Triple valve endocarditis by mycobacterium tuberculosis: a case report.

BACKGROUND: Granulomas caused by Mycobacterium Tuberculosis have been observed at autopsy in the heart, pre-dominantly in the myocardium and endocardium, but rarely involving the coronary vessels and valvular structures. Mycobacterium tuberculosis valvular endocarditis is extremely rare, with most reports coming from autopsy series. CASE PRESENTATION: We report the case of a 17 year old immunocompetent girl who presented with history of fever, malaise, foot gangrene and a left sided hemiparesis. On investigation she was found to have infective endocarditis involving the aortic, mitral and tricuspid valves. She had developed a right middle cerebral artery stroke. She underwent dual valve replacement and tricuspid repair. The vegetations showed granulomatous inflammation but blood cultures and other biological specimen cultures were negative for any organisms. She was started on antituberculous treatment and anticoagulation. CONCLUSION: This is the first reported case of triple valve endocarditis by Mycobacterium Tuberculosis in an immunocompetent host. Especially important is the fact that the right heart is involved which has been historically described in the setting of intravenous drug abuse.This implies that Tuberculosis should be considered in cases of culture negative endocarditis in endemic areas like Pakistan even in immunocompetent hosts

Implementation of ventilator bundle in pediatric intensive care unit of a developing country

The aim of this study was to assess the frequency of VAP(ventilator associated pneumonia) after strict implementation of ventilator bundle in PICU. Medical records of all children (age 1 month - 16 years) were retrospectively reviewed, who were on mechanical ventilation (MV) for more than 48 hours and received all key components of ventilator bundle from January 2012 to December 2014. Out of 1050, 565 (54%) patients were enrolled. The mean age was 4.02 SD 4.29 years and 62 (69%) were male. The indications of MV were respiratory illness (54%), neurological illness (31%), shock (9%), and postoperative care (6%). The mean duration of MV was 7.05 SD 5.4 days. Only 4 patients (0.7%) developed VAP. The incidence-density of VAP was 1.6 per 1000 ventilator days. The strict implementation of simple, inexpensive interventions (ventilator bundle) in care of mechanically ventilated children can decrease significantly VAP even in resource-limited country

Quebec platelet disorder

A case of Quebec platelet disorder is hereby reported. A 33 years old woman presented with history of epistaxis and gum bleeding since childhood and menorrhagia and bleeding per vaginum after puberty, also had history of excessive blood loss after birth of child. Her coagulation profile was normal but platelet function testing by platelet aggregation assay showed abnormal aggregation of platelet with epinephrine. This type of response is seen in Quebec platelet disorder which is a rare autosomal dominant disorder of platelet function characterized by increased bleeding after any injury or trauma

WAS IT A ONE-MAN SHOW?

It was 2nd March 1992, when I entered my office. Everything was the same but I felt a silence in the atmosphere and my colleagues were busy in discussion with each other in a manner that I have not seen before in my whole working experience of 8 years. I came to my cabin and looked at the table clock that was again saying to me: “Yes! You are right on time, 5 minutes before 9:00 am”. My mind was again struck with the fact that why am I feeling so different today? And what is the reason behind this deadly silence in the atmosphere? Suddenly I felt a hand on my shoulder I turned around and it was none other than my friend and my colleague, an intelligent engineer from our Research and Development department. He was a friend, one of the four in the office, who were of the same batch of NED University

Attitudes and Perceptions of Teachers Towards Code-switching in the EFL College Classrooms of Sindh, Pakistan

This quantitative descriptive study investigates the attitudes in general and perceptions of college teachers towards the functional category of code-switching. Research data was collected through a survey questionnaire, which was comprised of 24 items. Attitude items were scaled as negative and positive; however, the functional category has three components: Curriculum Access, Classroom Management, and interpersonal relationship. Collected data were analyzed through SPSS software using percentage and mode. Code-switching is a natural phenomenon that occurs in bilingual and multilingual classrooms in Pakistan. However, the medium of instruction in Pakistan’s classrooms is English. Participants for this study were 50 EFL college teachers from 20 different colleges of Sindh Pakistan; in them, 31 (62%) were male, and 19 (38%) were female. It was found that; code-switching is being used extensively in the EFL college classrooms of Sindh for different reasons. Almost all the teachers who participated in the study have positive attitudes towards code-switching. According to the results of survey results, teachers’ do not deny code-switching in teaching in learning. Results conclude that Teachers use code-switching as a teaching technique to compensate the students' limited expertise in the target language. Educational officials and policymakers must recognize and make appropriate adjustments to overcome the constraints in the current curriculum. Keywords: Code-switching, EFL classrooms, Attitudes, Perceptions, Code-switching functions. DOI: 10.7176/JLLL/78-05 Publication date: April 30th 202

