Postpartum maternal tachycardia - diagnostic pitfalls!

PURPOSE OF REVIEW: Maternal tachycardia is a common sign with a multitude of causes. We attempt to look at the most common sinister ones in the postpartum period. RECENT FINDINGS: Current guidelines differ in the definition of maternal tachycardia. It has been associated with adverse outcomes such as increased length of stay as well as higher mortality if there is underlying peripartum cardiomyopathy. Some recent studies look at common investigations and how these apply to peripartum women, such as ECG markers of arrhythmogenesis, reference ranges for PCT and echocardiogram findings during pregnancy prior to diagnosis of peripartum cardiomyopathy. SUMMARY: Physiological changes make it difficult to interpret maternal tachycardia and thus how best to manage it. We propose the idea of a three-step approach for the assessment of patients, aiming to identify causes including tachyarrhythmias, obstetric haemorrhage, sepsis, venous thromboembolism and peripartum cardiomyopathy.The first step 'BEDSIDE' applies to all patients looking at observations, history and examination. The second step 'BASIC', applies to most patients and covers ECG and basic blood tests. The final step 'EXTRA' assesses the need for further investigations including additional blood tests and imaging. By using this model, clinicians and healthcare professionals should be able to rationalise the need for more invasive investigations whilst maintain good high-quality care.

An Unfortunate Incident Of A Surgical Swab Left In The Sphenoid Sinus For Eight Years.

Retained foreign bodies are foreign materials which are left accidentally inside a patient's body after a procedure. In this report we present the case of a 57 year old man who presented to the ENT clinic with a history of symptoms stretching over 8 years back to when he underwent a hypophysectomy through the transsphenoidal approach. These symptoms included cacosmia, ageusia, altered taste at times, foul smelling discharge, nasal discharge and dizziness. He had undergone multiple radiological examinations as well as antibiotic courses. It was only after the examination of the nose under general anaesthesia, conducted by the corresponding author that a swab was found in the sphenoid sinus which was left behind from his surgery 8 years ago. Cases of retained foreign bodies are very rare and are easily preventable. This case highlights the importance of adherence to health and safety protocols to prevent such an avoidable complication.

An Effective Synchronization Approach to Stability Analysis for Chaotic Generalized Lotka-Volterra Biological Models Using Active and Parameter Identification Methods.

In this manuscript, we systematically investigate projective difference synchronization between identical generalized Lotka-Volterra biological models of integer order using active control and parameter identification methods. We employ Lyapunov stability theory (LST) to construct the desired controllers, which ensures the global asymptotical convergence of a trajectory following synchronization errors. In addition, simulations were conducted in a MATLAB environment to illustrate the accuracy and efficiency of the proposed techniques. Exceptionally, both experimental and theoretical results are in excellent agreement. Comparative analysis between the considered strategy and previously published research findings is presented. Lastly, we describe an application of our considered combination difference synchronization in secure communication through numerical simulations.

Respiratory Syncytial Virus-Associated Mortality Among Young Infants in Karachi, Pakistan: A Prospective Postmortem Surveillance Study.

BACKGROUND: Respiratory syncytial virus (RSV) is an important cause of infant morbidity and mortality and a potential target for maternal immunization strategies. However, data on the role of RSV in young infant deaths in developing countries are limited. METHODS: We conducted a community-based mortality surveillance from August 2018-March 2020 for infants ≤6 months in Karachi, Pakistan. We tested (reverse transcription-polymerase chain reaction) nasopharyngeal swabs from deceased infants for presence of RSV. We performed verbal autopsies and calculated odds of RSV-associated mortality with 95% CIs and used multivariable logistic regression to evaluate associations. RESULTS: We collected 490 nasopharyngeal specimens from 1280 eligible infant deaths. There were 377/490 (76.9%) live births and 14/377 (3.7%; 95% CI: 1.8-5.6) were RSV positive. Most deaths occurred in neonates (254/377; 67.4%), males (226/377; 59.9%), and respiratory illnesses (206/377; 54.6%). Postneonatal age (10/14, 71.4%; OR: 5.5; 95% CI: 1.7-18.0), respiratory symptoms (12/14, 85.7%; OR: 5.2; 1.2-23.7), and high RSV season (9/14, 64.3%; OR: 4.4; 1.4-13.3) were associated with RSV mortality. In multivariable logistic regression analysis, respiratory symptoms (OR: 6.6; 95% CI: 1.3-32.5), RSV seasonality (6.1; 1.8-20.4), and age (9.2; 2.6-33.1) were significant predictors of RSV-associated mortality. CONCLUSIONS: RSV has a significant mortality burden in early infancy in Karachi, Pakistan. Age, RSV seasonality, and respiratory symptoms were significant predictors of RSV-associated mortality. Our findings have implications for clinical management of young infants with cold-like symptoms, policy development, and research regarding maternal immunization against RSV during pregnancy, in resource-constrained, low-income, and vaccine-hesitant populations.

