Clinical Outcomes Associated With Balloon Aortic Valvuloplasty in the Contemporary Era.

BACKGROUND: Severe aortic stenosis is the most common acquired valvular disorder. Balloon aortic valvuloplasty (BAV) is considered for patients who are not suitable for surgical aortic valve replacement (SAVR) and transcatheter aortic valve insertion (TAVI). The American Heart Association and European Society of Cardiology recommend BAV as a bridging procedure for SAVR and TAVI due to the significant morbidity and mortality associated with it. We aim to investigate the morbidity and mortality associated with BAV only, BAV bridged to TAVI and TAVI-only patients over 3 years in Epworth Richmond, a tertiary hospital in Victoria, Australia. METHODS: We divided patients into three groups including BAV only, BAV bridged to TAVI and TAVI only and assessed the baseline demographics, procedural complications, and mortality between the groups. RESULTS: Of 438 patients, 26 patients underwent BAV only, 36 patients bridged to TAVI post-BAV and 376 patients underwent TAVI directly. All patients had significant reductions in their mean AV pressure gradient (p<0.01). There was no significant difference in periprocedural morbidity and mortality between the groups. At 6-month follow-up, the mortality in patients undergoing only BAV was 31%, compared with 8.3% in BAV bridged to TAVI and 1.9% in TAVI-only group (p<0.01). The 12-month follow-up demonstrated a similar pattern; 42.3% vs 13.9% vs 4.5% (p<0.01). CONCLUSIONS: This study suggests no significant difference in inpatient and periprocedural morbidity and mortality between the three groups but a significant mortality benefit at 6-month and 12-month post valve insertion, either directly or post BAV.

Inborn errors of type I interferon immunity in patients with symptomatic acute hepatitis E.

BACKGROUND AND AIMS: The clinical spectrum of human infection by HEV ranges from asymptomatic to severe acute hepatitis. Furthermore, HEV can cause diverse neurological manifestations, especially Parsonage-Turner syndrome. Here, we used a large-scale human genomic approach to search for genetic determinants of severe clinical presentations of HEV infection. APPROACH AND RESULTS: We performed whole genome sequencing in 3 groups of study participants with PCR-proven acute HEV infection: (1) 24 patients with symptomatic acute hepatitis E; (2) 12 patients with HEV-associated Parsonage-Turner syndrome; and (3) 16 asymptomatic blood donors (controls). For variant calling and annotation, we used GATK4 best practices followed by Variant Effect Predictor (VEP) and Annovar. For variant classification, we implemented the American College of Medical Genetics and Genomics/Association for Molecular Pathology Bayesian classification framework in R. Variants with a probability of pathogenicity >0.9 were considered damaging. We used all genes with at least 1 damaging variant as input for pathway enrichment analyses.We observed a significant enrichment of type I interferon response pathways in the symptomatic hepatitis group: 10 out of 24 patients carried a damaging variant in one of 9 genes encoding either intracellular viral sensors ( IFIH1 , DDX58 , TLR3 , POLR3B , POLR3C ) or other molecules involved in type I interferon response [interferon regulatory factor 7 ( IRF7 ), MYD88 , OAS3 , GAPDH ]. We did not find any enriched pathway in the Parsonage-Turner syndrome group or in the controls. CONCLUSIONS: Our results highlight the essential role of type I interferon in preventing symptomatic acute hepatitis E.

Combined spontaneous coronary artery dissection (SCAD) and Takotsubo syndrome (TTS): a case series.

BACKGROUND: Spontaneous Coronary Artery Dissection (SCAD) and Takotsubo Syndrome (TTS) are two different entities with several shared risk factors, but their management is different. They can co-exist in patients with chest pain which affects their management. We present two cases of combined SCAD and TTS in patients presented with chest pain. CASE PRESENTATION: Case 1: 80F admitted with typical chest pain and dynamic ECG changes on the background of known anxiety/depression and social stresses. Her coronary angiogram showed SCAD affecting distal LAD. The left ventriculogram (LV gram) showed apical ballooning consistent with Takotsubo Syndrome (TTS). Patient was discharged on aspirin as well as angiotensin receptor blocker (ARB). Case 2: 60F admitted with typical chest pain in the setting of emotional trauma on the background of known cardiovascular risk factors. She was found to have ST elevation in inferior leads with no reciprocal changes. Subsequently, coronary angiogram showed SCAD affecting mid-left anterior descending artery (LAD) with normal distal wrap around LAD. Her LV gram showed apical ballooning consistent with TTS. However, transthoracic echocardiogram showed akinetic left ventricular apex. She was discharged on aspirin as well as an ACE inhibitor and warfarin to prevent LV thrombus. CONCLUSIONS: SCAD and TTS can co-exist in patients with chest pain. It is important to identify SCAD in patients with TTS as it may affect their short as well as long-term management.

