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The prevalence of congenital coronary artery anomalies is approximately 1% in the general population. They are a common cause of sudden death in younger persons. The origination of the posterior descending artery (PDA) from left anterior descending (LAD) artery is an extremely rare anomaly. We present a case of a 54-year-old female who presented with diabetic ketoacidosis with co-existing non-ST elevation myocardial infarction, therefore, had an invasive angiogram that identified the anomalous origin of PDA from LAD. It is vital to define coronary anatomy as anomalies dictate which cardiac intervention should be attempted in cases of ischemia.

Patient: Male, 34 Final Diagnosis: Spontaneous coronary artery dissection Symptoms: Chest pain Medication: — Clinical Procedure: — Specialty: Cardiology Objective: Rare disease Background: Spontaneous coronary artery dissection (SCAD) is primarily found in females. SCAD can have many precipitating factors such as exercise, trauma, pregnancy, drugs, and connective tissue disease. Prognosis is poor for left main stem, left anterior descending (LAD) artery, and multivessel involvement, especially for females. Case Report: We present a case of young African American male with sickle cell disease who presented with chest pain associated with shortness of breath. He was found to have non-ST elevation myocardial infarction (NSTEMI). He was diagnosed with SCAD during catheterization with the help of intravascular ultrasound imaging. Three drug-eluting stents were placed to cover the proximal LAD vessel along its whole length until resolution of the lesion. The patients’ hospital course was complicated by an additional finding of left ventricular thrombus, possibly a complication of NSTEMI, which was treated with anticoagulation to complete resolution. Conclusions: SCAD is fatal, it can proceed to cause myocardial infarction as in this particular patient’s case, and sudden death if not recognized early. It can be missed on angiography alone; further intracoronary imaging such as intravascular ultrasound and optical computed tomography should be used to confirm the diagnosis of SCAD so that early and appropriate treatment can ensue.

Patient: Male, 71 Final Diagnosis: Thrombotic thrombocytopenic purpura Symptoms: Abdominal and/or epigastric pain Medication: — Clinical Procedure: — Specialty: General and Internal Medicine Objective: Rare co-existance of disease or pathology Background: Thrombotic thrombocytopenic purpura is mostly characterized by symptoms and signs of hemolytic anemia, thrombocytopenia, renal impairment, fever and neurologic dysfunction. It is not always necessary to have all 5 characteristic symptoms, and presentations can vary. It can be congenital or acquired by any etiology that causes deficiency or dysfunction of ADAMST13 enzyme. Case Report: We present a case of a 71-year-old man who presented to our hospital initially with abdominal pain. He was diagnosed with pancreatitis, and conservative management was started with pain control and hydration. During the hospital course, the patient developed anemia that was hemolytic in nature, acute kidney injury and thrombocytopenia. He was then diagnosed as having TTP secondary to pancreatitis with additive effect of clopidogrel, as he had recently been started on clopidogrel due to percutaneous coronary intervention. He was started on prompt treatment with plasma exchange and intermittent dialysis, and he achieved full recovery after that. Conclusions: TTP is a potentially fatal disease with high mortality risk. It is judicious to recognize and have high suspicion of TTP being caused by such rare causes (pancreatitis and clopidogrel), as immediate recognition and treatment can enhance survival.

OBJECTIVE For more than a century since its introduction, mercury sphygmomanometer (HgS) had been the mainstay for office measurement of blood pressure (BP). In light of the environmental and health hazards associated with mercury, there is a need to replace it with mercury-free alternatives all over the world. We aimed to validate the widely used aneroid sphygmomanometer (AnS) by comparing its BP readings against BP readings taken with an HgS. METHODS We compared the BP readings using AnS vs. HgS on a sample of 300 patients of 18 years or older age admitted to a tertiary care hospital in Karachi, Pakistan. RESULTS The differences between mean HgS and AnS BP readings were found to be statistically significant (P-value

Background X-ray imaging is a common procedure performed on a regular basis for diagnostic purposes all over the world. The use of X-rays is increasing rapidly with the introduction of new radiation-oriented therapeutic practices. Although it carries significant diagnostic benefits, extensive exposure to X-ray imaging has been shown to be associated with multiple dose-dependent health risks. Awareness and knowledge among patients regarding the effects of X-ray imaging, therefore, becomes important. Through this study, we aimed to assess the knowledge and awareness of the hazards of X-ray imaging among different groups of patients visiting two of the public sector tertiary hospitals in Karachi, Pakistan. We also aimed to evaluate the necessary safety measures undertaken during X-ray imaging in these hospitals, and the perception of patients regarding the importance of these measures. Materials and methods A cross-sectional study was conducted in October and November 2018 at two well-known public sector tertiary care hospitals, Dr. Ruth KM Pfau Civil Hospital, Karachi and Jinnah Postgraduate Medical Centre, Karachi. A non-probability convenience sampling technique was adapted to recruit 200 participants for the study. A pretested questionnaire was used to assess the knowledge of radiation among patients and their perception regarding the necessary safety measures required to be undertaken during the X-ray imaging procedure. Data were entered and analyzed using the IBM Statistical Package for the Social Sciences 17.0 (IBM Corp., New York, USA). Frequencies were calculated for individual variables. Chi-square test was employed to measure the relationship between categorical variables. A p-value of

Congenital defects of the coronary arteries are noted in 0.2–1.4% of the general population. The first case of an anomalous origin of right coronary artery from pulmonary artery (ARCAPA) was described by Brooks in 1885. ARCAPA has an overall incidence of 0.002% in the general population. Most of the cases are asymptomatic; however, it can lead to serious complications such as heart failure, ischemia, and sudden death. A 57-year-old man presented to the cardiologist’s office with complaints of shortness of breath and fatigue. The patient also had a previous history of coronary stents and heart failure. Initially, he was evaluated with a stress test which was reported as abnormal. The patient then underwent an invasive coronary angiography that revealed anomalous origin of the right coronary artery (RCA) and multivessel disease. Cardiothoracic surgery evaluated the patient and coronary artery bypass graft was performed. During the surgery, the anomalous origin of RCA from the pulmonary artery was identified and was successfully corrected by reimplanting the RCA into the ascending aorta. The anomalous origin of RCA is a rare yet life-threatening condition. The RCA due to its location of origin from the pulmonary artery tends to be a low-pressure vessel with a very thin and fragile wall. It also serves as a retrograde venous conduit from the left coronary circulation into the pulmonary artery. This connection results in a left-to-right shunt that explains the increase in oxygen saturation in the pulmonary artery and the high cardiac output which is normally seen in these cases. The clinical presentation can vary from coronary ischemia to heart failure or sudden death. Therefore, surgical correction is recommended even in asymptomatic patients. We present a case of an anomalous origin of RCA from the pulmonary artery which, unlike the origin of left coronary from pulmonary artery, is very rare. Patients with this condition should have early correction even if they are asymptomatic in order to prevent long-term complications.

Endometriosis is a common condition in which endometrial cells and stroma are deposited in extrauterine sites. Its prevalence has been estimated to be 10% of reproductive age females. It is commonly found in the pelvis; however, it may be found in the abdomen, thorax, brain, or skin. Thoracic involvement is a relatively rare presentation of this common disease. Thoracic endometriosis commonly presents as pneumothorax in 73% of patients. A rarer presentation of thoracic endometriosis is hemothorax (