The obstetric patient in the Covid pandemic: anaesthesia and perioperative care.

PURPOSE OF REVIEW: : The Coronavirus Disease 2019 (COVID-19) pandemic has had an unprecedented impact on pregnant women, maternity services and healthcare workers. We review recent literature on the course of COVID-19 infection in pregnancy, and recommendations for treatment and service provision. RECENT FINDINGS: It has been increasingly recognised that pregnant women are at higher risk of severe disease associated with COVID-19 infection. Early critical care input is crucial to guide respiratory support and techniques such as prone positioning, with a low threshold for intubation in critical illness. Timing of delivery remains a highly individualised decision. Following the RECOVERY trial, the use of a course of steroids in cases of severe COVID-19 infection has been widely adopted, and emerging guidance recommends vaccination in pregnant women. SUMMARY: Rapidly emerging evidence has helped guide clinicians to identify those patients most at risk of severe disease in COVID-19 and implement early interventions to reduce morbidity and mortality.

Physical modification of starch: changes in glycemic index, starch fractions, physicochemical and functional properties of heat-moisture treated buckwheat starch.

Native buckwheat starch was extracted and modified by heat-moisture treatment (HMT) with different treatment time (15, 30 and 45 min) to investigate its effect on physicochemical, morphological, functional properties, starch profile (rapidly digestible starch, RDS; slowly digestible starch, SDS and resistant starch, RS fractions) and expected glycemic index (eGI). Results revealed that with increasing time duration of HMT from 15 to 45 min, amylose content, pasting temperature and thermostability increased substantially whereas swelling power, solubility and viscosity parameters decreased. The SEM micrographs showed that HMT caused fissures in the granule and surface indentation. HMT-45 (starch treated for 45 min) had the lowest RDS content (29.33%) and the highest SDS (51.30%) and RS (8.21%) levels. The decreased hydrolysis rate, high amylose and RS content of HMT-45 resulted in a significant decrease in estimated glycemic index (eGI) values from 51.49% (Native) to 44.16% (HMT-45) thus indicating its role in prevention of non-insulin- dependent diabetes.

Mini-Review: Drug-food interactions of commonly available juices of Pakistan.

Medicines are often consumed concurrently with food; sometimes to improve its absorption and efficacy. However, certain foods may modify the function of drug metabolizing enzymes or transport mechanisms that are crucial determinants of systemic drug availability. Extensive work has been reported on certain juices like grapefruit that affects the bioavailability of more than 60 medications. However, relatively less work has been reported on certain other commonly used fruit juices, especially in Pakistan, such as mango, strawberry, apple, banana, pomegranate and grape etc. Present review has taken an account of the current work done in this area.

Environmental Remediation and Application of Nanoscale Zero-Valent Iron and Its Composites for the Removal of Heavy Metal Ions: A Review.

The presence of heavy metals in the industrial effluents has recently been a challenging issue for human health. Efficient removal of heavy metal ions from environment is one of the most important issues from biological and environmental point of view, and many studies have been devoted to investigate the environmental behavior of nanoscale zerovalent iron (NZVI) for the removal of toxic heavy metal ions, present both in the surface and underground wastewater. The aim of this review is to show the excellent removal capacity and environmental remediation of NZVI-based materials for various heavy metal ions. A new look on NZVI-based materials (e.g., modified or matrix-supported NZVI materials) and possible interaction mechanism (e.g., adsorption, reduction and oxidation) and the latest environmental application. The effects of various environmental conditions (e.g., pH, temperature, coexisting oxy-anions and cations) and potential problems for the removal of heavy metal ions on NZVI-based materials with the DFT theoretical calculations and EXAFS technology are discussed. Research shows that NZVI-based materials have satisfactory removal capacities for heavy metal ions and play an important role in the environmental pollution cleanup. Possible improvement of NZVI-based materials and potential areas for future applications in environment remediation are also proposed.

