Acute Kidney Injury in Patients Admitted to the Intensive Care Unit: A Case Report.

Patients admitted to the intensive care unit are prone to various complications, one of which is acute kidney injury (AKI). The etiology of acute kidney injury can be multifactorial. Among the various causes, sepsis remains the most prevalent. Cholemic nephropathy (CN) is a rare cause of AKI. Patients with CN usually present with elevated total bilirubin levels of greater than 20 mg/dl. However, CN has been reported in patients with total bilirubin levels of less than 20 mg/dL. These patients were found to have chronic elevations of bilirubin due to chronic liver disease rather than an acute rise in bilirubin levels. In this case series, we present two cases of patients with chronic liver disease who were admitted to the intensive care unit and were found to have AKI with elevated total bilirubin levels over 15 mg/dl.

A Case of Metformin-Associated Lactic Acidosis.

Metformin is a US FDA-approved oral anti-hyperglycemic medication used to treat non-insulin-dependent diabetes mellitus (NIDDM). Metformin, a biguanide drug, works by reducing glucose production in the liver, decreasing intestinal absorption, and improving insulin sensitivity, leading to lower blood glucose levels. Metformin is generally considered to be a medication with a good safety profile and high tolerability. However, metformin therapy is associated with an uncommon but potentially serious complication known as metformin-associated lactic acidosis (MALA), which is marked by severe lactic acid accumulation in the bloodstream. This case introduces an elderly female with multiple comorbidities who presented with confusion, malaise, and lethargy. Her laboratory findings revealed acute renal failure, severe metabolic acidosis, and significantly elevated lactic acid levels consistent with sepsis and possibly MALA. Aggressive resuscitation with fluids and sodium bicarbonate was initiated. Antimicrobial drugs were started for urinary tract infections. She subsequently required endotracheal intubation with invasive ventilation, pressor support, and continuous renal replacement therapy. Her condition gradually improved over several days. The patient ultimately recovered, and at the time of discharge, metformin was discontinued, and a sodium-glucose cotransporter-2 (SGLT-2) inhibitor was initiated. This case underscores the relevance of MALA as a potential complication of metformin therapy, particularly in patients with underlying kidney disease or other risk factors. Timely detection and prompt management of MALA can prevent progression to a critical stage and thus avoid potentially fatal outcomes.

A Case of BRASH Syndrome in an Elderly Female With Acute Urinary Retention.

The BRASH syndrome is an uncommon but serious medical condition that is distinguished by a confluence of symptoms that include bradycardia, renal failure, AV node dysfunction, shock, and hyperkalemia. Bradycardia associated with BRASH syndrome is often refractory to conventional management guided by advanced cardiac life support (ACLS), therefore prompt and appropriate intervention can only be administered in the setting of early recognition. The management of BRASH syndrome in elderly patients can prove to be particularly challenging, primarily because of pre-existing comorbidities that place these patients at increased risk of complications. We present the case of an 82-year-old female who presented to the emergency department with acute urinary retention. Initial laboratory evaluation revealed severe hyperkalemia and acute kidney injury. Her EKG showed bradycardia with a junctional rhythm. Medication reconciliation revealed multiple potassium-sparing and AV nodal-blocking agents. The patient's presentation was consistent with the BRASH syndrome and the patient was treated with potassium lowering and vasoactive agents. Her bradycardia resolved upon treatment of hyperkalemia. Her admission was complicated by renal replacement therapy given the degree of renal dysfunction however the patient was ultimately discharged after renal function improved. Upon discharge, the suspected precipitants of BRASH syndrome including beta blockers, mineralocorticoid receptor antagonists, and angiotensin receptor antagonists were all discontinued.

The Impact of Granulocyte Colony-Stimulating Factor Administration in a Neutropenic Cancer Patient With COVID-19-Related Acute Respiratory Distress Syndrome.

