Case Report of Loeys Dietz Syndrome Presenting with Coronary Artery Aneurysm

Background

Loeys Dietz syndrome is a heritable disorder that presents with thoracic aortic aneurysm and/or dissection caused by a mutation in one of the transforming growth factor- B (TGFR-B) receptor or ligand genes. It is associated with widespread familial arterial aneurysm and rupture.

Case Summary

We present a case of a 70 year old male with a family history of heritable thoracic aortic aneurysm disease (h-TAAD) who presented to the emergency department with chest pain. His presenting electrocardiogram was significant for ST elevation in the inferior leads with complete heart block. Computed tomography-angiography (CTA) was done to rule out aortic dissection, which was negative for aortic dissection but did reveal 3.9 cm infrarenal abdominal aortic aneurysm and 2.7 cm bilateral iliac artery aneurysms. He was then taken for invasive angiography and was found to have aneurysmal dilation of the entire right coronary artery (RCA) measuring up to 6 mm with 100% occlusion secondary to thrombus in the distal segment. He was found to have obstructive disease in the left anterior descending (LAD) artery and first and second obtuse marginals (OM). Genetic testing performed confirmed a pathogenic mutation in the TGFBRI gene (TGFBRI c.934G > A p.Gly312Ser) consistent with the diagnosis of Loeys-Dietz syndrome.

Discussion

Although Loeys-Dietz syndrome is known to cause arterial aneurysms throughout the arterial tree, there have been no other cases of primary coronary aneurysms reported in this patient population. This case represents the first description of a patient with genetically confirmed Loeys-Dietz syndrome presenting with coronary artery aneurysm.

Synchronization of Fractional Order Neurons in Presence of Noise

The firing rate of some biological neurons such as neocortical pyramidal neurons is consistent with fractional order derivative, and the fractional-order neuron models depict the firing rate of neurons more accurately than other integer order neuron models do. For this reason, first, the dynamical characteristics of fractional order Hindmarsh Rose (HR) neuron are investigated, here and then a two coupled neuronal system based on Hindmarsh Rose neuron is presented. The results show several differences in the dynamical cha.racteristics of integer order and fractional order Hindmarsh Rose neuron model. The integer order model shows only one type of firing characteristics when the parameter of the model remained the same. The fractional-order model depicts several dynamical behaviors even for the same parameters as the order of the fractional operator is varied with the same parameter values. The firing frequency increases as the order of the fractional operator decreases. The fractional-order is therefore key in determining the firing characteristics of biological neuron models. A linearized model of HR neuron is also given for hardware resource minimizations and to implement this neuronal network on a large scale. A synchronized system of two fractional-order fractional Hindmarsh-Rose (HR) neurons in the presence of noise is also presented. The dynamical characteristics of the modified coupled neuron are determined by the parameters of the neuron model and the coupling function. The robustness of the network in the presence of noise is verified by both amplitude and phase synchronization techniques. A simplification of the coupling function is also presented to reduce the hardware cost. The synchronization results show that the model can produce the desired behavior with acceptable error.

What Knot to Do: Retrieval of a Kinked and Trapped Coronary Catheter

Diagnostic coronary artery catheter knotting and kinking are uncommon but potentially catastrophic complications. Our case emphasizes the importance of avoiding this problem and provides recommendations for catheter retrieval in the unlikely event of this complication. To our knowledge, the technique used in our case has not been described before. (Level of Difficulty: Intermediate.).

