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Background:Varicella-zoster virus (VZV) is one of the most common infections of childhood causing chickenpox, which in a majority of cases is self-limiting without any complicating consequences. However, in a meagre 0.01-0.03% cases, chickenpox may lead to serious neurological complications. Among them is acute cerebellar ataxia, which presents with the characteristic sign of broad-based gait abnormality, progressing gradually over the course of days, the mechanism of which is still debated upon. As a treatment option, the use of antiviral remains controversial, and some recommend it for better prognosis while others do not base on its autoimmune pathogenesis. This case is being communicated due to its rarity. Case Presentation:A case of a two-year-old female with a recent history of chickenpox eruption presented with the complaint of progressive loss of normal gait and difficulty in talking followed by generalized to-and-fro movements of her body leading to a diagnosis of post-viral acute cerebellar ataxia. There was no significant history of any past illnesses. Bacille Calmette Guerin (BCG) vaccine was given at birth, later followed by a single dose of pentavalent (Penta) vaccine. Management:Central nervous system (CNS) examination showed ataxic gait, pupils bilaterally equally reflective to light (BERL), nystagmus, dysmetria, and decreased muscle tone. Laboratory investigations were within the normal range. Imaging modalities that were all normal excluded other causes, including metabolic, tumors, and toxins. The patient was empirically treated with IV acyclovir BD for one week. Conclusion:As the rash of chickenpox resolves spontaneously in most cases, it is important that children infected with VZV should be closely observed for any neurological symptoms for timely and effective intervention. Link:http://aeirc-edu.com/ojs14/index.php/IJEHSR/article/view/459/592

Postural orthostatic tachycardia syndrome (POTS) is an autonomic disorder characterized by symptoms such as palpitations, dyspnea, chest discomfort, and lightheadedness affecting various systems. The pathophysiology of POTS is not completely understood due to a variety of symptoms showing that the disease is multifactorial. There is no approved uniform management strategy for POTS and hence, no drug has been approved by the United States (US) Food and Drug Administration (FDA) for it. Ivabradine is an FDA-approved drug for stable symptomatic heart failure (HF) and patients with an ejection fraction (EF) of ≤35%. Previous studies have depicted improvement in symptoms of POTS with the use of ivabradine. It is a selective inhibitor of funny sodium channels (If) in the sinoatrial (SA) node cells resulting in the prolongation of the slow diastolic depolarization (phase IV) and reduction in the heart rate (HR). Although beta-adrenoceptor blockers are commonly used to lower HR in patients with POTS, they are less ideal due to numerous adverse effects. This review aims to provide a comprehensive and up-to-date picture of all the studies and case reports that utilized ivabradine for the treatment of POTS along with a precise overview of epidemiology, pathophysiology, and types of POTS. To conclude, we recommend further research on the effectiveness of ivabradine in patients who experience symptoms of POTS. Other than stable chronic angina pectoris, its application in this setting has been proven to be effective and safe. Further evaluation by means of randomized control trials is required to encourage use of this HR-lowering agent in common disorders other than HF and stable angina, i.e. POTS.

Since its origin in China, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has become a pandemic and spread to 209 countries. As coronavirus disease 2019 (COVID-19) is a very rapidly emerging disease, organ-specific studies related to it have been reported. Apart from respiratory findings, some studies have highlighted inflammatory consequences in the heart, kidney, and/or liver as well. Cardiac involvement in COVID-19 seems to be a result of an inflammatory storm in response to the infection. Moreover, direct viral invasion of cardiomyocytes, as well as a myocardial injury due to oxidative stress, may account for acute cardiac injury in COVID-19. Nevertheless, the mechanism of heart injury in COVID-19 is not clear yet. However, multiple studies that highlight the clinical features, laboratory findings, and prognosis of acute myocardial injury (AMI) in COVID-19-affected individuals have been published. In this review, we have summarized the findings of all those studies as well as the clinical features and management of cardiac injury discussed by some case reports.

