Simultaneous bilateral posterior fracture dislocation of the shoulders in a young man with unexpected severe vitamin D deficiency

Simultaneous bilateral posterior fracture dislocation of the shoulders is a rare clinical presentation. There are three main etiologies described in the literature. Given that it presents with relatively uncharacteristic symptoms, in many cases it is diagnosed late. We present the case of a man who was admitted with bilateral posterior fracture dislocation of the shoulders following a seizure. Investigations revealed severe vitamin D deficiency as the principal contributory factor to his injury. This is an important association because failure to recognize and treat this can result in significant morbidity in susceptible groups

Reappraising the Role of Eplerenone in the Management of Heart Failure

Background: In India, the prevalence of heart failure (HF) is increasing at 1.2/1,000 people according to a study in northern India, and the mortality rate at 1 year (INTERnational Congestive Heart Failure [INTER-CHF]) is 37%. Due to the diverse phenotypes of HF, nonadherence to guideline-directed medical therapy (GDMT), resistance to uptitration of medication and underuse of mineralocorticoid receptor antagonists (MRAs), such as eplerenone, a uniform management approach may not be feasible. This review is aimed at assessing the burden of HF, reasons for underutilization of MRAs in treatment, evaluating the evidence and reappraising the disease-modifying role of eplerenone in HF management. Methods: An electronic database search was performed to identify relevant literature. Results: The review details various studies that demonstrate the role of MRA eplerenone as a disease-modifying agent in patients with mild-to-moderate hypertension and those with acute myocardial infarction (MI) complicated by left ventricular dysfunction and HF. It also outlines different patient profiles for eplerenone use and ways to handle minor side-effects. Conclusions: Eplerenone shows a promising effect in selectively blocking aldosterone receptors to suppress fibrosis and reverse cardiac remodeling

Fibromyalgia in Behçet's disease: a narrative review.

IntroductionFibromyalgia is characterised by chronic widespread pain and tenderness. It has often been reported to occur concomitantly with chronic rheumatological conditions. Behçet's disease is a chronic relapsing, multisystem, autoinflammatory disease. There is only limited understanding of a potential relationship between fibromyalgia and Behçet's disease.AimGiven the potential detrimental influence of pain on the outcome of chronic disease, the aim of this narrative review is to gain an understanding of the incidence and presentation of fibromyalgia in Behçet's disease.MethodsElectronic databases Scopus, Medline, PubMed and UpToDate were searched.ResultsA total of 269 studies were identified, and limitations and exclusion/inclusion criteria were applied to ensure accurate and comparable selection of studies; four studies were selected. All cases were assessed for the presence of fibromyalgia according to the 1990 or 2010 diagnostic criteria of the American College of Rheumatology, with Behçet's disease diagnosed according to the International Study Group (ISG) for Behçet's disease criteria. A higher prevalence of fibromyalgia (5.7-37.1%) was reported in Behçet's disease compared to that of the general population (2.9-4.7%).DiscussionWhile an increased prevalence of fibromyalgia was found in patients with Behçet's disease, this needs to be considered within the context of limited available evidence. The potential impact of these conditions on the disease activity of each other is not clear and may require a prospective study.ConclusionFibromyalgia appears to be more prevalent in those with Behçet's disease than would be expected in the overall population. Significance: This review provides some evidence that fibromyalgia is more prevalent in those with Behçet's disease. To ensure appropriate patient treatment choices, it is important that both conditions are diagnosed where they co-exist

Myopericarditis as a presentation of eosinophilic granulomatosus with polyangiitis (EGPA)

A 60-year-old woman was admitted to the hospital with worsening dyspnoea, cough and chest pain. This was on a background of weight loss, decreased appetite, mononeuritis multiplex, chronic eosinophilia and a single episode of a non-blanching rash. Investigations demonstrated a raised troponin and ischaemic changes on ECG, and she was therefore initially treated for a presumed myocardial infarction. However, her symptoms failed to improve with treatment for the acute coronary syndrome. A coronary angiogram revealed no significant flow-limiting disease, and further investigations yielded confirmation of raised eosinophils and a positive perinuclear antineutrophil cytoplasmic antibody test. An echocardiogram demonstrated a pericardial effusion, and subsequent cardiac magnetic resonance features were compatible with myopericarditis. In light of these findings, the patient was diagnosed with eosinophilic granulomatous with polyangiitis and commenced on high-dose intravenous methylprednisolone and cyclophosphamide. She made an excellent recovery and remains in remission on azathioprine and a tapering dose of corticosteroids

