Challenging diagnosis of IgM multiple myeloma.

IgM monoclonal gammopathies such as IgM myeloma and Waldenström macroglobulinaemia are distinct haematological conditions; however, differentiating between these entities can often present as a challenge.In this review, we explore the challenging diagnosis and treatment of IgM myeloma in a patient presenting with unexplained macrocytic anaemia, elevated serum protein and IgM levels in the absence of t(11;14) and lytic bone lesions that are classically associated with the diagnosis of IgM myeloma. The diagnosis was established based on 40% monoclonal plasma cell population on a bone marrow biopsy, gain of 1q21 on fluorescence in situ hybridisation, cyclin D1 positivity and absence of MYD88 mutation.

Implementation of an Intelligent Exam Supervision System Using Deep Learning Algorithms.

Examination cheating activities like whispering, head movements, hand movements, or hand contact are extensively involved, and the rectitude and worthiness of fair and unbiased examination are prohibited by such cheating activities. The aim of this research is to develop a model to supervise or control unethical activities in real-time examinations. Exam supervision is fallible due to limited human abilities and capacity to handle students in examination centers, and these errors can be reduced with the help of the Automatic Invigilation System. This work presents an automated system for exams invigilation using deep learning approaches i.e., Faster Regional Convolution Neural Network (RCNN). Faster RCNN is an object detection algorithm that is implemented to detect the suspicious activities of students during examinations based on their head movements, and for student identification, MTCNN (Multi-task Cascaded Convolutional Neural Networks) is used for face detection and recognition. The training accuracy of the proposed model is 99.5% and the testing accuracy is 98.5%. The model is fully efficient in detecting and monitoring more than 100 students in one frame during examinations. Different real-time scenarios are considered to evaluate the performance of the Automatic Invigilation System. The proposed invigilation model can be implemented in colleges, universities, and schools to detect and monitor student suspicious activities. Hopefully, through the implementation of the proposed invigilation system, we can prevent and solve the problem of cheating because it is unethical.

Early postoperative arrhythmias after pediatric congenital heart disease surgery: a 5-year audit from a lower- to middle-income country.

BACKGROUND: Arrhythmias are known complication after surgery for congenital heart disease (CHD). This study aimed to identify and discuss their immediate prevalence, diagnosis and management at a tertiary care hospital in Pakistan. METHODS: A retrospective study was conducted at a tertiary care hospital in Pakistan between January 2014 and December 2018. All pediatric (<18 years old) patients admitted to the intensive care unit and undergoing continuous electrocardiographic monitoring after surgery for CHD were included in this study. Data pertaining to the incidence, diagnosis, and management of postoperative arrhythmias were collected. RESULTS: Amongst 812 children who underwent surgery for CHD, 185 (22.8%) developed arrhythmias. Junctional ectopic tachycardia (JET) was the most common arrhythmia, observed in 120 patients (64.9%), followed by complete heart block (CHB) in 33 patients (17.8%). The highest incidence of early postoperative arrhythmia was seen in patients with atrioventricular septal defects (64.3%) and transposition of the great arteries (36.4%). Patients were managed according to the Pediatric Advanced Life Support guidelines. JET resolved successfully within 24 hours in 92% of patients, while 16 (48%) patients with CHB required a permanent pacemaker. CONCLUSIONS: More than one in five pediatric patients suffered from early postoperative arrhythmias in our setting. Further research exploring predictive factors and the development of better management protocols of patients with CHB are essential for reducing the morbidity and mortality associated with postoperative arrhythmia.

Does early surgery prevent Postoperative ICU admission after surgery for the fracture of the hip. Nested case control study of 911 patients.

