Interatrial Septal Dissection Complicating a MitraClip Procedure.

Left atrial dissection is an exceedingly rare complication of cardiac surgery, with an incidence of 0.16%-0.84%. We report the first case of interatrial dissection and hematoma in association with the MitraClip procedure. Hemodynamically stable patients can be managed conservatively, with echocardiographic imaging, often with resolution of the dissection over the course of weeks. Our patient remained hemodynamically stable and asymptomatic post operation; at 1-month follow-up, echocardiogram showed resolution of the interatrial septal dissection.

Novel Cerebral Protection Technique During Right Transcarotid TAVR in Bicuspid Aortic Stenosis and Porcelain Aorta.

Periprocedural stroke related to transcatheter aortic valve replacement (TAVR) is associated with increased morbidity and mortality. Cerebral embolic protection using the Sentinel device (Claret Medical) has demonstrated reduced rates of stroke during TAVR. However, alternative access such as a transcarotid approach precludes the use of the Sentinel device. We report a case using cerebral embolic protection during a right transcarotid TAVR.

Bi-Atrial Compression Due to Ascending and Descending Aortic Aneurysms.

Aortic aneurysms compressing an atrium causing symptoms are uncommon. We describe a case of bi-atrial compression due to ascending and descending aneurysms leading to dyspnea.

Percutaneous Closure of Two Acquired Aorto-Right Ventricular Fistulae Following Right Ventricular Outflow Tract Surgery.

The present case illustrates the successful transcatheter closure of an unusual double aortic root-to-right ventricular outflow tract fistula utilizing two Amplatzer duct occluders II.

Provider understanding of the 2013 ACC/AHA cholesterol guideline.

BACKGROUND: Providers' understanding of the 2013 American College of Cardiology (ACC)/American Heart Association (AHA) cholesterol guideline in clinical practice is not known. METHODS: We designed a questionnaire, which was administered to internal medicine, family practice, cardiology, and endocrinology providers at 21 venues across the United States. We compared responses between providers in training or practice and between specialists (cardiology and endocrinology) and nonspecialists (internal medicine and family practice). RESULTS: Response rate was 72.1% (543 of 725). About 43% of the providers in training and 48% of those in practice indicated having read the guideline. Almost 50% in each group were unable to identify the 4 statin benefit groups and a large proportion (41% in training and 49% in practice) were not aware of the ≥7.5% 10-year risk threshold for discussion regarding statin therapy. Most (∼85%) were unaware of the 4 outcomes assessed by the 10-year ASCVD risk equation. About 36% of the providers in training and 48% in practice could identify a patient with familial hypercholesterolemia and start a discussion regarding statin therapy. Only 27.6% of the providers in training and 40.4% in practice recommended repeating a lipid panel 6-8 weeks after starting statins in a patient with recent myocardial infarction. Similar gaps were noted when comparing specialists to nonspecialists. CONCLUSION: Most providers do not completely understand the 2013 ACC/AHA cholesterol guideline. As an unintended consequence, providers are moving away from lipid testing to document response and adherence to statin therapy. Efforts are needed to address these gaps.

Large pleural effusions causing cardiac tamponade: a case report and review of the literature.

Hemodynamically significant cardiac tamponade physiology is an uncommon complication of a large pleural effusion. Previous reports have shown that this physiology can be reversed with thoracentesis. We describe a case of a 69-year-old man with multiple cardiac risk factors presenting with decompensated congestive heart failure and unstable angina. A coronary stent was placed in the left anterior descending artery. Two days postprocedure, he became unresponsive and hemodynamically unstable. A chest x-ray (CXR) revealed bilateral large-sized pleural effusions with transthoracic echocardiography demonstrating a small pericardial effusion, large right pleural effusion, and evidence of cardiac tamponade. A right thoracentesis was performed, draining almost 1,000ml of fluid and resulting in a rapid improvement of his hemodynamic profile.

Self-inflicted vertebral artery dissection: a case report and review of literature.

Vertebral artery dissection (VAD) is an important cause of stroke in the young. It can present nonspecifically and may be misdiagnosed leading to adverse consequences. Dissections are usually preceded by trauma or mechanical stress; the vascular stressors may be trivial as this condition has been described in association with manipulation and stretching of the neck. Early recognition of VAD is paramount, as timely initiation of appropriate anticoagulation can be crucial in ensuring full recovery. We present a case of self-inflicted vertebral artery dissection complicated by multiple embolic strokes where early treatment with anticoagulation led to a complete neurological recovery.

