Anticoagulation in COVID-19: a single-center retrospective study.

Introduction: COVID-19 induces a pro-thrombotic state as evidenced by microvascular thrombi in the renal and pulmonary vasculature. Therapeutic anticoagulation in COVID-19 has been debated and data remain anecdotal. Hypothesis: We hypothesize that therapeutic anticoagulation is associated with a reduction in in-hospital mortality, upgrade to intensive care unit, invasive mechanical ventilation, and acute renal failure necessitating dialysis by decreasing the over-all clot burden. Methods: A retrospective cohort study was done to determine the impact of therapeutic anticoagulation in hospitalized COVID-19 patients. Independent t-test and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios (aOR) with its 95% confidence interval (CI) respectively. Results: A total of 176 hospitalized COVID-19 patients were divided into two groups, therapeutic anticoagulation and prophylactic anticoagulation. The mean age, baseline comorbidities and other medications used during hospitalization were similar in both groups. The aOR for in-hospital mortality (OR 3.05, 95% CI 1.15-8.10, p = 0.04), upgrade to intensive care (OR 3.08, 95% CI 1.43-6.64, p = 0.006) and invasive mechanical ventilation (OR 4.27, 95% CI 1.95-9.34, p = 0.00) were significantly lower while there was no statistically significant difference in the rate of developing acute renal failure (OR 1.87 95% CI 0.46-7.63, p = 0.64) between two groups. Conclusions: In patients with COVID-19, therapeutic anticoagulation offers a significant reduction in the rate of in-hospital mortality, upgrade to intensive medical care, and invasive mechanical ventilation. It should be preferred over prophylactic anticoagulation in COVID-19 patients unless randomized controlled trials prove otherwise.

Impact of Body Mass Index on COVID-19-Related In-Hospital Outcomes and Mortality.

BACKGROUND: Given the high prevalence of obesity around the globe, patients with coronavirus disease 2019 (COVID-19) are at an increased risk of devastating complications. METHODS: A retrospective cohort study was performed to determine the association of basal metabolic index (body mass index (BMI)) with the need for invasive mechanical ventilation (IMV), dialysis, upgrade to an intensive care unit (ICU) and mortality. Independent t-test and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios (aORs) with its 95% confidence interval (CI), respectively. RESULTS: A total of 176 consecutive patients with confirmed COVID-19 diagnosis were included. The mean age was 62.2 years, with 51% being male patients. The mean BMI for non-surviving patients was significantly higher compared to patients surviving on the seventh day of hospitalization (35 vs. 30 kg/m2, P = 0.022). Similarly, patients requiring IMV had a higher BMI (33 vs. 29, P = 0.002) compared to non-intubated patients. The unadjusted OR for patients with a higher BMI requiring IMV (56% vs. 28%, OR: 3.3, 95% CI: 1.6 - 7.0, P = 0.002) and upgrade to ICU (46% vs. 28%, OR; 2.2, 1.07 - 4.6, P = 0.04) were significantly higher compared to patients with a lower BMI. Similarly, patients with a higher BMI had higher in-hospital mortality (21% vs. 9%, OR: 3.2, 95% CI: 1.3 - 8.2, P = 0.01) compared to patients with a normal BMI. Despite a numerical advantage in the lower BMI group, there was no significant difference between the two groups in terms of the need for dialysis (5% vs. 13%, OR: 3.8, 13% vs. 4%, 1.1 - 14.1, P = 0.07). aORs controlled for baseline comorbidities and medications mirrored the overall results, except for the need to upgrade to ICU. CONCLUSIONS: In patients with confirmed COVID-19, morbid obesity serves as an independent risk factor of high in-hospital mortality and the need for IMV.

Safety and Efficacy of Colchicine in Patients with Stable CAD and ACS: A Systematic Review and Meta-analysis.

