Pneumocystis jirovecii pneumonia in a patient treated with trastuzumab-deruxtecan

Trastuzumab-deruxtecan (T-DXd) is a novel antibody drug conjugate that has improved treatment outcomes in patients with ERBB2-positive cancer, including locally advanced or metastatic gastric and gastro-oesophageal junction adenocarcinoma. One of the reported side effects of this medication is drug-induced pneumonitis. We present in this case report, a diagnostic dilemma of a patient presenting with clinical and radiographical features of drug-induced pneumonitis but was found to have pneumocystis jirovecii pneumonia (PJP). Our case is the first of PJP in a patient treated with T-DXd, highlighting the increasing incidence of this opportunistic infection in patients with solid malignancy. It also highlights the clinical and radiographical similarities between the PJP and drug-induced pneumonitis.

750 An Unusual Presentation of a Rare Clinical Entity – A Case Report of Spontaneous Common Bile Duct Perforation in an Adult

Spontaneous or non-traumatic perforation of the extrahepatic biliary system is a rare clinical phenomenon, with few cases reported since its first mention in medical literature by Freeland in 1882. Given the rarity, misdiagnosis is common with the diagnosis almost always made during urgent exploratory laparotomy. We describe a case of spontaneous common bile duct (CBD) perforation in an 83-year-old female with no associative underlying disease process identified.

The patient presented with sudden onset abdominal pain with no identifiable trigger, with minimal past medical history. Examination was remarkable for findings of epigastric tenderness and guarding. Haematological investigation was remarkable only for hyperamylasaemia and leucocytosis. Pneumoperitoneum was ruled out and following contrast CT abdomen and pelvis a working diagnosis of mild pancreatitis was made. US Abdomen and MRCP found no evidence of cholelithiasis, with minimal biliary duct dilatation. The patient continued to deteriorate on the ward, with aspiration of new intrabdominal fluid collection raising suspicion of perforated viscus. Exploratory laparotomy revealed a 1-cm defect in the CBD with frank bile leak. A T-tube was placed in the common bile duct defect, with an abdominal robertson drain also inserted. No further bile leak was identified via Tubogram, with the patient successfully discharged following multidisciplinary rehabilitation in intensive care and the ward setting.

Surgeons should seek out this uncommon diagnosis in patients with hyperamylasaemia and suspected cholelithiasis who do not conform to normal biliary/pancreatic disease progression patterns.

A 48-Year-Old Woman With Chronic Cough, Dyspnea, and Bronchiectasis

CASE PRESENTATION

A 48-year-old woman sought a second opinion for dyspnea and chronic productive cough; she was a never smoker. Mild respiratory symptoms persisted since childhood and had progressively worsened over the previous decade. In addition, an unintentional 30-pound weight loss had occurred over several years. Six years previously, a diagnosis of hypersensitivity pneumonitis was made following right upper lobe wedge resection that revealed chronic bronchiolitis with interstitial pneumonia and non-necrotizing granulomatous inflammation. Subsequent use of prednisone elicited mild intermittent improvement. She had used feather pillows in the past without any other significant exposures. There were no reports of sinus or GI symptoms.

GP access to FIT increases the proportion of colorectal cancers detected on urgent pathways in symptomatic patients in Nottingham

OBJECTIVE

Service evaluation of GP access to Faecal Immunochemical Test (FIT) for colorectal cancer (CRC) detection in Nottinghamshire and use of FIT for "rule out", "rule in" and "first test selection".

DESIGN

Retrospective audit of FIT results, CRC outcomes and resource utilisation before and after introduction of FIT in Primary Care in November 2017. Data from the new pathway up to December 2018 was compared with previous experience.

RESULTS

Between November 2017 and December 2018, 6747 GP FIT test requests yielded 5733 FIT results, of which 4082 (71.2%) were <4.0 μg Hb/g faeces, 579 (10.1%) were 4.0-9.9 μg Hb/g faeces, 836 (14.6%) were 10.0-149.9 μg Hb/g faeces, and 236 (4.1%) were ≥150.0 μg Hb/g faeces. The proportion of "rule out" results <4.0 μg Hb/g faeces was significantly higher than in the Getting FIT cohort (71.2% vs 60.4%, Chi squared 42.8, p < 0.0001) and the proportion of "rule in" results ≥150.0 μg Hb/g faeces was significantly lower (4.1% vs 8.1%, Chi squared 27.3,P < 0.0001). There was a 33% rise in urgent referrals across Nottingham overall during the evaluation period. 2 CRC diagnoses were made in 4082 patients who had FIT<4.0 μg Hb/g faeces. 58.4% of new CRC diagnoses associated with a positive FIT were early stage cancers (Stage I and II). The proportion of all CRC diagnoses that follow an urgent referral s rose after introduction of FIT.