Transition-metal nitride halide dielectrics for transition-metal dichalcogenide transistors.

Using first-principles calculations, we investigate six transition-metal nitride halides (TMNHs): HfNBr, HfNCl, TiNBr, TiNCl, ZrNBr, and ZrNCl as potential van der Waals (vdW) dielectrics for transition metal dichalcogenide (TMD) channel transistors. We calculate the exfoliation energies and bulk phonon energies and find that the six TMNHs are exfoliable and thermodynamically stable. We calculate both the optical and static dielectric constants in the in-plane and out-of-plane directions for both monolayer and bulk TMNHs. In monolayers, the out-of-plane static dielectric constant ranges from 5.04 (ZrNCl) to 6.03 (ZrNBr) whereas in-plane dielectric constants range from 13.18 (HfNBr) to 74.52 (TiNCl). We show that the bandgap of TMNHs ranges from 1.53 eV (TiNBr) to 3.36 eV (HfNCl) whereas the affinity ranges from 4.01 eV (HfNBr) to 5.60 eV (TiNCl). Finally, we estimate the dielectric leakage current density of transistors with six TMNH bilayer dielectrics with five monolayer channel TMDs (MoS2, MoSe2, MoTe2, WS2, and WSe2). For p-MOS TMD channel transistors 25 out of 30 combinations have a smaller leakage current than hexagonal boron nitride (hBN), a well-known vdW dielectric. The smallest bilayer leakage current of 1.15 × 10-2 A cm-2 is predicted for a p-MOS MoSe2 transistor with HfNCl as a gate dielectric. HfNBr, ZrNBr, and ZrNCl are also predicted to yield small leakage currents in certain p-MOS TMD transistors.

Identification of two-dimensional layered dielectrics from first principles.

To realize effective van der Waals (vdW) transistors, vdW dielectrics are needed in addition to vdW channel materials. We study the dielectric properties of 32 exfoliable vdW materials using first principles methods. We calculate the static and optical dielectric constants and discover a large out-of-plane permittivity in GeClF, PbClF, LaOBr, and LaOCl, while the in-plane permittivity is high in BiOCl, PbClF, and TlF. To assess their potential as gate dielectrics, we calculate the band gap and electron affinity, and estimate the leakage current through the candidate dielectrics. We discover six monolayer dielectrics that promise to outperform bulk HfO2: HoOI, LaOBr, LaOCl, LaOI, SrI2, and YOBr with low leakage current and low equivalent oxide thickness. Of these, LaOBr and LaOCl are the most promising and our findings motivate the growth and exfoliation of rare-earth oxyhalides for their use as vdW dielectrics.

Horner's syndrome secondary to internal carotid artery occlusion.

Horner's syndrome results from interruption of the sympathetic innervation to the eye. This interruption may occur at three anatomical levels along the sympathetic trunk pathway. There are numerous causes of Horner's syndrome, including injury to the carotid artery, of which arterial dissection is the commonest pathology. Occlusive carotid disease secondary to atherosclerosis is a relatively rare cause of Horner's syndrome. We describe a patient with Horner's syndrome due to complete occlusion of the ipsilateral internal carotid artery.

Surgical correction of grade III hypertelorism.

Orbital hypertelorism is an increased distance between the bony orbits and can be caused by frontonasal malformations, craniofacial clefts, frontoethmoidal encephaloceles, glial tumors or dermoid cysts of the root of the nose, and various syndromic or chromosomal disorders. We report a series of 7 cases of hypertelorism that were treated in our hospital. The underlying causes in our series were craniofacial clefts 0 to 14 (4 cases), craniofacial clefts 1 to 12 (1 case), and frontonasal encephalocele (2 cases), all congenital. Surgical techniques used to correct the deformity were box osteotomy and medial wall osteotomy with or without calvarial and rib grafts. A few of our cases were reoperations with specific challenges.

