A Case of Pure Pericarditis Associated With COVID-19: Application of Classical Clinical Evaluation for Differential Diagnosis.

Pericarditis of varying severity is being recognized as a rare complication of the COVID-19 infection. We present a patient with an electrocardiogram (EKG) and physical exam findings that initially seemed to most likely be pericarditis related to the COVID-19 infection. The differential diagnosis was a bit difficult because it included ST-segment elevation myocardial infarction (STEMI) due to some EKG changes and early repolarization changes that were rather robust. Treatment options for STEMI could cause severe harm if the process turned out to be pericarditis. Treatment options for pericarditis could cause severe harm if the process turned out to be STEMI. And treatment options for early repolarization might be no treatment at all, which could cause harm if the process turned out to be STEMI or pericarditis. In this case, a correct diagnosis was very important to ensure a good clinical outcome. We would like to share our thought processes in the management of this case.

Brugada-type electrocardiographic pattern induced by electrocution.

Heart is one of the most frequently affected organs in electrocution. Electrical injury can cause life-threatening cardiac complications such as asystole, ventricular fibrillation, and myocardial rupture. In this case report, we describe a 22-yr-old male patient who sustained electric burn injury and presented with electrocardiogram showing transient Brugada type pattern.

The 2017 International Joint Working Group recommendations of the Indian College of Cardiology, the Academic College of Emergency Experts, and INDUSEM on the management of low-risk chest pain in emergency departments across India.

There have been no published recommendations for the management of low-risk chest pain in emergency departments (EDs) across India. This is despite the fact that chest pain continues to be one of the most common presenting complaints in EDs. Risk stratification of patients utilizing an accelerated diagnostic protocol has been shown to decrease hospitalizations by approximately 40% with a low 30-day risk of major adverse cardiac events. The experts group of academic leaders from the Indian College of Cardiology and Academic College of Emergency Experts in India partnered with academic experts in emergency medicine and cardiology from leading institutions in the UK and USA collaborated to study the scientific evidence and make recommendations to guide emergency physicians working in EDs across India.

Physical growth and psychomotor development of infants exposed to antiepileptic drugs in utero.

OBJECTIVE: To evaluates the physical growth and psychomotor development of infants born to women with epilepsy on regular Anti Epileptic Drugs (AEDs). SETTING: Govt. Stanley Medical College and Hospital, Tertiary care referral centre, Chennai. DESIGN: Open prospective cohort study with a control group. MATERIALS AND METHODS: Consecutive women with epilepsy who were on regular anticonvulsants were followed up from their first trimester. Their babies were examined at birth and anthropometric measurements including anterior fontanelle size were noted. They were followed up till one year and periodically evaluated at 1st, 6th and 12th month of age. Development testing using Griffith scale was done at 2nd, 6th and 12th month. An equal number of control babies were also studied using the same scale for one year at the specified intervals. The results in both the groups were compared. RESULTS: 30 babies were enrolled in the case and control group. The AEDs received by the mothers with epilepsy were Phenytoin, Carbamazepine, and Sodium valproate. At birth and 1st month the weight, head circumference and length of case and control babies were equal. At 6th and 12th month reduction in the above 3 parameters were noted in the case babies ( P < 0.01). Area of anterior fontanelle (AF) was larger in the study group particularly in those exposed to phenytoin in utero (P < 0.001). In the case babies reduction in the sitting, prone and erect progression of the locomotor scores was observed at 2nd month (P < 0.001). Prone progression alone improved by 12th month and other two remained less than the control (P < 0.001). No difference was observed in reaching behaviour and personal/social scores in both groups. Infants exposed to Phenytoin monotherapy had a negative impact on sitting progression. CONCLUSION: Among infants exposed to AEDs in utero physical growth was equal to that of control at birth but reduced at 6th and 12th month probably due to extraneous factors. The Locomotor scores showed reduction in all areas in 2nd, 6th and 12th month except prone progression which alone improved by 12th month. Phenytoin exposure in utero resulted in large AF and it had a negative impact on sitting progression in comparison with Carbamazepine and Sodium valproate.

Patients' preferences towards antiepileptic drug therapy following first attack of seizure.

