Driving Under the Influence: An Unusual Case of Basal Ganglia Stroke Misdiagnosed as Intoxication

Traditionally, strokes are characterized by negative symptoms, including contralateral hemiparesis, facial paralysis, and sensory loss in the upper face and upper extremities. Strokes rarely cause movement disorders such as ballismus, a severe chorea characterized by brief, sudden dance-like movements. Early identification of non-traditional stroke symptoms and risk factors for cerebrovascular disease is vital in providing timely treatment and improving patient outcomes. Our case highlights an uncommon complication of stroke and the need to use advanced imaging modalities, including MRI, to identify brain lesions when other testing is negative. This report adds to the body of literature highlighting ballismus, a rare presentation of stroke, and the lessons learned from managing this case.

Environmentally friendly protocol for the determination of sitagliptin phosphate in pharmaceutical preparations and biological fluids using l-tyrosine as a fluorescence probe

A responsive spectrofluorometric method was developed for the determination of sitagliptin phosphate using l-tyrosine as a fluorescence probe. The fluorescence intensity of l-tyrosine was quenched with sitagliptin phosphate. The fluorescence intensity was recorded at 307 nm using a 272 nm excitation wavelength. The calibration plot between fluorescence intensity and the concentration of drug was linear in the range of 0.1 to 2.0 mM with a good correlation value of 0.997. The limit of detection and quantification were established to be 3.7 × 10-4 and 1.23 × 10-3  mM, respectively. Commonly used excipients did not interfere with sitagliptin phosphate measurement. The proposed method was used to measure the sitagliptin phosphate in its standard type, dosage form, and biological samples. The percent recovery ranged from 97.41-103.36%. The static quenching was shown to be responsible for quenching as indicated by the Stern-Volmer plot. The method was validated using ICH guidelines and profitably applied for the content uniformity test, resulting in a high percent recovery and small relative standard deviation. The proposed approach is effortless, susceptible, selective, economic, and provides a high precision and accuracy, and can be used to determine sitagliptin phosphate in the pharmaceutical industry.

Prodromal Symptoms in Patients Presenting With Myocardial Infarction

Background Prodromal symptoms are warning signs of an impending acute myocardial infarction (AMI). However, they are often overlooked by both patients and primary clinicians, and little is known about them. Therefore, this study aims to assess the frequency and types of prodromal symptoms in patients with AMI. Methodology This descriptive cross-sectional study was conducted at a tertiary care cardiac center. Consecutive patients diagnosed with AMI within the last week were evaluated for prodromal symptoms. The prodromal symptoms included chest pain, chest heaviness, chest burning, palpitations, fatigue, sleep disturbance, shortness of breath (SOB), dizziness, anxiety, sudden heat or cold, back pain, and vomiting. Results In a sample of 242 patients, 79.6% were males, with a mean age of 54.7 ± 12.2 years, and 179 (74%) were diagnosed with ST-segment elevation myocardial infarction (STEMI). Among the participants, 142 (58.7%) showed no prodromal symptoms. Among those with prodromal symptoms, chest pain was the predominantly reported prodromal symptom with a frequency of 68%, followed by chest heaviness at 44%, palpitations at 42%, shortness of breath at 34%, and chest burning at 27%. Unusual fatigue in 23% and sleep disturbance in 22% of the patients were also reported. Conclusion The findings from this study revealed that prodromal symptoms were present in a significant proportion of acute myocardial infarction (MI) cases, with more than four in 10 patients reporting these early warning signs. The most commonly observed prodromal symptoms were chest pain, chest heaviness, palpitations, shortness of breath, and chest burning. The timely identification of these symptoms can help prevent infarction, thereby reducing the burden of heart failure and other related mortalities.

Progressive Dysregulation of Tau Phosphorylation in an Animal Model of Temporal Lobe Epilepsy

Tau is an intracellular protein known to undergo hyperphosphorylation and subsequent neuro-toxic aggregation in Alzheimer's disease (AD). Here, tau expression and phosphorylation at three canonical loci known to be hyperphosphorylated in AD (S202/T205, T181, and T231) were studied in the rat pilocarpine status epilepticus (SE) model of temporal lobe epilepsy (TLE). We measured tau expression at two time points of chronic epilepsy: two months and four months post-SE. Both time points parallel human TLE of at least several years. In the whole hippocampal formation at two months post-SE, we observed modestly reduced total tau levels compared to naïve controls, but no significant reduction of S202/T205 phosphorylation levels. In the whole hippocampal formation from four month post-SE rats, total tau expression had reverted to normal, but there was a significant reduction in S202/T205 tau phosphorylation levels that was also seen in CA1 and CA3. No change in phosphorylation was seen at the T181 and T231 tau loci. In somatosensory cortex, outside of the seizure onset zone, no changes in tau expression or phosphorylation were seen at the later time point. We conclude that total tau expression and phosphorylation in an animal model of TLE studied do not show hyperphosphorylation at the three AD canonical tau loci. Instead, the S202/T205 locus showed progressive dephosphorylation. This suggests that changes in tau expression may play a different role in epilepsy than in AD. Further study is needed to understand how these changes in tau may impact neuronal excitability in chronic epilepsy.