Barriers and perceptions regarding code status discussion with families of critically ill patients in a tertiary care hospital of a developing country: A cross-sectional study

Background: In Asian societies including Pakistan, a complex background of illiteracy, different familial dynamics, lack of patient’s autonomy, religious beliefs, and financial constraints give new dimensions to code status discussion. Barriers faced by physicians during code status discussion in these societies are largely unknown.Aim: To determine the barriers and perceptions in discussion of code status by physicians.Design: Questionnaire-based cross-sectional study.Setting and participants: This study was conducted in the Department of Medicine of The Aga Khan University Hospital, Karachi, Pakistan. A total of 134 physicians who had discussed at least five code statuses in their lifetime were included.Results: A total of 77 (57.4%) physicians responded. Family-related barriers were found to be the most common barriers. They include family denial (74.0%), level of education of family (66.2%), and conflict between individual family members (66.2%). Regarding personal barriers, lack of knowledge regarding prognosis (44.1%), personal discomfort in discussing death (29.8%), and fear of legal consequences (28.5%) were the top most barriers. In hospital-related barriers, time constraint (57.1%), lack of hospital administration support (48.0%), and suboptimal nursing care after do not resuscitate (48.0%) were the most frequent. There were significant differences among opinions of trainees when compared to those of attending physicians.Conclusion: Family-related barriers are the most frequent roadblocks in the end-of-life care discussions for physicians in Pakistan. Strengthening communication skills of physicians and family education are the potential strategies to improve end-of-life care. Large multi-center studies are needed to better understand the barriers of code status discussion in developing countries

Syntheses and crystal structures of mixed-ligand copper(II)–imidazole–carboxylate complexes

Crystallographic data for the structures in this paper have been deposited with the Cambridge Crystallographic Data Center, CCDC, 12 Union Road, Cambridge CB2 1EZ, UK. Copies of the data can be obtained free of charge on quoting depository numbers CCDC-1543434 (1), CCDC-1543435 (2) and CCDC-1543436 (3) (Fax:+44-1223-336–033; E-mail: [email protected]; http://www.ccdc.cam.ac.uk). Supplemental data for this article can be accessed at https://doi.org/10.1080/00958972.2018.1460471.Peer reviewedPostprin

A randomized controlled behavioral intervention trial to improve medication adherence in adult stroke patients with prescription tailored Short Messaging Service (SMS)-SMS4Stroke study.

Background: The effectiveness of mobile technology to improve medication adherence via customized Short Messaging Service (SMS) reminders for stroke has not been tested in resource poor areas. We designed a randomized controlled trial to test the effectiveness of SMS on improving medication adherence in stroke survivors in Pakistan. Methods: This was a parallel group, assessor-blinded, randomized, controlled, superiority trial. Participants were centrally randomized in fixed block sizes. Adult participants on multiple medications with access to a cell phone and stroke at least 4 weeks from onset (Onset as defined by last seen normal) were eligible. The intervention group, in addition to usual care, received reminder SMS for 2 months that contained a) Personalized, prescription tailored daily medication reminder(s) b) Twice weekly health information SMS. The Health Belief Model and Social Cognitive theory were used to design the language and content of messages. Frontline SMS software was used for SMS delivery. Medication adherence was self-reported and measured on the validated Urdu version of Morisky Medication Adherence Questionnaire. Multiple linear regression was used to model the outcome against intervention and other covariates. Analysis was conducted by intention-to-treat principle. Results: Two hundred participants were enrolled. 38 participants were lost to follow-up. After 2 months, the mean medication score was 7.4 (95 % CI: 7.2–7.6) in the intervention group while 6.7 (95 % CI: 6.4–7.02) in the control group. The adjusted mean difference (Δ) was 0.54 (95 % CI: 0.22–0.85). The mean diastolic blood pressure in the intervention group was 2.6 mmHg (95 % CI; −5.5 to 0.15) lower compared to the usual care group. Conclusion: A short intervention of customized SMS can improve medication adherence and effect stroke risk factors like diastolic blood pressure in stroke survivors with complex medication regimens living in resource poor areas