Chemotherapy-induced neutropenia is a serious adverse effect found in cancer patients treated with chemotherapy. As these patients are at risk of infections, granulocyte colony-stimulating factors (G-CSF) are commonly used in these patients to increase neutrophil counts. This report describes a case of a 73-year-old female with metastatic breast cancer treated with letrozole and palbociclib who presented to the hospital with flu-like symptoms and a positive SARS-CoV-2 test. She was saturating well on room air without the need for supplemental oxygen initially, however, she was febrile and lab work revealed neutropenia. Subsequently, she was given two doses of Tbo-filgrastim. Her respiratory status deteriorated shortly afterward and she required supplemental oxygen. The chest X-ray obtained at that time revealed increased atelectasis or infiltration in the middle and lower lung fields, and computed tomography angiography of the chest revealed bilateral patchy airspace and ground glass opacities. The timeline from symptom onset along with her imaging findings suggested COVID-19-related acute respiratory distress syndrome (ARDS) as a possible explanation for her respiratory status decline. Interestingly, her neutrophil-to-lymphocyte ratio (NLR) had consistently increased, along with her respiratory status deterioration, after the completion of the two doses of G-CSF. The patient was treated with dexamethasone. Her respiratory status eventually improved prior to discharge.

Hemophagocytic Lymphohistiocytosis in a Patient With Human Immunodeficiency Virus.

Hemophagocytic lymphohistiocytosis (HLH) is a rare and aggressive disorder that is often underdiagnosed due to its similarities in other forms of shock, most notably septic shock. In this case report, we discuss a patient who has a history of HIV presenting with altered mental status and cytopenias, ultimately going into shock and passing away. We initially thought we would be dealing with a case of septic shock, but a diagnostic workup during his hospital case lead to a diagnosis of hemophagocytic lymphohistiocytosis. This case illustrates how patients with HLH present very similar to septic shock and how to manage patients with this very aggressive disease.

Pre-service EFL teacher's perceptions of foreign language writing anxiety and some associated factors.

Researchers have been striving to investigate the causes and consequences associated with writing anxiety experienced by students of foreign languages. This study aimed to investigate the level and nature of writing anxiety experienced by learners of foreign languages, considering gender as a variable. The study's second goal was to uncover the learners' perspectives on writing anxiety and the factors that contribute to it. The convenience sample method was used to choose seventy-six students to participate in the English language teacher training course. Second Language Writing Anxiety Reasons Inventory (SLWARI) and Second Language Writing Anxiety Inventory (SLWAI) (Cheng, 2004; Kara, 2013) [1,2] were used in order to determine the levels and types of anxiety that are associated with learners' foreign language writing. Both inventories were used to determine what causes learners' foreign language writing. In order to gain a comprehensive understanding of how students perceive the level of anxiety they feel when writing, a semi-structured interview was conducted with each participant. The data showed that there was no difference when taking into account learners' gender concerning their anxiety levels and kinds. The vast majority of individuals reported feeling a significant amount of anxiety. The subjects exhibited cognitive anxiety symptoms, although there were no indications of gender effect. The responses to the interview questions highlighted a deficiency in both writing practice and linguistic expertise as critical contributors to anxious sentiments.

A Case of Left Ventricular Thrombus and Herpetic Esophagitis in an Immunocompetent Patient With COVID-19.

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been associated with thrombosis, both venous and arterial, but the mechanism behind this coagulation is not fully understood. Several cases involving coronavirus disease 2019 (COVID-19)-positive patients with left ventricular thrombus (LVT), particularly in those with low ejection fraction, have been reported. This report describes a case of a 57-year-old male patient who presented to the hospital with altered mental status and a positive SARS-CoV-2 polymerase chain reaction (PCR) test. CT of the chest revealed the presence of an LVT, and transthoracic echocardiography showed a reduced ejection fraction and confirmed the presence of the thrombus. The patient also reported epigastric chest pain and several bloody bowel movements. A colonoscopy revealed internal hemorrhoids. An esophagogastroduodenoscopy revealed the presence of multiple esophageal ulcers, and biopsy results confirmed herpes simplex virus (HSV) infection. The patient had no history of organ or bone marrow transplant, long-term immunosuppressive therapy, or HIV infection. He was eventually discharged on apixaban for his LVT and acyclovir for his HSV esophagitis.