Molecular based identification and phylogenetic relationship by using cytochrome b gene of Pangasius pangasius

Molecular appraoch for identification of unknown species by using Cytochrome b gene is an effective and reliable as compared with morphological based identification. For DNA barcoding universal molecular genes were used to identify the species. Cytochrome b is a specific gene used for identification purpose. DNA barcoding is a reliable and effective method compared to the different traditional morphological methods of specie identification. So,in the present study which was conducted to identify the species, a total of 50 fish samples were collected from five different sites. DNA was extracted by using the Phenol Chloroform method from muscle tissue. Five sequences were sequenced (one from each site), analyzed, and identified specific species as Pangasius pangasius. Identified sequences were variable in length from 369 bp (Site 1), 364 bp (Site 2), 364 bp (Site 3), 352 bp (Site 4), and 334 bp (Site 5). Identity matches on the NCBI database confirmed the specific specie as P. pangasius. A distancing tree was drawn to show maximum likelihood among the same and different species. Yet, in many cases fishes on diverse development stages are difficult to identify by morphological characters. DNA-based identification methods offer an analytically powerful addition or even an alternative tool for species identification and phylogenetic study. This work intends to provide an updated and extensive overview on the DNA based methods for fish species identification by using Cytochrome b gene as targeted markers for identification purpose.

A Deadly Herbicide 'Paraquat Poisoning' and Miserable Death of a 19 Years Boy

Poisoning by paraquat herbicide now a days is a major medical problem in many parts of Asia as well as in Bangladesh. Already it has been banned in the European Union and some other countries for several years. Paraquat is highly toxic if ingested, with clinical features including oral burns, sore throat, vomiting and diarrhoea, progressing to pneumonitis, pulmonary fibrosis and multi-organ failure. Recently we dealt with many cases of paraquat poisoning in Mymensingh Medical College Hospital and here we report one case. A 19 years old student intentionally ingested 10 ml of paraquat herbicide and presented with multi organ failure. His renal function was supported with 4 session's hemodialysis and regain normal renal function. But he also developed Acute Lung Injury (ALI) and liver dysfunction, was supported with ionotropic and invasive ventilation and couldn't save. On 14th day of poisoning he died.

Exogenous melatonin-mediated regulation of K+ /Na+ transport, H+ -ATPase activity and enzymatic antioxidative defence operate through endogenous hydrogen sulphide signalling in NaCl-stressed tomato seedling roots

Melatonin (Mel) and hydrogen sulphide (H₂ S) have emerged as potential regulators of plant metabolism during abiotic stress. Presence of excess NaCl in the soil is one of the main causes of reduced crop productivity worldwide. The present investigation examines the role of exogenous Mel and endogenous H₂ S in tomato seedlings grown under NaCl stress. Effect of 30 µm Mel on endogenous synthesis of H₂ S was examined in roots of NaCl-stressed (200 mm) tomato seedlings. Also, the impact of treatments on the oxidative stress markers, transport of K⁺ and Na⁺ , and activity of H⁺ -ATPase and antioxidant enzymes was assessed. Results show that NaCl-stressed seedlings supplemented with 30 µm Mel had increased levels of endogenous H₂ S through enhanced L-cysteine desulfhydrase activity. Mel in association with H₂ S overcame the deleterious effect of NaCl and induced retention of K⁺ that maintained a higher K⁺ /Na⁺ ratio. Use of plasma membrane inhibitors and an H₂ S scavenger revealed that Mel-induced regulation of K⁺ /Na⁺ homeostasis in NaCl-stressed seedling roots operates through endogenous H₂ S signalling. Synergistic effects of Mel and H₂ S also reduced the generation of ROS and oxidative destruction through the enhanced activity of antioxidant enzymes. Thus, it is suggested that the protective function of Mel against NaCl stress operates through an endogenous H₂ S-dependent pathway, wherein H⁺ -ATPase-energized secondary active transport regulates K⁺ /Na⁺ homeostasis.

Explicating genetic diversity based on ITS characterization and determination of antioxidant potential in sea buckthorn (Hippophae spp.)

BACKGROUND

Sea buckthorn (Hippophae) is in the focus of interest mainly for its positive effects on health of both human and animal organisms. Due to the similarities in vegetative morphology, Hippophae species are often misidentified. Therefore, current study was focused on ITS based sequence characterization of sea buckthorn species and comparative biochemical evaluation for its antioxidant properties.

METHODS AND RESULTS

DNA was extracted from leaf samples. Primer pairs K-Lab-SeaBukRhm-ITS1F1- K-Lab-SeaBukRhm-ITS1R1 and K-LabSeaBukTib- ITSF1- K-LabSeaBukTib-ITSR1 were used for PCR amplification. The purified PCR products were outsourced for sequencing. Phylogenetic tree was constructed based on neighbor-joining (NJ) method. Moreover, comparison of antioxidant potential of leaves of two sea buckthorn species (Hippophae rhamnoides and Hippophae tibetana) collected from different regions of Ladakh viz., Stakna, Nubra, DRDO Leh and Zanskar was determined by 2,2-diphenyl-1-picrylhydrazyl (DPPH), 2,2-azino-bis (3- ethylbenzothiazoline-6-sulphonic acid) diammonium salt (ABTS), and Total antioxidant capacity (TAC) by phosphomolybdenum assays. The present investigation led to the differentiation of two sea buckthorn species viz., H. rhamnoides and H. tibetana based on Internal Transcribed Spacer (ITS) region. Moreover, significant variation was observed in antioxidant potential of leaf extracts collected from different regions.

CONCLUSIONS

Primary ITS sequence analysis was found to be powerful tool for identification and genetic diversity studies in sea buckthorn. Leaves of sea buckthorn have pronounced antioxidant properties and can be used in food, neutraceuticals and pharmaceutical industries etc. The current study will pave the way to discover small bioactive molecules responsible for antioxidant and anticancer properties in sea buckthorn.

