Financial Literacy in Residency.

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To resuscitate or not to resuscitate? The crossroads of ethical decision-making in resuscitation in the emergency department.

Emergency physicians (EPs) working in low-resource settings, where patients mainly bear the cost of healthcare delivery, face many challenges. Emergency care is patient-centered and ethical challenges are numerous in situations where patient autonomy and beneficence are fragile. This review discusses some of the common bioethical issues in the resuscitation and postresuscitation phases of treatment. Solutions are proposed and the necessity for evidence-based ethics and unanimity on ethical standards is emphasized. After a consensus was reached on the structure of the article, smaller groups of authors (2-3) wrote narrative reviews of ethical issues such as patient autonomy and honesty, beneficence and nonmaleficence, dignity, justice, and specific practices and circumstances such as family presence during resuscitation after discussions with senior EPs. Ethical dilemmas were discussed, and solutions were proposed. Cases related to medical decision-making by proxy, financial constraints in management, and resuscitation in the face of medical futility have been discussed. Solutions proposed include the early-stage involvement of hospital ethics committees, financial assurance in place beforehand, and allowing some leverage on a case-to-case basis when care is futile. We recommend developing evidence-based national ethical guidelines and incorporating societal and cultural norms with autonomy, beneficence, nonmaleficence, honesty, and justice principles.

An Observational Study to Evaluate the Effectiveness of Rivaroxaban in the Management of Cerebral Venous Sinus Thrombosis.

Background and objectives Cerebral venous sinus thrombosis (CVST) is a relatively rare and underdiagnosed type of stroke. Rivaroxaban is licensed for venous thromboembolism in patients opting for elective knee and hip replacement surgeries, preventing pulmonary embolism and precluding stroke and systemic embolism in sufferers of non-valvular atrial fibrillation. Beneficial outcomes depicting the efficacious role of rivaroxaban in treating CVST are under study. Materials and methods We performed a prospective observational study in patients diagnosed with CVST in the medicine or neurology unit of a tertiary care hospital in Karachi, Pakistan, between January 2019 and December 2019. The diagnosis of CVST was made by magnetic resonance venography (MRV) in all the cases. Follow-up visits were scheduled at three months and six months, and the occurrence of thrombotic events or bleeding complications was recorded. Follow-up was done by magnetic resonance imaging at three and six months to assess vessel recanalization. Excellent outcome was defined as a modified Rankin Scale (mRS) of 0 or 1. A total of 31 patients were meeting the inclusion criteria and were inducted into the study after informed consent. Results The mean age of the study population was 35.11 ± 8.96 years with 71% females and 29% males. The most prevalent etiology was the pregnancy/postpartum period (52%) followed by antiphospholipid syndrome (23%). The frequent clinical manifestations were headache (84%) followed by vomiting (38%), altered level of consciousness (35%), focal deficit/limb weakness (32%), aphasia (29%), blurring of vision (26%), and seizures (23%). Radiological studies showed that the vessels chiefly occluded in our study were superior sagittal sinus (29%), transverse sinus (23%), sigmoid sinus (16%), jugular vein (9%), and cortical veins (3%). Common features on magnetic resonance imaging (MRI) were cerebral edema (45%), hemorrhage (39%), infarct incidence (32%), and raised intracranial pressure (26%). Clinical outcomes showed 55% of patients had partial recanalization and 39% had complete recanalization after a period of six months of the administration of rivaroxaban. Ninety-three percent (93%) of sufferers recovered excellently according to mRS and only 3% developed recurrent CVST within a span of six months. The frequency of thrombotic events and bleeding complications were reported in 6% of patients, respectively, while mortality reported was also 6%. Conclusion Rivaroxaban has shown promising results in the management of our CVST patients, hence, it further warrants randomized controlled trials of rivaroxaban against conventional treatments to prove its significant role.

Frequency of Comorbidities in Admitting COVID-19 Pneumonia Patients in a Tertiary Care Setup: An Observational Study.

Background The novel coronavirus disease 2019 (COVID-19) is a highly infectious and pandemic disease with a variable mode of action. Patients with underlying illnesses such as diabetes, hypertension, and other diseases are more prone to infection. An understanding of the different comorbidities that place patients at the highest risk of COVID-19 pneumonia and other fatal complications associated with COVID-19 is necessary for healthcare professionals. This study aimed to determine the frequency of different comorbid illnesses among COVID-19 patients admitted to a tertiary care hospital in Karachi, Pakistan. Methodology All patients diagnosed with COVID-19 who required admission for the care of their symptoms were included in this observational, cross-sectional study conducted from May 1 to July 30, 2020. The patients were treated at a specialized COVID-19 isolation ward built at the Dow University of Health Sciences at the Ojha campus. The patients were referred from the emergency department, medical and allied wards, and COVID-19 screening units. A detailed history and clinical examination were performed, and comorbidities were evaluated. Results A total of 212 patients were admitted during the study with a mean age of 52 ± 16 years. The study population consisted of 120 (56.6%) males and 92 (43.39%) females, and the most common comorbidities were uncontrolled diabetes with hypertension (n = 56; 26.4%), controlled diabetes (n = 22; 10.37%), obstructive airway disease (n = 16; 7.5%), and interstitial lung disease (n = 14; 6.6%). A total of 48 (22.64%) patients had no comorbidities. Conclusions Most COVID-19-positive patients with pneumonia were male, and common comorbidities included uncontrolled diabetes, hypertension, and obstructive and restrictive lung disease. The presence of comorbidities was associated with a marked increase in the risk of morbidity and mortality. Further studies are warranted to confirm these findings.

