Venous stroke secondary to varicella zoster virus infection

This is a case of cerebral venous sinus thrombosis (CVST) as a rare complication of varicella Zoster infection. A young male with no significant medical history presented with generalized tonic clonic seizures preceded by vesicular rash on the face diagnosed as Varicella zoster infection. The MRI showed bilaterial superficial hemorrhagic infarcts involving frontal and temporal lobes and MR Venogram was consistent with extensive CVST involving superioir sagittal, right transverse and superficial veins. After initial treatment with antiepileptic and anticoagulant, he showed marked improvement in symptomatology and made complete recovery subsequently with recanalization of sinuses seen on a follow up MRV done at fourth month. Our case emphasizes on having a high suspicion of Varicella Zoster infection in patient who presents with CVST with an underlying ongoing Rash or a prior history of recent body Rash

Gastrointestinal complications in critically ill children: Experience from a resource-limited country

Objectives: To determine the frequency and predictors of outcome of gastrointestinal complications (GIC) in critically ill children.Methods: This descriptive study was prospectively conducted in The Pediatric Intensive Care Unit (PICU), The Aga Khan University Hospital (AKUH), Karachi, from September 2015 to January 2017. After obtaining approval from the Ethical Review Committee of AKUH and informed consent from the parents, all children (aged one month to 18 years), of either gender, admitted to the Pediatric Intensive Care Unit (PICU) during the study period were included. The frequency of the defined GIC: vomiting, high gastric residue volume (GRV), diarrhea, constipation, and gastrointestinal bleed were recorded daily for the first week of the PICU stay. The data was collected by the primary investigator on a predesigned data collection form with inclusion of variables and predictors in light of existing literature and local expertise. The questionnaire was shared with the Pediatric Critical Care Medicine faculty and a consensus was sought on the elements to be incorporated.Results: GIC developed within the first 48 hours of admission in 78 (41%) patients. Of the patients who developed GIC, 37 (47.4%) patients developed high GRV: 31 (39.7%) patients developed constipation, 18 (23.1%) patients developed vomiting, 14 (17.9%) patients developed abdominal distension. With regards to prevalence by occurrence, 32/78 (41%) of patients presented with two GI complications, followed by 21 patients (27%) who presented with a single GIC. Only 11 patients (14%) presented with more than three complications. Median length of stay was higher in patients with GIC (8 days) than with those who did not develop GIC (4 days). The frequency of gastrointestinal complications was significantly higher in children receiving mechanical ventilation, on sedatives and relaxants and those with multiorgan dysfunction syndrome (MODS) and inotropes.Conclusion: GI complications are a frequent occurrence in the PICU and are associated with worse clinical outcomes. The use of sedative drugs and the presence of shock with MODS were amongst the important contributing factors

Colostrum and mature breast milk analysis of serum irisin and sterol regulatory element-binding proteins-1c in gestational diabetes mellitus

Background: We aimed to evaluate irisin and SREBP-1c levels in serum, colostrum and mature breast milk in women with and without gestational diabetes (GDM); and to relate them with maternal glucose, lipid profile and weight status of babies.Methods: GDM positive women (n = 33) and normal glucose tolerant women (NGT) (n = 33) were recruited. Maternal blood samples were collected at 28th week of gestation and later at 6-week post-partum while breast milk samples of the lactating mothers were collected within 72 hours of birth (colostrum) and at 6 weeks post-partum (mature milk). Irisin and SREBP-1c levels were analyzed by commercially available ELISA kits for all maternal samples.Results: Lower levels of irisin were seen in serum, colostrum and mature breast milk of GDM females (p \u3c .01). SREBP-1c profile showed a similar trend of low serum levels in GDM, however, they were undetectable in colostrum and mature breast milk. Weak to moderate correlations of serum irisin with BMI (r = 0.439; p \u3c .001), GTT 0 hours (r = 0.403; p = .01), HbA1c (r = -0.312; p = .011), Fasting blood glucose (r = 0.992; p = .008), and baby weight at birth (r = 0.486; p \u3c .001). Colostrum and mature breast milk irisin showed positive associations with baby weight at 6 weeks (r = 0.325; p = .017; r = 0.296; p = .022, respectively). Serum SREBP-1c at 6 weeks correlated with random blood glucose (r = 0.318; p = .009), and HbA1c (r= -0.292; p = .011). All correlations were lost once we adjusted for maternal BMI.Conclusions: Low irisin and SREBP1-c levels may favor development of GDM in pregnant subjects. Further, low mature breast milk levels may act as a continued stressor from fetal to infant life as long as breast-feeding is continued. Further studies are required to identify the mechanistic relationship between these biomarkers and GDM