Report: Antibacterial and antifungal activities of leaf extract of Achyranthes aspera (Amaranthaceae) from Pakistan.

Alcoholic extract and various fractions of Achyranthes aspera leaves, traditionally used in Pakistan for treatment of infectious diseases was screened for in vitro antibacterial and antifungal activity. The chloroform and butanol fractions were found to be the most active among the fractions, showing considerable antibacterial activity against Shigella flexneri and Escherichia coli. The highest activity was found in the ethylacetate fraction (17 mm zone of inhibition) against gram-negative (Salmonella typhi) bacteria, with MIC value as 0.29 mg/mL. In antifungal screening, moderate activity was shown by the chloroform fraction (50 % inhibition) against Microsporum canis, with MIC value as 0.25mg/mL. Considerable level of antifungal activity was depicted by crude extract, hexane and butanol fractions against Aspergillus flavus and Microsporum canis. The ability of various extracts of Achyranthes aspera to inhibit different strains of fungi and bacteria indicates its potential use for the treatment of microbial infections.

Report: screening of selected medicinal plants for their enzyme inhibitory potential - a validation of their ethnopharmacological uses.

In present study four medicinal plants namely Valeriana wallichii, Xanthium strumarium, Achyranthes aspera and Duchesnea indica belonging to different families were collected in Khyber Pakhtunkhwa province and crude extract and subsequent fractions were analyzed for their inhibitory potential against acetylcholinesterase, butyrylcholinesterase and α-glucosidase enzymes. Valeriana wallichii, Xanthium strumarium and Achyranthes aspera were significantly active against cholinesterases. Chloroform and ethylacetate fractions of Valeriana wallichii exhibited significant activity against acetylcholinesterase (IC50: 61µg/ml) and butyrylcholinesterase enzymes (IC50: 58µg/ml), respectively. Similarly ethylacetate fraction of Achyranthes aspera showed significant activity against acetylcholinesterase (IC50: 61 µg/ml) and butyrylcholinesterase enzymes (IC50: 61 µg/ml), respectively. In case of α-glucosidase enzyme, the chloroform fraction of Xanthium strumarium exhibited significant inhibitory activity (IC50: 72 µg/ml) as compared to the standard compound acarbose (IC50: 483 µg/ml). Duchesnea indica showed no such activities.

Evaluation of anti-inflammatory activity of selected medicinal plants of Khyber Pakhtunkhwa, Pakistan.

In present study, the anti-inflammatory potential of three medicinal plants, Xanthium strumarium, Achyranthes aspera and Duchesnea indica were evaluated, using both in vitro and in vivo assays. Carrageenan induced hind paw edema model was used to carry out the in vivo anti-inflammatory activity, while for in vitro screening lipoxygenase inhibition assay was used. Crude extract of all the selected plants depicted significant (plt;0.001) anti-inflammatory activity, at late phase of inflammation. Achyranthes aspera also showed considerable anti-inflammatory activity (47%) at relatively lower concentration (200 mg/ml), at the initial phase of inflammation. Similarly the ethyl acetate fraction of all the selected plants showed significant lipoxygenase inhibition activity when compared with the standard drug (Baicalein). The results obtained from both in vitro and in vivo anti-inflammatory activity suggest that the ethyl acetate fraction of the crude extract of all the selected plants can be used for the isolation of new lead compounds with better anti-inflammatory activity.

An Interesting Case of Wolf-Parkinson-White Syndrome in a Young Patient With Sensorineural Deafness.