Differential response of antioxidant defense in HepG2 cells on exposure of Livotrit®, in a concentration dependent manner

Livotrit^®, a polyherbal formulation (Zandu, India) is commonly prescribed for liver health. The present study was undertaken to elucidate possible mechanism of antioxidant potential of Livotrit^®. Livotrit^® exhibited concentration dependent radical scavenging activity, inhibition of lipid peroxidation as well as activation and gene expression of antioxidant enzymes. Interestingly, lower concentration of Livotrit^® (0.05%) significantly increased activities and gene expression of catalase, Glutathione reductase (GR) and Gluthathione peroxidase (GPx), while higher concentration of Livotrit^® (0.5%) significantly increased antioxidant enzyme Heme-oxygenase 1(HO-1) and not catalase (CAT), GR and GPx. Transcription factor, Nuclear factor erythroid 2-related factor 2 (Nrf2) required for expression of catalase, GR, GPx and HO-1 was efficiently translocated into the nucleus at both concentrations. Inspite of this, concentration dependent activation of these enzymes was found to be mediated through miRNAs involved in regulation of their gene expression.

Prevalence of chronic airflow limitation in Kashmir, North India: results from the BOLD study

BACKGROUND: Data on spirometrically defined chronic airflow limitation (CAL) are scarce in developing countries.

OBJECTIVE: To estimate the prevalence of spirometrically defined CAL in Kashmir, North India.

METHODS: Using Burden of Obstructive Lung Disease survey methods, we administered questionnaires to randomly selected adults aged ⩾40 years. Post-bronchodilator spirometry was performed to estimate the prevalence of CAL and its relation to potential risk factors.

RESULTS: Of 1100 participants initially recruited, 953 (86.9%) responded and 757 completed acceptable spirometry and questionnaires. The prevalence of a forced expiratory volume in 1 s/forced vital capacity (FEV₁/FVC) ratio less than the lower limit of normal was 17.3% (4.5) in males and 14.8% (2.1) in females. Risk factors for CAL included higher age, cooking with wood and lower educational status. The prevalence of current smoking was 61% in males and 22% in females; most smoked hookahs. CAL was found equally in non-smoking males and females, and was independently associated with the use of the hookah, family history of respiratory disease and poor education. A self-reported doctor's diagnosis of chronic obstructive pulmonary disease was reported in 8.4/1000 (0.9% of females and 0.8% of males).

CONCLUSION:Spirometrically confirmed CAL is highly prevalent in Indian Kashmir, and seems to be related to the high prevalence of smoking, predominantly in the form of hookah smoking.

AngioVac System Used as an Adjunct Treatment for Intra-Cardiac Lead and Valvular Vegetations

Infections are known complications of cardiovascular implantable electronic devices (CIEDs). We describe a case of a 62-year-old male who presented with pulseless electrical activity (PEA) cardiac arrest and respiratory failure. He had a history of cardiac resynchronization device and defibrillator (CRT-D) implantation for nonischemic cardiomyopathy. After resuscitation, he was found to have methicillin sensitive Staphylococcus aureus (MSSA) bacteremia on blood culture and large vegetations on the CRT-D lead and tricuspid valve found on echocardiography. The patient underwent extraction of the leads, but several large vegetations were present adherent to the tricuspid valve on intra-cardiac ultrasound (ICE). Due to comorbidities, the patient was not a candidate for surgical removal of these vegetations. Thus, he underwent percutaneous extraction of tricuspid and right atrial vegetations with the AngioVac device.

Vasospastic Angina Presenting With Syncope and Chest Pain: A Case Report and Brief Literature Review

A 65-year-old male presented to the hospital with chest pain associated with recurrent syncope. He had a history of coronary artery disease and a long-standing history of smoking. While he was hospitalized, he had an episode of chest pain during which he was found to have transient ST segment elevation in the inferior leads. He was also noted to have a brief cardiac tachyarrhythmia. Coronary arteriography revealed vasospasm of the left anterior descending artery and right coronary artery, which were relieved to a significant extent after administration of intracoronary nitroglycerin. Subsequent angiograms and fractional flow reserve studies, demonstrated underlying non-obstructive coronary artery disease at the sites of spasm. No percutaneous coronary intervention was pursued. The patient was started on a calcium channel blocker on dismissal from the hospital. Upon follow up several months later, he remained free of symptoms that brought him to the hospital.