Surgical correction of grade III hypertelorism

Orbital hypertelorism is an increased distance between the bony orbits and can be caused by frontonasal malformations, craniofacial clefts, frontoethmoidal encephaloceles, glial tumors or dermoid cysts of the root of the nose, and various syndromic or chromosomal disorders. We report a series of 7 cases of hypertelorism that were treated in our hospital. The underlying causes in our series were craniofacial clefts 0 to 14 (4 cases), craniofacial clefts 1 to 12 (1 case), and frontonasal encephalocele (2 cases), all congenital. Surgical techniques used to correct the deformity were box osteotomy and medial wall osteotomy with or without calvarial and rib grafts. A few of our cases were reoperations with specific challenges.

Efficacy of newly formulated ointment containing 20% active antimicrobial honey in treatment of burn wound infections.

BACKGROUND: Honey has been familiar to possess antimicrobial potential to clear infection against burn wound infecting bacteria since ancient times. The objective of the study was to evaluate the efficacy of the newly formulated honey ointment during the treatment of burn wound infections. The Experimental (Non comparative) study was conducted at outpatient department of Dermatology, Fauji Foundation Hospital, Rawalpindi from November 2009 to October 2010. METHODS: The antimicrobial activity of different Pakistani floral sources (Acacia nilotica species indica, Zizyphus, Helianthus annuus and Carisa opaca) honey samples were investigated by disc diffusion method against freshly isolated burn wounds infecting bacteria. Ointment containing 20% active antimicrobial honey was formulated as a sovereign remedy. A total number of twenty patients with second degree of burn wounds on different parts of the body were studied. A thin layer of honey ointment on gauze was applied to the wounds two to three times a day up to the complete healing. RESULTS: During microbiological study, Pakistani honey samples were discovered to exhibit a very promising antimicrobial activity against all the wound infecting microorganisms tested. Clinical trials demonstrated that the topical application of honey ointment have significant control of infections arising form pathogenic bacteria and up to 100% healing results were observed in all burn wound cases within mean healing time for the duration of 8.15 (3-18) days time period. CONCLUSION: Newly formulated ointment containing 20% active antimicrobial honey is more effective and low-cost alternative preparation for the treatment of burn wound infections.

The initial presentation of systemic lupus erythematosis with aplastic anemia successfully treated with rituximab.

Hematologic disorders are common in autoimmune diseases. First presentation of systemic lupus erythematosis with aplastic anemia is extremely rare. We report a patient with the diagnosis of secondary aplastic anemia associated with lupus. All routine medications were not effective. She received Rituximab and her response was satisfactory. Her hematologic parameters were within normal range until last follow-up, six months after therapy was initiated with Rituximab. Review of literature displayed 23 cases of acquired aplastic anemia secondary to systemic lupus erythematosis; however, this is the first time the new drug therapy was used for the treatment.

'Honey ointment': a natural remedy of skin wound infections.

BACKGROUND: Honey is a gift of nature, principally identified and valued to possess antimicrobial and anti-inflammatory activity and has been used as a natural remedy of wounds since ancient times. The objectives of this study were to evaluate the antimicrobial activity of honey against micro-organisms, to formulate a honey ointment and to evaluate the efficacy of such ointment by conducting clinical trials on skin wound infection. METHODS: This experimental study was conducted at Department of Pharmaceutics, Faculty of Pharmacy, University of Karachi and Out-patient Department of Dermatology, Fauji Foundation Hospital, Rawalpindi from November 2009 to October 2010. The antimicrobial activity of Pakistani floral sources (Trachysperm copticum, Acacia nilotica species indica, Zizyphus) honey samples was investigated by disc diffusion method against freshly isolated wound infecting bacteria (Staphylococci aureus, Staphylococci epidermidis, Streptococcus faecalis, Pseudomonas aeruginosa, Klebsiella pneumonia, Escherichia coli, Proteus vulgaris and Candida albicans), and Staphylococci aureus ATCC 6538, Pseudomonas aeruginosa ATCC 9022, Escherichia coli ATCC 25922, Candida albican ATCC 15146. An ointment containing 20% active antimicrobial honey was formulated. The efficacy of such ointment was evaluated by passing thought clinical trials. A total number of 27 patients (23 skin wound infection, and 4 diabetic foot ulcer) were involved in the study. Thin layer of newly formulated honey ointment on gauze were applied two to three times per day till complete healing. RESULTS: In microbiological assay the honey samples were found to exhibit a very promising antimicrobial activity against all the micro-organisms tested. In clinical trial very significant results (99.15%) healing was observed in skin wound infections cases with mean healing time of 5.86 (2-20) days, and 95% diabetic foot ulcers healed with the mean healing time of 20 (8-40) days. CONCLUSION: Newly formulated ointment containing 20% active antimicrobial honey is very effective and alternative low-cost product for the treatment of wound infections.

