The Interplay between Obstructive Sleep Apnea, Chronic Obstructive Pulmonary Disease, and Congestive Heart Failure: Time to Collectively Refer to Them as Triple Overlap Syndrome?

BACKGROUND AND OBJECTIVES: Obstructive sleep apnea-hypopnea syndrome (OSAHS) and chronic obstructive pulmonary disease (COPD) are independently linked to an increase in cardiovascular disease (CVD). Only a few studies have been published linking the association between overlap syndrome and congestive heart failure (CHF). This review highlights the interplay between overlap syndrome (OSAHS-COPD) and CHF. MATERIALS AND METHODS: We thoroughly reviewed published literature from 2005 to 2022 in PubMed, Google Scholar, and Cochrane databases to explore the link between overlap syndrome and cardiovascular outcomes, specifically congestive heart failure. RESULTS: Research indicates that individuals with overlap syndrome are more likely to develop congestive heart failure than those with COPD or OSA alone. Congestive heart failure is a common comorbidity of overlap syndrome, and it has a two-way connection with sleep-related breathing disorders, which tend to occur together more frequently than expected by chance. CONCLUSIONS: CHF seems to have a strong relationship with OS. Further research is required to understand the relationship between OS and CHF.

Waterhouse-Friderichsen syndrome, septic adrenal apoplexy.

Waterhouse-Friderichsen syndrome is a rare but potentially fatal disorder of the adrenal gland characterized by bilateral adrenal hemorrhage. It is classically a result of meningococcal sepsis and presents acutely with features of shock, petechial rashes, abdominal pain, and non-specific symptoms such as headache, fatigue, and vomiting. Treatment consists of fluid resuscitation, corticosteroid replacement, and possibly surgery. The prognosis is poor despite treatment. This chapter will review the etiology, pathogenesis, clinical features, and management of the disease.

Investigating awareness of artificial intelligence in healthcare among medical students and professionals in Pakistan: a cross-sectional study.

Objective: The purpose of this study is to find out the level of awareness and acceptance of artificial intelligence (AI) in Pakistan's medical community so as to comment on its future in our healthcare system. Methods: A survey consisting of 15 close-ended questions was conducted. The questions inquired about awareness about AI and discovered the opinions of healthcare professionals regarding its benefits and expected problems. The data were analyzed using SPSS version 26, and descriptive statistics for percentage and frequency were computed. χ2 test was used to analyze the subgroups (Significant p value <0.05). Results: A total of 351 participants were included in this study. General familiarity with AI was low. Only 75 (21.3%) participants answered that they had good familiarity with AI, and only 56 (16%) of them had good familiarity with the role of AI in medicine. One hundred sixty-eight (47.9%) participants disagreed that AI would out-compete the physician in the important traits of professionalism. Only 71 (20.2%) participants believed AI to be diagnostically superior to the physician. Two hundred fourteen (61.0%) were worried about completely trusting AI in its decisions, and 204(58.1%) believed that AI systems lacking human traits would not be able to mirror the doctor-patient relationship. Two hundred sixty-one (74.4%) participants believed that AI would be useful in Administrative tasks. A majority, 162 (46.2%), do not believe that AI would replace them. Finally, a huge majority of participants [225 (64.1%)] demanded the integration of AI in Pakistan's healthcare system. Conclusion: This study suggests that a majority of healthcare professionals in Pakistan do not believe that they are sufficiently aware of the role of AI in healthcare. This was corroborated by their answers to various questions regarding the capabilities of AI. This study indicates the need for a more comprehensive ascertainment of healthcare professionals' perceptions regarding the role of Artificial Intelligence in medicine and bridging the gap between doctors and technology to further promote a patient-centred approach to medicine.

Primary Sjogren's syndrome presenting as ptosis and eyelid swelling: A case report.