A Rare Case of Hyperglycemic-Hemichorea in a Young Patient.

Chorea is an abnormal, nonrhythmic, and purposeless movement of limbs. There is a long list of diseases responsible for chorea; long-standing hyperglycemia can sometimes result in it, which typically manifests on one side of the body. MRI brain is an added diagnostic tool, which commonly shows hyperintense basal ganglia lesion on T1-weighted images. Chorea in the context of hyperglycemia is a reversible and infrequent occurrence, best managed with insulin and haloperidol combination therapy. Here, we discuss a patient with hyperglycemic-hemichorea, whose symptoms resolved completely within two months of taking insulin and haloperidol.

The Frequency of Catamenial Epilepsy in Female Epileptic Patients of Reproductive Age Group Presented to the Tertiary Care Hospital.

Background and aim Catamenial epilepsy is the type of seizures during the reproductive phase of menstruation due to hormonal changes during the different phases of menstruation. This study aims to evaluate the frequency of epileptic seizures in women during the menstruation cycle and its management. Material and methods This study was conducted at the neurology department of Jinnah Postgraduate Medical Centre (JPMC), Karachi, Pakistan. The study's duration was six months, from the 22nd of January 2020 to the 22nd of July 2020. The sample size for catamenial epilepsy in female epileptic patients of reproductive age was 78%. After approval by the ethical committee of JPMC, data collection started. Data was collected and analyzed in the Statistical Package for the Social Sciences (SPSS, version 22; IBM Inc., Armonk, USA). Mean, and the standard deviation was calculated for age, duration of epilepsy, duration of antiepileptic, and antiepileptic drug. A Chi-square test was applied, and p≤0.05 was considered a statistically significant difference. Results A total of 184 female patients of reproductive age were selected for this study. The mean duration of epilepsy was 15.96 ± 8.85 months. The mean duration of antiepileptic drugs was 11.16 ± 7.53 months. In 73 patients (39.7%), EEG showed increased seizure activity during particular phases of the menstrual cycle. Catamenial epilepsy was seen in 73 patients (39.7%). The stratification according to age, duration of epilepsy, duration of antiepileptic drugs, the antiepileptic drug was done to observe the effect of these modifiers on catamenial epilepsy. Conclusion Catamenial epilepsy is relatively common epilepsy. The physician should evaluate patients when the seizures are refractory to the treatment. The females should manage a seizure diary, which will be beneficial in the management of epilepsy. In women with epilepsy, catamenial epilepsy should be considered in the diagnosis when the seizures are refractory to optimal treatment.

Frequency of Neurological Presentations of Coronavirus Disease in Patients Presenting to a Tertiary Care Hospital During the 2019 Coronavirus Disease Pandemic.

Background Coronavirus disease 2019 (COVID-19), caused by infection with the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), usually presents clinically with cough, fever, shortness of breath, and loss of taste and/or smell. COVID-19 can also present with neurologic signs and symptoms, including headache, hyposmia/anosmia, encephalopathy, meningoencephalitis, Guillain-Barré syndrome, stroke, and seizure. Viral transmission occurs through aerosols generated when an infected person coughs, sneezes, or exhales and by direct touching of contaminated surfaces. The present study evaluated the frequency of neurologic presentations of coronavirus disease in patients presenting at a tertiary care hospital during the COVID-19 pandemic. Methodology This cross-sectional study included 350 inpatients and outpatients (self-isolated) with polymerase chain reaction-confirmed SARS-CoV-2 infection who presented at Dow International Medical College of Karachi between March and June 2020. Of these 350 patients, 68 (18.9%) presented with neurological signs and symptoms and were further evaluated. The data were analyzed statistically using IBM Statistical Product and Service Solutions (SPSS) for Windows, version 20.0 (IBM Corp., Armonk, NY). Results The 350 patients with SARS-CoV-2 infection included 245 (70%) men and 105 (30%) women; of these, 262 (74.9%) were married, and 88 (25.1%) were unmarried. Patients ranged in age from 17 to 88 years (mean ± standard deviation, 49.5 ± 17.4 years), with 68 (18.9%) having neurological manifestations. Headache was the most frequent neurological symptom, reported in 21 (6%) patients, followed by vertigo in 12 patients (3.4%), numbness/paresthesia in 11 (3.1%), altered level of consciousness in seven (2%), hyposmia/anosmia in five (1.4%), and encephalitis in three (0.9%). Other symptoms included sudden hemiparesis (stroke) in two patients (0.6%), flaccid paralysis due to Guillain-Barre syndrome in one (0.3%), and seizure in one (0.3%). Conclusion Neurological involvement is not infrequent in patients with COVID-19. Neurologic manifestations should be carefully monitored in infected patients. COVID-19 should be suspected in patients presenting with neurological abnormalities and should be included in the differential diagnosis to prevent further virus transmission.