Methyl iodide poisoning presenting as a mimic of acute stroke: a case report

<p>Abstract</p> <p>Introduction</p> <p>Stroke mimics are usually non-vascular disease processes. These raise the possibility of a stroke and are common in clinical practice. It is necessary to distinguish these mimics in order to provide early and appropriate management, as well as reduce possible harm on our patient.</p> <p>Case presentation</p> <p>We report the case of a 50-year-old Caucasian man who developed symptoms suggestive of posterior circulation stroke after he was exposed to methyl iodide at his workplace. Results of stroke investigations of our patient were negative, and a detailed occupational history clinched the diagnosis. Acute presentation with a stroke-like picture is rare in cases of methyl iodide poisoning. We have attempted to discuss the differential diagnosis of stroke mimics through a review of literature.</p> <p>Conclusion</p> <p>Stroke mimics are difficult to diagnose in an emergency room situation and may be initially treated as stroke. This case report underlines the importance of history taking, especially occupational history, in the differential diagnosis of stroke. We also stress the need to recognize mimics at presentation in order to arrive at an early and appropriate management of patients.</p

Groundwater recharge sources in the Gandak alluvial aquifer, NE India : how important is leakage from irrigation canals?

Alluvial sediments in the Indo-Gangetic Basin (IGB) form one of the world’s largest and most heavily used aquifer systems. There is clear evidence for overabstraction and/or groundwater contamination in some parts of the IGB, but not in others. The hydrogeology and external influences on groundwater across the aquifer are complex and diverse. Of these influences, the role of leakage from irrigation canals is now a fundamental part of groundwater dynamics in the IGB aquifer. In some areas, aquifer recharge contains a high proportion of canal leakage (Joshi et al. 2018), but in others it is much less (Lapworth et al. 2015). The Gandak, in NE India, is a sub catchment of the IGB and provides an excellent laboratory for studying the evolution of groundwater-river-canal dynamics in the centre of the basin. Our study, carried out as part of the joint UK-India funded CHANSE project, is the first detailed investigation of the hydrochemistry, stable isotopes and residence time of groundwater in the Gandak aquifer, to quantify the contribution of recharge to the aquifer from canal leakage, the Gandak River and local monsoon rainfall; and to characterise groundwater flow and mixing behaviour

Model International Mobility Convention

While people are as mobile as they ever were in our globalized world, the movement of people across borders lacks global regulation. This leaves many refugees in protracted displacement and many migrants unprotected in irregular and dire situations. Meanwhile, some states have become concerned that their borders have become irrelevant. International mobility—the movement of individuals across borders for any length of time as visitors, students, tourists, labor migrants, entrepreneurs, long-term residents, asylum seekers, or refugees—has no common definition or legal framework. To address this key gap in international law, and the growing gaps in protection and responsibility that are leaving people vulnerable, the "Model International Mobility Convention" proposes a framework for mobility with the goals of reaffirming the existing rights afforded to mobile people (and the corresponding rights and responsibilities of states) as well as expanding those basic rights where warranted. In 213 articles divided over eight chapters, the Convention establishes both the minimum rights afforded to all people who cross state borders as visitors, and the special rights afforded to tourists, students, migrant workers, investors and residents, forced migrants, refugees, migrant victims of trafficking and migrants caught in countries in crisis. Some of these categories are covered by existing international legal regimes. However, in this Convention these groups are for the first time brought together under a single framework. An essential feature of the Convention is that it is cumulative. This means, for the most part, that the chapters build on and add rights to the set of rights afforded to categories of migrants covered by earlier chapters. The Convention contains not only provisions that afford rights to migrants and, to a lesser extent, States (such as the right to decide who can enter and remain in their territory). It also articulates the responsibilities of migrants vis-à-vis States and the rights and responsibilities of different institutions that do not directly respond to a right held by migrants