CONCLUSIONS

FIT allows GP's to select a more appropriate cohort for urgent investigation without a large number of missed diagnoses. FIT appears to promise a "stage migration" effect which may ultimately improve CRC outcomes.

Do we need to see to believe?-radiomics for lung nodule classification and lung cancer risk stratification

Despite multiple recent advances, the diagnosis and management of lung cancer remain challenging and it continues to be the deadliest malignancy. In 2011, the National Lung Screening Trial (NLST) reported 20% reduction in lung cancer related mortality using annual low dose chest computed tomography (CT). These results led to the approval and nationwide establishment of lung cancer CT-based lung cancer screening programs. These findings have been further validated by the recently published Nederlands-Leuvens Longkanker Screenings Onderzoek (NELSON) and Multicentric Italian Lung Detection (MILD) trials, the latter showing benefit of screening even beyond the 5 years. However, the implementation of lung cancer screening has been impeded by several challenges, including the differentiation between benign and malignant nodules, the large number of false positive studies and the detection of indolent, potentially clinically insignificant lung cancers (overdiagnosis). Hence, the development of non-invasive strategies to accurately classify and risk stratify screen-detected pulmonary nodules in order to individualize clinical management remains a high priority area of research. Radiomics is a recently coined term which refers to the process of imaging feature extraction and quantitative analysis of clinical diagnostic images to characterize the nodule phenotype beyond what is possible with conventional radiologist assessment. Even though it is still in early phase, several studies have already demonstrated that radiomics approaches are potentially useful for lung nodule classification, risk stratification, individualized management and prediction of overall prognosis. The goal of this review is to summarize the current literature regarding the radiomics of screen-detected lung nodules, highlight potential challenges and discuss its clinical application along with future goals and challenges.

80-year-old man with dyspnoea and bilateral groundglass infiltrates: an elusive case of COVID-19

COVID-19 is a novel viral infection caused by severe acute respiratory syndrome-coronavirus-2 virus, first identified in Wuhan, China in December 2019. COVID-19 has spread rapidly and is now considered a global pandemic. We present a case of a patient with minimal respiratory symptoms but prominent bilateral groundglass opacities in a 'crazy paving' pattern on chest CT imaging and a negative initial infectious workup. However, given persistent dyspnoea and labs suggestive of COVID-19 infection, the patient remained hospitalised for further monitoring. Forty-eight hours after initial testing, the PCR test was repeated and returned positive for COVID-19. This case illustrates the importance of clinical vigilance to retest patients for COVID-19, particularly in the absence of another compelling aetiology. As COVID-19 testing improves to rapidly generate results, selective retesting of patients may uncover additional COVID-19 cases and strengthen measures to minimise the spread of COVID-19.

A 31-Year-Old Man With Airflow Obstruction, Intrathoracic Adenopathy, and Pulmonary Nodules

CASE PRESENTATION

A 31-year-old white man presented for evaluation of productive cough and dyspnea on exertion of 2 months' duration. Associated symptoms included wheezing, chest tightness, and postnasal drip. He was recently treated for pneumonia with a 7-day course of levofloxacin because of an abnormal chest radiograph demonstrating bilateral infiltrates, but his symptoms failed to improve. He had a medical history of mild intermittent asthma and was on no active treatment. He was a nonsmoker. He was born in the United States. He denied any recent travel within or outside the United States, sick contacts, or illicit drug use. He did not have any pets and denied exposure to mold, hot tubs, a down comforter, or pillows. He worked in a vocational program and his hobbies included refinishing wood floors.

Traumatic brain injury as a risk factor for dementia

Introduction

The Centers for Disease Control and Prevention (CDC) reports that there were 2.87 million cases of traumatic brain injury (TBI) in the United States in 2014, 69 million worldwide. Some studies suggest a connection between TBI and increased risk of dementia, but it remains unclear whether the risk increases with age and TBI severity. Given our aging population, it is essential to better characterize the link between TBI and dementia.