Tuberculosis (TB) is a chronic infection caused by Mycobacterium tuberculosis (M. TB). It is transmitted through respiratory droplets. Increased cholesterol level is a predisposing factor for TB. M. TB uses cholesterol in the host macrophage membranes to bind and enter the macrophages. Statins are the drugs that are prescribed to hyperlipidemic patients to maintain their lipid levels in the normal range, thereby reducing the risk of stroke and cardiovascular events. Moreover, statins aid in reducing the levels of cholesterol in human macrophages. Therefore, a reduction in the membrane cholesterol minimizes the entry of TB pathogen inside macrophages. Furthermore, acting as vitamin D3 analogs and positively influencing pancreatic beta-cell function in a chronic diabetic state, statins minimize the occurrence of M. TB infection among diabetic population as well. This review aims to provide a comprehensive detail of all in vitro, in vivo, and retrospective studies that investigated the effects of statins in relation to the prevention or treatment of TB infection.

Protein C (PC) is a 62-kD vitamin K dependent glycoprotein produced by the liver as a zymogen and is activated by binding to the thrombin-thrombomodulin complex, with protein S (PS) acting as a cofactor. Among its various functions, PC acts as a naturally occurring anticoagulant and its deficiency, either homozygous or heterozygous, predisposes the individual to a state of thrombosis, particularly venous thromboembolism, and mainfests as myocardial infarction (MI), deep venous thrombosis, pulmonary embolism, or stroke. This review discusses the pathophysiology of the anticoagulatory effect of PC, mode of inheritance of its deficiency, the arterial and venous involvement in patients with stroke, and its risk factors. A detailed analysis of published case reports on PC deficiency as a causative agent of stroke in young adults has also been included along with the management of such patients.

Chylomicron retention disease (CMRD), also known as Anderson's disease, is an autosomal recessive condition with a genetic mutation in the secretion associated Ras related GTPase 1B (SAR1B) gene, a protein coding gene. CMRD classically manifests as steatorrhea, vomiting, failure to thrive or abdominal bloating shortly after birth or in childhood. Here, we report a rare case of a 50-day-old male infant who was, at first, overseen as a case of acute gastroenteritis with sepsis owing to the non-specific symptoms i.e. multiple episodes of loose stools with a low-grade fever and failure to thrive, and was managed accordingly. However, the symptoms did not resolve; moreover, the clinical condition deteriorated. Later, lipid profile, clinical presentation and pathological features led to a presumptive diagnosis of CMRD. Our patient showed significant improvement when treated with a trial of medium- and short-chain fatty acids. We conclude that, in resource-restricted countries, a therapeutic trial with the dietary changes is essential to not only prevent the devastating complication but also support the diagnosis.

Hereditary thrombophilia (HT), including the mutation of factor V gene and the deficiency of proteins C, protein S, or antithrombin, is a risk factor for portal vein thrombosis (PVT). PVT in acute cases is usually asymptomatic, whereas chronic cases mostly present as variceal bleeding and splenomegaly. However, cavernous transformation of the portal vein secondary to a long-standing PVT is very rare. Here we present a case of a 28-year-old female who was admitted with complaints of left upper abdominal pain and swelling for four to five years. Using laboratory and radiological examinations, a confirmatory diagnosis of cavernous transformation of a thrombosed portal vein due to protein C and S deficiency was made. The patient was managed through splenectomy with splenorenal shunting along with life-long prescription of anticoagulants.

The spleen is an intraperitoneal organ that performs vital hematological and immunological functions. It maintains both innate and adaptive immunity and protects the body from microbial infections. The removal of the spleen as a treatment method was initiated from the early 1500s for traumatic injuries, even before the physiology of spleen was properly understood. Splenectomy has therapeutic effects in many conditions such as sickle cell anemia, thalassemia, idiopathic thrombocytopenic purpura (ITP), Hodgkin’s disease, and lymphoma. However, it increases the risk of infections and, in some cases, can lead to a case of severe sepsis known as overwhelming post-splenectomy infection (OPSI), which has a very high mortality rate. Encapsulated bacteria form a major proportion of the invading organisms, of which the most common is Streptococcus pneumoniae. OPSI is a medical emergency that requires prompt diagnosis (with blood cultures and sensitivity, blood glucose levels, renal function tests, and electrolyte levels) and management with fluid resuscitation along with immediate administration of empirical antimicrobials. OPSI can be prevented by educating patients, vaccination, and antibiotic prophylaxis. This article summarizes the anatomy and physiology of the spleen and highlights its important functions. It primarily focuses on the pathophysiology of OPSI, its current management, and prevention strategies.