A quantitative link between face discrimination deficits and neuronal selectivity for faces in autism.

Individuals with Autism Spectrum Disorder (ASD) appear to show a general face discrimination deficit across a range of tasks including social-emotional judgments as well as identification and discrimination. However, functional magnetic resonance imaging (fMRI) studies probing the neural bases of these behavioral differences have produced conflicting results: while some studies have reported reduced or no activity to faces in ASD in the Fusiform Face Area (FFA), a key region in human face processing, others have suggested more typical activation levels, possibly reflecting limitations of conventional fMRI techniques to characterize neuron-level processing. Here, we test the hypotheses that face discrimination abilities are highly heterogeneous in ASD and are mediated by FFA neurons, with differences in face discrimination abilities being quantitatively linked to variations in the estimated selectivity of face neurons in the FFA. Behavioral results revealed a wide distribution of face discrimination performance in ASD, ranging from typical performance to chance level performance. Despite this heterogeneity in perceptual abilities, individual face discrimination performance was well predicted by neural selectivity to faces in the FFA, estimated via both a novel analysis of local voxel-wise correlations, and the more commonly used fMRI rapid adaptation technique. Thus, face processing in ASD appears to rely on the FFA as in typical individuals, differing quantitatively but not qualitatively. These results for the first time mechanistically link variations in the ASD phenotype to specific differences in the typical face processing circuit, identifying promising targets for interventions.

Legionella pneumonia complicated by myocarditis and torsades de pointes: A case report and review of literature.

Legionella infection most commonly manifests as pneumonia. Extrapulmonarylegionellosis is rare, but the clinical manifestations are often dramatic. Myocardialinvolvementis the most common extrapulmonary manifestation of legionellosis and can result in left ventricular dysfunction. We report a case of Legionellapneumopbila-induced myocarditis and acute left ventricular dysfunction with subsequent development of torsades de pointes (TdP) in a young adult with no other risk factors. Early recognition of this complication is paramount as timely initiation of appropriate antibiotics is crucial to ensure full recovery from this form of reversible carditis.

Antidiarrhoeal and spasmolytic activities of the methanolic crude extract of Alstonia scholaris L. are mediated through calcium channel blockade.

This study was aimed to provide a pharmacological basis to the medicinal use of Alstonia scholaris as an antidiarrhoeal and antispasmodic by using in vivo and in vitro techniques. In the in vivo study the crude extract of Alstonia scholaris (As.Cr), which tested positive for the presence of alkaloids, provided 31-84% protection against castor oil-induced diarrhoea in mice at 100-1000 mg/kg doses, similar to loperamide. In isolated rabbit jejunum preparation, the As.Cr caused inhibition of spontaneous and high K(+) (80 mm)-induced contractions, with respective EC(50) values of 1.04 (0.73-1.48) and 1.02 mg/mL (0.56-1.84; 95% CI), thus showing spasmolytic activity mediated possibly through calcium channel blockade (CCB). The CCB activity was further confirmed when pretreatment of the tissue with the As.Cr (0.3-1 mg/mL) caused a rightward shift in the Ca(++) concentration-response curves similar to verapamil, a standard calcium channel blocker. Loperamide also inhibited spontaneous and high K(+) precontractions as well as shifted the Ca(++) CRCs to the right. These results indicate that the crude extract of Alstonia scholaris possesses antidiarrhoeal and spasmolytic effects, mediated possibly through the presence of CCB-like constituent(s) and this study provides a mechanistic base for its medicinal use in diarrhoea and colic.

Massive fluid requirements and an unusual BUN/creatinine ratio for pre-renal failure in patients with cholera.