Methods

We conducted a retrospective cohort study of two major academic medical centers for years 2000-2015. We identified all patients with TBI, aged 45 and older. Variables included age, TBI severity, pre-existing dementia, dementia diagnosed after TBI, years to dementia, and follow-up time. TBI severity was determined by head/neck AIS score, using ICD-PIC software. Mild TBI was defined as AIS 0-2, and Moderate/Severe as AIS 3-6. Analysis was done in R.v.3.0.1 software.

Results

Overall, there were 14,199 patients with TBI, of which 9,938 (70%) were mild and 4,261 (30%) were moderate/severe. Mean age was 70.5 (±14.0). There were 1,422 cases (10%) of pre-existing dementia, and 850 (6%) cases of dementia diagnosed after TBI. The mean follow-up time was 1,129 (±1,474) days.

The 75-84 age group had the highest incidence of TBI (28%). When compared by age group and TBI severity, the proportion of moderate/severe TBI increased with increasing age. The proportion of pre-existing dementia increased with age, as expected. Notably, there is increased incidence of dementia after TBI in patients aged 65 and older (7-10%, p &lt; 0.001). There was no observed effect of TBI severity on the risk of dementia after TBI.

Conclusions

Our results indicate that TBI is a risk factor for the development of dementia, especially in patients aged 65 and older. Given the global public health burden of these two diseases it is critical to develop effective TBI primary prevention strategies.

Key messages

TBI is a risk factor for the development of dementia. Need for public health measures to mitigate the risk of TBI in the patient population 65 and older.

Diagnosis and treatment of acute pulmonary inflammation in critically ill patients: The role of inflammatory biomarkers

Pneumonia and acute respiratory distress syndrome are common and important causes of respiratory failure in the intensive care unit with a significant impact on morbidity, mortality and health care utilization despite early antimicrobial therapy and lung protective mechanical ventilation. Both clinical entities are characterized by acute pulmonary inflammation in response to direct or indirect lung injury. Adjunct anti-inflammatory treatment with corticosteroids is increasingly used, although the evidence for benefit is limited. The treatment decisions are based on radiographic, clinical and physiological variables without regards to inflammatory state. Current evidence suggests a role of biomarkers for the assessment of severity, and distinguishing sub-phenotypes (hyper-inflammatory versus hypo-inflammatory) with important prognostic and therapeutic implications. Although many inflammatory biomarkers have been studied the most common and of interest are C-reactive protein, procalcitonin, and pro-inflammatory cytokines including interleukin 6. While extensively studied as prognostic tools (prognostic enrichment), limited data are available for the role of biomarkers in determining appropriate initiation, timing and dosing of adjunct anti-inflammatory treatment (predictive enrichment).

Population-based cohort study of variation in the use of emergency cholecystectomy for benign gallbladder diseases

Background

The aims of this prospective population-based cohort study were to identify the patient and hospital characteristics associated with emergency cholecystectomy, and the influences of these in determining variations between hospitals.

Methods

Data were collected for consecutive patients undergoing cholecystectomy in acute UK and Irish hospitals between 1 March and 1 May 2014. Potential explanatory variables influencing the performance of emergency cholecystectomy were analysed by means of multilevel, multivariable logistic regression modelling using a two-level hierarchical structure with patients (level 1) nested within hospitals (level 2).

Results

Data were collected on 4744 cholecystectomies from 165 hospitals. Increasing age, lower ASA fitness grade, biliary colic, the need for further imaging (magnetic retrograde cholangiopancreatography), endoscopic interventions (endoscopic retrograde cholangiopancreatography) and admission to a non-biliary centre significantly reduced the likelihood of an emergency cholecystectomy being performed. The multilevel model was used to calculate the probability of receiving an emergency cholecystectomy for a woman aged 40 years or over with an ASA grade of I or II and a BMI of at least 25·0 kg/m2, who presented with acute cholecystitis with an ultrasound scan showing a thick-walled gallbladder and a normal common bile duct. The mean predicted probability of receiving an emergency cholecystectomy was 0·52 (95 per cent c.i. 0·45 to 0·57). The predicted probabilities ranged from 0·02 to 0·95 across the 165 hospitals, demonstrating significant variation between hospitals.

Conclusion

Patients with similar characteristics presenting to different hospitals with acute gallbladder pathology do not receive comparable care.