Prevalence of anxiety and depression in medical students of a public sector medical college in Islamabad and coping mechanisms adopted.

The objectives of this study were to find out the frequency of anxiety and depression in medical students and various coping mechanisms adopted by them to identify the coping trends and to stress the need of equipping these students with positive coping tools to deal with anxiety and depression. A cross-sectional, questionnaire-based observational study was conducted on a population of 500 medical students of Federal Medical and Dental College, Islamabad. The duration of the study was three months. By using the WHO sample size calculator, taking the confidence level 95%, anticipated population proportion 70% and absolute precision required 7%, the sample size was calculated at 165. The samples were collected by non-probability consecutive sampling via a questionnaire. In the study, two instruments were used: 1) Aga Khan University Anxiety and Depression Scale (AKUADS), and 2) Brief Cope Inventory. Self-administered questionnaires were filled by the students and the data collected from these questionnaires was analysed on SPSS version 19. Out of the sample size of 165 (98 female, 67 male) students, excluding 12 students with previous history of mental and physical illness, the prevalence of depressed students found after calculating their scores according to the Aga Khan Anxiety and Depression Scale (AKUADS score ≥19) was 95 (57.57%). The most used positive coping mechanisms by these students were religion (5.55±1.91), acceptance (5.28±1.56), planning (5.27±1.58) and active coping (4.85±1.45). The most used negative coping mechanisms were self-blame (5.52±1.83), self-distraction (5.29±1.56), and venting (4.67±1.49). The high presence of negative coping mechanisms indicates the urgency of the need for proper counselling and guidance of medical students about dealing correctly with anxiety and depression.

Estimation of Sialic Acid and IL10 Levels in Stage 1 and 2 Periodontitis Patients.

OBJECTIVE: The role of biomarkers in staging and grading periodontal disease has become detrimental in relation to the overall treatment plan. This study aimed at evaluating and comparing the role of sialic acid and IL10 in the early and moderate stages of periodontitis. MATERIALS AND METHODS: Patients were selected according to the assessment of pocket depth and radiographic bone loss. Bone loss was calculated as <15% for stage 1 and 15-33% for stage 2. Salivary samples were collected using spit technique 2 hrs post consumption of food. The unstimulated saliva was collected in a sterile graduated container every minute for 5-8 minutes. IL10 estimation was done using ELISA, and sialic acid estimation was done using the diphenylamine method. The variables for the three groups were assessed using ANOVA, and intragroup comparisons for quantitative data were evaluated using the post hoc Bonferroni test (P < 0.05). RESULTS: On comparing sialic acid levels among the three groups, stage 2 showed the highest mean (8.61) compared with the other two groups and was highly significant (P < 0.001). On the contrary, IL10 when compared to stage 1 and 2 periodontitis revealed insignificant change. CONCLUSION: The value of IL10 was higher as patients progressed from health to periodontitis.

Factors influencing father's antenatal and perinatal involvement in maternal health care.