Impact of clinical skill lab on students' learning in preclinical years.

BACKGROUND: As 1st year students have no prior training in handling and facing patients, Clinical Skill Lab (CSL) is the most suitable place to avoid direct doctor/patient interaction. The objective of this study was to evaluate the performance of recently established CSL and its impact on student learning in basic science subjects. METHODOLOGY: This study was carried out at the Departments of Physiology and Medical Education, Foundation University Medical College Islamabad, from January to October 2012. In this observational study, 150 of 1st year students were divided into 5 batches. Each batch attended clinical skill lab once a week. Each batch was subdivided into 6 batches of 5 students each to be facilitated by one postgraduate trainee from clinical subjects. Overall supervision was done by a consultant of status of Assistant Professor qualified to teach Medicine, Surgery and/or Physiology. Sessions were conducted for 2 hours daily (6 days a week) in which after an initial briefing, students were taught the communication skills, clinical skills and art of history taking and physical examination. Clinical integration of various modules taught in 1st year, i.e., skin, muscle and skeletal system (SMS), upper limb and breast, immunity and haematology, respiratory and cardiovascular modules was done from January to October 2012. Methods of teaching involved large group interactive sessions, small group interactive sessions, self-directed learning, tutorials, revision on computer and recordings of sessions given to students on flashes. Multiple choice questions and observed structured clinical examination were the main assessment tools. Combined assessment of 2 consecutive modules was done at the end of 2nd module making a total of 3 assessments for 1st year. Absentees were included in failures in view of impact of end of modules examinations on overall final assessment. RESULTS: More than 73% students passed examination of clinical skills securing more than 50% marks in each module. Overall impact of CSL was also seen in the subjects of Anatomy and Physiology. Result of purely anatomy SMS and breast modules increased from 64% (year 2011 class) to 79% (year 2012 class). Result of purely Physiology modules (Immunity and Haematology) increased from 77% (year 2011 class) to 94% (year 2012 class). Similarly Respiratory and Cardiovascular modules result improved from 68% to 90.5%. CONCLUSION: The performance of CSL in imparting clinical skills, communication skills, history taking and physical examination was satisfactory. The experience of integrating clinical teaching with basic sciences not only improved students' clinical experience reflected by evaluation, but was also rewarding in improving the results of various modules related to anatomy and physiology.

Effects of combined interferon alpha and ribavirin therapy on thyroid functions in patients with chronic hepatitis C.

OBJECTIVE: To determine the frequency of thyroid dysfunction in patients of chronic hepatitis C during treatment with interferon alpha-2b and ribavirin therapy. STUDY DESIGN: A cohort study. PLACE AND DURATION OF STUDY: Army Medical College and Military Hospital, Rawalpindi, from February 2006 to January 2007. METHODOLOGY: One hundred and sixty seven non-cirrhotic chronic hepatitis C patients were grouped into treatment group (n=107) and control group (n=60) awaiting treatment. Baseline serum(s.) Alanine Transferase (ALT) and S. Aspartate Transferase (AST) were measured by IFCC method. Serum Thyroid Stimulating Hormone (S. TSH), serum free thyroxine (S. Free T4) and serum total triiodothyronine (S.T3) level were determined by chemiluminescence. Study group patients underwent 24 weeks IFN and ribavirin therapy and were followed-up for thyroid dysfunction at weeks 0, 12 and 24. Control group patients underwent the same tests at weeks 0, 12 and 24. Statistical analysis was done on SPSS 15. RESULTS: Out of 107 patients of treatment group, 20 patients (18.69%) developed thyroid dysfunction. Females were at higher risk with Relative Risk (RR) of 11.25 and Attributable Risk (AR) of 91%. Hypothyroidism was more common than hyperthyroidism. CONCLUSION: Interferon-alpha and ribavirin therapy induces thyroid dysfunction in chronic hepatitis C patients. Hypothyroidism was more common. Females are at a higher risk of developing thyroid dysfunction.