Clinical course and outcome of acute severe asthma (status asthmaticus) in adults

OBJECTIVE

To evaluate the clinical course and outcomes in patients with acute severe asthma in a tertiary care setting.

METHODS

The retrospective cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of patients of age 16 and above who were admitted with a diagnosis of acute severe asthma from January 2000 to December 2013. These patients had undergone clinical evaluation to assess the severity of illness as well as the complications and eventual outcomes. SPSS 16 was used for statistical analysis.

RESULTS

Of the 50 patients in the study, 41 (82%) were females. The overall mean age was 53.1±20.3 years. Ventilator support was required by 37(74%) patients. Presence of acidaemia was associated with the need for invasive ventilation (p<0.033) which in turn was associated with increased hospital stay (p<0.043). Complications were observed in 37(74%) patients, the most common being respiratory failure in 35(70%) and arrhythmias in 8(16%). Use of both non-invasive and invasive ventilation was found to be significantly associated with development of complications (p<0.001 and p<0.009). A total of 4(8%) patients died. Presence of acidaemia was found to be significantly associated with mortality (p<0.032).

CONCLUSION

Overt acidaemia at initial presentation in patients with acute severe asthma was significantly associated with higher rates of invasive ventilation leading to increased hospital stay, complications and higher mortality rate.

Clinically significant contrast induced acute kidney injury after non-emergent cardiac catheterization--risk factors and impact on length of hospital stay

OBJECTIVE

To evaluate the frequency and risk factors associated with clinically significant contrast-induced nephropathy (CIN) in patients undergoing non-emergent coronary angiography.

STUDY DESIGN

Descriptive study.

PLACE AND DURATION OF STUDY

The Aga Khan University Hospital, Karachi, from January 2005 to December 2007.

METHODOLOGY

Case records of patients who underwent coronary angiography with a serum creatinine of 1.5 mg/dl at the time of procedure were evaluated. Clinically significant contrast induced nephropathy (CSCIN) was defined as either doubling of serum creatinine from baseline value within a week following the procedure or need for emergency hemodialysis after the procedure.

RESULTS

One hundred and sixteen patients met the inclusion criteria. Mean age was 64.0 ± 11.5 years, 72% were males. Overall prevalence of CIN was 17% (rise of serum creatinine by ≥ 0.5 mg/dl) while that of clinically significant CIN (CSCIN) was 9.5% (11 patients). Patients with CSCIN had significantly lower left ventricular ejection fraction (p = 0.03, OR: 0.24; 95% CI = 0.06 - 0.91) and higher prevalence of cerebrovascular disease (p < 0.001, OR: 14.66; 95% CI = 3.30 - 65.08). Mean baseline serum creatinine was significantly higher, 3.0 ± 1.5 vs. 2.0 ± 1.1 mg/dl (p = 0.03, OR: 1.47; 95% CI = 1.03 - 2.11) whereas mean GFR estimated by Cockcroft-Gault formula was significantly lower at 25 ± 7.4 vs. 41.0 ± 14.6 ml/minute (p = 0.001, OR = 0.89, 95% CI = 0.84 - 0.95) at the time of procedure in patients with CSCIN. Mean length of hospital stay was significantly higher in this group compared to those without CIN, 9.0 ± 5.1 vs. 3.0 ± 3.2 days (p = 0.001, OR = 1.31, 95% CI = 1.12 - 1.54). Multivariate analysis revealed low GFR (p = 0.001, OR = 0.88; 95% CI = 0.82 - 0.95) and low ejection fraction (p = 0.03, OR = 0.20; 95% CI = 0.04 - 0.91) to be independent factors associated with CSCIN. No significant differences were noted between the two groups in patients with hypertension, diabetes and heart failure.

CONCLUSION

CSCIN is a significant concern in high risk groups despite prophylaxis. Patients with lower EF, cerebrovascular disease and low GFR at the time of procedure are more likely to have CIN.

A rare aetiology of respiratory failure in a 10-year-old boy: inflammatory myofibroblastic tumour

Primary neoplasms of the respiratory tract are rarely encountered in the paediatric population. Inflammatory myofibroblastic tumour (IMT) is a rare soft tissue mesenchymal tumour but a distinct disease entity accounting for less than 1% of all primary lung tumours. We report a case of a 10-year-old boy who presented with respiratory failure and left lung collapse. On flexible fiberoptic bronchoscopy, a pedunculated mass in the lower part of the trachea originating from the left main stem bronchus was identified. The patient subsequently underwent a left-sided pneumonectomy with complete resection of the mass. The histopathological analysis was consistent with IMT. Two years of follow-up and the patient remains well.