Wolff-Parkinson-White (WPW) syndrome is a condition associated with tachycardia due to accessory pathways in the heart, and it is one of the most common causes of tachycardia in infants and children. WPW may also be associated with mitochondrial encephalomyopathy, lactic acidosis, stroke-like episodes (MELAS syndrome) or LEOPARD syndrome (LS). We report a case of pre-excitation WPW syndrome in a 17-year-old man who was brought to the hospital by ambulance following the collapse. WPW syndrome type A was diagnosed from precordial leads. Electrocardiography (ECG) revealed a short PR interval, delta waves, and positive waves with dominant R in all pericardial leads. Blood test results showed an isolated elevated ALT level. Subsequent echocardiography was unremarkable, with an ejection fraction of 55%, apart from septal and inferior wall dyssynchrony. With regard to the past medical history, he had sensorineural deafness (SND) since childhood and had a family history of SND. Consequently, the patient was transferred to the cardiac electrophysiology department at another hospital after consultation and underwent ablation. A successful post-ablation electrocardiogram revealed the resolution of the WPW syndrome signs and post-ablation features, such as peak T waves.

Statistical analysis of Cotton-Jute blended ratio for producing good quality blended yarn.

The present world is focusing on sustainable products. Most of the natural products collected from are environmentally friendly. In the textile sector the main raw material is fiber. Most textile products are made from the natural cotton fibers. But because of the shortage of this fiber, most of the researchers are looking forwards to other sources of natural fibers. Here in Bangladesh the natural jute fiber is available and the textile industries are making jute products but the jute products are comparatively lower price than cotton products. That's why some factories are making cotton-jute blended yarn to minimise the cost and increase the product's quality and appearance. Here in this research work, it was tried to identify the best cotton-jute blended ratio for producing good quality yarn. 80C-20 J, 60C-40 J and 40C-60 J blended ratios are compared with 100 C and 100 J yarn to analyse the results. The CV m%, Thick/Km +50 %, Neps/Km +200 %, IPI, RKM and Elongation% of blended yarns are evaluated and compared the results between the ratios. After that the yarn quality index (YQI) was calculated to identify the ratio which indicates a relation between yarns strength, elongation% and CVm. The other quality index was fiber quality index (FQI) which indicates a relation between fibers strength, fiber mean length, elongation% and fiber fineness. One way ANOVA was applied to see the significance level between the independent variables. Box plot was applied to see the visual effect of statistical analysis at the same time the regression results show the impact of cotton-jute ratio with an equation, through which it was easy to identify the perfect ratio. It was found that higher percentage of cotton and lower percentage of jute fiber blended yarn shows good results than others. The products which were made from the ratios were shown good results for their different use of purposes.

Sex-specific associations between circadian-related genes and depression in UK Biobank participants highlight links to glucose metabolism, inflammation and neuroplasticity pathways.

Depressive disorders have increased in global prevalence, making improved management of these disorders a public health priority. Prior research has linked circadian clock genes to depression, either through direct interactions with mood-related pathways in the brain or by modulating the phase of circadian rhythms. Using machine learning and statistical techniques, we explored associations between 157,347 SNP variants from 51 circadian-related genes and depression scores from the patient health questionnaire 9 (PHQ-9) in 99,939 UK Biobank participants. Our results highlight multiple pathways linking the circadian system to mood, including metabolic, monoamine, immune, and stress-related pathways. Notably, genes regulating glucose metabolism and inflammation (GSK3B, LEP, RORA, and NOCT) were prominent factors in females, in addition to DELEC1 and USP46, two genes of unknown function. In contrast, FBXL3 and DRD4 emerged as significant risk factors for male depression. We also found epistatic interactions involving RORA, NFIL3, and ZBTB20 as either risk or protective factors for depression, underscoring the importance of transcription factors (ZBTB20, NFIL3) and hormone receptors (RORA) in depression etiology. Understanding the complex, sex-specific links between circadian genes and mood disorders will facilitate the development of therapeutic interventions and enhance the efficacy of multi-target treatments for depression.

Anti-inflammatory activity of the topical preparation of Valeriana wallichii and Achyranthes aspera leaves.