BACKGROUND: Cholera is an important infectious cause of secretory diarrhea. The primary symptom of infection is the sudden onset of watery diarrhea with subsequent volume depletion causing renal insufficiency. The objective of this research is to study the level of dehydration at presentation and subsequent fluid management in patients with cholera. METHODS: This study was conducted on 191 patients of Cholera admitted at a tertiary care hospital in Karachi, Pakistan during the period of 5 years. Medical charts were evaluated retrospectively for initial hydration status, baseline lab investigations on admission and discharge and fluid therapy given to all the patients while their stay in the hospital and the data was analyzed on SPSS 15.0. RESULTS: Out of the 191 patients, 83(43%) were males and 108 (57%) were females with mean age of 42.3 years (SD+/-18.34). The average duration of symptoms was 3.75 days (SD+/-2.04). Of 191 patients, 175 (92.1%) presented with dehydration, 80 (42.3%) were given Ringer's Lactate (R/L) + Normal Saline (N/S), 45 (24%) patients were given R/L + N/S + Oral Rehydration Therapy (ORS), 27 (14.3%) of the patients were kept on R/L only and remaining were given various combinations of R/L, N/S, ORS and Dextrose Saline (D/S). On admission mean Blood Urea Nitrogen (BUN) was 24.54 (SD+/-16.6), mean creatinine was 2.47 (SD+/-2.35) and mean BUN/Creatinine ratio was 11.63 (SD+/-5.7). CONCLUSION: Aggressive fluid rehydration remains the cornerstone of management of cholera. Instead of presenting with a classical BUN/Creatinine ratio of >20:1, patients with pre-renal failure in cholera may present with a BUN/Creatinine ratio of <15:1.

Does admission hyperglycemia predict intracranial and extracranial vasculopathy?

OBJECTIVE: To study the association between admission hyperglycaemia and the presence and pattern of intracranial and extracranial vascular disease. METHODS: This retrospective study was conducted at a major tertiary care hospital in Karachi, Pakistan. Patients who had presented with acute stroke and had undergone a carotid ultrasound Doppler of the carotids and/or Magnetic Resonance Angiography (MRA) of the brain were included in the study. A multiple logistic regression analysis of variables was done for an abnormal finding on each investigation. RESULTS: Out of the total of 216 patients, the age of majority of the patients (83.3%) was > 50 years and 134 (62%) were male. One hundred and fourteen patients (52.8%) had admission hyperglyaemia. Multiple logistic regression analysis revealed that increasing age and admission hyperglycaemia (P = 0.045, Odds ratio = 1.9 [95% CI: 1.0-3.6]) were independent predictors of an abnormal finding on a carotid Doppler investigation. Admission hyperglycaemia did not predict the presence of general intracranial vasculopathy but it was significantly associated with focal stenosis as visualized on a MRA. CONCLUSION: Admission hyperglycaemia is associated with large vessel disease manifesting itself in the carotids as plaques and in the intracranial circulation as focal stenosis. Acute stroke patients presenting with admission hyperglycemia would require a more careful investigation for large artery disease especially in the extracranial vessels.

Assessment of asthma control using the asthma control test at a tertiary care centre in Karachi, Pakistan.

The aim of our study was to assess asthma control among asthmatics at a tertiary care setting in Karachi using ACT questionnaire. The ACT questionnaire was filled by known asthmatics in January 2007. A total of 150 questionnaires were filled of which, 61 (40%) were males and 89 (60%) females. Mean ACT score was 17.71 +/- 4.41. Association between sex and asthma control was not statistically significant. Significant association was seen with asthma control and Ipratropium bromide inhaler. Asthma control among patients at a tertiary care centre is moderate. ACT can be used to follow patients in the hospital.

Frequency of endometriosis among infertile women and association of clinical signs and symptoms with the laparoscopic staging of endometriosis.

OBJECTIVE: The study aimed to determine the frequency of endometriosis in women who underwent diagnostic laparoscopy for evaluation of infertility and the association of clinical, ultrasonographic and laparoscopic findings of endometriosis with the laparoscopic stages of the disease. METHOD: It was a retrospective study of women presenting to gynaecologic clinics of the Aga Khan University Hospital from January 1999 to December 2005 with primary complaint of primary or secondary infertility and were diagnosed with endometriosis through laparoscopy. Relevant demographic and clinical information was entered and analyzed in SPSS version 14.0. RESULTS: The frequency of endometriosis in women with primary compliant of infertility was found to be 16.8%. Statistically significant associations was found between staging of the disease and thin built (p=0.007) and restricted uterine mobility on pelvic examination (p=0.035). The patients' ultrasound and laparoscopic examination showed significant association with staging of the disease with the presence of cysts on ultrasound (p-value < 0.0001) and adhesions on laparoscopy (p value <0.00001). CONCLUSION: The variability of the definition and inconsistency in diagnostic methods makes the prevalence of endometriosis difficult to determine and we might underestimate the true burden of the disease. Most of the signs and symptoms of endometriosis do not correlate with the severity (staging) of the disease. Hence, Laparoscopy remains the gold standard for diagnosis as well as staging of endometriosis.