INTRODUCTION: Since most hip fractures are treated surgically, it is imperative to find an optimum fracture-to-surgery time to decrease the potential complications and enhance postoperative outcomes. In comparison to the vast plethora of literature available on surgical delay and its implications on mortality, very little, if any, research is available on the impact of delayed surgery on postoperative ICU admission. The primary objective of our study is to examine the factors influencing post-surgical ICU admission in order to work on preventive strategies to reduce the potential associated morbidity. MATERIAL AND METHODS: Investigators did a nested case control study in a university hospital. A case was defined as a patient who had postoperative ICU admission while controls were patients who did not have postoperative ICU admission after hip fracture surgery. The primary outcome variable was postoperative ICU admission. The exposure variable was defined as the time to surgery which was categorized into two categories; early and late; the early surgery included patients who were operated within ≤ 48 h and the late included patients who had their surgery >48 h. Information on potential confounders including age, type of the procedure and comorbidities were also obtained. Result reported in-line with STROCSS criteria. RESULTS: A total cohort of 1084 hip fracture surgeries were performed from January 2010 to December 2018. After screening for eligibility criteria, 911 patients were eligible for the final simple logistic regression analysis (48 cases and 863 controls). Our exposure variable i.e. time from admission to surgery showed no difference between cases and controls. The odds of being treated with Hemiarthroplasty among cases admitted in ICU was 2.42 times as compared to controls (aOR = 2.42; 95% C.I. 1.21-4.86). CONCLUSION: Our study did not find an association between surgical delay and post-operative ICU admission after accounting for other covariates and potential confounders.

Current Challenges of Digital Health Interventions in Pakistan: Mixed Methods Analysis.

BACKGROUND: Digital health is well-positioned in low and middle-income countries (LMICs) to revolutionize health care due, in part, to increasing mobile phone access and internet connectivity. This paper evaluates the underlying factors that can potentially facilitate or hinder the progress of digital health in Pakistan. OBJECTIVE: The objective of this study is to identify the current digital health projects and studies being carried out in Pakistan, as well as the key stakeholders involved in these initiatives. We aim to follow a mixed-methods strategy and to evaluate these projects and studies through a strengths, weaknesses, opportunities, and threats (SWOT) analysis to identify the internal and external factors that can potentially facilitate or hinder the progress of digital health in Pakistan. METHODS: This study aims to evaluate digital health projects carried out in the last 5 years in Pakistan with mixed methods. The qualitative and quantitative data obtained from field surveys were categorized according to the World Health Organization's (WHO) recommended building blocks for health systems research, and the data were analyzed using a SWOT analysis strategy. RESULTS: Of the digital health projects carried out in the last 5 years in Pakistan, 51 are studied. Of these projects, 46% (23/51) used technology for conducting research, 30% (15/51) used technology for implementation, and 12% (6/51) used technology for app development. The health domains targeted were general health (23/51, 46%), immunization (13/51, 26%), and diagnostics (5/51, 10%). Smartphones and devices were used in 55% (28/51) of the interventions, and 59% (30/51) of projects included plans for scaling up. Artificial intelligence (AI) or machine learning (ML) was used in 31% (16/51) of projects, and 74% (38/51) of interventions were being evaluated. The barriers faced by developers during the implementation phase included the populations' inability to use the technology or mobile phones in 21% (11/51) of projects, costs in 16% (8/51) of projects, and privacy concerns in 12% (6/51) of projects. CONCLUSIONS: We conclude that while digital health has a promising future in Pakistan, it is still in its infancy at the time of this study. However, due to the coronavirus disease 2019 (COVID-19) pandemic, there is an increase in demand for digital health and implementation of health outcomes following global social distancing protocols, especially in LMICs. Hence, there is a need for active involvement by public and private organizations to regulate, mobilize, and expand the digital health sector for the improvement of health care systems in countries.

Charlson comorbidity index predicts postoperative complications in surgically treated hip fracture patients in a tertiary care hospital: Retrospective cohort of 1045 patients.