BACKGROUND: Evidence from recent trials has shown conflicting results in terms of the utility of colchicine in patients with coronary artery disease (CAD). METHODS: Multiple databases were queried to identify all randomized controlled trials (RCTs) comparing the merits of colchicine in patients with acute coronary syndrome (ACS) or stable CAD. The pooled relative risk ratio (RR) of major adverse cardiovascular events (MACE), its components, and gastrointestinal (GI) adverse events were computed using a random-effect model. RESULTS: Ten RCTs comprising a total of 12,761 patients were identified. At a median follow-up of 12 months, there was a significantly lower risk of MACE [RR 0.66, 95% confidence interval (CI) 0.45-96], ACS (RR 0.66, 95% CI 0.45-0.96), ischemic stroke (RR 0.42, 95% CI 0.22-0.81), and need for revascularization (RR 0.61, 95% CI 0.42-90) in patients receiving colchicine compared with placebo. A subgroup analysis based on the clinical presentation showed that the significantly lower incidence of MACE and stroke were driven by the patients presenting with ACS. The use of colchicine in patients with stable CAD did not reduce the incidence of MACE (RR 0.55, 95% CI 0.28-1.09), ACS (RR 0.52, 95% CI 0.25-1.08), or stroke (RR 0.61, 95% CI 0.33-1.13). There was no significant difference in the relative risk of cardiac arrest, ACS, cardiovascular mortality, and all-cause mortality between the two groups in both ACS and stable CAD populations. The risk of GI adverse events was significantly higher in patients receiving colchicine (RR 2.10, 95% CI 1.12-3.95). CONCLUSION: In patients presenting with ACS, low-dose colchicine might reduce the incidence of MACE, stroke, and the need for revascularization at long follow-up durations. Colchicine might offer no benefits in reducing the risk of ischemic events in patients with stable angina.

Predictors of Permanent Pacemaker Implantation in Patients Undergoing Transcatheter Aortic Valve Replacement - A Systematic Review and Meta-Analysis.

Background As transcatheter aortic valve replacement (TAVR) technology expands to healthy and lower-risk populations, the burden and predictors of procedure-related complications including the need for permanent pacemaker (PPM) implantation needs to be identified. Methods and Results Digital databases were systematically searched to identify studies reporting the incidence of PPM implantation after TAVR. A random- and fixed-effects model was used to calculate unadjusted odds ratios (OR) for all predictors. A total of 78 studies, recruiting 31 261 patients were included in the final analysis. Overall, 6212 patients required a PPM, with a mean of 18.9% PPM per study and net rate ranging from 0.16% to 51%. The pooled estimates on a random-effects model indicated significantly higher odds of post-TAVR PPM implantation for men (OR, 1.16; 95% CI, 1.04-1.28); for patients with baseline mobitz type-1 second-degree atrioventricular block (OR, 3.13; 95% CI, 1.64-5.93), left anterior hemiblock (OR, 1.43; 95% CI, 1.09-1.86), bifascicular block (OR, 2.59; 95% CI, 1.52-4.42), right bundle-branch block (OR, 2.48; 95% CI, 2.17-2.83), and for periprocedural atriorventricular block (OR, 4.17; 95% CI, 2.69-6.46). The mechanically expandable valves had 1.44 (95% CI, 1.18-1.76), while self-expandable valves had 1.93 (95% CI, 1.42-2.63) fold higher odds of PPM requirement compared with self-expandable and balloon-expandable valves, respectively. Conclusions Male sex, baseline atrioventricular conduction delays, intraprocedural atrioventricular block, and use of mechanically expandable and self-expanding prosthesis served as positive predictors of PPM implantation in patients undergoing TAVR.

Cardiac Tamponade Due to Inferior Vena Cava Filter Removal: A Case Report and Review of Literature.