Is selective late sodium current inhibition different from class I/B antiarrhythmic action? Comparison of the effects of GS967 to mexiletine in canine ventricular myocardium

Funding Acknowledgements

Type of funding sources: Public grant(s) – EU funding. Main funding source(s): National Research, Development and Innovation Office New National Excellence Programme

Enhancement of the late Na+ current (INa,late) increases arrhythmia propensity in the heart, while suppression of the current is antiarrhythmic. GS-458967 (GS) is an agent considered to be a selective blocker of INa,late. In the present study, effects of GS967 on INa,late, on L-type calcium current (ICaL), and on action potential (AP) morphology were studied in canine ventricular myocytes by using conventional voltage clamp, action potential voltage clamp and sharp microelectrode techniques. These effects of GS were compared to tetrodotoxin (TTX) and to the class I/B antiarrhythmic compound mexiletine.

GS (1 μM), mexiletine (40 μM) and TTX (10 μM) dissected largely similarly shaped inward currents under action potential voltage clamp conditions. In case of GS and mexiletine, the amplitude and integral of this inward current was significantly smaller when measured in the presence of 1 μM nisoldipine, while no difference was observed in case of TTX. Under conventional voltage clamp conditions, INa,late was significantly reduced by 1 μM GS and 40 μM mexiletine (about 79% and 63% reduction of current integrals, respectively). The integral of ICa,L was moderately but significantly decreased by both drugs (reduction of 9% and 14%, respectively). These changes were associated with a faster inactivation of ICa,L.

Drug effects on early Na+ current (INa,early) were assessed by analyzing the maximal rate of depolarization (V + max) in multicellular preparations. Both GS and mexiletine showed fast onset and offset kinetics: 110 ms and 289 ms offset time constants, respectively, as determined from V + max measurements in right ventricular papillary muscles, while the onset kinetics was characterized by 5.3 AP and 2.6 AP lengths, respectively, at 2.5 Hz.

Effects on beat-to-beat variability of AP duration (APD) was studied in isolated myocytes. Short-term variability was significantly decreased by both GS and mexiletine (average reduction of 42% and 24%, respectively) while they caused similar shortening of the APD.

The electrophysiological effects of GS are similar to those of mexiletine, but with a somewhat faster offset kinetics of V + max block. However, since GS reduced V+ max and INa,late in the same concentration, the currently accepted view that GS that selectively blocks INa,late has to be questioned and it is suggested that GS should be classified as a class I/B (or I/B + IV) antiarrhythmic agent.

Application of spore morphology to solve identification problems in certain species of family Dryopteridaceae from Malakand Division, Pakistan

Here we investigate the morphology of the spores of 12 native taxa of Dryopteridaceae that grow in Malakand division, Pakistan; most of these species not fully described before. This study intends to survey the taxonomic significance of spore morphological features and their variation useful for species identification in 7 species of Polystichum and 5 taxa of Dryopteris. The spores examinations were accomplished utilizing a light microscope (LM), and scanning electron microscope (SEM). The spores are monolete, medium-sized, with variable shapes in both equatorial and polar views. The mean estimation of equatorial diameter ranging from 28.3 to 58.3 μm and the polar diameter varied from 27.6 to 45.8 μm. The exospore thickness ranges between 1.6 to 3.8 μm, and the thickness of perispore is 0.8-6.7 μm. The perispore is perforated, ornamentation elements occur in different ways in the studied taxa of Polystichum. In investigated Dryopteris taxa, rugate perispore type is found. Results of multivariate statistical analysis (UPGMA, and PCA) established on quantitative and qualitative morphological traits of spores demonstrate that the species form distinct groups, not reflecting any phylogenetic relationships. A key to the spores types is provided for species identification, which dependent on the diagnostic characters of spores. The results of this study indicate that variation of spore morphological traits; in particular, the ornamentation and perispore characteristics, which is surface texture, have diagnostic value at the species level. Our data will help in the identification of spores of the family Dryopteridaceae in palynological and taxonomic studies.

Enhancing Value-Based Care With a Walk-in Clinic: A Primary Care Provider Intervention to Decrease Low Acuity Emergency Department Overutilization

Background Emergency department overutilization is a known contributor to the high per-capita healthcare cost in the United States. There is a knowledge gap regarding the substitution effect of walk-in clinic availability in primary care provider (PCP) offices and emergency department utilization (EDU). This study evaluates associations between PCP availability and EDU and analyzes the potential cost savings for health systems. Methods A retrospective cohort analysis compared low acuity EDU rates in established patients at a family medicine residency's PCP office before and after walk-in clinic implementation. The practice had 12 providers, 12 residents, and a patient panel of approximately 7,000-8,000. Inclusion criteria were met if patients were: (1) established with the PCP office, (2) had a low acuity emergency department (ED) visit (emergency index score level 4 or 5) OR had a walk-in clinic visit at the family practice. ED visits were tracked from January 2018 to January 2020 and encounters were compared numbers to pre and post-implementation of a walk-in clinic. Cost savings for comparable management was estimated with average price differences for low acuity encounters in the ED versus clinic. Results Over the two-year timeframe, there were 10,962 total visits to the ED by family practice patients, 4,250 of these visits were low acuity. Despite gross monthly increases of EDU from 2018-2020, after implementation of a walk-in clinic in 2019, rates of total EDU decreased by 1.5% and low acuity utilization rates also decreased. The average annual patient census nearly doubled from 5,763 to 8,042. T-tests confirmed statistical significance with p-values <0.05. Average low acuity ED visits ($437) cost 4.9 times more than comparable PCP office visits ($91). Managing 2,387 patients in the walk-in clinic resulted in an estimated annual cost savings of $825,902. Conclusion Extended walk-in availability in primary care offices provides non-ED capacity for low acuity management and might mitigate low acuity ED utilization while providing more cost-effective care. This study supports similarly described pre-hospital diversions in reducing ED over-utilization by increasing access to care. Higher levels of evidence are needed to establish causality.