Need of physical and chemical restraints: Experiences at inpatient psychiatric ward in a tertiary care hospital in Karachi, Pakistan

In psychiatry, agitated / aggressive patients are often treated with de-escalation techniques. If this does not work, physical or chemical restrains are required; but in the event of resistance, seclusion is applied. We report the findings of baseline study of experiences of physical and chemical restraints in a tertiary care hospital in Karachi, where 104 files were evaluated retrospectively. The mean age of patients was 32.5 ±14.3 years with 54.8% men, while the average length of stay was 11.5 ±9.3 days. Agitation, violent behaviour, and aggression were the most common indications for restraints. In total, 94.5% of patients had both physical and chemical restraints with the latter being used as the first choice in 70 patients; whereas, 67.1% of patients\u27 families were not informed before application of restraints. The seclusion need assessment was conducted in 4.1% of patients

Early postoperative arrhythmias after pediatric congenital heart disease surgery: a 5-year audit from a lower- to middle-income country

Background Arrhythmias are known complication after surgery for congenital heart disease (CHD). This study aimed to identify and discuss their immediate prevalence, diagnosis and management at a tertiary care hospital in Pakistan. Methods A retrospective study was conducted at a tertiary care hospital in Pakistan between January 2014 and December 2018. All pediatric (<18 years old) patients admitted to the intensive care unit and undergoing continuous electrocardiographic monitoring after surgery for CHD were included in this study. Data pertaining to the incidence, diagnosis, and management of postoperative arrhythmias were collected. Results Amongst 812 children who underwent surgery for CHD, 185 (22.8%) developed arrhythmias. Junctional ectopic tachycardia (JET) was the most common arrhythmia, observed in 120 patients (64.9%), followed by complete heart block (CHB) in 33 patients (17.8%). The highest incidence of early postoperative arrhythmia was seen in patients with atrioventricular septal defects (64.3%) and transposition of the great arteries (36.4%). Patients were managed according to the Pediatric Advanced Life Support guidelines. JET resolved successfully within 24 hours in 92% of patients, while 16 (48%) patients with CHB required a permanent pacemaker. Conclusions More than one in five pediatric patients suffered from early postoperative arrhythmias in our setting. Further research exploring predictive factors and the development of better management protocols of patients with CHB are essential for reducing the morbidity and mortality associated with postoperative arrhythmia

Use of intravenous thrombolysis in acute ischemic stroke management in patients with active malignancies: A topical review

Objectives: Our review aims to present existing data on the safety of Intravenous thrombolysis (IVT) use in acute ischemic stroke (AIS) patients with concomitant central nervous system or systemic malignancies, with attention to special circumstances pertaining to specific cancer subtypes to help in acute decision making, especially for neurologists and emergency medicine physicians.Methods: A literature search was conducted on electronic databases inclusive of Medline, EMBASE and CINAHL for articles published or available in English between January 1, 2000 to June 1, 2020 using the following search terms: acute ischemic stroke, cerebrovascular disease, Intravenous thrombolysis, tissue plasminogen activator, cancer patients, and neoplasm .Conclusion: Recognition of stroke symptoms in patients with active cancer, in particularly those involving the brain, requires astute clinical judgement. Decision-making can be improved by understanding baseline functional status, cancer prognosis and expected disability from stroke, as well as utilizing diagnostic modalities such acute MRI where needed. While this article does not encourage use of IVT in patients with all malignancies, it lays the groundwork for decision making should thrombolysis be a consideration in a patient with AIS in a cancer patient