Cardiac tamponade is a condition characterized by the accumulation of pericardial fluid, compromising the hemodynamics of the circulation. It has several known causes, including traumatic injury to the pericardium, idiopathic, neoplastic or purulent pericarditis, and, rarely, iatrogenic etiology. Inferior vena cava (IVC) filter removal can lead to multiple complications including but not limited to IVC perforation, air embolism, pneumothorax or filter migration. Here, we present a case of a middle-aged woman presenting with cardiac tamponade after IVC filter removal. She was successfully managed with pericardiocentesis followed by pericardial window placement. As this case and literature review illustrates, cardiac tamponade is a rare but potentially devastating complication of IVC filter manipulation.

Is therapeutic anticoagulation improving renal outcomes in COVID-19?

We present three patients with COVID-19 who developed acute renal failure during hospitalization and were seen to have an improvement in their kidney function after being started on therapeutic anticoagulation with heparin (Target PTT 58-93 seconds) for varying indications (atrial fibrillation, popliteal vein thrombosis and a pulmonary embolism). Their kidney functions improved significantly following anticoagulation with a clear temporal relationship between the former and latter. Anticoagulation was held for one patient due to concern of gastrointestinal bleeding and his kidney functions worsened a day after stopping anticoagulation. D-dimer levels also improved with anticoagulation but the trend of other inflammatory markers remained unpredictable.

Efficacy of antibacterial envelope in prevention of cardiovascular implantable electronic device infections in high-risk patients: A systematic review and meta-analysis.

BACKGROUND: Limited evidence is available to determine the efficacy of an antibacterial enveloped (AE) cardiovascular implantable electronic device (CIED). OBJECTIVE: To assess if the use of antibacterial enveloped devices in high-risk patients are associated with lower chances of major CIED infections and mortality compared to non-enveloped devices. METHODS: A comprehensive literature search on multiple databases was performed. The relative odds ratio (OR) of major CIED infection and mortality was calculated using a random-effect model. RESULTS: A total of six studies consisting of 11,897 patients, were included; 5844 with an AE-CIED and 6053 with conventional CIED. In the pooled cohort, patients with AE-CIED had a 66% lower odds of major CIED infection (OR 0.34, 0.13, 0.86, CI 95%, p = 0.02) compared to CIED. Propensity matched analysis showed a 71% lower odds of major infection in the AE-CIED group (OR 0.29, 95% CI 0.10-0.82, p = 0.02). Stratified analysis based on the type of study (retrospective vs. prospective) and duration of follow up (6 months vs. greater than six months) also showed numerically lower infection odds in the AE-CIED. Similarly, the relative odds of mortality were lower in patients with AE-CIED (OR 0.55, 95% CI 0.16-1.91, p = 0.34) compared to CIED patients; however, this difference was statistically non-significant. CONCLUSION: In high-risk patients, AE-CIED might offer lower odds of CIED infections. It has numerically lower (45%) but statistically non-significant odds of mortality if used in conjunction with the standard infection prevention protocol. More large scale studies and long-term follow-ups are required to validate our findings.

Lymphocyte-to-C-Reactive Protein Ratio: A Novel Predictor of Adverse Outcomes in COVID-19.

