Beta-hemolytic streptococcus group A endocarditis: a rare clinical presentation

A case report of an elderly gentleman is reported herein, who presented with one week history of fever, drowsiness and left lower limb weakness. Examination revealed left lower limb weakness with power of grade 3/5. His workup showed evidence of infection and multiple cerebral infarcts on the right side. Blood culture grew Streptococcus pyogens. Echocardiogram showed two vegetations on the aortic valve. Fever was the main presenting feature in this case but it was the presentation of patient with multiple cerebral infarcts that lead to the diagnosis of infective endocarditis. The organism causing Infective Endocarditis (IE) in this patient was a rare one

Primary billiary cirrhosis (antimitochondrial antibody negative) leading to secondary amyloidosis

A 49 years old lady presented with low-grade fever (99-100degreesF) for 2 years. During this time she was extensively worked-up for pyrexia of unknown origin but no diagnosis could be established. Her Initial blood work-up was all negative except high alkaline phosphatase and gamma GT (374 IU and 195 IU respectively). She later presented to our tertiary care centre with facial swelling, flushing and bilateral pedal swelling for 3 months. Along with generalized body swelling she had frothy urine. She was diagnosed as nephrotic syndrome on the basis of nephrotic range proteinuria. Her Renal biopsy done for workup of nephrotic was positive for AA amyloid. Also, her gastrointestinal biopsy was suggestive of amyloidosis. As a workup for secondary amyloidosis, her liver biopsy was done which revealed features of primary billiary cirrhosis (PBC)

Better physician-patient communication; an important milestone in control of hypertension, a multicenter study from Karachi, Pakistan.

Control of hypertension is an important cornerstone in prevention of cardiovascular morbidity and mortality. This study was designed to compare physician encounter score in patients with controlled and uncontrolled hypertension. It was conducted at three tertiary care hospitals in Karachi. Patients were categorized into controlled and uncontrolled hypertension based on their initial blood pressure readings on presentation. Primary outcome variable was control of hypertension and physician encounter score (a composite score of 12 item question) was the main candidate variable. Higher scores reflected favorable encounter with physician. Mean age of participants was 57.7 ± 12 years; 224 (50.1%) were men. Controlled hypertension was present in 72.3% (323) and uncontrolled hypertension was present in 27.4% (124). Mean physician encounter score in uncontrolled hypertensive was 7.25 ± 2.64 versus 7.83 ± 2.22 (p=0.02) in controlled hypertensive. Patient-physician encounter is an important milestone in control of hypertension in hypertensive patients and directly translates into better adherence to antihypertensives in these patients

Depression and cardiovascular diseases

Background and aim The concept of depression as a risk factor for cardiovascular diseases (CVD) is now well known. However, weather the severity of depression has a dose response effect on risk of CVD is not known. Also the role of risk factors which might be shared between depression and CVD, their interaction with depression and the combined effect on risk of CVD is still not well understood. For example, high level neuroticism is a risk factor for depression but also for CVD, but the combined effect of depression and high-level neuroticism on risk of CVD is not known. Likewise having comorbid conditions is linked to both depression and CVD, but the combined effect of depression and certain non-cardiovascular morbid conditions on risk of CVD is not known. The role of certain specific genotypes like Catechol-O methyltransferase (COMT) genotype and depression on risk of CVD is also less studied. The main aim of this PhD thesis is to increase the knowledge on the association between depression and cardiovascular diseases. Methods and Results For the purpose of this thesis I used the PART study (acronym in Swedish for: Psykisk hälsa, Arbete och RelaTioner, In English: Physical Health, Work and Relations), a longitudinal study of mental health, work and relations among adults > 20 years of age residing in Stockholm County, Sweden. The study included three data collections, wave 1 (W1) in 1998–2000, wave 2 (W2) in 2001–2003 and wave 3 (W3) in 2010. In total 10,443 individuals were included. Depression was assessed using the Major Depression Inventory (MDI). Severity of depression was assessed using MDI and additionally measuring anxious distress according to DSM-5 (paper I). Neuroticism was assessed by the Swedish Scale of Personality (SSP) for paper II. COMT genotype was measured using saliva from a subsample of the participants (paper III). Non-cardiovascular morbidity was assessed by asking current status of non-cardiovascular morbid conditions (paper IV). All participants from W1 were followed for cardiovascular outcomes through the National Patient register. For study III on genotype all participants from W1 were invited to contribute saliva for DNA analysis, but only 4349 participated. Logistic regression and Cox regression was used to estimate the risk of CVD. In study I, I found that depression increased the risk of CVD at different severity levels of depression, and the highest risk was for those suffering from moderate depression. The increased risk was present for both ischemic heart disease and stroke. Also, those who suffered from depression with anxious distress were at higher risk for CVD. In study II on depression, neuroticism and CVD, I found that those who were depressed and had high level neuroticism were at increased risk of CVD than those depressed with low level of neuroticism. The interaction effect was confirmed by a synergy index > 1. In study III, the genetic study on the subsample of the PART, I found that those who were depressed and had a high activity COMT Val158Met genotype were at increased risk of CVD compared to those depressed with low activity COMT Val158Met. In Study IV, those who had depression and non-cardiovascular morbidity were at increased risk for CVD compared to those depressed with no non-cardiovascular morbidity. This risk was present also after accounting for age, gender, socioeconomic status and lifestyle factors. The interaction effect was confirmed by synergy index > 1. Conclusion This thesis has overall increased the knowledge on the association between depression and CVD. It further elaborated and created new knowledge on the effect of other factors like personality trait neuroticism, genes and non-cardiovascular morbid conditions on the association between depression and CVD. More studies are required to confirm the biological mechanism in this relation and also design interventions to timely treat depression and other related factors to counter the risk of CVD

