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Introduction COVID-19 has manifested a striking disarray in healthcare access and provision, particularly amongst patients presenting with life-threatening ischemic heart disease (IHD). The paucity of data from low-middle income countries has limited our understanding of the consequential burden in the developing world. We aim to compare volumes, presentations, management strategies, and outcomes of IHD amongst patients presenting in the same calendar months before and during the COVID-19 pandemic. Methods We conducted a retrospective cross-sectional analysis at the Aga Khan University Hospital, one of the premier tertiary care centres in Pakistan. Data were collected on all adult patients (>18 years) who were admitted with IHD (acute coronary syndrome (ACS) and stable angina) from March 1 to June 30, 2019 (pre-COVID) and March 1 to June 30, 2020 (during-COVID), respectively. Group differences for continuous variables were evaluated using student t-test or Mann-Whitney U test. The chi-squared test or Fisher test was used for categorical variables. Values of p less than 0.05 were considered statistically significant. P-value trend calculation and graphical visualization were done using STATA (StataCorp, College Station, TX). Results Data were assimilated on 1019 patients, with 706 (69.3%) and 313 (30.7%) patients presenting in each respective group (pre-COVID and during-COVID). Current smoking status (p=0.019), admission source (p

Background The care of patients presenting with chest pain to multidisciplinary services hospital gets compromised due to the busy triage system. A separate and specialized equipped cardiac emergency unit (CAR-ERU) can improve patient's outcomes. Objectives To enhance early recognition and treatment of acute myocardial infarction (AMI) patients. To sustain key performance quality indicators (KPIs) for AMI. Methods In October 2016, a separate CAR-ERU was established inside the multidisciplinary emergency department (MED). A dedicated specialized heart-lung and vascular teams were hired under the supervision of service line leadership. The KPIs that were identified benchmark with international practice guidelines. Data were collected and stored for analysis. Exemption from the ethical review committee was obtained. Results A total of 2914 patients visited CAR-ERU from October 2016 to September 2017 for a period of one year. Out of which 30% were diagnosed with acute coronary syndrome (ACS) and this included 8% diagnosis with ST-segment elevation myocardial infarction (STEMI). Over 98.8% of the electrocardiogram (ECG) was done within 10 minutes of arrival while aspirin was given to 96.5% of patients within one hour. The door to balloon time (DBT) of

Cervical necrotizing fasciitis (CNF) is a rapidly spreading deep neck infection with a high mortality rate if left untreated. The occurrence of necrotizing infections in the head and neck region is uncommon; therefore, it is a rare cause of chest pain presenting to the emergency department. Here, we present an interesting case of fungal cervical skin abscess complicated by necrotizing fasciitis that progressed to involve the mediastinum, causing necrotizing mediastinitis with pneumomediastinum in an elderly female. The patient presented to the emergency department with chest pain, shortness of breath, and fever. She had a 10-day history of a mass in the anterior midline of her neck with odynophagia. After radiologic confirmation, she was taken to the operating room where she underwent incision and drainage with debridement and washout. Postoperatively, she was given broad-spectrum antibiotics empirically, which were later replaced with intravenous (I/V) fluconazole after culture reports. Prompt diagnosis and treatment lead to the early recovery of the patient and subsequent discharge without any complications. We report this case to draw the attention of emergency medicine physicians and clinicians to this rare and life-threatening but treatable condition. Expeditious diagnosis and treatment lead to early recovery and fewer postoperative complications.

Introduction Postoperative atrial fibrillation (AF) is the commonest of all the known cardiac arrhythmias after cardiac surgery. The postoperative AF has both short- and long-term adverse impacts on patients, like prolonged intensive care unit (ICU) stay, increased frequency of reoperations, myocardial infarction, increased use of inotropes, and intra-aortic balloon pump (IABP). There is a paucity of data regarding the postoperative AF after isolated coronary artery bypass grafting (CABG) and its risk factors in our geographic location. Therefore, the aim of this study was to determine the frequency of postoperative atrial fibrillation among patients undergoing isolated CABG at a tertiary care hospital of Karachi, Pakistan. Methods This prospective observational study was conducted on 163 consecutively selected patients undergoing first time isolated CABG at the Department of Cardiothoracic Surgery, Aga Khan University Hospital, Karachi. Patients with redo-sternotomy, preoperative atrial fibrillation and with other cardiac pathology were excluded from the study. Postoperative AF was defined in the patients with postoperative 12-lead electrocardiographic (ECG) finding of absence of P waves, replaced by unorganized electrical activity and irregular R-R intervals. Data analysis was carried out using IBM SPSS Statistics for Windows, Version 21.0 (IBM Corp., Armonk, NY, USA). Results A total of 163 patients were enrolled with the mean age of 58.66 ± 9.77 years ranging between 40 and 85 years with male predominance of 81% (132). The most common comorbidity was hypertension in about 68.1% (111), followed by diabetes mellitus in 54.6% (89) patients. Postoperative AF was observed in 42 (25.8%) patients. Most of the patients who developed postoperative AF, were overweight with mean body mass index (BMI) of 27.04 ± 4.85 kg/m2, 76.2% (32) had a history of hypertension, diabetes mellitus was associated with 33.3% (14) patients with postoperative AF and 50.0% (21) of them were smokers. Distribution of coronary artery disease in patients with postoperative AF was observed as three vessels coronary artery disease (3VCAD) in 83.3% (35), two-vessel coronary artery disease (2VCAD) was present in 7.1% (three), and rest of 9.5% (four) patients had single-vessel coronary artery disease (SVCAD). Conclusion The frequency of postoperative atrial fibrillation in our study was found to be 25.9% which is comparable to world literature. An important finding that comes through this study is a younger population undergoing CABG, which raises the possibility of early manifestation of ischemic heart disease in our region. This, however, needs further investigation. We were unable to point out the factors predictive of postoperative AF; studies with larger sample size would help in that regard.

A 46-year-old man presented with shortness of breath and recurrent, left-sided pleural effusions. A computed tomography (CT) scan of the chest showed a large, left-sided pleural effusion with a mass in the posterior mediastinum. A pleural tap showed lymphocytic exudate. The biopsy of the mass was inconclusive. A left posterolateral thoracotomy was performed, which showed a large posterior mediastinal mass adherent to the left lung. The mass was completely excised and the histopathology proved it to be giant predominantly cystic schwannoma. The pleural effusion resolved after tumor resection.

Hernia of Morgagni is congenital defects in the diaphragm. They are mostly asymptomatic and present with vague symptoms when they do so. A high index of suspicion is required for timely diagnose of this condition. Here we present the case of a 65-year-old male patient presented to our institute with constipation for the past six months. Chest radiology raised the suspicion of a hernia which was further confirmed by contrast studies. Laparotomy was done and the hernia sac identified, colon and greater omentum reduced and defect repaired. He was discharged in stable condition and was doing well on follow-up.