Key Clinical Message: This unique case report of primary Sjogren's syndrome (pSS) shows bilateral ptosis and significant periorbital edema, compromising vision. To avoid misleading diagnosis, antibody tests must be evaluated and interpreted in the context of clinical findings. Abstract: Primary Sjögren's syndrome is an idiopathic, autoimmune disorder involving the lacrimal and salivary glands characterized by both localized and systemic manifestations including xerostomia and keratoconjunctivitis sicca. Myasthenia Gravis (MG) is also an autoimmune disorder characterized by the development of auto-antibodies against nicotinic acetylcholine receptors that causes decreased muscle response to stimulation. It usually presents with ptosis and generalized body weakness. Ophthalmological involvement is common in both disorders but ptosis is very rarely seen in pSS. We report the case of a 27-year-old woman presenting to our clinic with the complaint of ptosis and eyelid swelling. She also had a positive anti-acetylcholine receptor antibody test and her initial presentation mimicked Myasthenia Gravis. Her autoimmune workup revealed a positive titer of Anti Ro SSA antibodies. Myasthenia Gravis was ruled out on electrodiagnostic studies which showed no decremental response, and pSS was confirmed on lip biopsy. Our case highlights that it is important to interpret the antibody test results in the context of clinical findings as we can have spurious results in autoimmune diseases. Autoimmune conditions can have varying presenting complaints hence, clinical judgment should always overrule diagnostic investigations and should thus guide patient management.

Efficacy and safety of albumin for the treatment of hepatic encephalopathy: an updated systematic review and meta-analysis of randomized controlled trials.

Background: Albumin acts as a scavenger of reactive oxygen species and an inhibitor of inflammatory processes that underlie hepatic encephalopathy (HE). However, the role of albumin in hepatic encephalopathy is not well-established. The authors performed this meta-analysis to evaluate the efficacy and safety of albumin in the management of hepatic encephalopathy. Methods: The authors carried out an extensive search across multiple databases, including MEDLINE (via PubMed), Embase, CENTRAL, and various trial registries, to identify randomized controlled trials (RCTs) evaluating the impact of albumin administration in HE. The authors used a random-effects model for analyses and presented dichotomous outcomes and continuous outcomes as relative risk and mean difference, along with corresponding 95% CIs, respectively. Heterogeneity was assessed using both the I2 index and χ2 test. Results: Our meta-analysis included 4 RCTs involving 306 patients. Our primary outcomes, mortality, and persistence of HE were reported by all four studies. Albumin was found to significantly decrease mortality in patients with HE [risk ratio (RR) 0.52, 95% CI 0.32-0.83; I2 =0%]. Persistence of HE was found to be comparable between the two groups (RR 0.83, 95% CI 0.68-1.00; I2 =24%). There was no significant difference between the albumin and control groups regarding length of hospital stay (MD -1.55, 95% CI -3.5 to 0.14; I2 =41%), adverse events (RR 1.00, 95% CI 0.87-1.16; I2 =0%), and severe adverse events (RR 0.89, 95% CI 0.59-1.35). Conclusion: Albumin administration in patients with hepatic encephalopathy decreases mortality but does not significantly impact the persistence of HE. Further high-quality, large-scale randomized controlled trials are needed to provide conclusive evidence.

Efficacy and safety of mavacamten for the treatment of hypertrophic cardiomyopathy: an updated systematic review and meta-analysis of randomized controlled trials.