HCN Channel Phosphorylation Sites Mapped by Mass Spectrometry in Human Epilepsy Patients and in an Animal Model of Temporal Lobe Epilepsy

Because hyperpolarization-activated cyclic nucleotide-gated (HCN) ion channels modulate the excitability of cortical and hippocampal principal neurons, these channels play a key role in the hyperexcitability that occurs during the development of epilepsy after a brain insult, or epileptogenesis. In epileptic rats generated by pilocarpine-induced status epilepticus, HCN channel activity is downregulated by two main mechanisms: a hyperpolarizing shift in gating and a decrease in amplitude of the current mediated by HCN channels, I_h. Because these mechanisms are modulated by various phosphorylation signaling pathways, we hypothesized that phosphorylation changes occur at individual HCN channel amino acid residues (phosphosites) during epileptogenesis. We collected CA1 hippocampal tissue from male Sprague Dawley rats made epileptic by pilocarpine-induced status epilepticus, and age-matched naïve controls. We also included resected human brain tissue containing epileptogenic zones (EZs) where seizures arise for comparison to our chronically epileptic rats. After enrichment for HCN1 and HCN2 isoforms by immunoprecipitation and trypsin in-gel digestion, the samples were analyzed by mass spectrometry. We identified numerous phosphosites from HCN1 and HCN2 channels, representing a novel survey of phosphorylation sites within HCN channels. We found high levels of HCN channel phosphosite homology between humans and rats. We also identified a novel HCN1 channel phosphosite S791, which underwent significantly increased phosphorylation during the chronic epilepsy stage. Heterologous expression of a phosphomimetic mutant, S791D, replicated a hyperpolarizing shift in I_h gating seen in neurons from chronically epileptic rats. These results show that HCN1 channel phosphorylation is altered in epilepsy and may be of pathogenic importance.

Formation of 3-Aminophenols from Cyclohexane-1,3-diones

meta-Aminophenols are formed by the action of DBU on 3-amino-2-chlorocyclohex-2-en-1-ones at room temperature in MeCN. The chloro compounds are generated by treating 3-aminocyclohex-2-en-1-ones with the easily prepared halogenating agent BnNMe₃·ICl₂ in MeOH-CH₂Cl₂. The amino group must carry two substituents, either two aryl, one aryl and one alkyl, or two alkyl groups; 3-aminocyclohex-2-en-1-ones of this type are readily made from cyclohex-2-en-1-one and a primary or secondary amine.

Inhibition of microbial growth by silver nanoparticles synthesized from Fraxinus xanthoxyloides leaf extract

AIMS

Conventional antibiotics have been failed to treat infectious diseases due to emergence of multidrug resistance (MDR) in some common pathogens. The current study aimed to formulate new antimicrobials from greener sources. In the midst of these efforts, nanotechnology is a newly emerged field, in which the synthesis of new nanoparticles through novel and efficient means is on the rise.

METHODS AND RESULTS

The current work has been carried out to assess the potential of Fraxinus xanthoxyloides (FX) leaf extract in biosynthesis of silver nanoparticles (FX-AgNPs). This method is economical and simple one-step approach to synthesize AgNPs. Characterization of FX-AgNPs has been done by UV-Visible spectroscopy, scanning electron microscope (SEM), X-ray diffraction (XRD), transmission electronic microscope (TEM) and Fourier transforms infrared spectroscopy (FT-IR). The formation of FX-AgNPs has confirmed through UV-Visible spectroscopy (at 430 nm) by change of colour owing to surface Plasmon resonance. Based on the XRD pattern, the crystalline property of FX-AgNPs has established. Functional groups existing in F. xanthoxyloides leaf extract are confirmed by FT-IR spectrum. SEM and TEM authenticated morphology of the AgNPs. The newly synthesized nanoparticles were evaluated for their antimicrobial potential. Minimum inhibitory concentration was determined against Escherichia coli, methicillin-resistant Staphylococcus aureus (MRSA) strains, Pseudomonas aeruginosa and Candida albicans by microtiter plate assay. The lowest inhibition (69%) observed against MRSA was at a concentration of 50 ppm FX-AgNPs and maximum inhibition (81%) observed was against P. aeruginosa. The biosynthesized AgNPs triggered up to 68·6% reduction of the P. aeruginosa biofilm when compared to the control.

CONCLUSION

It can be concluded that nanoparticles could be a better alternative of antibiotics with greater efficacies and represent a valuable milestone to fight against infections caused by MDR pathogens.

SIGNIFICANCE AND IMPACT OF THE STUDY

This study imparts a useful insight into the development of a new antimicrobial agent from a novel source.

Determination of cefixime in pure form, in pharmaceutical products and biological samples through fluorescence quenching of eosin Y

A simple, economic and validated spectrofluorimetric method was developed to assay cefixime (CFX). The technique relies on the quenching effect of CFX on the fluorescence intensity of eosin Y in the presence of acetate buffer pH 3.4 to produce an ion-pair complex that is measured at 549 nm using an excitation wavelength of 300 nm. Reaction-influencing factors were carefully investigated and optimized. The fluorescence quenching value was linear to the CFX concentration in the range 0.2-40 μg/ml with a correlation coefficient of 0.992. The calculated limit of detection and limit of quantification were found to be 0.00242 and 0.0080 μg ml^-1 , respectively. The selectivity of the method was confirmed by studying the effects of excipients and no interference was distinguished. The developed method was used to determine CFX in marketable products and in biological samples. To validate the method, directives of the International Conference on Harmonization were applied and per cent recoveries obtained ranged from 95.30 to 102.50% for pharmaceutical products and from 97.00 to 103.00% for biological fluids.