Extrapleural hydatid disease of chest: a case of recurrent hydatid disease.

Hydatid disease is a parasitic infestation by a tapeworm of the genus Echinococcus. We present the case of 34-year-old female who complained of chest pain and had a past history of hydatid cyst resection four times in last 15 years. She was found to have extrapleural hyatid cysts of chest that were removed via thoracotomy. The patient fully recovered and experienced an uneventful follow-up.

Awareness of cancer risk factors among patients and attendants presenting to a tertiary care hospital in Karachi, Pakistan.

OBJECTIVE: To determine awareness of cancer risk factors in the patients and attendants of Out-patient Clinics at a University Hospital in Karachi, Pakistan. METHODS: A cross-sectional survey was conducted on 315 respondents reporting to a tertiary care hospital in Karachi, Pakistan, to assess their level of awareness regarding risk factors of cancer. RESULTS: The respondents belonged to an urban population with the mean time spent in Karachi of 29.1 years (SD +/- 13.94). There were 213 (67%) males and 102 (33%) females. All respondents had heard of the word 'cancer', while only 57.5% were aware of cancer risk factors. However, only 42.8% could identify age, 33% diet, 35% drugs and 31% obesity as risk factors for cancer. Even those who were aware of the risk factors were not able to appreciate personal risk of cancer. CONCLUSION: Despite awareness regarding some of the risk factors, the surveyed population was not aware of intrinsic risk factors for cancers like increasing age and obesity. It is important to create awareness through educational programs on cancer prevention, dissemination of knowledge pertaining to the preventable and avoidable cancer risk factors, the benefits of early diagnosis, and availability of screening tests.

Reducing the rate of primary caesarean sections--an audit.

OBJECTIVE: To evaluate how the implementation of universally acceptable standards affects rates for primary caesarean sections, without compromising maternal or foetal safety. METHODS: A complete audit cycle of all the primary caesarean sections performed in the maternity unit of Aga Khan University was conducted from 1st January to 31st March during years 2003 and 2004. New labour management guidelines were implemented after the first audit (appendix). The rates of caesarean section, induction of labour, failed induction, and maternal and foetal outcomes were compared before and after the implementation of the guidelines. RESULTS: Primary emergency caesarean section rate decreased from 16% to 12%. A reduction in primary caesarean sections was noted in the induced cases. Practice of checking cord blood for foetal pH and maintaining partograms improved markedly. There were no significant adverse maternal and perinatal outcomes. CONCLUSION: Implementation of standard labour management strategies can reduce primary caesarean section rate without compromising maternal and foetal safety.

Rhabdomyosarcoma embryonal type: in a three and a half year old girl.

Rhadomyosarcoma is the most common tumour of the soft tissues in infants and children. We report a case of a 3 1/2 year old girl who presented with a swelling over the neck. Swelling was diagnosed as Rhabdomyosarcoma (embryonal type). Tumour mass was found to be unresectable initially. The patient was subjected to multiple courses of checmotherapy, which shrunk the tumour significantly. There was simultaneous development of cystic lesions in upper lobe of right lung. Excision of the remnant rhabdomyosarcoma mass and biopsy of right lung with cystectomy of right upper lobe cystic lesion was performed. The patient fully recovered and experienced an uneventful 6 months of follow-up.

Extensive primary malignant thymoma involving pericardium, pleura, diaphragm and lungs--a case report.

Malignant thymoma is an extremely rare entity. According to a study, the annual incidence of malignant thymoma was estimated to be 0.15 per 100,000 person-years. We present the case of a 42-year-old female who came to us with a Type AB, Masaoka stage III malignant (invasive) thymoma with widespread involvement of the mediastinum.