In vivo and in vitro screening of anti inflammatory activity of Valeriana wallichii and Achyranthes aspera leaves crude extract was performed, using standardized procedures. Methanolic crude extract topical formulation (cream) of Valeriana wallichii and Achyranthes aspera leaves (Family Valerianaceae and Amaranthaceae respectively), were screened for their anti-inflammatory activity, through "Carrageenan induced hind paw edema" test, for their effect on the acute and chronic phase inflammation models in male Wistar rats. Methanolic extract and its fractions were also evaluated for their in vitro anti-inflammatory activity using lipoxygenase inhibition assay. Leaves of Valeriana wallichii showed significant (P<0.001), dose dependant anti inflammatory activity, comparable with that of the standard, in animal model. The ethyl acetate fraction of Valeriana wallichii also showed considerable (IC 50=73 ± 0.36) in vitro anti-inflammatory activity as compared to standard (6.11 ± 0.02). Similarly Achyranthes aspera leaves showed relatively weak (p>0.05) in vivo anti-inflammatory activity. However, its activity was comparable with that of standard at 10% concentration after 5 hrs of carrageenan injection. This activity was present in ethyl acetate fraction during in vitro screening (IC 50=76 ± 0.14) as compared to that of standard (IC 50=6.11 ± 0.02). The combined in vitro and in vivo Anti-inflammatory screening shows that the ethyl acetate fraction of the crude extract of Valeriana wallichii and Achyranthes aspera can be used for the isolation of new Anti-inflammatory lead compounds.

An Unusual Case of Deep Vein Thrombosis and Concurrent Necrotizing Fasciitis Following a Fall.

A 74-year-old male patient presented to the emergency department following a fall with signs and symptoms consistent with right lower extremity (RLE) deep vein thrombosis (DVT) and non-specific skin changes. Further imaging confirmed the initial diagnosis of DVT, and the patient was appropriately treated. However, his condition continued to deteriorate with worsening overlying skin changes, which prompted a computed tomography (CT) scan of his right femur without intravenous (IV) contrast. This revealed fluid tracking along the lateral compartment muscles, which raised suspicion of an abscess. Suspicion for necrotizing fasciitis (NF) was raised with a subsequent CT of the right femur with IV contrast that demonstrated a considerable increase in rim-enhancing fluid collections intramuscularly and extending into both the anterior and posterior compartments, likely correlating with increasing intermuscular abscesses. On imaging, no subcutaneous emphysema or gas accumulation was found, which is a common finding in NF. However, necrotic-appearing muscle was found on surgical debridement and wound cultures confirmed the diagnosis of methicillin-resistant Staphylococcus aureus (MRSA) NF. The patient was then treated with appropriate IV antibiotics and was discharged to long-term inpatient wound care. Similar presentations of DVT and NF made a prompt diagnosis of NF difficult, and it highlights the need for further imaging to rule out NF when a patient has a confirmed diagnosis of DVT.

A homeostatic gut-to-brain insulin antagonist restrains neuronally stimulated fat loss.

In C. elegans mechanisms by which peripheral organs relay internal state information to the nervous system remain unknown, although strong evidence suggests that such signals do exist. Here we report the discovery of a peptide of the ancestral insulin superfamily called INS-7 that functions as an enteroendocrine peptide and is secreted from specialized cells of the intestine. INS-7 secretion increases during fasting, and acts as a bona fide gut-to-brain homeostatic signal that attenuates neuronally induced fat loss during food shortage. INS-7 functions as an antagonist at the canonical DAF-2 receptor in the nervous system, and phylogenetic analysis suggests that INS-7 bears greater resemblance to members of the broad insulin/relaxin superfamily than to conventional mammalian insulin and IGF peptides. The discovery of an endogenous insulin antagonist secreted by specialized intestinal cell with enteroendocrine functions suggests that much remains to be learned about the intestine and its role in directing neuronal functions.

Diagnostic Accuracy Of Contrast Enhanced Ct For Detection Of Renal Cell Carcinoma Taking Histopathology As Gold Standard.