Coronary Artery Anomalies in Tetralogy of Fallot Patients Undergoing CT Angiography at a Tertiary Care Hospital

Background

The aim of this study was to determine the frequency of coronary artery anomalies (CAAs) in Tetralogy of Fallot (TOF) patients undergoing computed tomography (CT)-angiography in a tertiary care hospital.

Methodology

In this observational study, we included consecutive TOF patients undergoing CT-angiography without prior history of cardiac surgery or congenital heart disease. CAAs were defined based on either origin or course of the artery.

Results

Out of 441 TOF patients, the prevalence of CCAs was 3.6% (16), of which 13 were below 18 years of age. Anomalous left main artery was observed in six (1.4%) patients, followed by left anterior descending artery and right coronary artery, observed in four (0.9%) patients each, and two (0.5%) patients had a single coronary artery originating from the left coronary cusp with an interarterial course.

Conclusions

CAAs were observed in a significant number (3.6%) of TOF patients. A CT-angiographic assessment before surgical correction would help identify the exact anatomy for better surgical planning to minimize complications.

Multivessel Coronary Artery Disease and Subsequent Thrombolysis in Myocardial Infarction Flow Grade After Primary Percutaneous Coronary Intervention

Background

In underdeveloped countries, coronary artery disease (CAD) has developed into a serious health issue due to the high rates of risk factors such as obesity and smoking amongst the population. This study has been performed to find the rate of multivessel CAD (MVD) and subsequent thrombolysis in myocardial infarction (TIMI) flow grade III in patients undergoing primary percutaneous coronary intervention (PCI).

Methods

This transverse study was carried out involving 110 patients from the emergency department of the National Institute of Cardiovascular Diseases, Karachi, Pakistan, from August 2015 to March 2016. All patients were diagnosed as ST-segment elevation myocardial infarction (STEMI) and had gone through primary PCI. Pre-procedure angiographic findings regarding the number of vessels involved and post-procedure TIMI flow grade were assessed and analysed.

Results

The average age of the study sample was 56.3 ± 11.4 years. The proportion of male patients was 81.8% (n=90), and hypertension was the most prevalent risk factor followed by type II diabetes with a frequency of 67.3% (n=74) and 40.0% (n=44), respectively. Coronary angiography showed MVD in 50.0% (n=55) of the patients, of whom 34 patients had two-vessel disease, and the remaining 21 had three-vessel disease. Ninety percent (n=99) of the patients exhibited TIMI flow grade III after the procedure with no significant difference between patients with MVD and those with single-vessel disease with a rate of 87.3% (n=48/55) versus 92.7% (n=51/55, P=0.527), respectively.

Conclusion

Post-procedure TIMI flow grade III was accomplished in almost 90% of the subjects with or without MVD. It can be concluded that primary PCI has a significant role in the early restoration of myocardial blood flow following STEMI regardless of the vessels involved.

Partial Annuloplasty Rings in the Repair of Functional Ischemic Mitral Regurgitation

Background

Acute myocardial infarction (MI) is the leading cause of worldwide cardiac morbidities and mortalities. Mitral regurgitation (MR) is a common complication of MI. The severity of ischemic MR (IMR) can range widely, both clinically and hemodynamically. Mitral valve (MV) repair by lifting annuloplasty is a surgical procedure used to correct the pathology of IMR. The immediate outcomes of this technique have not yet been determined. The present study, therefore, evaluated the immediate results of MV annuloplasty performed to complement MV repair in patients with IMR.

Methodology

All adult patients with IMR who underwent lifting posterior mitral annuloplasty (LPMA) plus concomitant coronary artery bypass grafting (CABG) were included. Immediate outcomes were evaluated by transesophageal color Doppler echocardiography. The frequency of successful outcomes was compared in patients with different baseline characteristics.

Results

Posterior mitral annuloplasty was successful in 93.1% of patients, including in 92.8% of men and 94.1% of women. The percentages of successful immediate outcomes differed significantly in patients with and without diabetes and hypertension, and in patients with two- and three-vessel disease.

Conclusion

LPMA resulted in a high percentage of successful immediate outcomes in patients with IMR. Further studies should compare rates of immediate, intermediate, and late outcomes of this technique.

Outcome at Six Months After Primary Percutaneous Coronary Interventions Performed at a Rural Satellite Center of Sindh Province of Pakistan

Introduction

Primary percutaneous coronary intervention (PPCI) is now a well-established treatment of acute ST-elevation myocardial infarction (STEMI). For the first time in Pakistan, various off-site satellite centers are established to perform PPCI 24-hours. Our population mainly resides in the rural area with low literacy rate and poor socioeconomic conditions. The majority of the patients who are presented in the satellite center had either never received any long-term treatment plan or were non-compliant to their medication. The objective of this study was to determine the outcome of patients at six months who underwent primary PCI at a rural satellite center of Sindh, Pakistan.

Methods

This study was conducted at Larkana satellite center of National Institute of Cardiovascular Diseases, Karachi. Patients who underwent PPCI for STEMI from October 2017 to March 2018 were enrolled in the study. In case of death of the patient, data were obtained from the attendant of the deceased. Patients, on follow-up visits, were interrogated for post-procedure symptoms.