Background Non-alcoholic fatty liver disease (NAFLD) is a common liver disorder caused by the deposition of lipids and fats in the hepatocytes, in individuals who consume little or no alcohol, which eventually progresses to cirrhosis and carcinoma. Apart from the known risk factors like obesity, metabolic syndrome (MS), and lack of physical activity (PA), diet also plays a major role in the development of NAFLD. A high body mass index (BMI) and waist circumference (WC) have positive associations with NAFLD. The aim of this study was to find the prevalence of risk factors of hepatic steatosis in NAFLD population and to raise public awareness about the condition. Method We conducted a cross-sectional study from October to December 2019 with a sample size of 98 subjects determined by using a confidence interval (CI) of 99.9%. Patients presenting to Essa Laboratory, Karachi for abdominal ultrasound (US) were scanned for fatty changes in the liver, after obtaining consent, and were then assessed for risk factors by administering a 20-item questionnaire along with registering their BMI and WC measurement. The collected data was analyzed using the Statistical Package for Social Sciences (SPSS), version 22 (IBM, Armonk, NY). The independent sample t-test was applied for the exploration of variables and a p-value

Insulinomas are rare, functional pancreatic neuroendocrine tumors arising from the pancreatic multipotent stem cells or neuroendocrine islet, occurring with a higher proportion in females. Majority of insulinomas have a sporadic etiology; however, only 5%-10% develop as a part of multiple endocrine neoplasm type 1 syndrome. They usually present with symptoms of hypoglycemia including disturbance in orientation, tremors, diaphoresis, altered mental state, seizures and visual changes among others. The diagnosis is based on appreciation of the classic Whipple triad, i.e. neuroglycopenic symptoms and sympathetic drive along with low serum glucose levels (

Meckel’s diverticulum (MD), a congenital abnormality of the gastrointestinal tract, is usually found in the pediatric population younger than two years of age; hence, its incidence in adults is rare. Although MD is mostly clinically silent, in adults, it may present with intestinal obstruction and diverticulitis. The complications of MD include hemorrhage, perforation, enterolith formation, torsion, Littre’s hernia, ulceration and neoplasm. Among these, torsion is one of the rarely reported complications of MD. MD being attached to the ileal mesentery or umbilicus, presence of mesodiverticular band, and the length, breadth and base diameter of the diverticulum contribute as a risk factor for torsion. A similar clinical picture of acute appendicitis must be excluded. We report a case of a 25-year-old male who presented with signs of intestinal obstruction in whom intraoperative finding of a torted MD with necrotic and twisted base was found upon emergency exploratory laparotomy.

Protein C (PC) and protein S (PS) are natural anticoagulants that protect the body against thrombosis, and their deficiency, either inherited or acquired, renders the body to a hypercoagulable state. This leads to venous thromboembolism manifesting as thrombosis, pulmonary embolism and superficial thrombophlebitis among other causes. The involvement of arteries is rare and has been explained by only a few studies. Hence, the presentation of PC and PS deficiencies with stroke and myocardial infarction (MI) is rarely observed, especially in young patients. We report a case of a 33-year old male with a past medical history of stroke and MI for which no underlying cause was found. He presented now with shortness of breath and left-sided chest pain and after a series of workup, eventually diagnosed as a rare case of PC and PS deficiencies.

Hydatid cysts are caused by a tapeworm Echinococcus granulosus. They usually occur in the liver. When occurring in spleen they present with vague symptoms which make it difficult for the physicians to diagnose. We present a case of a 10-year-old male who presented with fever, abdominal pain, and burning micturition along with vomiting. Abdominal exam revealed no visceromegaly. Abdominal ultrasound (US) and computed tomography (CT) scan showed multiple hypoechoic and hypo-dense areas, respectively. Splenic abscess, abdominal tuberculosis (TB), pyelonephritis and malignancy were ruled out with appropriate investigations. The patient was not responding to triple therapy of antibiotics (ceftriaxone, metronidazole, and cloxacillin). A final diagnosis of hydatid cyst of spleen was made when serum echinococcus immunoglobulin G (IgG) antibodies were found to be positive. The patient was treated with albendazole and was discharged on improvement. It is vital to be vigilant and consider echinococcal hydatid cyst as a differential in the lesions of spleen, especially if the patient has a rural background.