How well can physicians manage tuberculosis? A public-private sector comparison from Karachi, Pakistan

Background

Tuberculosis (TB) is endemic in Pakistan which ranks fifth amongst the twenty two countries designated to be highly burdened by TB according to the World Health Organization. However, there is paucity of data regarding the knowledge of diagnosis of TB and its management amongst public and private practitioners. In this study, we endeavor to identify this gap in knowledge regarding the diagnosis and management of TB between public and private doctors and the factors affecting these knowledge scores in urban Pakistan.

Methods

This cross sectional survey was conducted between June and December 2011. Doctors from public hospitals, private hospitals and private clinics scattered in all eighteen towns of Karachi were included in the study. Qualified MBBS doctors working in any specialty were eligible to participate whereas doctors working in both the public and private sectors were excluded from the study. Vignette based clinical scenarios were given to assess the knowledge score regarding the diagnosis and management of TB.

Results

A total of 196 doctors participated in the study. There was a significant difference between private and public physicians in terms of age and years of practice (p-value <0.05). Significant differences in the proportion of knowledge scores were observed between the public and private doctors and National TB Control Program trained and untrained doctors in Karachi. Factors associated with inadequate knowledge scores were being female gender [OR: 2.76 (95% CI: 1.418-5.384)], private employment status [OR: 1.50 (95% CI: 1.258-2.439)], and not trained by NTP [OR: 2.98 (95% CI: 1.286-3.225)] on multivariate logistic regression analysis.

Conclusion

It is concluded that a knowledge gap exists between the public and private doctors in Karachi. Strengthening of currently implemented public private mix model along with improvement in the trainings of public and private practitioners is highly recommended to control TB in Pakistan.

Wilson's disease in pregnancy: case series and review of literature

BACKGROUND

Wilson's disease is a rare, autosomal recessive inherited disorder characterized by impaired liver metabolism of copper leading to decreased biliary excretion and incorporation of ceruloplasmin levels mainly in the liver and brain. Untreated Wilson's disease has been shown to cause subfertility and even in cases where pregnancy occurs, it often results in spontaneous miscarriage.

CASE PRESENTATIONS

We present four cases of successful pregnancy outcomes in three patients diagnosed with Wilson's disease along with the literature review. All the patients were managed with zinc sulphate without any postnatal complications.

CONCLUSION

Patients with Wilson's disease receiving regular treatment who remain asymptomatic are usually able to conceive and achieve successful outcomes. However, these pregnancies should be considered high risk and merit regular surveillance.

Patient communication in radiology: current status of breaking bad news among radiologists and radiology trainees in Pakistan

Breaking bad news can be an intimidating task for any physician. The aim of this study was to record the practices of breaking bad news to the patients by Pakistani radiologists and trainees. The radiologists and trainees attending the 26th National Radiological Conference in October 2010 in Karachi, Pakistan, were surveyed. The response rate was 76%. The respondents included residents (51%), private practicing radiologists (28%), academic radiologists (13%), and other trainees (8%). Most of the academic radiologists communicated with their patients. The daily frequency of breaking bad news by residents was noted, which was highest in the public teaching hospitals (71%). For severe abnormalities such as malignancy, 50% residents, 55% of the academic radiologists and 74% of the private practicing radiologists were very uncomfortable in disclosure of results. Differences in frequency of communication with patients were noticed with both different training levels, and different settings of practice in a developing country.

Coronary calcium scoring: are the results comparable to computed tomography coronary angiography for screening coronary artery disease in a South Asian population?

Background

The need of having feasible screening tools like Coronary Calcium Scoring (CCS) and CT Coronary Artery (CTCA) for Coronary Artery Disease (CAD) has become paramount. We aimed to evaluate the accuracy of CCS in determining the degree of stenosis of coronary vessels as compared to that determined by CTCA in a South Asian population.

Methods

A retrospective study was conducted at The Aga Khan University Hospital. A total of 539 patient records were reviewed who had undergone CCS and CTCA between 2008 and 2010. Patient records were reviewed by comparing their CCS and CTCA results.