A review of the molecular mechanisms of traumatic brain injury

Traumatic brain injury (TBI) refers to any insult to the brain resulting in primary (direct) and secondary (indirect) damage to the brain parenchyma. Secondary damage is often linked to the molecular mechanisms that occur post TBI and result in excitotoxicity, neuroinflammation and cytokine damage, oxidative damage, and eventual cell death as prominent mechanisms of cell damage. We present a review highlighting the relation of each of these mechanisms with TBI, their mode of damaging brain tissue, and therapeutic correlation. We also mention the long-term sequelae and their pathophysiology in relation to TBI focusing on Parkinson disease, Alzheimer disease, epilepsy, and chronic traumatic encephalopathy. Understanding of the molecular mechanisms is important in order to realize the secondary and long-term sequelae that follow primary TBI and to devise targeted therapy for quick recovery accordingly

Fungal isolation from wound samples submitted for culture at a tertiary care hospital laboratory

Fungal wound infections are increasing worldwide. The aim of this retrospective study, conducted at the Aga Khan University laboratory, Karachi, Pakistan, was to determine the frequency of fungal isolation in wound specimens. Data of wound samples received for culture from all over the country between September and October 2018 was reviewed. Samples were processed for bacterial cultures and additionally inoculated on Sabouraud’s dextrose medium. Demographic information, medical history and information on the type of wound was collected. A total of 140 cases were included, of which 87 (81%) were culture positive, while 10 (7%) cases yielded fungi. Burn and blast wounds had the highest proportion of fungal isolation, i.e. 2 out of 4 (50%). Candida species were the most common fungi (n=4), followed by Fusarium species (n=3). This study reports an alarming rate of fungal wound infections. As fungal necrotising wound infections have high morbidity and mortality, it is, therefore, important to accurately diagnose and treat such infections in local setting. Keywords: Wounds and Injuries, Fungal Infections, Diabetic Foot, Infections, Skin and Soft Tissue Infections

Pain management consultation for acute pancreatitis: Impact on length of stay and opioid utilization

Aim: The purpose of the study was to understand the impact of a pain management consult for acute pancreatitis patients on their inpatient length of stay, morphine milligram equivalences (MMEs) and pancreatitis severity. Materials & methods: Adult patient data were extracted from the electronic health records from 1 October 2016 to 31 December 2018. Results & conclusion: Of 277 patients with a single acute pancreatitis hospitalization, 23 had a pain consultation (treatment group), whereas 254 did not (control group). There were statistically significant differences in median length of stay, median MME total and median MME per day between the treatment and control groups with comparable severity and pain scores (6.8 vs 3.1 days, 196.5 vs 33.8 MMEs, 30.9 vs 12.1 MMEs, respectively, p \u3c 0.0001). This study emphasizes the complexity of pain management and the importance of further research in the field

Early postoperative arrhythmias after pediatric congenital heart disease surgery: A 5-year audit from a lower- to middle-income country

Background: Postoperative arrhythmias are a known complication after surgical repair for congenital heart disease (CHD). This study aimed to identify and discuss the prevalence, diagnosis, and management of common rhythm disturbances seen in the immediate postoperative period after surgery for CHD in the pediatric population at a tertiary care hospital in Pakistan. Methods: A retrospective study was conducted at a tertiary care hospital in Pakistan between January 2014 and December 2018. All pediatric (old) patients admitted to the intensive care unit and undergoing continuous electrocardiographic monitoring after surgery for CHD were included in this study. Data pertaining to the incidence, diagnosis, and management of postoperative arrhythmias were collected. Results: Amongst 812 children who underwent surgery for CHD, 185 (22.8%) developed arrhythmias. Junctional ectopic tachycardia (JET) was the most common arrhythmia, observed in 120 patients (64.9%), followed by complete heart block (CHB) in 33 patients (17.8%). The highest incidence of early postoperative arrhythmia was seen in patients with atrioventricular septal defects (64.3%) and transposition of the great arteries (36.4%). Patients were managed according to the Pediatric Advanced Life Support guidelines. JET resolved successfully within 24 hours in 92% of patients, while 16 (48%) patients with CHB required a permanent pacemaker. Conclusion: More than one in five pediatric patients suffered from early postoperative arrhythmias in our setting. Further research exploring predictive factors and the development of better management protocols of patients with CHB are essential for reducing the morbidity and mortality associated with postoperative arrhythmia