Cavernous transformation of the portal vein (CTPV), also known as portal cavernoma, is a sequelae of thrombosis in the portal vein causing its occlusion and portal hypertension. The etiology, however, remains unknown. Gastroesophageal variceal bleeding, splenomegaly, portosystemic collaterals, and ultimate hematologic abnormalities are among the prominent clinical features. Among the causes, predisposing an individual to CTPV is natural anticoagulant protein C and antithrombin III deficiencies. Determination of the etiology of CTPV may also give a direction toward the management plan to not only relieve the patient of the already developed complications but also to treat the primary cause of the pathology We discuss a case of a nine-year-old male child diagnosed as CTPV secondary to protein C and antithrombin III deficiency who was treated symptomatically for anemia and varices and was referred for transjugular intrahepatic portosystemic shunt (TIPS).

Inositol, an emerging novel therapy for the treatment of gestational diabetes mellitus (GDM), is a cyclic polyol that has insulin-like effects and plays an important role in glucose homeostasis. The conventional treatment of GDM with insulin and oral antihyperglycemic drugs usually comes with side effects, paving the way for and shedding spotlight on clinical trials involving inositol. This review analyzed a host of recent trials that involved inositol supplementation for preventing GDM and their positive outcomes in reducing the rate of GDM among obese and overweight pregnant women, as well as women with polycystic ovarian syndrome (PCOS) or a family history of type 2 diabetes mellitus.

Michelin tire baby syndrome (MTBS) is a benign hamartomatous condition with ring-like lesions present on the limbs and trunk. MTBS is a rare genodermatosis. According to our search, only 20 cases have been reported. We present a case of a six-month-old female child, with complaints of fever and seizures. Since birth, she had asymptomatic multiple, asymmetric skin folds on all four limbs, resembling "Michelin Man" logo of the French tire manufacturer. She had microcephaly with characteristic round face hypertelorism, depressed nasal bridge, hypertrichosis with low set ears, a thin down-turned vermillion border of the upper lip, and a short neck. MRI was normal. Clinically, the diagnosis of MTBS was made. In addition, the parents were counseled about the self-limiting course of this disorder. MTBS itself might not be a single disorder but may manifest as a clinical finding associated with other disorders; therefore, a regular follow up of these patients is usually advised.

Malignant rhabdoid tumor of the kidney (MRTK) is a rare neoplasm of infancy. We report a case of a nine-month-old male infant who presented to the pediatrics outpatient department with the history of fever, lethargy, and abnormal head movements. On gross examination, the patient had a firm, non-tender, intra-abdominal mass at the right lumbar region with irregular margins. Computed tomography scan of the abdomen revealed a lobulated soft tissue arising from the kidney with areas of necrosis. Brain magnetic resonance imaging was also performed, which showed a large heterogeneous lesion in the posterior fossa. Histopathologic study revealed loss of INI1 protein. Since MRTK and atypical teratoid rhabdoid tumor (ATRT) of the brain share a common mutation in the gene (hSNF5/INI1), hence a diagnosis of MRTK with co-existent ATRT of the brain was established. Actinomycin-D and vincristine failed to show any improvement and the condition of the patient deteriorated progressively, resulting in his death within 15 days of hospital admission.

Background Opioid analgesics, also known as narcotics, are medicinal drugs used primarily for the management of pain secondary to any type of cancer, severe injury or surgery. Due to the ease of availability, opioids are commonly abused. In 2015, reported deaths exceeded 33,000 Americans from opioid overdose. A survey in 2013 revealed nearly 1.6 million Pakistanis abusing prescription opioids for non-medical needs. Although commonly prescribed by primary care physicians, most of them are diffident to stand by all the recommended strategies to reduce the incidence of opioid abuse. Methods A cross-sectional study was conducted during the period of August through October 2018. A sample size of 365 was determined using a 95% confidence interval at a degree of precision of 5%. A 22-item questionnaire was given to doctors with at least two years practicing experience either from a private or a public healthcare setup. Doctors who had never prescribed opioids were excluded from the study. Out of the eligible participants, 15 refused to take part in the survey, and the co-operation rate was recorded as 95.8%. Collected data were analyzed using statistical package for social science (SPSS) version 22 for Windows. Frequencies, percentages, mean, standard deviation, and chi-square were used to explore the variables. The statistical significance level was considered at p < 0.5. Results Opioids were reported to be used mainly for treating acute pain (40.5%), chronic pain (24.7%) and both acute and chronic (34.8%). A minority of doctors (29%) screened their patients for opioid addiction. A significant association (p = 0.000) between the frequency of opioid prescription and prior screening for depression was determined. Surprisingly, only 23.2% clinicians frequently screened their patients for depression before prescribing opioids. The rate of counselling regarding drug tapering was found to be 71.6%. A majority, i.e., 88%, of the respondents anticipated the misuse of opioids they prescribe whereas 74% also held a belief that patients self-medicate their untreated pain. Participants reported addiction (54%) as the most common reason for abuse followed by the role of pharmaceutical companies (43%) and pharmacies (41%). About 80.2% clinicians believed that patients addicted to opioids could get well and return to their daily routine. Conclusion The rising opioid epidemic is a major concern for doctors prescribing opioids. Adaptation of medical school curricula and appropriate training can equip doctors for better management of patients requiring opioids. This includes the screening of patients using standard risk assessment tools for opioid abuse leading to a more controlled opioid prescription practice. Dissemination of these tools will boost doctors' confidence and may help in reducing morbidity and mortality from opioid abuse.

