Racial Impact on Inpatient Stroke Quality of Care in Two Community Hospitals.

INTRODUCTION: This analysis was conducted as a part of a quality improvement project aiming at identifying racial disparity in inpatient stroke quality of care. METHODS: The Get With The Guidelines (GWTG) database was used to identify all patients discharged with any stroke diagnosis between January and December 2021. An additional chart review was conducted to ensure the accuracy of racial/ethnic categorization. The sample was dichotomized into white vs. non-white groups and compared with univariate analysis. RESULTS: The study sample comprised 1408 encounters (1347 patients) with Mean age of 71 ± 15 years, 51% women, 82% white patients, 15% non-white patients, 72% acute ischemic stroke (AIS); 15% transient ischemic attack (TIA), 9% intracerebral hemorrhage (ICH), 3% subarachnoid hemorrhage (SAH), and 1% stroke not otherwise specified. Non-white patients were younger and had fewer concomitant diagnoses, a lower proportion of TIA, and a higher proportion of ICH (p = 0.004). In the AIS cohort, compared to white patients, non-white patients had less frequent ambulance (p = 0.009), arrived at the hospital later than white patients (7.7 h longer; p < 0.001), had more severe strokes, and had less frequent IV thrombolysis utilization (7% vs. 13%; p = 0.042). Similarly, in the TIA cohort, non-white patients' utilization of EMS was lower than that of white patients, and their hospital arrival was delayed. In the ICH cohort, non-white patients were younger and had a lower frequency of atrial fibrillation and a non-significant trend toward higher disease severity. The SAH cohort had only eight non-white patients, six of whom were transferred to a higher level of hospital care within a few hours of arrival. Importantly, the hospital-based quality metrics, such as door-to-CT time, door-to-needle time, and the Joint Commission stroke quality metrics, were similar between the two groups. CONCLUSIONS: There is a racial disparity in the pre-hospital phase of the stroke chain of survival of non-white patients, impacting IV thrombolysis utilization. The younger age and worse lipid profile and hemoglobin A1c of non-white patients suggest the need for better preventative care starting at a young age.

Usefulness of neutrophil-to-lymphocyte ratio as a predictor of functional outcome in patients with acute ischemic stroke after thrombolysis therapy.

In stroke patients, a high neutrophil-to-lymphocyte ratio (NLR) has been associated with poor functional outcome at 3 months, higher mortality, and a higher hemorrhagic transformation. We assessed the role of NLR in patients with acute ischemic stroke who received thrombolysis. The charts of 98 patients treated between 2015 and 2019 were retrospectively reviewed. The mean NLR was compared using an independent Student's t test. At 3 months, a good functional outcome was seen in 31 patients (32%) and a poor functional outcome was seen in 67 patients (68%). Patients with NLR >2.39 had a poor functional outcome (odds ratio 2.7; 95% confidence interval 1.11-6.39; P < 0.02). Our study revealed that patients who present with acute ischemic stroke and have an increased NLR at the time of administration of thrombolysis have a poor functional outcome at 3 months.

Comparison of High-Resolution Computed Tomography and Real-Time Reverse Transcriptase Polymerase Chain Reaction in Diagnosis of COVID-19 Pneumonia in Intensive Care Unit Population.

Introduction The efficacy of high-resolution computed tomography (HRCT) chest in common respiratory infections is well-established; however, its use in the diagnosis of COVID-19 pneumonia is less popular. The previous studies have failed to establish the efficacy of HRCT in the diagnosis of COVID-19 pneumonia. Objective The current study aimed to assess the efficacy of HRCT as compared to a polymerase chain reaction (PCR) in diagnosing COVID-19 pneumonia in patients in our setting. Methodology A prospective observational study was conducted at the Department of Chest Medicine, Shifa International Hospital from April 2020 to December 2020. A total of 250 patients were admitted to medical intensive care units. Findings of HRCT and PCR were documented. The accuracy of HRCT compared with PCR was assessed. Data were analyzed using SPSS version 24 (IBM Corp., Armonk, NY). Results COVID-19 infection was more prevalent in male patients (62.8% vs 37.2%). The mean age was 60 years (interquartile range, IQR, 49-72). Sensitivity and specificity of HRCT segregated into typical, indeterminate, and atypical HRCT were (94.8%, 56.8%), (92.7%, 47.2%), and (91.7%, 76.8%), respectively. The positive predictive value for typical HRCT was 84.3% (p≤0.001). Conclusion We concluded that typical HRCT findings have diagnostic utility in the diagnosis of COVID pneumonia. Similarly, a negative HRCT chest reliably excludes the possibility of COVID pneumonia. HRCT chest is a reliable alternative to RT-PCR.

A Rare Case of Paroxysmal Nocturnal Hemoglobinuria With Bilateral Renal Vein Thrombosis.