The efficacy and safety profile of mavacamten, a cardiac myosin inhibitor for the treatment of hypertrophic cardiomyopathy (HCM) is not well-established, prompting the need for an updated meta-analysis. The authors conducted an extensive search across multiple electronic databases, including Embase, MEDLINE (via Pubmed), and CENTRAL, to identify randomized controlled trials (RCTs) assessing the efficacy and safety of mavacamten in HCM. Review Manager 5.4 (Revman) was employed to pool risk ratios (RR) and mean differences (MD). Our literature search yielded 4 RCTs with a total of 503 patients. Mavacamten was found to be associated with higher rates of greater than or equal to 1 New York Heart Association (NYHA) class improvement (RR 2.20, 95% CI: 1.48-3.28; I2=51%) and change from baseline in the Kansas City Cardiomyopathy Questionnaire- Clinical Summary Score (KCCQ-CSS) (MD 7.50, 95% CI: 3.44-11.55; I2 =50%). Mavacamten was also associated with improved resting left ventricular outflow tract (LVOT) gradient (MD -38.33, 95% CI: -49.38 to -27.28; I2 =75%), Valsalva LVOT gradient (MD -48.08, 95% CI: -62.21 to -33.96; I2 =78%), post-exercise LVOT gradient (MD -37.1, 95% CI: -44.37 to -29.84; I2 =0%), LVMI (MD -16.91, 95% CI: -28.29 to -5.54; I2 =88%), and lower rates of septal reduction therapy (SRT) (RR 0.30, 95% CI: 0.22-0.40; I2 =0%). There were no significant differences between mavacamten and placebo regarding the composite functional outcome, greater than or equal to 1 treatment-emergent adverse event, greater than or equal to 1 serious adverse event, and atrial fibrillation. The authors; findings suggest that mavacamten contributes to improvements in NYHA class, KCCQ-CSS scores, and LVOT gradients while reducing the incidence of SRT in patients with HCM.

Susceptibility - weighted imaging: A valuable diagnostic tool for early detection of high-altitude cerebral edema: A case report.

High altitude cerebral edema (HACE) is a clinical spectrum of high-altitude illness. The working diagnosis of HACE should be based on the history of rapid ascent with signs of encephalopathy. Magnetic resonance imaging (MRI) can be crucial in the timely diagnosis of the condition. A 38-year-old female was airlifted from Everest base camp due to sudden onset of vertigo and dizziness. She had no significant medical or surgical history, and routine laboratory tests showed normal results. MRI was performed, which showed no abnormalities except for the detection of subcortical white matter and corpus callosum hemorrhages on susceptibility-weighted imaging (SWI). The patient was hospitalized for 2 days and treated with dexamethasone and oxygen, and had a smooth recovery during follow-up. HACE is a serious and potentially life-threatening condition that can occur in individuals who rapidly ascend to high altitudes. MRI is a valuable diagnostic tool in the evaluation of early HACE, and can detect various abnormalities in the brain that may indicate the presence of HACE, including micro-hemorrhages. Micro-hemorrhages are tiny areas of bleeding in the brain that may not be visible on other MRI sequences but can be detected on SWI. Clinicians especially radiologists, should be aware of the importance of SWI in the diagnosis of HACE, and ensure that it is included in the standard MRI protocol for evaluating individuals with high altitude-related illnesses for early diagnosis and appropriate treatment to prevent further neurological damage and improve patient outcomes.

Concurrent occurrence of acute pancreatitis and intracerebral hemorrhage as presenting manifestations in lupus: a case report.

Systemic lupus erythematosus (SLE) is a rare autoimmune condition that may affect almost every organ system and has a wide range of disease severity. It is characterized by a spectrum of clinical manifestation, a plethora of autoantibodies, and immune complex formation. The symptoms can come from any organ system, alone or in a group, and they can be of any severity, which makes diagnosis and prognosis difficult. Case presentation: The authors hereby present the case of an 18-year-old female with chief complaints of fever, abdominal pain, headache, vomiting, and loss of vision. She was diagnosed with acute pancreatitis (AP) and intracerebral hemorrhage (ICH) with an etiology linked to SLE. SLICC criterion was used to diagnosed SLE while ATLANTA criteria for AP and neuro-radiological findings for ICH. Emergency temporo- parietal-occipital-osteoplastic craniotomy was done for ICH as well as started with immunosuppressive therapy for SLE. On the 18th day of admission, she was discharge with maintenance medications for SLE. While the vision took over a month to come to a premorbid state, she was clinically improved within 2 weeks of admission. Clinical discussion: Clinical manifestation of SLE vary greatly. AP and intracranial bleeding are few of the rare presentation of SLE. Acute presentation of both conditions in an otherwise healthy individual in the initial course of disease left the clinician with a wide array of differentials. Literature shows very little evidence of co-occurrence of ICH and pancreatitis as an initial manifestation in SLE patients. The exclusive diagnosis of these potentially fatal condition is made holistically with clinical, biochemical, and radiological parameters. Conclusion: SLE may present with atypical, life-threatening initial manifestations. Early diagnosis and timely intervention in therapy can lead to successful management. The treating physician must consider, SLE when a straightforward diagnosis is associated with inexplicable multiple concomitant abnormalities, especially in young women.