Background: The prostate gland is a male sexual organ which has a number of diseases associated with it, such as prostatitis, benign prostatic hyperplasia (BPH), and prostatic cancer (PC). BPH is the most common neoplasm, and it causes significant urinary symptoms in adult males. According to the World Health Organization (WHO) report of 2014, out of all the cancers, PC had the fifth highest incidence in males throughout Pakistan. The purpose of this study was to determine the awareness of elderly men of Karachi regarding prostate diseases (PDs) and their attitude towards screening practices. Method: From September to December 2018, a cross-sectional study was performed among 450 men of Karachi older than 50 years of age. Frequencies and percentages were evaluated for categorical variables using Statistical Package for Social Sciences (SPSS), version 22 (IBM SPSS Statistics, Armonk, NY). Chi-square test was used to determine if there was any significant difference. A p-value of < 0.05 was considered significant. Result: A total of 350 respondents answered the questionnaire. The mean age of the respondents was 61 years. Almost half of the population had heard about the prostate but 64% did not know any PDs, whereas 48% were aware of the increased risk of PDs in the elderly. Almost 48% of the respondents believed that age was the main cause of disorders involving the prostate. Even though the knowledge was lacking, people had an overall positive attitude. Most respondents (66%) had the attitude that all adult men must undergo prostate screening. The majority of respondents (85%) had not undergone screening of the prostate as the huge group of participants (86%) had not been advised to do it. Upon statistical testing, having heard about the prostate and undergoing prostate screening in the past (p = 0.008 and 0.024, respectively) was significantly associated with age. Having prior experience with prostate screening was also associated significantly with marital status (p < 0.001). Conclusion: Respondents have inadequate knowledge about PC but a good attitude about undergoing prostate examination. It is absolutely crucial to increase information on the risks of PDs, particularly PC, and the benefits of early detection.

Protein C and protein S are vitamin K dependent anti-coagulant proteins required for the inhibition of activated protein V and VIII. In an inherited thrombophilia, hypercoagulability caused by the deficiency of protein C and protein S predisposes an individual to increased risk of thromboembolism (TE) that could herald as a venous thromboemboilsm (VTE) in the leg, pulmonary embolism (PE), stroke, or Budd-Chiari syndrome. However, very rarely does inherited thrombophilia cause coronary artery thrombosis leading to the development of myocardial infarction (MI). We report a case of a young male with combined protein C and protein S deficiency who presented with acute MI, worsened ventricular systolic function, and progressive declination of ejection fraction (EF) secondary to dilated cardiomyopathy (DCM).

Hemophilia A is an X-linked hereditary bleeding disorder that is rarely encountered by most physicians and surgeons in their practice. Patients with mild hemophilia A tend to bleed profusely after surgery or trauma whereas a severe variant may manifest as spontaneous bleeding after minor trauma, mainly into the joints and muscles. However, seldom do we find a case where the patient experiences bleeding into multiple joints at the same time. In the South Asian population, the incidence of hemarthrosis in hemophilic patients holds scarce literature, making this an under-reported entity.