Results

A total of 271 patients were enrolled in the study. The mean age ± standard deviation of patients was 54.84 ± 10.64 years. The most common culprit artery was left anterior descending (LAD) artery with 161 (59.4%) patients, followed by right coronary artery (RCA) with 98 (36.2%) patients. Only 41 (15%) patients had a three-vessel disease, while 141 (52%) patients had single-vessel disease. On follow-up, 70 (25.8%) patients complained of chest pain grade II, 20 (7.4%) complained of shortness of breath (SOB) grade II, 44 (16.2%) complained of vertigo, and 16 (5.9%) complained of nonspecific weakness. The mortality rate of 6.3% (17) was observed after six months of PPCI. The mortality rate was found to be lower for patients with LAD disease (p = 0.036) and higher among patients with RCA as the culprit artery (p = 0.045). The mortality rate was significantly associated with the number of diseased vessels and the type of stent deployed.

Conclusion

Primary PCI, at a rural satellite center, has an overall positive outcome. Steps should be taken to provide free medication along with encouragement towards compliance of dual antiplatelet medication. Furthermore, the facility for subsequent procedures should be provided at the same set-up.

Fluorescence Quenching of the Probes L-Tryptophan and Indole by Anions in Aqueous System

A fluorescence quenching study of the fluorescent probes L-tryptophan and indole by anions (NO3-, Cl-, SO42-) was carried out in an aqueous system. The ions NO3-, Cl- and SO42- showed very good quenching of both the probes. Quenching of L-tryptophan by all the anions studied was higher as compare to the quenching of indole. The data was fitted with the Stern-Volmer equation. Stern-Volmer constants were observed in the order NO3- > Cl- > SO42-. Stern-Volmer constants reflect the sensitivity of the method for the studied anions. Limit of detection (LOD) was calculated as three times the standard deviation of the blank for n = 10 (3 × SD) while the limit of quantification (LOQ) was calculated as ten times the standard deviation of the blank for n = 10 (10 × SD). In the case of L-tryptophan LOD and LOQ varied from 4.08 × 10-5 - 4.56 × 10-4 mol L-1, while in the case of indole the values ranged from 3.87 × 10-5 - 6.59 × 10-4 respectively. Fluorescence quenching of L-tryptophan and indole by the studied anions showed good reproducibility and the method could be very effective for the determination of anions.

Selective hyperactivation of JNK2 in an animal model of temporal lobe epilepsy

c-Jun N-terminal kinases (JNKs) are members of the mitogen-activated protein kinase (MAPK) family and are derived from three genes, Jnk1-3. These kinases are involved in cellular responses to homeostatic insults, such as inflammation and apoptosis. Furthermore, increased JNK expression and activation are associated with debilitating neurodegenerative diseases, including Alzheimer’s and Parkinson’s. We previously reported elevated levels of phosphorylated JNK (pJNK), indicative of JNK hyperactivation, in the CA1 hippocampus of chronically epileptic rats. We also showed that pharmacological inhibition of JNK activity reduced seizure frequency in a dose-dependent fashion (Tai TY et al., Neuroscience, 2017). Building on these observations, the objectives of this current study were to investigate the timeline of JNK activation during epileptogenesis, and to identify the JNK isoform(s) that undergo hyperactivation in the chronic epilepsy stage. Western blotting analysis of CA1 hippocampal homogenates showed JNK hyperactivation only during the chronic phase of epilepsy (6–9 weeks post-status epilepticus), and not in earlier stages of epileptogenesis (1 h, 1 day, and 1 week post-status epilepticus). After enrichment for pJNK by immunoprecipitation, we identified JNK2 as the only significantly hyperactivated JNK isoform, with expression of the 54 kDa pJNK2 variant elevated to a greater extent than the 46 kDa pJNK2 variant. Expression of the total amounts of both JNK2 variants (phosphorylated plus non-phosphorylated) was reduced in epilepsy, however, suggesting that activation of upstream phosphorylation pathways was responsible for JNK2 hyperactivation. Since our prior work demonstrated that pharmacological inhibition of JNK activation had an antiepileptic effect, JNK2 hyperactivation is therefore likely a pathological event that promotes seizure occurrences. This investigation provides evidence that JNK2 is selectively hyperactivated in epilepsy and thus may be a novel and selective antiepileptic target.

Outcomes of Primary Percutaneous Coronary Intervention through a Transradial Approach in a Tertiary Care Cardiac Center

Background Transradial approach for percutaneous coronary intervention (PCI) is gaining popularity due to lesser bleeding and other access site related complications. This study aims to determine the in-hospital outcomes of primary PCI through a transradial approach in a tertiary care cardiac center. Methods Consecutive patients with ST-segment elevation myocardial infarction presenting within 12 hours with symptoms without a previous history of thrombolytic therapy, coronary angioplasty, or cardiac surgery were included in the study. All patients underwent a diagnostic angiogram followed by primary PCI of the infarct-related artery through a radial route and were kept under observation during the hospital stay for forearm hematoma or mortality. Results A total of 180 patients were included in this study, with a mean age of 52.04±7.31 years. Majority (87.2%) of the patients were male, and diabetes (72.8%) was the most commonly observed co-morbid condition followed by hypertension (67.2%). Hospital mortality rate was 3.9% (7 patients), and post-procedure forearm hematoma was noted in 5.6% (10 patients). An increased mortality rate was found to be associated with age above 50 years (7.1% vs. 0.0%; p=0.012) and non-hypertension (8.5% vs. 1.7%; p=0.026). An increased incidence of forearm hematoma was found to be associated with age above 50 years (10.2% vs. 0.0%; p=0.002), diabetic mellitus (7.6% vs. 0.0%; p=0.047), hyperlipidemia (11% vs. 0.0%; p=0.001), and non-smoking (10.2% vs. 0.0%; p=0.003). Conclusion Our study showed that primary PCI through a transradial approach is a safe option with excellent success rates in terms of both mortality rates and morbidity such as forearm hematoma.