Clinical factors associated with mortality in dengue infection at a tertiary care center

We conducted a cross-sectional study to investigate the clinical factors associated with mortality in Patients with dengue viral infection at a tertiary care center over a 3 year period. Six hundred ninety-nine Patients with a clinical diagnosis of dengue fever (DF), dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) during the study period were included in the study. Data were collected with a predesigned form comprised of demographics, duration of fever, associated symptoms, diagnosis of DF, DHF and DSS, and laboratory parameters [complete blood count, coagulation tests, creatinine, serum glutamic pyruvic transaminase (SGPT)], dengue IgM was checked in all Patients by ELISA Outcomes (survival/mortality) and complications were recorded. Mortality was the primaryoutcome measure. DF constituted 86 4% (604), DHF constituted 11.6% (81) and DSS constituted 2% (14) of Patients. The mortality rate was 2 7% (19). The mean white blood cell count in those who died was 13 3, in those who survived was 5.3, the difference was significant (p=0 02) The mean BUN in those who died was 33 2, those who survived was 13.8, (p=0.007). The mean bicarbonate level in those who died was 17 1, those who survived was 185 (p 300 mg/dl, bleeding, an altered mental status and shock at presentation were all significantly associated with mortality in Patients with dengue virus infection (p=0 008, p001, p001, p001, respectively

Multifocal venous thrombosis in behcet’s disease

Behcet\u27s disease is a multisystem inflammatory vascular disorder with a chronic course characterized by recurrent oral and genital ulcers, eye lesion, arthritis and skin lesions. It has a typically waxing and waning course. The cause and pathogenesis of the disease are unclear and specific treatment is not available. A 39 years old man presented with rash, ocular manifestation and left leg swelling. He was found to have deep venous thrombosis of left leg along with recurrent cerebral venous thrombosis. He was a known case of Behcet\u27s disease since 3 years and had been on anticoagulants since then

Acuity level of care as a predictor of case fatality and prolonged hospital stay in patients with COVID-19: A hospital-based observational follow-up study from Pakistan

Objectives: To determine if there is an association between acuity level of care (ALC), case fatality and length of stay in patients admitted to hospital due to COVID-19.Design: A hospital-based observational follow-up study.Setting: Internal Medicine Service of the Aga Khan University Hospital, Pakistan, from 26 February 2020 to 30 June 2020.Participants: Adult patients with confirmed COVID-19, aged ≥18 years.Methods: ALC was categorised into low, intermediate and high level and patients were triaged using the standard emergency severity illness score. All patients were followed until the end of hospital admission for the outcome of case fatality and length of stay.Results: A total of 822 patients with COVID-19 were admitted during the study period and 699 met inclusion criteria. The mean age was 54.5 years and 67% were males; 50.4% were triaged to low, 42.5% to intermediate and 7.2% to high acuity care. The overall case-fatality rate was 11.6%, with the highest (52%) in high acuity level followed by 16.2% in intermediate and 2% in low acuity care. Acuity level was associated with case fatality, with an HR (95% CI) of 5.0 (2.0 to 12.1) for high versus low acuity care and an HR of 2.7 (1.2, 6.4) for intermediate versus low acuity care, after adjusting for age, sex and common comorbidities including diabetes, hypertension, ischaemic heart disease and chronic lung disease. Similarly, acuity level was also associated with length of hospital stay.Conclusion: High and intermediate acuity level is associated with higher case fatality rate and prolonged length of hospital stay in patients admitted with COVID-19. In resource-limited settings where the provision of high acuity care is limited, the intermediate care acuity could serve as a useful strategy to treat relatively less critical patients with COVID-19

Knowledge of coronary artery disease (CAD) risk factors and coronary intervention among university students