BACKGROUND: Systemic inflammation elicited by a cytokine storm is considered a hallmark of coronavirus disease 2019 (COVID-19). This study aims to assess the validity and clinical utility of the lymphocyte-to-C-reactive protein (CRP) ratio (LCR), typically used for gastric carcinoma prognostication, versus the neutrophil-to-lymphocyte ratio (NLR) for predicting in-hospital outcomes in COVID-19. METHODS: A retrospective cohort study was performed to determine the association of LCR and NLR with the need for invasive mechanical ventilation (IMV), dialysis, upgrade to an intensive care unit (ICU) and mortality. Independent t-test and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios (aORs) with its 95% confidence interval (CI), respectively. RESULTS: The mean age for NLR patients was 63.6 versus 61.6, and for LCR groups, it was 62.6 versus 63.7 years, respectively. The baseline comorbidities across all groups were comparable except that the higher LCR group had female predominance. The mean NLR was significantly higher for patients who died during hospitalization (19 vs. 7, P ≤ 0.001) and those requiring IMV (12 vs. 7, P = 0.01). Compared to alive patients, a significantly lower mean LCR was observed in patients who did not survive hospitalization (1,011 vs. 632, P = 0.04). For patients with a higher NLR (> 10), the unadjusted odds of mortality (odds ratios (ORs) 11.0, 3.6 - 33.0, P < 0.0001) and need for IMV (OR 3.3, 95% CI 1.4 - 7.7, P = 0.008) were significantly higher compared to patients with lower NLR. By contrast, for patients with lower LCR (< 100), the odds of in-hospital all-cause mortality were significantly higher compared to patients with a higher LCR (OR 0.2, 0.06 - 0.47, P = 0.001). The aORs controlled for baseline comorbidities and medications mirrored the overall results, indicating a genuinely significant correlation between these biomarkers and outcomes. CONCLUSIONS: A high NLR and decreased LCR value predict higher odds of in-hospital mortality. A high LCR at presentation might indicate impending clinical deterioration and the need for IMV.

Predictability of CRP and D-Dimer levels for in-hospital outcomes and mortality of COVID-19.

BACKGROUND: Systemic inflammation elicited by a cytokine storm is considered a hallmark of coronavirus disease 2019 (COVID-19). This study aims to assess the clinical utility of the C-reactive protein (CRP) and D-Dimer levels for predicting in-hospital outcomes in COVID-19. METHODS: A retrospective cohort study was performed to determine the association of CRP and D-Dimer with the need for invasive mechanical ventilation (IMV), dialysis, upgrade to an intensive care unit (ICU) and mortality. Independent t-test and multivariate logistic regression analysis were performed to calculate mean differences and adjusted odds ratios (aOR) with its 95% confidence interval (CI), respectively. RESULTS: A total of 176 patients with confirmed COVID-19 diagnosis were included. On presentation, the unadjusted odds for the need of IMV (OR 2.5, 95% CI 1.3-4.8, p = 0.012) and upgrade to ICU (OR 3.2, 95% CI 1.6-6.5, p = 0.002) were significantly higher for patients with CRP (>101 mg/dl). Similarly, the unadjusted odds of in-hospital mortality were significantly higher in patients with high CRP (>101 mg/dl) and high D-Dimer (>501 ng/ml), compared to corresponding low CRP (<100 mg/dl) and low D-Dimer (<500 ng/ml) groups on day-7 (OR 3.5, 95% CI 1.2-10.5, p = 0.03 and OR 10.0, 95% CI 1.2-77.9, p = 0.02), respectively. Both high D-Dimer (>501 ng/ml) and high CRP (>101 mg/dl) were associated with increased need for upgrade to the ICU and higher requirement for IMV on day-7 of hospitalization. A multivariate regression model mirrored the overall unadjusted trends except that adjusted odds for IMV were high in the high CRP group on day 7 (aOR 2.5, 95% CI 1.05-6.0, p = 0.04). CONCLUSION: CRP value greater than 100 mg/dL and D-dimer levels higher than 500 ng/ml during hospitalization might predict higher odds of in-hospital mortality. Higher levels at presentation might indicate impending clinical deterioration and the need for IMV.

Non-Sustained Ventricular Tachycardia as a Sign of Lung Cancer.

The leading cause of death due to malignancy in the USA is lung cancers. They can be divided into small cell lung cancer and non-small cell lung cancer. Of the latter, adenocarcinoma comprises the majority of lung cancers. Manifestations of lung cancer can be divided into thoracic, extra-thoracic and paraneoplastic syndromes. We describe a case of ventricular tachycardia in a patient who presented with dysphagia, ultimately found to have a non-small cell lung cancer invading the esophagus and heart.

Optimal Duration for Clopidogrel Suspension Prior to Coronary Artery Bypass Grafting.