Perceptions and Practices towards Medication Non-Adherence among Hypertensive Patients: An Observational Study

Background

The present study broadly evaluates the adherence to pharmacotherapy, perceptions, and practices among ambulatory hypertensive patients attending a cardiac institution in Karachi, Pakistan.

Methods

A cross-sectional, single-center study was conducted at the National Institute of Cardiovascular Diseases Karachi, Pakistan. The study continued from 4 July 2019 to 3 September 2019. A total of 200 patients with a primary diagnosis of hypertension (HTN) were recruited for the study. The data was collected through a questionnaire based on a nine-item modified adherence predictor scale to assess medication adherence. Along with the demographic details patients smoking status, history of comorbidities and past complications were noted.

Results

It was found that the mean age of the study population was 56.45±12.36 years. A total of 62.5% of patients were taking medication daily while 15.5% were consuming medications intermittently and only 6.5% patients were not adherent at all. Around 35% patients preferred follow-up visits once in a month. Besides this, 35.5% patients never monitored their blood pressure while more than half of the studied population believed that their BP has mostly been controlled and skipped the prescribed medication.

Conclusion

The study indicated that the perception and awareness among the hypertensive patients regarding their medical condition are suboptimal. Concerted strategies like health education program and campaigns must be launched in order to help the sufferers.

Brachial Plexus Schwannoma: A Case Report with Emphasis on Imaging

Brachial plexus tumors are rare. Schwannomas are benign nerve sheath tumors and only about 5% arise from brachial plexus. Diagnosis of these tumors are challenging for radiologists as well as clinicians as they are rare and the anatomy of the neck is complex. We report a case of a middle aged woman who was admitted in Mymensingh Medical College in Neurosurgery Department on 15th December 2017 with right supraclavicular swelling; based on the clinical findings was provisionally diagnosed as supraclavicular lymphadenopathy; Ultrasonography and Magnetic Resonance Imaging suggested schwannoma. Complete excision of the mass through supraclavicular approach showed the origin of it from the brachial plexus, which subsequently was confirmed to be a schwannoma with histopathology.

Identification of a novel homozygous TRAPPC9 gene mutation causing non-syndromic intellectual disability, speech disorder, and secondary microcephaly

TRAPPC9 gene mutations have been linked recently to autosomal recessive mental retardation 13 (MRT13; MIM#613192) with only eight families reported world-wide. We assessed patients from two consanguineous pedigrees of Pakistani descent with non-syndromic intellectual disability and postnatal microcephaly through whole exome sequencing (WES) and cosegregation analysis. Here we report six further patients from two pedigrees with homozygous TRAPPC9 gene mutations, the novel nonsense mutation c.2065G>T (p.E689*) and the previously identified nonsense mutation c.1423C>T (p.R475*). We provide an overview of previously reported clinical features and highlight common symptoms and variability of MRT13. Common findings are intellectual disability and absent speech, and frequently microcephaly, motor delay and pathological findings on MRI including diminished cerebral white matter volume are present. Mutations in TRAPPC9 should be considered in non-syndromic autosomal recessive intellectual disability with severe speech disorder.

Lateralized microstructural changes in early-stage Parkinson's disease in anterior olfactory structures, but not in substantia nigra

Parkinson's disease (PD) is a progressive neurological disorder characterized by motor symptoms as well as severe deficits in olfactory function and microstructural changes in olfactory brain regions. Because of the evidence of asymmetric neuropathological features in early-stage PD, we examined whether lateralized microstructural changes occur in olfactory brain regions and the substantia nigra in a group of early-stage PD patients. Using diffusion tensor imaging (DTI) and the University of Pennsylvania Smell Identification Test (UPSIT), we assessed 24 early-stage PD patients (Hoehn and Yahr stage 1 or 2) and 26 healthy controls (HC). We used DTI and a region of interest (ROI) approach to study the microstructure of the left and right anterior olfactory structures (AOS; comprising the olfactory bulbs and anterior end of the olfactory tracts) and the substantia nigra (SN). PD patients had reduced UPSIT scores relative to HC and showed increased mean diffusivity (MD) in the SN, with no lateralized differences. Significant group differences in fractional anisotropy (FA) and MD were seen in the AOS, but these differences were restricted to the right side and were not associated with the primary side of motor symptoms amongst PD patients. No associations were observed between lateralized motor impairment and lateralized microstructural changes in AOS. Impaired olfaction and microstructural changes in AOS are useful for early identification of PD but asymmetries in AOS microstructure seem unrelated to the laterality of PD motor symptoms.

High-grade glioma management and response assessment-recent advances and current challenges

The management of high-grade gliomas (hggs) is complex and ever-evolving. The standard of care for the treatment of hggs consists of surgery, chemotherapy, and radiotherapy. However, treatment options are influenced by multiple factors such as patient age and performance status, extent of tumour resection, biomarker profile, and tumour histology and grade. Follow-up cranial magnetic resonance imaging (mri) to differentiate treatment response from treatment effect can be challenging and affects clinical decision-making. An assortment of advanced radiologic techniques-including perfusion imaging with dynamic susceptibility contrast mri, dynamic contrast-enhanced mri, diffusion-weighted imaging, proton spectroscopy, mri subtraction imaging, and amino acid radiotracer imaging-can now incorporate novel physiologic data, providing new methods to help characterize tumour progression, pseudoprogression, and pseudoresponse. In the present review, we provide an overview of current treatment options for hgg and summarize recent advances and challenges in imaging technology.

Outcomes of Cardiopulmonary Resuscitation and Estimation of Healthcare Costs in Potential 'Do Not Resuscitate' Cases

OBJECTIVES

Cardiopulmonary resuscitation (CPR) is a life-saving procedure which may fail if applied unselectively. 'Do not resuscitate' (DNR) policies can help avoid futile life-saving attempts among terminally-ill patients. This study aimed to assess CPR outcomes and estimate healthcare costs in potential DNR cases.