Results

About 268 out of 301 (89%) patients with a CCS of 0–9 were found to be free of stenosis on CTCA. On a CCS of 10–99, 110 out of 121 (91%) patients were either free of stenosis or had mild stenosis. About 66 out of 79 (84%) patients had moderate or severe stenosis with a calcium score of 100–400 while none of the patients were free of stenosis. Around 28 out of 38 (74%) patients with a CCS of more than 400 had severe stenosis. However, only 04 patients (11%) were found to have mild stenosis. Spearman’s rho revealed a correlation coefficient of 0.791 with a p-value of <0.001.

Conclusion

Our study reaffirms that in South Asian population, low CCS (<100) is associated with no or minimal stenosis while high CCS warrants further investigation; hence, making it a reliable tool for screening patients with CAD.

Benign granulomatous polyp obstructing the bronchus

Inflammatory endobronchial polyps are rarely encountered. We report a case of a 14 years old girl with a benign granulomatous polyp originating in the bronchus. Computed tomography scan showed an intraluminal soft tissue opacity while fiberoptic bronchoscopy revealed a large soft tissue mass completely occluding the left lower lobe. Rigid bronchoscopy under general anaesthesia identified a fleshy mass in the left main stem bronchus which was excised via bronchoscopy. The histopathology showed benign polyp with non-specific inflammation. The patient's symptoms improved subsequently and no recurrence was reported till two years of follow-up.

An unusual combination of extra-adrenal pheochromocytoma and arteriovenous malformation of the ureter in a young adult

We present a case of a 24-year-old gentleman who presented with painless pan haematuria for 2 weeks. During the workup, he was diagnosed to have a retrocaval mass after a CT scan while cystoscopy revealed a polypoidal pulsating lesion in the left ureter. After surgical manipulation of the retrocaval mass, the blood pressure of the patient raised to 260/130 mm Hg. It was completely resected and diagnosed as extra-adrenal pheochromocytoma (paraganglioma) after histopathology. The lesion in the ureter was completely excised and fulgurated and diagnosed as an arteriovenous malformation. To the best of our knowledge, this is the first patient to be presented in the literature with this unusual combination.

A randomized, double-blind, placebo-controlled trial of oral montelukast in acute asthma exacerbation

Background

Leukotriene receptor antagonists (LTRAs) are well established in the management of outpatient asthma. However, there is very little information as to their role in acute asthma exacerbations. We hypothesized that LTRAs may accelerate lung function recovery when given in an acute exacerbation.

Methods

A randomized, double blind, placebo-controlled trial was conducted at the Aga Khan University Hospital to assess the efficacy of oral montelukast on patients of 16 years of age and above who were hospitalized with acute asthma exacerbation. The patients were given either montelukast or placebo along with standard therapy throughout the hospital stay for acute asthma. Improvements in lung function and duration of hospital stay were monitored.

Results

100 patients were randomized; their mean age was 52 years (SD +/− 18.50). The majority were females (79%) and non-smokers (89%). The mean hospital stay was 3.70 ± 1.93 days with 80% of patients discharged in 3 days. There was no significant difference in clinical symptoms, PEF over the course of hospital stay (p = 0.20 at day 2 and p = 0.47 at day 3) and discharge (p = 0.15), FEV₁ at discharge (p = 0.29) or length of hospital stay (p = 0.90) between the two groups. No serious adverse effects were noted during the course of the study.

Conclusion

Our study suggests that there is no benefit of addition of oral montelukast over conventional treatment in the management of acute asthma attack.

Trial registration

Trial registration number: 375-Med/ERC-04

Etiology and outcome of severe community acquired pneumonia in immunocompetent adults

BACKGROUND

Community Acquired Pneumonia (CAP) is a commonly encountered disease, one third of which is Severe Community Acquired Pneumonia (SCAP) that can be potentially fatal. There is a paucity of data on etiology and outcome of patients with SCAP in South Asian Population.

METHODS

A retrospective cross-sectional study was conducted from March 2002 till December 2008 on patients of 16 years and above who were admitted with the diagnosis of SCAP in accordance to the criteria of American Thoracic Society Guidelines (2001). The patients underwent clinical and diagnostic evaluations to detect the severity of illness as well as the etiology and other risk factors influencing the eventual outcome of SCAP.