Takayasu arteritis in a young male patient: a case report and review of literature.

Takayasu arteritis is a systemic inflammatory disorder that causes harm to the large and medium arteries and their branches. It is primarily prevalent in Asia, Africa, and Latin America, with the incidence rate in Asia being reported to be 100 times higher than in Europe and North America. Females in their second or third decades of life are most commonly affected by this condition. In our case, a 26-year-old male patient was diagnosed with Takayasu arteritis after he experienced a headache and left upper limb weakness. The initial presentation of Takayasu arteritis includes nonspecific constitutional symptoms like fever, malaise, weight loss, and anorexia. Unfortunately, due to the delayed diagnosis of the disease, patients often experience claudication, absence of pulses, hypertension, myocardial infarction, and cerebrovascular accidents. An early and accurate diagnosis of Takayasu arteritis is vital to reduce the economic, social, and psychological burdens associated with the disease.

Sarcomatoid Carcinoma of Orbit in a Patient With Xeroderma Pigmentosum.

Spindle cell carcinoma (SpCC), also referred to as sarcomatoid carcinoma, makes up less than 3% of all head and neck squamous cell carcinomas (SCCs). It is an uncommon and unusual biphasic malignant tumor primarily affecting the upper aero-digestive tract. SpCC consists of spindled or pleomorphic tumor cells. Mostly, these tumors are seen in the fifth or sixth decades of life and are strongly associated with smoking and alcohol. We hereby report an infrequently encountered case of SpCC in a patient with xeroderma pigmentosum (XP), who was young, nonsmoker, and did not consume alcohol. The mass arose from the right orbit and involved the entire right face. The postoperative histopathological report showed SpCC. Surgical excision of the mass was performed. We aimed to add to the prevailing literature by reporting this case.

Anaemia among Third-trimester Pregnant Women in a Community Hospital: A Descriptive Cross-sectional Study.

Introduction: Anaemia has haemoglobin levels of less than 11/100 ml in the first and third trimesters and less than 10/100 ml in the second. Maternal anaemia is a global health issue that has a negative impact on neonatal outcomes. The prevalence is more common in developing nations like Nepal. Positive correlations have been found between third-trimester maternal haemoglobin and neonatal birth weight. Our study aimed to find out the prevalence of anaemia among third-trimester of pregnant women in a community hospital. Methods: This was a descriptive cross-sectional study conducted in the outpatient Department of Obstetrics and Gynecology from September 2020 to September 2021. Ethical approval was taken from the Nepal health research council (Registration number: 577/2020P). The haemoglobin level of 375 participants was recorded. Data were analyzed using Statistical package for social sciences (SPSS) version 22. Convenience sampling was used. Point estimate and 95% Confidence Interval were calculated. Results: Out of a total of 375 pregnant females in the third trimester, 31 (8.27%) (5.48-11.06, 95% Confidence Interval) were anaemia. Conclusions: The prevalence of anaemia was lower as compared to other studies done in similar settings. Keywords: anemia; maternal-child health services; prevalence.

Combination Therapy in Diabetes Mellitus Patients Attending Outpatient Department in a Tertiary Care Centre: A Descriptive Cross-sectional Study.