Future strategies in treatment of parkinson’s disease

Parkinson’s disease (PD) is a neurodegenerative disorder. COMT inhibitors, MOA-B inhibitors, Levodopa, Levodopa in combination with Dopa Decarboxylase (DDC) inhibitors, Entacapone, Tolcapone, Pramipexole, Ropinirole, Zonisamide, Cholinesterase inhibitors such as rivastigmine, galantamine and donepezil are used for treatment of Parkinson’s disease. Gene therapy of cellular and brain circuit pathways for the treatment of PD is under trials. Recently nuclear transfer embryonic stem cells or induced pluripotent stem derived cells can be used. The presence of Lewy bodies, reduced dopamine transporter and tyrosine hydroxylase expression within transplanted cells indicated that grafted cells are pathological. Adult and fetal neural stem cells are self-renewable.Journal of College of Medical Sciences-Nepal, 2011, Vol-7, No-2, 67-71DOI: http://dx.doi.org/10.3126/jcmsn.v7i2.6687

Isolation, identification, and phylogenetic analysis of reassortant low-pathogenic avian influenza virus H3N1 from Pakistan

During routine avian influenza surveillance in Pakistan, a low-pathogenic avian influenza virus (LPAI) subtype H3N1 was isolated for the first time from domestic chickens. The higher seroprevalence of H3N1 was recorded in both commercial and domestic poultry in ecological zones of Pakistan where the geographical proximity with neighboring countries and attractive birding sites provide better opportunities for frequent movements of wild and migratory birds, and their intermingling with the local domestic and commercial poultry. Subsequent whole genome sequencing of this virus revealed a new introduction of a reassortant Eurasian avian strain, which was distinguishable from corresponding human and swine strains isolated elsewhere. Phylogenetically, the HA gene was mostly clustered with Nordic (Scandinavian) strains of influenza viruses, whereas the NA and PB1 genes showed a maximum nucleotide sequence homology with the Indian H11N1, and the PB2 gene was found to be closely related to the Altai H5N2. The Matrix and NP genes of H3N1 mostly clustered with the European avian influenza viruses (AIV), whereas its NS and PA genes showed maximum nucleotide homologies with the African (Egypt) AIV strains. A sequence and amino acid analysis revealed an LP motif, avian-like receptor specificity, potential glycosylation sites, and sensitivities to oseltamivir, zanamivir, and amantadine. Some point mutations possessed by this Pakistani AIV H3N1 were also found in human, equine, and swine H3 influenza viruses. This H3N1 isolate showed less nucleotide sequence homology with the previously known Pakistani AIV as compared with other Eurasian AIV strains.

Methodology: a modified method for high-quality DNA extraction for molecular analysis in cereal plants

Cereal crops that have rigid non-cellulose components in the cell wall tissues of leaves and high starch and protein content in grains face limitations in DNA extraction. Advanced molecular genetic techniques such as mapping and marker-assisted selection programs require pure and quick DNA extraction. In this study, we developed methods for isolating high-quality genomic DNA from leaves and seeds of major cereal crops with minor modifications. DNA yields ranged from 300 to 1800 ng for 0.01 g seed or leaf tissue.

Injury pattern of suicide bomb attacks in Pakistan

PURPOSE

The aim of our study was to analyze the pattern of injuries, hospital care, and outcome of the victims of suicide bomb attacks in Pakistan.

METHODS

This prospective, cohort study was conducted at the Combined Military Hospital Rawalpindi during the last 3 years. Seriously injured patients in the "immediate category" were resuscitated in the emergency operation theater adjacent to the emergency room and, after resuscitation, the patients were transferred to the main operation theaters, where consultant surgeons were available.

RESULTS

During the study period, 1,296 terrorist victims presented to the emergency department and (86.9%) were admitted, with a mean hospital stay of 8.2 ± 2.1 days. The majority of patients arrived by ambulance (91%) and only 38 (3%) were evacuated by air. Penetrating splinter injuries were the most prevalent (87%), and 29% patients also had associated injuries. Open bone fractures were found in 48% and 42% had injured hollow and solid viscous. Overall, 33% of patients had thoracic injuries and neuro-trauma was observed in 16% of the study population. Deafness was a feature in 33% patients, 121 had to undergo limb amputations, and mortality remained in 7% of patients.