Hoffmann’s syndrome (HS) is a rare manifestation of hypothyroidism myopathy that presents with weakness, stiffness, and eventually pseudohypertrophy of muscles, especially calf muscles. We report a case of a 28-year-old male who presented with the history of generalized weakness with swelling in lower limbs and gradual progressive facial puffiness for the past few years. Physical examination of our patient showed diffuse bilateral pseudohypertrophy of deltoid and calf muscles with positive Gowers’ sign (GS). Laboratory results of low serum thyroid hormones and muscle biopsy report confirmed the diagnosis of HS. Pendred syndrome (PS) is a genetic disorder leading to congenital bilateral sensorineural hearing loss with mild hypothyroidism. On account of his congenital bilateral sensorineural hearing loss and negative serum anti-thyroid peroxidase antibodies (anti-TPO Ab), PS was declared as the cause of HS in this case. Our patient showed excellent response to levothyroxine therapy with progressive improvement in his symptoms. We outlined this case due to its rarity.

Congenital talipes equinovarus (CTEV), otherwise known as clubfoot (CF), is a common congenital abnormality of the foot, stemming in most cases from an idiopathic cause or in the remaining non-idiopathic occurrences, from meningomyelocele (MMC). Ponseti method (PM), being a gold standard treatment for the correction of this foot deformity, requires a series of regular casting usually accompanied by percutaneous tenotomy of the Achilles tendon and later maintained via abduction braces. Osteomyelitis (OM), as a complication of PM, is rarely reported especially in cases of CF-associated with MMC in which majority of the patients present with varying level of sensory deficit in the lower limbs. Therefore, the absence of pain due to neuropathy leads to a delayed diagnosis of cellulitis and chronic abscesses. We present a case of an eight-year-old male child with exogenous OM as a complication of PM affecting the tarsal bones of his right foot. After an established diagnosis using laboratory results and imaging modalities, the patient was successfully treated with broad spectrum antibiotics achieving full resolution of his clinical symptoms. We report this case due to its rarity.

Rhino-oculo cerebral mucormycosis (ROCM) is a rare, invasive, and rapidly progressive fungal infection affecting nose, paranasal sinuses and often extending to orbit, brain, and palate. The immunocompromised, more commonly patients with diabetes mellitus, fall victim to this lethal form of fungus. Although the therapeutic approach includes aggressive surgical and medical interventions, ROCM remains a life-threatening infection with poor prognosis. This rare case addresses the outcomes of ROCM in a young patient with delayed diagnosis and resistance to amphotericin B (Ampho B) contributing to dreadful outcomes.

Cases on concurrent infection of dengue and malaria are uncommon in Pakistan. Dengue and malaria are the two very common, mosquito-borne infections, which may have significant morbidity and mortality if not managed properly. Concurrent infections of dengue and malaria are rare due to the different habitats of its vectors and activities of different bearer mosquitoes. The first case was reported in 2005. Since then, several co-existing infections have been reported consisting of the dengue virus (DENV) and the malaria protozoans. Symptoms of each infection may be disguised by a coincident second infection, resulting in delayed treatment and severe complications. We report a case of concurrent malaria and dengue viral hemorrhagic fever in a 19-year-old male.

Colorectal cancer (CRC) is an unchecked proliferation of abnormal cells that initiates in the colon or rectum. Most of them start as small growths termed adenomatous polyps causing alteration in the layers of colon, spreading to nearby lymph nodes and distant parts of the body. Its incidence is increasingly reported in younger population i.e. less than 40 years of age. In Pakistan, it is concerned that an aging population over the coming decade and changing lifestyle patterns may lead to a higher incidence of CRC [1]. Risk factors of colorectal carcinoma are enumerated as older age, inherited gene mutations, inflammatory intestinal conditions, diabetes, smoking, alcohol intake, low fiber and high fat diet and sedentary life style [2]. Bleeding per rectum and anaemia are high risk clinical features for CRC.