Paroxysmal nocturnal hemoglobinuria (PNH) is an acquired hematopoietic stem cell (HSC) disorder characterized by a partial or complete deficiency of glycosyl-phosphatidylinositol (GPI)-linked membrane proteins, which leads to intravascular hemolysis. The loss of CD55 and CD59, two GPI-anchored proteins on red blood cell surfaces, from mutations in the X-linked phosphatidylinositol glycan class A (PIGA) gene, causes unrestricted proliferation of complement activation. The loss of CD59 especially leads to 'paroxysms' of acute intravascular hemolysis during events of stress. Extravascular hemolysis also occurs without CD55 as the accumulation of C3 on red blood cell surfaces leads to their destruction by the reticuloendothelial system. Diagnosis of PNH relies primarily on clinical presentation and flow cytometry assays used to detect the GPI-anchored proteins, CD55 and CD59; however, fluorescein-labeled proaerolysin variant (FLAER) is seen to have a significant advantage over CD55 and CD59. Typical symptoms of the disorder include fatigue, shortness of breath, hemoglobinuria, abdominal pain and bone marrow failure. Thrombosis also occurs secondary to nitric oxide (NO) deficiency, release of procoagulants, increased tissue factor and reduced fibrinolysis. The classification of PNH is subdivided into three types: classical, PNH with another bone marrow disorder and subclinical PNH. Management of hemolysis, thrombosis and pancytopenia is based on the pathogenesis involved. Inhibition of complement in the form of humanized monoclonal antibody against complement C5 (eculizumab) is seen as an emerging treatment option, while stem cell/bone marrow transplant may also be offered. We present a rare case of PNH with bilateral renal vein thrombosis, who was diagnosed with classical PNH on clinical presentation and flow cytometry. He was initially offered bone marrow transplantation but was lost to follow-up and later presented with bilateral renal vein thrombosis. He was managed conservatively with transfusions and anticoagulation, and was discharged for follow-up on an outpatient basis.

A Rare Case of Acute Transverse Myelitis (ATM) and Acute Motor and Sensory Axonal Neuropathy (AMSAN) Overlap.

Concomitant acute transverse myelitis (ATM) and Guillain-Barre syndrome (GBS) is described as GBS and ATM overlap. Its presentation varies greatly, thus making the diagnosis difficult. Overlap syndrome is more commonly associated with acute motor axonal neuropathy (AMAN) subtype of GBS. However, we present a case of a middle-aged gentleman with combined ATM and acute motor and sensory axonal neuropathy (AMSAN) subtype of GBS. This combination is quite rare, and only a few cases have been reported so far.

A Rare Coincidence of Measles with Typhoid Fever.

Typhoid, otherwise known as enteric fever, and measles both have a high incidence worldwide. However, a coincidence of both has been only documented twice previously in 1866 and 1949. We present a case of a 24-year-old male who presented with high-grade fever and diffuse abdominal tenderness. He was diagnosed with typhoid initially, but during the course of his illness, he developed a maculopapular rash and pathognomonic Koplik's spots. Further investigations confirmed measles that was concurrent with typhoid. This highlights the importance of further comprehensive investigations even in diagnosed cases, and that overlapping symptoms should raise the clinical suspicion of concurrent diseases. One should always keep an open mind when assessing a patient, not just at the time of making a diagnosis but throughout the course of illness.

A Unique Case of Acute Cerebral Venous Sinus Thrombosis Secondary to Primary Varicella Zoster Virus Infection.

Primary varicella zoster virus (VZV) infection, predominantly in the pediatric population, presents with pyrexia and a classic pruritic vesicular rash. In adults, although less common, it is more severe and linked to more complications. Neurological complications, which account for less than 1% of all VZV complications, include meningitis, encephalitis, arterial vasculopathy, and venous thrombosis. We present a case of a 39-year-old male who developed extensive cerebral venous sinus thrombosis following primary VZV infection. Venous thrombosis in VZV has been suggested to be caused by autoantibodies against protein S, pre-existing hypercoagulability, or endothelial damage. The patient was acutely managed using intravenous acyclovir and heparin. Long-term anticoagulation therapy with warfarin was continued after discharge. We concluded that clinicians should be aware of the rare complications of this common pathology so that a timely diagnosis can be made, followed by prompt management. Further studies need to be done to better understand acute cerebral venous sinus thrombosis secondary to VZV.

Glanular Hypospadias Management with Modified Circumcision and Firlit Procedure.

OBJECTIVE: To document the results of using simple technique of Firlit procedure with modified circumcision for treatment of glanular hypospadias. STUDY DESIGN: Descriptive case series. PLACE AND DURATION OF STUDY: Department of Urology, Shifa International Hospital, Islamabad, from January 2011 till May 2017. METHODOLOGY: The subjects included pediatric patients who underwent repair of glanular hypospadias by using modified circumcision and Firlit procedure. Patients were analyzed for operative time, age, hospital stay, and peroperative and postoperative complications. Chart review was done for collection of data on specified proforma. RESULTS: There were 73 patients with mean age of 1.81 ±0.92 years. Children were discharged on the same day. None of them needed catheterization and dressing. Temporary dressing was used for mild bleeding immediate post op in 13 (17.80%) cases only. Postoperative complication such as urinary retention, fever, severe pain, or urinary tract infection were not seen in children. Meatal stenosis was not seen on a 2-24 months' follow-up. Satisfactory urine stream and good cosmesis was noted by the parents. CONCLUSION: The Firlit technique for the repair of glanular hypospadias was simple and satisfactory in terms of urine stream and cosmesis with minimal complications.

Valproic-induced Hyperammonemic Encephalopathy in a Known Case of Epilepsy.

Valproic acid, a broad-spectrum anticonvulsant drug, commonly causes elevated ammonia levels, which is usually asymptomatic in most cases. On rare occasions, potentially fatal hyperammonemia-induced encephalopathy can occur. We present a case of a 24-year-old female who presented to the emergency department with status epilepticus that was being managed with valproic acid. Further workup was done because of prolonged postictal state, which revealed increased ammonia levels; she was eventually diagnosed with valproic-induced hyperammonemic encephalopathy. Discontinuing valproic acid resulted in drastically improved symptoms and a gradual decline in ammonia levels. A clinician should be aware of rare drug adverse effects and drug interactions to conclusively reach the correct diagnosis. A prolonged postictal state should warrant further workup to rule out other possible etiologies.