BACKGROUND: Antiepileptic drug (AED) therapy following first unprovoked seizure is controversial. AIM: To study the patients' preferences towards AED therapy following first unprovoked generalized tonic clonic seizure (GTCS). DESIGN: Prospective cohorts with one year follow-up study. SETTING: Government teaching hospital, a tertiary care center. MATERIALS AND METHODS: Patient cohort included patients with first attack of unprovoked GTCS within 30 days of onset, aged between 18-60 years and with normal brain CT scan. Counseling was done for all the patients and the relatives regarding seizure recurrence, duration and adverse effects of AED therapy if preferred. Patients were encouraged to make their own decision in preferring or deferring AED with reasons. They were followed up for one year. RESULTS: Of the 73 enrolled (54 males and 19 females) 39 (53%) preferred to go on AED therapy. The reasons for preferring AED therapy were; (a) fear of seizure recurrence, 21 (54%); (b) risky occupation, 14 (36%); and (c) fear of injury, 4 (10%). The reasons for deferring were: (a) fear of adverse effects of long-term AED therapy, 19 (56%) and (b) preferring to wait for the second attack, 15 (44%). All the patients were happy about being involved in the decision-making. CONCLUSION: Following first attack of unprovoked GTCS the decision regarding AED therapy may be taken by the patients and their family members after adequate counseling and such decisions have more relevance from their perspective.

Nonepileptic attack disorder among married women.

AIM: To study the clinical features, precipitating stressful life events and prognosis of nonepileptic attack disorder (NEAD) among married women. DESIGN: Prospective cohort study with 1-year follow-up. SETTING: A tertiary care teaching hospital. SUBJECTS: Of the 1020 patients with epilepsy referred to the epilepsy clinic during 2002-2003, 30 were married women with NEAD. MATERIALS AND METHODS: The diagnostic criteria for NEAD included normal EEG during ictal and post-ictal phase of the generalized 'attack.' The data collected included clinical characteristics, semiology of the attacks, precipitating stressful events, and co-morbid psychiatric disorders. The control group included 30 age-matched married women with generalized tonic-clonic seizures. The long-term outcome and factors influencing the outcomes were analyzed. RESULTS: The mean duration of illness was 18 months, and the pattern of the attack was 'fall and lying still' in 53% and 'fall with generalized motor movements' in 47%. The frequency was one or more per week in 57% and occasionally in 43%. The important stressful events were matrimonial discord following illegal relationship of the husband with another woman (chi2 = 9.02, P = 0.003) and constant quarrel with other family members (chi2 = 5.19, P = 0.02). The prevalence of sexual abuse was low (7%). Co-morbid psychiatric disorder was observed in 70%. At the end of 1 year, 39% were free from the attack. Resolution of the stressful life events (chi2 = 4.52, P = 0.03) and lower frequency of attack at the time of reporting (chi2 = 3.88, P = 0.05) correlated with good outcomes. CONCLUSION: Among patients with NEAD in India, the major precipitating factors were matrimonial discord following illegal relationship of the husband with another woman and constant quarrel with other family members and not sexual abuse. Women with low frequency of attack at the time of reporting and the remission of the stressful events had better outcomes.

Update on the use of percutaneous nephrostomy/balloon dilation for the treatment of renal transplant leak/obstruction.

PURPOSE: Retrospective evaluation of the efficacy of percutaneous nephrostomy and nephroureteral stent placement for treatment of post-transplant ureteral leak, and percutaneous nephrostomy and balloon dilation for treatment of post-transplant ureteral obstruction. PATIENTS AND METHODS: Data were reviewed for all patients who underwent percutaneous therapy for complications after renal transplantation between January 1985 and June 1995. A total of 61 patients with complications (leak, n = 17; obstruction, n = 44) had been treated. Patients underwent percutaneous nephrostomy followed by antegrade placement of a nephroureteral stent. In addition, all patients with obstruction also underwent ureteral balloon dilation. Follow-up ranged from 9 weeks to 24 months. Positive outcome was defined as nonsurgical closure of leak, significant improvement in renal function, and removal of the nephroureteral stent with maintenance of stable renal function. RESULTS: Regarding ureteral leak, 10 of 17 patients (59%) healed after treatment. Seven patients (41%) did not respond and went on to surgical repair. All patients with early (n = 13) ureteral obstruction (< 3 months after transplantation), had improved renal function (P < .025). Sixty-two percent of patients with early obstruction were cured (tube out with stable renal function) and 38% went to surgery for ureteral repair. In patients with late (n = 31) obstruction (> 3 months after transplantation), renal function improved in only 58% (P < .01). Only 16% of patients with late obstruction were cured (tube out with stable renal function). Ureteral obstruction was persistent in the remaining patients and did not respond to multiple balloon dilations. All complications were minor and included 23 of 61 (38%) patients with urinary tract infections and nine of 61 (14%) patients with limited hematuria. CONCLUSION: Percutaneous nephrostomy is very effective in improving renal function in patients with early obstruction. It is moderately successful in treating ureteral leak. Ureteral balloon dilatation is moderately effective for treatment of obstruction in the early (< 3 months) postoperative period. However, balloon dilation is minimally successful in curing ureteric obstruction occurring more than 3 months after transplantation.