INTRODUCTION: Hip fractures are of major concern due to the aging population worldwide. Surgery on this vulnerable population carries high risk. Charlson comorbidity index (CCI), has been reported to predict the mortality in these patients. Investigators in this study aimed at studying the prediction effect of CCI on hip fracture surgery complications after controlling other patents' and procedures' related factors. METHODOLOGY: We conducted a retrospective cohort of 1045 patients with hip fractures who were treated surgically at our tertiary care and level 1 trauma Center between 2010 and 2018. Primary exposure was CCI and primary outcome was in-hospital and 30 days postoperative complications (major and minor). Cox proportional algorithm analysis was done at univariate and multivariable levels to report Crude Relative Risk (RR) and Adjusted Relative Risk (aRR), respectively. Results were reported in line with STROBE criteria. RESULTS: Exposed group included 867 (83%) of patients with 340 (39%) males. Postoperative complications occurred in 449 (43%) of the patients in exposed group with (62) 6% patients admitted in ICU postoperatively. At multivariable model, CCI was significantly associated with postoperative complications; patients with moderate-severe systemic diseases were 1.45 times (95% CI: 1.05-1.99) at risk of developing postoperative complications as compared to patients with low CCI scores after controlling for other variables in the model. Other significant factors included ASA status and postoperative ICU admission. CONCLUSION: CCI can be a good predictor independent variable of postoperative complications after hip fracture surgery. These patients need extra care and counseling to reach an informed decision keeping in mind the benefits versus risks of surgery. We recommend multi-center studies for corroboration.

Seasonal influence on postoperative hip fracture complications: Retrospective cohort of more than 1000 patients from a tertiary-care university hospital.

BACKGROUND: Hip fractures account for one of the most debilitating conditions affecting the general population amongst the developed and developing nations. Investigators aimed to study the influence of the ongoing season i.e. whether patients operated upon in summer or winter, on post-operative complications occurring within 30 days of surgical procedure for hip fractures at a tertiary care hospital and level 1 trauma center. MATERIALS AND METHODS: Investigators conducted a non-funded, non-commercialized retrospective cohort of 1045 patients with hip fractures managed surgically. Primary exposure was surgical procedures undertaken during the summer months (April-September). Our primary outcome was determining post-operative complication rates from January 2010 to December 2018 and evaluating impact of the season through univariate and multivariable regression analyses using Cox Proportional Hazard Algorithm with STATA V15. The work has been reported in line with the STROCSS criteria. RESULTS: Age, ASA status, type of procedure, mechanism of injury and Charlson Comorbidity Index (CCI) were identified as significant associated factors with postoperative complications after hip fracture surgery. Although overall results revealed a rising rate of complications during the summer season with a relative risk (RR; 95% CI) of 1.1(0.89-1.32), univariate and multivariable analysis did not show any significant correlations. CONCLUSIONS: The results of this study did not demonstrate a significant seasonal variability in the rate of postoperative complications for hip fracture patients operated upon during the hot months of summer. More research is required to analyze postoperative complications in order to optimize patients' outcomes.

Do new trainees pose a threat to postoperative complications after hip fracture surgeries? Retrospective cohort of 1045 patients over a decade at a university hospital.

INTRODUCTION: Induction of new residents and surgical trainees in most institutes occurs once a year. Fresh residents with no experience, may pose a threat to the surgical procedure outcome and there can be a potential increase in patients' morbidity and mortality as a result of this turnover. Literature is inconclusive about this effect. Our aim was to study the "new residents' induction effect" on postoperative complications after hip fracture surgeries. METHODOLOGY: This is non funded non commercialized study from a university hospital. Investigators studied a retrospective cohort of 1045 adult hip fracture patients who were operated at our tertiary care and level 1 trauma centre of a metropolitan city between 2008 and 2018. We defined primary exposure as the time period of new resident's induction (January-March) with the primary outcome in-hospital and 30days postoperative complications. Cox proportional hazard algorithm analysis was done at univariate and multivariable levels reporting Crude Relative Risk (RR) and Adjusted Relative Risk (aRR), respectively. Results were reported in line with STROBE criteria. RESULTS: There were 274 (26%) patients in exposed group out of whom 109 (40%) developed postoperative complications. Interestingly, patients who had their surgeries during the induction period of new residents had 8% less risk of developing postoperative complications. However, result was statistically insignificant at both univariate and multivariable levels with RR; 95% C.I of 0.9 (0.78-1.22) and aRR; 95% C.I of 0.9 (0.78-1.22) after adjusting for the all other independent variables. CONCLUSION: The association of new residents' induction on postoperative hip fracture surgery complications, although protective, was insignificant after controlling for the potential confounding effect of patients' background and demographic characteristics. We recommend further multi-centre high powered studies to analyze this.