BACKGROUND: Maternal health care refers to the better outcome of labor and reduced maternal mortality. Antenatal care utilization is an important determinant for improved maternal health care. In this study, we examine how father's involvement influences antenatal and perinatal care utilization by mothers. METHODS: A community-based cross-sectional study was performed in the Pakistan Institute of Medical Sciences for three months. Systematic random sampling method was used for obtaining the desired sample. Safe Motherhood Questionnaire (Woman) developed by Johns Hopkins Program for International Education in Gynecology and Obstetrics (JHPIEGO) was adapted and utilized to gather the required data. Sample size for the study was calculated as 303 by the WHO calculator keeping confidence level at 95% and with an associated prevalence of 73%. The data were entered into SPSS version 21 (Chicago, IL). Frequencies and percentages were calculated for qualitative variables. Mean and standard deviation was calculated for quantitative variables. RESULTS: This study revealed that the father's attitude toward antenatal care was found to be significantly (p < .05) associated with a higher education and greater income level. While father's favorable attitude toward childbirth was found to be significantly (p < .05) associated with higher education and lower age (18-29 years). Frequency of fathers who disagreed to the statement "It is not necessary for a husband/partner to accompany his wife to antenatal care visits" was 204 (67.1%), whereas those who disagreed with the statement "It is not necessary for a husband/partner to accompany his wife when she is giving birth" were 255 (83.8%). While frequency of fathers who disagreed with the statement "Giving birth is mostly a woman's matter; Husbands/partners have little to contribute" was 267 (87.9%). CONCLUSIONS: Our study found a positive association between father's involvement in maternal health and factors such as paternal education level, age, income level and father's attitude. Fathers' antenatal involvement was associated with paternal age and income level, while their perinatal involvement was associated with paternal age and education level. Our study on father's attitude toward presence at time of birth showed 83.8% compliance. Similarly, there was 67.1% compliance for presence during antenatal checkups.

Shorter Perceived Outpatient MRI Wait Times Associated With Higher Patient Satisfaction.

PURPOSE: The aim of this study was to assess differences in perceived versus actual wait times among patients undergoing outpatient MRI examinations and to correlate those times with patient satisfaction. METHODS: Over 15 weeks, 190 patients presenting for outpatient MR in a radiology department in which "patient experience" is one of the stated strategic priorities were asked to (1) estimate their wait times for various stages in the imaging process and (2) state their satisfaction with their imaging experience. Perceived times were compared with actual electronic time stamps. Perceived and actual times were compared and correlated with standardized satisfaction scores using Kendall τ correlation. RESULTS: The mean actual wait time between patient arrival and examination start was 53.4 ± 33.8 min, whereas patients perceived a mean wait time of 27.8 ± 23.1 min, a statistically significant underestimation of 25.6 min (P < .001). Both shorter actual and perceived wait times at all points during patient encounters were correlated with higher satisfaction scores (P < .001). CONCLUSIONS: Patients undergoing outpatient MR examinations in an environment designed to optimize patient experience underestimated wait times at all points during their encounters. Shorter perceived and actual wait times were both correlated with higher satisfaction scores. As satisfaction surveys play a larger role in an environment of metric transparency and value-based payments, better understanding of such factors will be increasingly important.

Pictorial review: Imaging features of unusual patterns and complications of hydatid disease.

Hydatid disease is a worldwide zoonosis produced by the larval stage of the Echinococcus tapeworm. We demonstrate rare locations and unusual complications of this entity during past 6 years. Rare locations during our observation included lumbar spine, sacral spine, spleen, ovary, abdominal wall, diaphragm, pelvis and right kidney. Unusual complications included formation of bronchopulmonary fistula, complete collapse of left lung secondary to hilar location of Hydatid cyst and hydatiduria.

An unusual vesical calculus.

We report a 52 year old patient presenting with a bladder stone formed over a migrated intrauterine device (Copper-T). Her history was pertinent for intrauterine contraceptive (IUCD) device placement 10 years back. Investigations included plain ultrasound of abdomen, X-ray of abdomen, urinalysis, and urine culture. Ultrasound and plain X-ray of the pelvis confirmed a bladder stone formed over a migrated copper-T intrauterine device. The device was removed through suprapubic cystolithotomy. Of all the reported cases of vesical stone formation over a migrated IUCD, this case is unique as the patient was an elderly - 52 year old - female. All previously reported cases are of younger age.

Hydatid cysts in abdominal wall and ovary in a case of diffuse abdominal hydatidosis: Imaging and pathological correlation.

We report a case of diffuse abdominal hydatidosis with correlation of imaging findings with gross pathology. The patient had involvement of liver, diaphragm, pelvic cavity, ovary and abdominal wall. Hydatid cysts were morphologically different from each other including calcified, uniloculated and multiloculated cystic lesions. Our case is rare as ovary and abdominal wall involvement is described in less than 1 % cases of hydatid disease.

Fetal acrania - prenatal sonographic diagnosis and imaging features of aborted fetal brain.