BACKGROUND: Renal cell carcinoma being the commonest primary renal malignancy of adulthood accounts for approximately 80-90% renal malignant lesions. The purpose of radiological imaging modalities when devising the treatment options for renal masses is crucial as it significantly influence the clinical outcome and prognosis of the disease. Subjective impression by a radiologist for diagnosing a mass lesion is known to be critical and its precision is improved by contrast enhanced CT as demonstrated by certain retrospective analyses. We aimed to ascertain the diagnostic accuracy of contrast enhanced computed tomography to diagnose renal cell cancers by verifying through histopathology reported diagnoses. METHODS: This Cross-sectional (validation) study was carried out in Radiology and Urology departments of Ayub Teaching Hospital; Abbottabad, from 1st November 2020 to 30th April 2022. The study population included all admitted symptomatic patients with age range 18-70 years of either gender. The patients were subjected to detailed clinical examination and history and an ultrasound and contrast enhanced CT abdomen and pelvis. CT scans were reported under supervision of single consultant radiologist. Data was analysed in SPSS version 20.0. RESULTS: Mean age of the patients was 38.88±11.62 years ranging from 18-70 years and mean duration of symptoms was 54.64±49.171 ranging from 3-180 days. All of the total 113 patients underwent contrast enhanced CT scan and later operated to confirm the diagnoses by histopathology. The comparison yielded true positive (TP) cases to be 67, True Negative (TN) 16, False Positive (FP) 26, and 4 False Negative (FN) as per CT scan diagnoses. CT scan had a diagnostic Accuracy of 73.45% with 94.37% sensitivity and 38.10% specificity. CONCLUSIONS: Contrast-enhanced CT has a high sensitivity for making the diagnosis of renal cell carcinoma; however, its specificity is low. A multidisciplinary approach is necessary to overcome the low specificity. Therefore, collaboration between radiologists and urologic oncologists should be considered while devising treatment plan for patients.

Pheochromocytoma-Induced Hypertension After Traumatic Brain Injury.

A 23-year-old female presented to the emergency department (ED) after sustaining a motor vehicle accident and subsequent loss of consciousness. In the ED, the patient was hemodynamically stable and was appropriately discharged with a diagnosis of mild traumatic brain injury. The patient presented 10 days post-injury to the outpatient brain injury clinic with complaints of headache, anxiety, and dizziness, with an elevated blood pressure of 160/100 mmHg. Initial head imaging, drug screen, complete blood count, and complete metabolic panel were unremarkable, however, urine and plasma metanephrines were found to be elevated. Abdominal computed tomography imaging revealed a pheochromocytoma, and the patient was adequately treated with medication and adrenalectomy with complete resolution of symptoms. Existing literature has indicated that stress and physical trauma can contribute to the escalation of pheochromocytoma symptoms in previously asymptomatic individuals; here, the stress and trauma stemming from an automobile accident and mild traumatic brain injury may have precipitated the onset of pheochromocytoma symptoms in the patient. Symptoms of pheochromocytoma can align with those commonly observed after traumatic brain injury (TBI), encompassing headaches, anxiety, and dizziness. Our case demonstrates the need for clinicians to consider the presence of pheochromocytoma in a post-traumatic brain injury patient.

An Atypical Case of Neuroleptic Malignant Syndrome Associated With Ciprofloxacin and Quetiapine.

A 29-year-old male presented to the emergency department with complaints of shortness of breath and numbness in bilateral upper and lower extremities that started a few hours prior to arrival. On physical examination, the patient was afebrile, disoriented, tachypneic, tachycardic, and hypertensive with generalized muscle rigidity. Further investigation revealed that the patient had recently been prescribed ciprofloxacin and restarted on quetiapine. The initial differential diagnosis was acute dystonia, and subsequently, the patient was placed on fluids, lorazepam, diazepam, and later benztropine. The patient's symptoms began to resolve, and psychiatry was consulted. Given the patient's autonomic instability, altered mental status, muscle rigidity, and leukocytosis, psychiatric consultation revealed an atypical case of neuroleptic malignant syndrome (NMS). It was postulated that the patient's NMS was caused by a drug-drug interaction (DDI) between ciprofloxacin, a moderate cytochrome P450 (CYP) 3A4 inhibitor, and quetiapine, which is primarily metabolized by CYP3A4. The patient was then taken off quetiapine, admitted overnight, and discharged the next morning with complete resolution of his symptoms along with a prescription for diazepam. This case highlights the variable presentation of NMS and the need for clinicians to consider DDI when managing psychiatric patients.