RESULTS

A total of 189 patients were included in the study. The mean age was 60 ± 18.0 years and 110 (58%) patients were males. The most common isolated pathogens were Staphylococcus aureus (15 patients), Streptococcus pneumoniae (14 patients) and Pseudomonas aeruginosa (9 patients). The highest mortality was seen in patients with Pseudomonas aeruginosa (89%) and Staphylococcus aureus (53%). Overall mortality rate was 51%. On univariate analysis, septic shock (p <0.001), prior antibiotic use (p = 0.04), blood urea nitrogen > 30 mg/dl (p = 0.03), hematocrit < 30% (p = 0.03) and Acute Physiology and Chronic Health Evaluation (APACHE) II score > 20 (p < 0.001) were significantly different between the patients who survived as compared to those who did not. On multivariate analysis, septic shock (p <0.001, OR: 4.70; 95% CI= 2.49-8.87) was found to be independently associated with mortality.

CONCLUSION

The microbes causing SCAP in our study are different from the usual spectrum. Staphylococcus aureus and Pseudomonas aeruginosa were the common causative pathogens and associated with high mortality. It is important to establish clinical guidelines for managing SCAP according to the etiologic organisms in our setting.

Imaging and intervention for coronary artery disease following irradiation of malignant thymoma

Thymomas are rare malignant epithelial growths, constituting 20% of mediastinal tumours. Resection followed by irradiation may be employed in all thymomas except for stage 1 thymomas. Mediastinal irradiation is associated with coronary artery disease. The mean duration of presentation of post-irradiation coronary artery disease is 16 years (range 3-29 years). In our patient coronary artery disease was found only a year post irradiation. A 55 year old male who presented with complaints of dyspnoea, retrosternal chest pain and heaviness since one year underwent resection for malignant thymoma followed by radiotherapy. He presented with coronary artery disease a year after undergoing mediastinal irradiation. On follow-up, patient was treated successfully by coronary artery bypass graft. This case is an unusual occurrence and suggests that mediastinal irradiation may result in significant coronary artery disease as early as within one year.

Acetaminophen induced Steven Johnson syndrome-toxic epidermal necrolysis overlap

Steven Johnson Syndrome and Toxic Epidermal Necrolysis are rare but severe form of hypersensitivity inflammatory reactions to multiple offending agents including drugs. Acetaminophen is extensively used due to its analgesic and anti-pyretic properties. It is rendered to be relatively safe, with hepatotoxicity considered to be the major adverse effect. However, very few cases of Steven Johnson Syndrome and Toxic Epidermal Necrolysis have been reported with acetaminophen usage in the past. We present the case of a 40 years old lady who developed an overlap of the two condition after taking several doses of acetaminophen for fever. She presented with widespread maculopapular rash, stinging in the eyes, oral mucosal ulcerations and high grade fever. She was successfully treated with corticosteroid therapy along with the supportive treatment. This case addresses the fact, that severe hypersensitivity reactions can occur with acetaminophen which can be potentially life threatening.

Virological and clinical characteristics of hepatitis delta virus in South Asia

Background & Aims

There is a paucity of data on the impact of hepatitis D virus (HDV) in patients with hepatitis B virus (HBV) infection from South Asia. We studied the impact of HDV co-infection on virological and clinical characteristics.

Methods

We collected data of 480 patients with HBsAg positive and a detectable HBV DNA PCR, who presented to the Aga Khan University, Karachi and Isra University in Hyderabad, Pakistan in the last 5 years. HDV co-infection was diagnosed on the basis of anti-HDV. ALT, HBeAg, HBeAb and HBV DNA PCR quantitative levels were checked in all patients. We divided all patients into two groups based on anti-HDV, and compared their biochemical, serological & virological labs and clinical spectrum. Clinical spectrum of disease included asymptomatic carrier (AC), chronic active hepatitis (CAH), immuno-tolerant phase (IP), and compensated cirrhosis (CC).

Results

HDV co-infection was found in 169 (35.2%). There were 164 (34.6%) HBeAg positive and 316 (65.4%) HBeAg negative patients. Mean ALT level was 66 ± 73 IU. 233 (48.5%) had raised ALT. HBV DNA level was ≥ 10e5 in 103(21.5%) patients. Overall, among HBV/HDV co-infection, 146/169 (86.4%) had suppressed HBV DNA PCR as compared to 231/311 (74.3%) patients with HBV mono-infection; p-value = 0.002. Among HBeAg negative patients 71/128(55.5%) had raised ALT levels among HBV/HDV co-infection as compared to 71/188 (37.8%) with HBV mono-infection (p-value = 0.002); levels of HBV DNA were equal in two groups; there were 27/128 (21%) patients with CC among HBV/HDV co-infection as compared to 23 (12%) in HBV mono-infection (p-value = 0.009); there were less AC (p-value = 0.009) and more CAH (p-value = 0.009) among HBV/HDV co-infection patients. Among HBeAg positive patients, serum ALT, HBV DNA levels and the spectrum of HBV were similar in the two groups.

