypertension 2013: an update.

We provide a review of recent additions to the antihypertensive armamentarium in the form of combination therapy. These include two-drug and three-drug combinations in a single pill. There is evidence that such combinations are more efficacious than the individual components and that patient adherence to therapy is improved.