METHODS

This retrospective study was carried out between March and June 2014 and included 50 adult cardiac arrest patients who had undergone CPR at Sultan Qaboos Hospital in Salalah, Oman. Medical records were reviewed and treating teams were consulted to determine DNR eligibility. The outcomes, clinical risk categories and associated healthcare costs of the DNR candidates were assessed.

RESULTS

Two-thirds of the potential DNR candidates were ≥60 years old. Eight patients (16%) were in a vegetative state, 39 (78%) had an irreversible terminal illness and 43 (86%) had a low likelihood of successful CPR. Most patients (72%) met multiple criteria for DNR eligibility. According to clinical risk categories, these patients had terminal malignancies (30%), recent massive strokes (16%), end-stage organ failure (30%) or were bed-bound (50%). Initial CPR was unsuccessful in 30 patients (60%); the remaining 20 patients (40%) were initially resuscitated but subsequently died, with 70% dying within 24 hours. These patients were ventilated for an average of 5.6 days, with four patients (20%) requiring >15 days of ventilation. The average healthcare cost per patient was USD $1,958.9.

CONCLUSION

With careful assessment, potential DNR patients can be identified and futile CPR efforts avoided. Institutional DNR policies may help to reduce healthcare costs and improve services.

Osteopetrosis

A 15 years old Bangladeshi boy presented with hepatosplenomegaly, anaemia, multiple fractures (symptomatic and asymptomatic) without jaundice was investigated. Laboratory findings revealed leukoerythroblastic blood picture with reduced haemoglobin (7.7 gm/dl). Skeletal survey showed generalized increased bone density, sclerosed medulary space, Rugger-Jersey spine and diploic space filled with dense materials. Overlapping clinical features of both intermediate autosomal recessive and adult autosomal dominant variety of osteopetrosis were found in this patient but diagnosis were made on the basis of typical radiological finding which was mostly consistent with the adult autosomal dominant variety. The patient was treated conservatively and specialist consultation was taken in managing bony abnormalities. This patient was discharged with advised of subsequent follow-up.

Primary disseminated MDR-TB in a Bangladeshi man: a silent and emerging clinical problem for clinicians

A 26 years old Bangladeshi man experienced sudden gross haematuria for 10 days when he was working in Italy in June'07 that was resolved spontaneously. Six months' later he again developed haematuria and was admitted into an Italian hospital for its evaluation and management. In the mean time, he developed low grade fever, cough, back pain, spinal angulations, walking difficulty. His X-ray chest postero-anterior view revealed cavitary lesions in upper zones of both lung fields. Intravenous Urography (IVU) was done which revealed hydronephrosis and hydroureter of left kidney. Magnetic Resonance Imaging (MRI) of dorso-lumber spine revealed collapse of D10-12 and L4-5 vertebral bodies with perivertebral and epidural abscess. Sputum and urine smear for Acid-Fast-Bacilli (AFB) demonstrated the organisms on Z-N stain and AFB culture and sensitivity demonstrated that it was resistant to isoniazide, Rifampicin and streptomycin and diagnosed as primary disseminated multi-drug Resistant tuberculosis (MDR-TB). Second-line drugs were started in Italy on 15th January'08 and were continued thereafter in National Institute of Diseases of the Chest and Hospital (NIDCH). A ureteric stent which was given in Italy to get relief of hydro-ureter was removed in Dhaka. A neurosurgery (costo-transversectomy with decompression of spine) was done in Bangabandhu Sheikh Mujib Medical University (BSMMU), Dhaka and patient get relief of back pain paresthesia. Lastly, his sputum and urine AFB smear and AFB culture became negative. So, primary disseminated MDR-TB with renal, spinal and pulmonary involvement was diagnosed in this Bangladeshi man who had a sputum AFB culture and sensitivity during his initial diagnostic work-up in Italy. It's an alarming case that demonstrated necessity of sputum AFB culture and sensitivity during initial diagnostic work-up.

Early complications after biliary enteric anastomosis for benign diseases: a retrospective analysis

Background

Biliary-enteric anastomosis (BEA) is a common surgical procedure performed for the management of biliary obstruction or leakage that results from a variety of benign and malignant diseases. Complications following BEA are not rare. We aimed to determine the incidence and the factors associated with early complications occurring after BEA for benign diseases.

Methods

We reviewed the medical records of all patients who underwent BEA for benign diseases at our institution between January 1988 and December 2009. The primary outcome was early post operative complication. Logistic regression analysis was done to identify factors predicting the occurrence of complications.

Results

Records of 79 patients were reviewed. There were 34 (43%) males and 45 (57% females). Majority (53%) had choledocholithiasis with impacted stone or distal stricture, followed by traumatic injury to the biliary system (33%). Thirty-four patients (43%) underwent a hepaticojejunostomy, 19 patients (24%) underwent a choledochojejunostomy, and choledochoduodenostomy was performed in 26 patients (33%). Early complications occurred in 39 (49%) patients - 41% had local complications and 25% had systemic complications. Most frequent complications were wound infection (23%) and bile leak (10%). Four (5%) patients died. On multivariate analysis, low serum albumin level (odds ratio = 16, 95% CI = 1.14-234.6) and higher ASA levels (odds ratio = 7, 95% CI: 1.22-33.34) were the independent factors predicting the early complications following BEA.

Conclusions

Half of the patients who underwent BEA for benign diseases had complications in our population. This high incidence may be explained by the high incidence of hypoalbuminemia and the high-risk group who underwent operation.