Conclusions

HBV/HDV co-infection results in the suppression of HBV DNA. A fair proportion of HBV/HDV co-infected patients with HBeAg negative have active hepatitis B infection and cirrhosis as compared to those with mono-infection.

Comparison of three T-Wave Delineation Algorithms based on Wavelet Filterbank, Correlation and PCA

There is a large interest in analysing the QT-interval, as a prolonged QT-interval can cause the development of ventricular tachyarrhythmias such as Torsade de Pointes. One major part of QT-analysis is T-end detection. Three automatic T-end delineation methods based on wavelet filterbanks (WAM), correlation (CORM) and Principal Component Analysis PCA (PCAM) have been developed and applied to Physionet QT database.All algorithms tested on Physionet QT database showed good results, while PCAM produced better results than WAM and CORM achieved best results. Standard deviation in sampling points (f(s)=250Hz) have been 33.3 (WAM), 8.0 (PTDM) and 7.8 (CORM). It could be shown that WAM is prone to interference while CORM is the most stable method even under bad conditions. Furthermore it was possible to detect significant QT-prolongation caused by Moxifloxacin in Thorough QT Study # 2 using CORM. QT-prolongation is significantly correlated to blood plasma concentration of Moxifloxacin.

Efficacy of fluoroscopically guided, contrast-enhanced lumbosacral interlaminar epidural steroid injections: a pilot study

OBJECTIVE

To assess the efficacy of fluoroscopically guided, contrast-enhanced lumbar interlaminar epidural steroid injections (IL-ESI) for lower limb pain greater than axial low back pain using self-reported pain scores.

STUDY DESIGN

Prospective, single-arm, pilot, observational human study.

SETTING

An outpatient private practice interventional spine specialty referral center.

DATA/RESULTS

Twenty-one patients were initially included in analysis. Thirteen patients had "complete data" and completed 3 months of data after their most recent IL-ESI. Their self-reported 3-day average Numeric Pain Rating Scale (NPRS) score (0 to 10) at inception, 2 weeks, 6 weeks, and 3 months were 6.38, 3.00, 2.88, and 3.04, respectively. The average NPRS score at 3 months was significantly lower than at inception after the IL-ESI for this group (P = 0.0001, 95% confidence interval [1.69, 5.00]). Eight patients had "incomplete data." Their self-reported 3-day average NPRS scores at inception, 2 weeks, and 6 weeks were 6.69, 4.25, and 4.00, respectively. Of the eight patients who had incomplete data, two patients had surgical intervention, five patients had lumbar transforaminal epidural steroid injections, and one patient was unable to be contacted after 6 weeks.

DISCUSSION/CONCLUSION

This prospective, single-arm pilot study demonstrates that subjects who have had fluoroscopically guided, contrast-enhanced lumbar IL-ESIs for radicular > axial pain can have improved (lowered) NPRS for at least 3 months. It would be worthwhile to pursue a more rigorous study.

Analyzing Thorough QT Study 1 & 2 in the Telemetric and Holter ECG Warehouse (THEW) using Hannover ECG System HES : A validation study

Following the ICH E14 clinical evaluation guideline [1], the measurement of QT/QTc interval prolongation has become the standard surrogate biomarker for cardiac drug safety assessment and the faith of a drug development. In Thorough QT (TQT) study, a so-called positive control is employed to assess the ability of this study to detect the endpoint of interest, i.e. the QT prolongation by about five milliseconds. In other words the lower bound of the one-sided 95% confidence interval (CI) must be above 0 [ms]. Fully automated detection of ECG fiducial points and measurement of the corresponding intervals including QT intervals and RR intervals vary between different computerized algorithms. In this work we demonstrate the ability and reliability of Hannover ECG System (HES(®)) to assess drug effects by detecting QT/QTc prolongation effects that meet the threshold of regulatory concern as mentioned by using THEW database studies namely TQT studies one and two.