Case Report: Novel Coronavirus-A Potential Cause of Acute Pancreatitis?

A 32-year-old medical practitioner presented to the emergency department with complaints of severe abdominal pain, fever, and vomiting, 1 week after the diagnosis of COVID-19. The patient did not report any comorbid conditions, alcohol usage, or gallstone disease. Laboratory and radiological investigations revealed the diagnosis of acute pancreatitis. He underwent conservative management and was discharged after 3 days of hospital admission. This case highlights a possible association between COVID-19 and acute pancreatitis, and the need for clinicians to carefully evaluate patients presenting with gastrointestinal complaints during the current pandemic.

Case Report: Diagnosis of COVID-19 versus Tropical Diseases in Pakistan.

A 25-year-old medical student presented in Multan, Pakistan with a high fever, cough, myalgia, and diarrhea consistent with the typical signs and symptoms of novel coronavirus disease (COVID-19). The patient had traveled to high COVID-19-risk areas within Pakistan and had no significant medical and surgical history. Based on nasopharyngeal and oropharyngeal swab testing, the patient was found to be negative for COVID-19. He subsequently developed a diffuse rash and had serology consistent with dengue and measles. The patient was treated symptomatically, and his condition gradually improved over 7 days. This case highlights the high prevalence of many tropical diseases in low-income countries and the need for clinicians to consider alternate diagnoses in addition to testing for COVID-19 during the pandemic.

First Bahraini adolescent with anti-NMDAR-Ab encephalitis.

Anti-N-methyl-D-aspartate-receptor (NMDA-R) encephalitis is a new autoimmune, often paraneoplastic disorder that presents with complex neuropsychiatric symptoms. It was first described in 2007 by Dalmau et al. Our patient presented with headache, behavioral changes and then seizures with hallucinations. She was initially misdiagnosed to have schizophrenia and was prescribed antipsychotics. She deteriorated and developed further seizures with hypoventilation and choreoathetosis. Her blood investigations were positive for mycoplasma IGM. Her CSF studies showed high white cell counts, predominantly lymphocytes, and high anti-NMDA-R titre. Her brain MRI scans showed high tbl2 and FLAIR intensities in the grey and white matter of the left cerebellar hemisphere suggestive of acute disseminated encephalomyelitis. She responded to treatment with antibiotics, multiple antiepileptics, steroids and needed five sessions of plasmapheresis. There was no underlying malignancy on repeated scanning of the abdomen. She needed around one year for full recovery with intensive rehabilitation. The objective of this paper was to highlight the occurrence of this fairly new, challenging, easily missed, not-so-rare form of encephalitis often occurring in the absence of fever.

A new tyrosine hydroxylase genotype with orofacial dyskinaesia.

Tyrosine hydroxylase (TH) deficiency is a rare autosomal recessive and often treatable neurometabolic disorder with variable phenotypes. More than 20 pathological mutations have been identified in patients with TH deficiency. We report the case of a 10-month-old male patient who presented with developmental delay, hypotonia and oculogyric crises to the Salmaniya Medical Complex in Manama, Bahrain. At a later stage, he developed orofacial dyskinaesia and tremors with hyper-reflexia and clonus. A magnetic resonance imaging scan of the brain showed mild atrophy with widened ventricles and genetic testing revealed a novel homozygous mutation (c.938G>T; p.Arg313Leu) in exon 9 of the TH gene. The patient showed a remarkable response to treatment using combined levodopa-carbidopa. In this case, the orofacial dyskinaesia may be a specific clinical association unique to this novel mutation, which is the first to be described in Bahrain and the Middle East.

Angelman syndrome.

Angelman syndrome is characterized by severe mental retardation, absence of speech, bursts of laughter, ataxia, seizure disorder and facial dysmorphism. This report describes the first 3 children with Angelman syndrome from Bahrain. The diagnosis was based on clinical features and confirmed by the presence of microdeletion of 15q11q13 using fluorescence in situ hybridization.