CONCLUSION

Most of the problems encountered were logistic in nature. Early evacuation of the victims remains pivotal in saving lives. The major causes of death in peripheral patients was hypovolemic shock, sepsis, and hypothermia. Mortality and morbidity can be enhanced by ample fluid resuscitation, tetanus prophylaxis, and proficient first aid at the site of injury.

Necrotizing fasciitis of the lower extremity: a case report and current concept of diagnosis and management

Necrotizing fasciitis is a severe soft tissue infection characterized by rapidly progressing necrosis, involving subcutaneous tissues. This rare condition carries high mortality rate and require prompt diagnosis and urgent treatment with radical debridement and antibiotics. We describe a case of 21-year old man who presented with the history of trivial injury to the knee. Initially he was admitted and treated for septic arthritis but later was diagnosed as necrotizing fasciitis which was successfully treated with no ill effects what so ever from this devastating condition. This rare condition has been reported in literature but still early diagnosis, which is a key for successful treatment, remains a challenge.

Comparative distribution of the scalp hair trace metal contents in the benign tumour patients and normal donors

The scalp hair samples of benign tumour patients (n = 77) and normal donors (n = 86) were analysed for selected trace metal contents using atomic absorption spectrophotometry. In the scalp hair of benign tumour patients, highest average levels were found for Ca (1,401 microg/g), followed by Na (476.9 microg/g), Mg (441.6 microg/g), Zn (438.3 microg/g), K (119.2 microg/g) and Fe (96.38 microg/g) while in comparison, the maximum mean levels in the scalp hair of normal donors were shown by Ca (556.5 microg/g), followed by Zn (154.2 microg/g), Mg (153.4 microg/g), Na (97.45 microg/g) and Fe (81.68 microg/g). Almost all metal levels revealed higher dispersion and asymmetry in the scalp hair of benign tumour patients compared with the normal donors. The average concentrations of Ca, Cd, Co, K, Mg, Mn, Na, Ni, Pb, Sb, Sr and Zn were significantly higher in the hair of benign tumour patients compared with the normal donors. Significant gender-based differences were also observed in the scalp hair metal contents of benign tumour patients. Strong positive correlations were found between Cd-Cr (0.547) and Cd-Co (0.507) in the hair of benign tumour patients whereas Ca-Mg, Mg-Sr, Co-Cd, Cr-Cd, Li-Cr, Li-Co, Li-Cd, Na-Cd, Na-Co and Na-Li exhibited strong relationships (r > 0.50) in the hair of normal donors. Cluster analysis (CA) and principal component analysis (PCA) were used for the source identification and apportionment of scalp hair trace metals in the two donor groups. The scalp hair of benign tumour patients and normal donors revealed six and five main clusters of trace metals, respectively. PCA extracted seven principal components of trace metals in the scalp hair of benign tumour patients while six principal components were observed in the case of normal donors. The study evidenced significantly different patterns of metal distribution in the hair of benign tumour patients in comparison with normal donors.

Plasma lipid profile in gynecologic cancers

BACKGROUND

Lipids are associated with cancer because they play a key role in the maintenance of cell integrity. We studied the relationship of plasma lipids with gynecologic cancer.

METHODS

A total of 196 female individuals were included in the study. Of these 50 were normal subjects. The remaining were cancer patients: 80 breast cancer, 40 ovarian cancer and 26 patients with other gynecologic cancers. Plasma levels of triglycerides, total cholesterol, LDL-cholesterol and HDL-cholesterol were estimated by using spectrophotometer.