We report a 35 year old female patient referred to our ultrasound department to rule out congenital anomalies. The fetus was found to have a completely formed brain, base of the skull and facial structures but lacking a cranium. The fetus was therapeutically aborted. We correlated our antenatal sonographic findings with gross pathological features and CT Scan of the fetal head. Despite an extensive search, CT features of aborted fetal brain and base of skull were not found in the literature.

Comparison of vaginal and abdominal hysterectomy: peri- and post-operative outcome.

BACKGROUND: Abdominal and vaginal hysterectomies are the two predominant operative modalities for various uterine conditions; however the indications for selecting a particular procedure in any setting may not be optimally defined. This study was undertaken to evaluate the appropriate route of hysterectomy (abdominal or vaginal) in a hospital population for women with benign disease by comparing peri-operative and post-operative complications. METHODOLOGY: This quasi-experimental study was undertaken at the Department of Obstetrics and Gynaecology, Fauji Foundation Hospital/Foundation University Medical College, Rawalpindi from January to December 2007. Eighty subjects were equally divided into vaginal and abdominal hysterectomy groups by convenience (non-probability) sampling. The primary outcome measures were operative time, primary haemorrhage, wound infection, post-operative analgesia, febrile morbidity, hospital stay and secondary haemorrhage; secondary outcome measure were estimated cost, re-admission and reopening. RESULTS: There were no differences in the patients' mean age, parity, body mass index, and preoperative haemoglobin levels between groups. Vaginal hysterectomy was associated with less febrile morbidity, wound infection operative time, economic cost, bleeding requiring transfusion and re-admission than abdominal hysterectomy. Main indication for women having abdominal operation was leiomyomas, whereas more women having uterovaginal prolapse had vaginal hysterectomy. CONCLUSION: Patients requiring a hysterectomy for benign lesions having a moderate-sized uterus can be offered vaginal route for surgery.

Multiple bronchoceles in a non-asthmatic patient with allergic bronchopulmonary aspergillosis.

Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction due to a fungus, Aspergillus fumigatus. It is typically seen in patients with long-standing asthma. Our patient was a non-asthmatic 18 years old male who presented with chronic cough for 2 years. Peripheral blood eosinophilia and elevated scrum IgE were observed. His x-ray chest revealed v-shaped opacity in the left upper lobe close to the hilum. High resolution computed tomographic scan of the chest revealed multiple dilated bronchi filled with mucous (bronchoceles) and central bronchiectasis (CB) involving main segmental bronchi. Central bronchiectasis (CB) was typical of ABPA but bronchocele formation was a rare manifestation of the disease. The patient was managed with oral prednisolone and was relieved of his symptoms. Occurrence of ABPA in non-asthmatics is very rare and deserves reporting.

Inverted Meckel's diverticulum causing intussusception in an adult.

Adult intussusception is rare, making-up only about 1% of the causes of bowel obstruction intussusception, secondary to an inverted Meckel's diverticulum, is also a rare occurrence. Chronic abdominal pain, lower gastrointestinal bleeding, and recurrent obstructive symptoms may lead to an unnecessary delay in diagnosis. This case report describes a rare cause of adult intestinal intussusception due to inverted Meckel's diverticulum. Intussusception was diagnosed on emergency ultrasound of the patient, who was successfully managed with surgery.

Multifocal osseous tuberculosis involving hand and feet.

A rare case of multifocal cystic tuberculosis of hands and feet is presented in an adolescent female. The presence of multiple lytic areas mimicked secondary metastases and biopsy remained the mainstay for final diagnosis.

Hematometrocolpos associated with common cloacal anomaly.

A rare case of hematometrocolpos is presented in a 14 years old female with known common cloacal malformation. It presented as a slowly growing tender pelvic mass. Ultrasound and CT scan of the pelvis revealed vagina and uterus filled with blood. A diagnosis of hematometrocolpos was made. Per-operatively multiple adhesions were found in the pelvis necessitating the removal of blood-filled uterus.