OBJECTIVE: To elucidate knowledge of coronary artery disease (CAD) risks factors and coronary intervention in adult students of Karachi East. To calculate the mean knowledge score about CAD risk factors among them. METHODS: A multi center crossectional study was conducted in Universities and colleges of Karachi East from April-September 2005. Questionnaires were distributed to 200 adult students of different non-medical universities and colleges. The questionnaire contained assessment of knowledge of risk factors on CAD and awareness about coronary angiography. Those belonging to medical colleges and universities were excluded from the study. Knowledge was assessed as a continuous variable. Risk factors for CAD were taken as categorical variables. RESULTS: The mean age of students was 20 yrs +/- 2.2 years and 62% were females. The mean score of knowledge about risk factors of CAD was 11.47 +/- 2.37. Sixty percent students thought that heart diseases are the number one cause of death in our population. Twenty five percent students graded smoking as the top most risk factor for CAD. Twenty five percent students refused to quit smoking for CAD prevention. Forty eight percent students correctly defined coronary angiography. Eighty five percent students thought that cost is the major hindrance in getting timely treatment. Knowledge of fifty percent students was based on personal and family experience of heart disease. CONCLUSION: Students graded smoking as the topmost risk factor for CAD and cost as the major hindrance in getting timely treatment for heart disease. Only half of the students were aware about coronary angiography. The mean knowledge score among them was above the median score but not up to the mark

Emergency evaluation of acute chest pain

OBJECTIVE: To determine the sensitivity and specificity of initial clinical assessment about the diagnosis of acute coronary syndrome (ACS) in patients presenting with acute chest pain by a cardiology resident in the emergency room and assess the 30-day outcome of patients with ACS and non ACS. STUDY DESIGN: Cohort study. PLACE AND DURATION OF STUDY: The study was conducted in the emergency department and cardiac care units of the Aga Khan University in 2006-07. METHODOLOGY: A total of 202 patients, who presented to the emergency room with chest pain, were given an initial ECG and troponin check. Patients were assigned to initial ACS and non-ACS groups by the cardiology resident. After cardiac workup, patients were assigned to final ACS/final non ACS group. They were followed for outcome after 30 days of initial presentation. Sensitivity and specificity, if initial workup was determined, keeping final assessment after cardiac workup as the gold standard. RESULTS: Out of the 202 patients, 61.9% were males. Their mean age was 54.05+13 years. Sixty eight percent were placed in the initial ACS group and 30.7% were placed in the initial non ACS group. After workup, 36% were placed in the final ACS group and 28.7% in the final non-ACS group and 35% were undecided. The sensitivity of initial assessment of ACS by the cardiology resident was 100%. However, the specificity was 54.2%. In the 30-day outcome, one patient (1.3%) died in the ACS group due to myocardial ischemia while no patient died from the non ACS group. CONCLUSION: Initial assessment about ACS by cardiology resident based on character of chest pain, ECG and troponin I is highly sensitive. However, the specificity is low

Increased level of morning surge in blood pressure in normotensives: across-sectional study from Pakistan.

Objective: To determine the mean morning surge (MS) in blood pressure, the frequency of increased morning surge in normotensive subjects, and to compare those with morning surge with those without MS. Study Design: A cross-sectional, comparative study. Place and Duration of Study: The Department of Medicine, The Aga Khan University Hospital, Karachi, from April 2011 to March 2012. Methodology: Adult normotensive healthy volunteers aged 35 to 65 years were inducted. Their ambulatory blood pressure (ABP) was measured over a 24-hour period, using digital ambulatory blood pressure monitors. Morning surge was calculated as the average of four readings after waking minus the lowest three nocturnal readings. Increased morning surge was defined as \u3e 11 mm Hg in systolic (SBP) or \u3e 12 mm Hg in diastolic (DBP). Dipping was defined as \u3e 10% dipping in blood pressure. Results: Eighty-two healthy volunteers were recruited. Their mean age was 36.9 ±1.2 years; 74.4 (61%) were men, and 58.5 (48%) woke up for morning prayers. Mean overall SBP was 113 ±1.6 mm Hg, overall DBP was 73.9 ±0.7 mm Hg, and overall heart rate was 75 (10) beats/minute. Mean morning surge was 17.6 ±1.0 mm Hg in SBP and 16.0 ±0.8 mm Hg in DBP. The frequency of increased morning surge was 66 (80.5%) in SBP, and 57 (69%) in DBP. On comparison of participants with normal morning surge and increased morning surge in SBP, there was a significant difference in nondipping status (13.4% in normal vs. 18.3% in increased morning surge, p= 0.001). Conclusion: Mean morning surge in SBP and DBP are relatively higher in this subset population in a tertiary care center in Pakistan. These values are higher than those reported in the literature