Summary Background and objectives HIV-associated nephropathy (HIVAN) is well described, but the clinical features of a group of renal pathologies characterized by Ig or immune complex depositions referred to as HIV-associated immune complex kidney disease (HIVICK) have not been well established. The objective of this study is to assess risk factors for HIVICK compared with contemporaneous control participants. Design, setting, participants, & measurements A nested case-control study of 751 HIV-infected patients followed from January 1996 to June 2010 was conducted. Groups were compared using the chi-squared test or rank-sum analysis. Conditional logistic regression was used to estimate odds ratios (ORs) for HIVICK. Incidences of overall ESRD and with/without combined antiretroviral therapy (cART) exposure were calculated. Results HIVICK patients were predominantly African American (92%). Compared with matched controls, patients with HIVICK were more likely to have HIV RNA >400 copies/ml (OR, 2.5; 95% confidence interval [95% CI], 1.2 to 5.2), diabetes (OR, 2.8; 95% CI, 1.1 to 6.8), and hypertension (OR, 2.3; 95% CI, 1.2 to 4.5). Compared with HIVAN, patients with HIVICK had more antiretroviral therapy exposure, lower HIV viral loads, and higher CD4 and estimated GFR. ESRD was less common in the HIVICK versus the HIVAN group (30% versus 82%; P Conclusions HIVICK was predominantly observed in African-American patients and associated with advanced HIV disease. ESRD incidence is lower in HIVICK patients compared with those with HIVAN. Unlike HIVAN, cART use was not associated with the incidence of ESRD in HIVICK.

Currently home to 180 million people, Pakistan's population continues to rise, with an estimated increase of 66 million in the next 15 years.1 While it is encouraging to note that women in developing countries have shown an interest in limiting their family size and appropriately spacing out pregnancies by means of modern contraceptive methods, most women in developing countries still find it difficult to obtain contraception. Also, failure to correctly and consistently use modern contraceptive methods has led to an increase in the number of unwanted pregnancies.2 In Pakistan, the contraceptive prevalence ratio is alarmingly low at 29%.3 Consequently physicians need to be able to explain the correct use of different contraceptive methods to …

To determine the angiocardiographic findings in patients with unstable angina showing biphasic inversion of T-waves in precordial leads on electrocardiogram, commonly referred to as the Wellen's syndrome.The descriptive, cross-sectional study was carried out at the National Institute of Cardiovascular Diseases, Karachi, between February and November, 2010. Using convenience sampling, the first 100 consecutive patients showing the characteristic electrocardiogram pattern with a history of chest pain indicative of unstable angina and undergoing coronary angiography were included. Data was collected with the aid of a questionnaire to assess the coronary risk factors, and angiographic findings were recorded during cardiac catherisation of the patients. All the data collected was sorted and analysed on SPSS version 16 for statistical analysis.Biphasic T-wave inversion was seen most commonly in leads v2-v3 in 26 (26%) patients, and in leads v2-v4 in 25 (25%) patients. Angiographic findings revealed that 50 (50%) patients had coronary artery stenosis in the proximal part of the left anterior descending artery, while 22 (22%) showed the occlusion in the middle segment. Right coronary artery established the dominance of heart in 75 (75%) of the patients and the two-vessel disease was most commonly observed during cardiac catherisation.The classical pattern of biphasic T-wave inversion on electrocardiogram was seen associated with stenosis in the proximal as well as middle part of the left anterior descending coronary artery. This electrocardiogram pattern may not be well defined during the symptomatic phase of acute ischaemia and, hence, maybe overlooked. Prompt recognition and early intervention may significantly reduce morbidity and mortality in such patients.

Hepatorenal syndrome occurs in patients with advanced liver cirrhosis and is associated with functional renal impairment and poor prognosis. These patients present a challenge to physicians and management strategies. Although various pharmacological therapies are available, large randomized controlled trials are required to determine which treatment modality is most effective to improve survival rates along with its dose and duration of treatment. The overproduction of tumor necrosis factor-alpha (TNF-alpha) has been postulated to play a role in progression of this disease, being associated with hyperdynamic circulation and inflammatory process. Moreover, increasing the levels of TNF-alpha during the course of hospitalization is suggested to be associated with increased mortality. Hence the role of TNF-alpha inhibitors, such as pentoxifylline, may prove to be become a new clinical pathway. Various randomized clinical trials have demonstrated a significant reduction in mortality in patients receiving pentoxifylline, in comparison to the control group. This survival rate benefit was associated with decrease in the incidence of hepatorenal syndrome in these patients. We propose a double-blinded trial to test the hypothesis, in which patients with advanced liver disease without evidence of hepatorenal syndrome are recruited. The control group receives the standard management while the case group receives standard management along with TNF-alpha blockers. If the cases develop hepatorenal syndrome at a significant duration later in comparison to the control group, our hypothesis will be confirmed. Our methodology is limited due to costs of TNF-alpha inhibitors in a developing country setup, hence it has only been proposed as a hypothesis. If the recommended trial confirms our hypothesis, we might see favorable outcomes and improved survival rates in patients with decompensated liver diseases.