Paroxysmal atrial fibrillation presenting as anterior wall STEMI in an elderly woman

A 77-year-old woman without traditional risk factors for coronary artery disease (CAD) underwent coronary CT-angiography for evaluation of palpitations after negative Holter monitoring and non-diagnostic ECG exercise stress test. Coronary artery calcium score was reported zero; 1 day later, she was admitted with anterior-wall ST elevation myocardial infarction. Acute left anterior descending artery thrombus was treated with mechanical thrombectomy and Percutaneous Coronary Intervention (PCI). Interestingly, the coronary arteries were angiographically normal. During hospitalisation, paroxysmal atrial fibrillation was noted followed by initiation of anticoagulation. Echocardiogram did not show thrombus or atrial shunt. Cardioversion with Sotalol was successful. Myocardial infraction was most likely cardioembolic secondary to paroxysmal atrial fibrillation-consistent with longstanding history of palpitations. Accounting for 3% of acute coronary syndromes, coronary embolism is treated with therapeutic anticoagulation for at least 3 months irrespective of cause and carries a higher risk of adverse cardiovascular events

Cytogenetic abnormalities in myelodysplastic syndromes: An overview

Karyotype is one of the main constituents of the International Prognostic Scoring System (IPSS) and revised-IPSS that are the cornerstones for the prognostication of patients with myelodysplastic syndromes (MDS). Del(5q), -7/del(7q), +8 and -Y are among the most extensively studied cytogenetic abnormalities in MDS. The same applies for normal karyotype. There are hundreds of other rare cytogenetic abnormalities that have been reported in MDS, included but not limited to -X, 3q abnormalities, +13/del(13q), i(17q), +21/-21. However, due to a very low number of patients, their impact on the prognosis of MDS is limited. Knowledge of the molecular consequences of different cytogenetic abnormalities allows us to modify treatment regimens based on drugs most active against the specific karyotype present, allowing for the opportunity to individualize MDS treatment and improve patient care and prognosis

Lyme carditis presenting as atrial fibrillation in a healthy young male

We present a case of a 23-year-old man coming with palpitations, found to be in atrial fibrillation (AF). He was initially managed with metoprolol for rate-controlled therapy-reverted to normal sinus rhythm and discharged home. He returned a few days later-this time in varying degrees of atrioventricular block including transient complete heart block. He was empirically started on intravenous ceftriaxone for suspected Lyme carditis, which subsequently led to the resolution of high-degree heart block. Lyme immunoglobulin G (IgG) and IgM returned positive. Follow-up ECG after the course of antibiotic exhibited normal sinus rhythm. AF is a rare presentation of Lyme disease but still exists. It should be considered in terms of appropriate treatment, especially in Lyme-endemic areas

Comparison of the clinical presentations of Naegleria fowleri primary amoebic meningoencephalitis with pneumococcal meningitis: a case-control study.

Background: Primary amoebic meningoencephalitis (PAM) is a rare but fatal infection caused by Naegleria fowleri. The infection is acquired by deep nasal irrigation with infected water. Patients present with signs and symptoms similar to pneumococcal meningitis, leading to delayed diagnosis and treatment and hence high mortality. Methods: We conducted a case–control study comparing culture proven cases of PAM with pneumococcal meningitis presenting to our center between April 2008 and September 2014. Only patients with blood and/or cerebrospinal fluid cultures positive for Streptococcus pneumoniae during the same time period were included for comparison. Results: There were 19 cases of PAM and pneumococcal meningitis, each. When comparing PAM with pneumococcal meningitis, patients with PAM were more likely to be male (89.5 vs. 36.8 %), younger (mean age: 30 vs. 59 years), present with seizures (42.1 vs. 5.3 %). Both groups of patients presented with similar vital signs and there were no remarkable differences on physical examinations, Glasgow Coma Scale scores, laboratory and radiological investigations and cerebrospinal fluid parameters. PAM was also more likely to present if the city’s average maximum temperature was higher in the previous week (mean: 34.6 vs. 30 °C). There was history of fresh water contact in only one patient. On multivariate analysis, PAM was more likely if patients presented when the city’s average maximum temperature was high, being young males. Conclusion: PAM and pneumococcal meningitis remain virtually indistinguishable; however, these predictive features should be validated in a prospective study and may lead to a viable algorithm for early management of these patients

Evaluation of a quality improvement intervention to reduce anastomotic leak following right colectomy (EAGLE): pragmatic, batched stepped-wedge, cluster-randomized trial in 64 countries

Background Anastomotic leak affects 8 per cent of patients after right colectomy with a 10-fold increased risk of postoperative death. The EAGLE study aimed to develop and test whether an international, standardized quality improvement intervention could reduce anastomotic leaks. Methods The internationally intended protocol, iteratively co-developed by a multistage Delphi process, comprised an online educational module introducing risk stratification, an intraoperative checklist, and harmonized surgical techniques. Clusters (hospital teams) were randomized to one of three arms with varied sequences of intervention/data collection by a derived stepped-wedge batch design (at least 18 hospital teams per batch). Patients were blinded to the study allocation. Low- and middle-income country enrolment was encouraged. The primary outcome (assessed by intention to treat) was anastomotic leak rate, and subgroup analyses by module completion (at least 80 per cent of surgeons, high engagement; less than 50 per cent, low engagement) were preplanned. Results A total 355 hospital teams registered, with 332 from 64 countries (39.2 per cent low and middle income) included in the final analysis. The online modules were completed by half of the surgeons (2143 of 4411). The primary analysis included 3039 of the 3268 patients recruited (206 patients had no anastomosis and 23 were lost to follow-up), with anastomotic leaks arising before and after the intervention in 10.1 and 9.6 per cent respectively (adjusted OR 0.87, 95 per cent c.i. 0.59 to 1.30; P = 0.498). The proportion of surgeons completing the educational modules was an influence: the leak rate decreased from 12.2 per cent (61 of 500) before intervention to 5.1 per cent (24 of 473) after intervention in high-engagement centres (adjusted OR 0.36, 0.20 to 0.64; P < 0.001), but this was not observed in low-engagement hospitals (8.3 per cent (59 of 714) and 13.8 per cent (61 of 443) respectively; adjusted OR 2.09, 1.31 to 3.31). Conclusion Completion of globally available digital training by engaged teams can alter anastomotic leak rates. Registration number: NCT04270721 (http://www.clinicaltrials.gov)