Introduction: Assessing anti-diabetic drug use patterns in hospitals is an important activity which helps to promote the rational use of drugs and may suggest measures to change prescribing habits for the better. This study aimed to find the use of combination therapy in diabetes mellitus patients attending the outpatient department of a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among 201 diabetes mellitus patients in the internal medicine department from 2 March 2022 to 30 June 2022 for a duration of four months after approval from the Institutional Review Committee (Protocol No: IRC-LMC-01/R-022). Diabetic patients prescribed at least one anti-diabetic drug in prescription forms were included. Socio-demographic profiles, clinical characteristics and anti-diabetic drug use pattern-related data were collected. Convenience sampling was used. Point estimate and 95% Confidence Interval were calculated. Results: Among 201 patients, 134 (66.66%) (60.14-73.18, 95% Confidence Interval) patients were given combination therapy. The most common combination therapy was metformin 500 mg and sitagliptin 50 mg. A total of 324 anti-diabetic drugs were used. The average number of drugs prescribed per patient was 1.6±0.7. The number of anti-diabetic drugs prescribed by generic name and from the national essential drugs list was 74 (22.83%) and 188 (58.02%) respectively. Biguanides were used in 176 (87.56%) patients. Conclusions: These findings were similar to some other studies conducted in similar settings. In most patients, combination drug therapy was more prevalent. Among combination therapy, two drug combinations were more prevalent. Keywords: diabetes mellitus; drug combinations; outpatients; teaching hospital.

Penile strangulation, a study of two cases.

INTRODUCTION: Penile strangulation is one of the rarest clinical findings. So, we aimed to present the clinical case of two cases that we encountered at our institute. PRESENTATION OF CASES: Case 1. A 26-year-male with bipolar disorder presented to emergency room with complaints of metallic ring entrapment in the penis for 4 days. A gold-plated metallic ring measuring 1 × 0.25 cm was found encircling the coronal sulcus along with foul-smelling pus and slough underneath as a result of necrosis of the skin. Jumbo cutter was used to cut the ring. Loose sutures were applied to the injured part with debridement. CASE 2: A 66-year-old man presented to emergency with complaints of penile swelling and poor urinary stream for the last 2 days. Local examination showed a plastic ring of water bottle seen stuck at the root of penis. Distal penis was edematous with multiple areas of skin discoloration and petechia. The ring was cut with simple surgical scissor. DISCUSSION: This clinically emergency condition may lead to wide range of vascular and mechanical injuries if the treatment is delayed. Plastic rings can be easily cut out whilst metallic objects which are thick and hard are difficult to remove. Pliers' application or use of jumbo cutter as in one of our cases is beneficial for prompt release of edematous pressure and salvage of the penis. CONCLUSION: Penile strangulation due to foreign body is a rare clinically emergency condition. Urgent intervention is necessary to remove the object causing constriction along the penis.

Risk Factors Associated with Low Birth Weight among Deliveries at Bharatpur Hospital.

BACKGROUND: Babies with a birth weight of less than 2500 grams, irrespective of the period of their gestation are termed as Low Birth Weight (LBW) babies. Despite consistent efforts to improve the quality of maternal and child health, more than twenty million low birth-weight (LBW) babies are born every year throughout the world. Though, the health situation of Nepal has improved substantially over the years, the low birth-weight (LBW) rate is still high. The objective of this study was to assess the proportion of low birth weight and identify the associated factors for low birth weight in a live born infant among the institutionally delivered newborns. METHODS: A hospital based cross sectional study was conducted in Obstetrics and Gynaecology ward of Bharatpur hospital, Bharatpur, from 17th September to 4th October , 2012. Altogether 480 respondents were taken and respondents were mothers who had delivered newborns in Bharatpur hospital. RESULTS: A total of 480 births occurred during the study period, of which 480 met the study criteria. Among which 9.4% were low birth weight and 90.6% were normal birth weight .Overall mean birth weight was found to be 2.96 kg. Out of total 9.4% newborns were weighing less than 2.50 kg and mean birth weight 2.96kg. CONCLUSIONS: This study suggests that there were several factors interplaying which lead to LBW babies; which are age of mother at delivery,weight gain by mother during pregnancy, short, low body mass index and hyperemesis gravidarum was the strongest predictor in this study.