BACKGROUND: American College of Cardiology (ACC) guidelines suggest clopidogrel (Plavix) suspension for 5 days before non-emergent cardiac surgery (class IIa, level B). It puts the patients with recent angioplasty and ongoing ischemia at a higher risk of stent thrombosis. We sought to determine the bleeding risk in patients who stopped clopidogrel at 3 and less than 3 days before coronary artery bypass grafting (CABG) as compared to the usual 5 days prior to CABG. METHODS: A retrospective single center study was performed; and a total of 90 patients were included. Forty patients were not on clopidogrel but underwent CABG and hence were used as a control group (group 3). Fifty remaining patients were divided into three groups. Patients in whom clopidogrel was stopped 3 days or less before CABG were included in group 1 (n = 25); group 2 included patients who followed the standard ACC guidelines and clopidogrel was suspended 5 days before the CABG (n = 17); and finally patients who had stopped clopidogrel 4 days prior to surgery were included in group 4 (n = 8). This was compared to controls. Postoperative hemoglobin drop was analyzed between subgroups using IBM SPSS version 25. RESULTS: The mean age of the included population was 69.9 years (46 - 88) with 65% of them being male and 35% female patients. The difference in the hemoglobin fall was compared amongst these groups using the one-way ANOVA. There were no outliers, as assessed by boxplot, the data were normally distributed for each group, as assessed by Shapiro-Wilk test (P > 0.05), and there was homogeneity of variances, as assessed by Levene's test of homogeneity of variances (P > 0.05). The fall in hemoglobin for the four different groups was analyzed. The fall in hemoglobin in group 1 (stopped clopidogrel 3 days or less before CABG) was (n = 25, 2.36 ± 1.24), the fall in group 2 (stopped clopidogrel 5 days prior to CABG) was (n = 17, 2.89 ± 1.22), the fall in hemoglobin in group 3 (patients not on clopidogrel) was (n = 40, 2.54 ± 1.35), and the fall in hemoglobin in group 4 (patients stopped clopidogrel 4 days prior to CABG) was (n = 8, 2.02 ± 1.31). ANOVA was subsequently performed on the patient data, which showed no statistical difference between all the four groups regarding the fall in hemoglobin during surgery (P = 0.41). CONCLUSIONS: Our study concludes that there was no significant difference in the hemoglobin drop of the patients who had clopidogrel stopped 3 days prior to the major procedure like CABG in comparison to the patients who stopped clopidogrel 5 days before surgery. We advocate, that early cessation of clopidogrel is posing a threat of thrombosis in high risk patients with no additional benefit of decreased bleeding risks. However, large population studies are needed to validate the results.

A Case of Fibroelastoma with Widespread Embolism to the Brain, Kidney, and Spleen.

Cardiac papillary fibroelastoma (CPF) is the second most common primary cardiac tumor, which is diagnosed incidentally or with embolic phenomena, mostly in the form of a transient ischemic attack (TIA) and stroke. We present a case of a 58-year-old female who presented with fatigue and low-grade fever and was found to have multiple systemic infarcts. Her blood cultures and transthoracic echocardiography (TTE) were negative, ruling out infective endocarditis. However, transesophageal echocardiography (TEE) revealed a mobile mass at the aortic valve. The mass was surgically removed, and the aortic valve was repaired. The histological examination of the mass finally revealed a papillary fibroelastoma. To our knowledge, this is the first reported case where fibroelastoma presented with splenic and renal infarcts in combination with the cerebral infarcts. Since cardiac fibroelastoma can cause embolization to the cerebral, splenic, and renal vessels, we, therefore, advocate that it should be considered as one of the possible causes of widespread embolism. We also stress upon the importance of doing TEE in case of a suspected cardiac mass, as the TTE is more likely to give false-negative results.

Duration of in-hospital cardiopulmonary resuscitation and its effect on survival.