RESULTS

In breast cancer patients there is moderate increase in the plasma levels of triglycerides (18%) and cholesterol (21%), and a high increase in LDL-cholesterol (43%), while there is a moderate decrease in HDL-cholesterol levels (30%) when compared with normal subjects. In ovarian cancer patients, there is a high decrease in the plasma levels of triglycerides (31%) and HDL-cholesterol (39%), while a moderate decrease in cholesterol (28%) and LDL-cholesterol levels (11%) when compared with normal subjects. In gynecologic cancers other than breast and ovarian cancer, there is a moderate decrease in plasma levels of the triglycerides (25%), cholesterol (21%), and HDL-cholesterol levels (27%), while a non-significant decrease in LDL-cholesterol (6.2%) when compared with normal subjects.

CONCLUSIONS

Plasma lipid levels, except HDL-cholesterol, are raised in breast cancer and are decreased in other gynecologic cancers. HDL-cholesterol is decreased in all gynecologic cancers. As there is an alteration in the plasma lipid profile during gynecologic cancers, it may be helpful for diagnosis of the disease.

Burns from a stove burst: analysis of 34 cases

Burns continue to be a major environmental factor responsible for significant morbidity and mortality in developing countries and, in particular, burns due to stove bursts are a major problem. Two types of stoves are available in Pakistan: gas stoves and kerosene stoves. The state is considered of patients burned by stove bursts in general, and also with specific reference to 34 adult patients admitted with stove burns to our hospital in Pakistan. Various treatment options were used, and the patients' treatment and outcome are reported. The continued commercialization of such stoves, and especially of the gas stove, is is a cause of serious and permanent consequences that represent a danger for the population. Proper care should be observed when handling them because, as always, prevention is better than cure.

Experience of burn injuries at the pakistan institute of medical science, islamabad, pakistan*

The objective of this prospective study was to consider the demographical data of burn patients admitted to the Pakistan Institute of Medical Sciences (PIMS), Islamabad, Pakistan. The study was carried out at PIMS from January 2002 to December 2003. Only admitted patients of either sex of age more than 12 yr were included. Patients below 12 yr were excluded. Patients requiring outpatient treatment were also excluded. A total number of 77 males and 65 females fulfilled the criteria. The mean age of the males was 32.2 yr and of the females 24.4 yr, while the male/female ratio was 1/1.18. Burns were commonest during the winter season (42.2%). In 6% of the patients, the burns were due to suicide attempts and in 15% to homicidal intent. The burns were accidental in 79% of cases. The major mechanism in females was stove burst (22%) and in males direct flame (18%). The kitchen was the commonest site of the accident in females (27%). Housewives were the most frequently affected (35%). More married males (39%) were burned than unmarried females (18%). Inhalational injury was present in 23% of the patients. Males had average total body surface area burned of 27.4% compared with 39.5% in females. Eighteen per cent of the deaths occurred among males and 16% among females. This study provides a comprehensive overview of hospitalized burn patients in Pakistan. Prevention is always the rule to be safe from burns but, once they occur, immediate and proper care should be given with aggressive treatment in order to minimize post-burn problems.

Pattern of bacterial invasion in burn patients at the pakistan institute of medical sciences, islamabad

A prospective study was carried out in the Department of Plastic Surgery, Pakistan Institute of Medical Sciences, Islamabad, from January 2002 to December 2003. A total number of 142 patients were included in the study. The patients' mean age was 32.2 yr for males and 24.4 yr for females. The male/female ratio was 1.18:1.0. Micro-organisms from 86 patients were cultured for the first five days and in 77 patients from day 6 onwards. Staphylococcus aureuswas found in 24.4%, which decreased to 18.2% after the first week. Pseudomonas aeruginosawas found in 27.3% of patients. Methicillin-resistant Staphylococcus aureuswas observed in 11.7% of cases. No case of methicillin-sensitive Staphylococcus aureuswas found. Seven patients, after admission day 6, showed no growth. Eighteen per cent of males and 16% of females died during their stay in hospital. This study highlights the predominant bacterial pathogens among the infected burn wounds treated in our centre.