OBJECTIVE: This study aims to determine the correlation between the duration of cardiopulmonary resuscitation (CPR) and the return of spontaneous circulation (ROSC) in an in-hospital cardiac arrest cohort. METHODS: All patients (age ≥ 17 years) who underwent CPR at our institution from 2015 to 2017 were included. The primary endpoint was ROSC or death. A total of 88 patients were included in the study. The Pearson correlation of CPR duration with the establishment of ROSC was calculated using the IBM SPSS, version 25. RESULTS: In all, 88 patients who received CPR, 55% (n = 48) experienced ROSC and survived. The remaining 45% (n = 40) of the total and 56% (n = 27) of those with ROSC died during the same hospitalization (Fig. 1). Among the 48 patients with ROSC, the documented duration of their CPR was about 10 min on average in comparison with 27.5 min CPR for patients who did not achieve ROSC (Fig. 2). Among all the patients, there was a negative correlation between the duration of the CPR and the establishment of ROSC. This is shown in Fig. 3. CONCLUSION: Our study shows that CPR duration is inversely associated with the establishment rates of ROSC. Most of the benefits of CPR can be achieved in the first 15 min, and a further increase in the duration of CPR provides a minimal gain. Still, survival was achievable till 38 min in some cases, and the ideal duration of resuscitation should remain a bedside decision taking into consideration the whole clinical picture.

Great saphenous vein stump: a risk factor for superficial/deep venous thrombosis and an indication for prophylactic anticoagulation? - a retrospective analysis.

Background: Great saphenous vein (GSV) grafts are used for coronary artery bypass surgeries, but the remaining stump of the GSV may be the nidus for superficial and deep vein thrombosis. This study aims to determine the risk of thrombosis in the GSV stump in patients who developed lower extremity swelling following coronary artery bypass graft (CABG). Methods: We conducted a single-center retrospective analysis at Abington Jefferson Hospital of 100 patients who underwent CABG with GSV. Patients were monitored via follow-up for seven days for the development of saphenous vein thrombosis without any prophylactic anticoagulation for venous thrombosis. Risk factors including age, diabetes, hypertension, smoking, familial thrombophilia's, family history of thrombosis, malignancy, and confounding factor-like early mobilization that may potentially alter the results were recorded. Results: The mean age of included patients was 70 years, and 65% of participants were men, 35% were women. Fourteen percent of the patients developed pain, swelling and edema in a leg where the graft was taken. We included patients aged >50 years with coronary artery disease who underwent CABG with SVG and developed lower extremity symptoms concerning for thrombosis. These patients underwent duplex ultrasound for possible GSV stump thrombosis. Any patients with coronary artery disease but no CABG or no lower extremity edema were excluded from the study. We found no saphenous vein thrombosis in the stump of the GSV in patients with clinical symptoms of thrombosis in their lower extremities based on duplex imaging. Conclusion: Based on our findings, the postoperative risk of developing thrombosis at the GSV stump and its extension to the deep veins is low and does not warrant prophylactic anticoagulation for venous thromboembolism. However, we recommend that further prospective studies with larger samples for an extended duration are warranted for better assessment of the risk of venous thrombosis in the GSV stump with minimal confounding factors.

Role of echocardiography in diagnostic evaluation of patients admitted to observation unit.

BACKGROUND: Syncope is a transient loss of consciousness due to transient decrease in cerebral perfusion. Syncope accounts for a 3-6% of all emergency department visits. Etiology of syncope can be neural, cardiogenic, or vascular. Previous studies have evaluated the types and management of syncope. Echocardiography is a commonly used test in the evaluation of causes of syncope. Whether the benefit compared to financial burden of this diagnostic study is in all subsets of syncope cases remains unclear. AIM: To evaluate the impact of echocardiography in the diagnostic evaluation of syncope and to evaluate the subset of patients that would benefit more from this diagnostic imaging. METHODS: We performed a retrospective chart review of patients > 18 years of age with a primary diagnosis of syncope in a period of January 1st 2015-January 31st 2017. Our inclusion criteria included patients > 18 years of age who were admitted to the observation floor with the primary complaint as syncope, had a normal or abnormal physical examination for syncope, had a normal or abnormal electrocardiogram during admission, had an echocardiography performed at admission. Our exclusion criteria included patients with seizures, hypoglycemia, myocardial infarction, patients who didn't get echocardiography, and patients who had a positive marker of cardiac injury. RESULTS: A total of 369 patients were initially identified with a primary diagnosis of syncope, however only 120 of these patients fulfilled our inclusion and exclusion criteria. A total of n=25 of included patients had either an abnormal physical exam or abnormal echocardiography. Among this "high risk" group, 24% (n=6) of the patients had an abnormal finding on their transthoracic echocardiography. On the other hand, in the "low risk" group with a normal physical examination and electrocardiogram (EKG), 14 had a trans-thoracic echocardiography (TTE) positive for cause of syncope, that led to a change in medication, workup, or intervention in 6.7% (n=8) of the patients. CONCLUSION: The analysis of our study suggested that the diagnostic yield of transthoracic echocardiography in syncope is very limited in the absence of an abnormal physical exam or electrocardiogram, and it increase the health care cost burden with no additional benefits.

Role of Laparoscopy in the Management of Acute Surgical Abdomen Secondary to Phytobezoars.

A bezoar is a collection of indigestible material found in the alimentary canal, which can cause mechanical obstruction of the gastrointestinal tract. Phytobezoar is a variant composed of mostly plant material and indigestible fiber. Phytobezoar is a rare cause of small bowel obstruction (SBO) and happens more commonly in patients with risk factors predisposing to impaired gastrointestinal motility. We present a rare case of SBO secondary to phytobezoar in a 60-year-old female patient with type 2 diabetes. There was no prior history of any abdominal surgery. The abdominal computed tomography (CT) scan was inconclusive. Laparoscopy was found to be an effective diagnostic and therapeutic procedure in this patient.

Hindgut Duplication: A Unique Case of Six Perineal Openings.

Complete hindgut duplication is a rare and intriguing entity, often coupled with genitourinary abnormalities and neural tube defects. The diagnosis demands a thorough clinical exam and radiological workup. Timely recognition and expeditious treatment of these patients can lead to a better quality of life. We present a case of a 10-month-old female with complete hindgut duplication and associated genitourinary duplication treated with surgical intervention.

Sarcoma Arising from the Chest Wall : A Case Report.

Chest wall contains a wide array of tissues ranging from soft tissues like skin and muscle to bone. A variety of sarcomas can present with a painful or painless mass, which often requires histological testing for diagnosis. Chest wall sarcomas are very rare entities which are often growing slow . A multidisciplinary team is necessary for the management of chest wall sarcomas. We present a case of a 30-year-old male with spindle cell sarcoma of the chest wall and he underwent wide local excision along with surgical reconstruction.

Acute Renal Failure due to Organophosphate Poisoning: A Case Report.

Organophosphate (OP) poisoning is a commonly seen condition in many countries. OP poisoning classically presents with symptoms of cholinergic excess. It can rarely affect other organ systems but when it does, it can worsen a patient's overall prognosis. We present a case of a 23-year-old man with an extremely rare case of acute kidney injury due to OP, who was successfully treated with a combination of hemodialysis, atropine and pralidoxime days after OP poisoning with reservations on the aging process.

A Unique Case of Empyema Secondary to Amoebic Liver Abscess.

An amoebic liver abscess is an extraintestinal manifestation of amoebiasis that can present with complaints such as right upper quadrant pain and fever. It might not necessarily be associated with abdominal complaints and can have many other atypical presentations. It may present with lung diseases, cardiac diseases, or brain abscesses. We present a case of a patient with empyema secondary to amoebic liver abscess whose diagnosis was delayed due to an unusual presentation. A combination of radiology, serology, and therapeutic interventions led to the accurate management of the patient.