Glue embolization to the lung vasculature following histoacryl injection sclerotherapy: A neglected etiology of pulmonary embolism

Pulmonary embolism is a significant complication of N-butyl-2-cyanoacrylate, commonly known as histoacryl, used to sclerose bleeding gastroesophageal varices. We present a 50-year-old female with seronegative chronic liver disease who was managed with endoscopic histoacryl injection sclerotherapy for bleeding gastric fundal varices. Following treatment, the patient developed sudden respiratory distress due to multiple pulmonary glue emboli, requiring inpatient supportive care along with close monitoring for a week. The patient slowly recovered with conservative management. On subsequent outpatient follow-up, the patient showed no signs of any long-term consequences. Our aim is to alert physicians regarding the uncommon occurrence of acute respiratory distress secondary to pulmonary embolism following histoacryl injection sclerotherapy, as well as to describe its clinical and radiological manifestations.

A Rare Case of Brain Abscesses Caused by Acremonium Species

Acremonium species are saprophytic fungi that are rarely pathogenic in humans. According to several reports, Acremonium species can cause various diseases, ranging from superficial infections after traumatic inoculation in immunocompetent individuals to invasive infections in the immunocompromised. To the best of our knowledge, this is the first case report of brain abscess in an 18-year-old male caused by Acremonium species in Pakistan. A combination of intravenous amphotericin B and oral voriconazole was administered to the patient, which resulted in marked clinical improvement. However, the recurrence of fungiwas observed after three months of completion of the antifungal course. The purpose of this report is to alert clinicians regarding this pathogen and its ability to cause systemic disease.

Susceptibility profile of methicillin-resistant Staphylococcus aureus to linezolid in clinical isolates

OBJECTIVE

To determine the resistance and sensitivity pattern of methicillin-resistant Staphylococcus aureus (MRSA) isolates to linezolid (LZD) along with its prevalence in a tertiary care hospital of Karachi, Pakistan.

MATERIALS AND METHODS

A cross-sectional study was carried out. This study lasted for about 1 year. Prevalence and sensitivity of LZD, vancomycin, and oxacillin was tested against isolates of MRSA.

RESULTS

Out of total 369 specimens 165 were found to be MRSA making the prevalence in our study 44.7%. All of the isolates which were tested positive for MRSA were susceptible to LZD and no resistance was noted when compared with previous studies performed in Europe and USA.

CONCLUSION

Stringent implementation of infection control measures along with screening for resistance in patients on prolonged LZD therapy or who previously went under LZD therapy should be performed, coupled with judicious usage of the aforementioned antibiotic should be undertaken, as sufficient data is not available at this point for the clinical spectrum of LZD resistant S. aureus, antimicrobial resistance.

Projecting the direct cost burden of osteoarthritis in Canada using a microsimulation model

OBJECTIVES

To estimate the future direct cost of OA in Canada using a population-based health microsimulation model of osteoarthritis (POHEM-OA).

METHODS

We used administrative health data from the province of British Columbia (BC), Canada, a survey of a random sample of BC residents diagnosed with OA (Ministry of Health of BC data), Canadian Institute of Health Information (CIHI) cost data and literature estimates to populate a microsimulation model. Cost components associated with pharmacological and non-pharmacological treatments, total joint replacement (TJR) surgery, as well as use of hospital resources and management of complications arising from the treatment of osteoarthritis (OA) were included. Future costs were then simulated using the POHEM-OA model to construct profiles for each adult Canadian.

RESULTS

From 2010 to 2031, as the prevalence of OA is projected to increase from 13.8% to 18.6%, the total direct cost of OA is projected to increase from $2.9 billion to $7.6 billion, an almost 2.6-fold increase (in 2010 $CAD). From the highest to the lowest, the cost components that will constitute the total direct cost of OA in 2031 are hospitalization cost ($2.9 billion), outpatient services ($1.2 billion), alternative care and out-of-pocket cost categories ($1.2 billion), drugs ($1 billion), rehabilitation ($0.7 billion) and side-effect of drugs ($0.6 billion).

CONCLUSIONS

Projecting the future trends in the cost of OA enables policy makers to anticipate the significant shifts in its distribution of burden in the future.

The skin we are in--knowledge and practices regarding skin cancer in pre-clinical medical students

OBJECTIVE

To assess the level of knowledge about skin cancer in youth and to explore the influence of gender and system of education on their knowledge and practices.

MATERIALS AND METHODS

A questionnaire-based study was conducted at The Aga Khan University Medical College (AKUMC), on Year 2 pre-clinical medical students. Descriptive analyses to examine the frequency distribution, chi-square test and factor analysis were applied using SPSS.

RESULTS

Seventyone students participated in the study; 90% scored > 55% in the questions regarding knowledge of Malignant melanoma (MM), whereas in the questions assessing practice only 11% of the respondents scored > 52%. They were largely unaware that appearance of a new mole is a risk factor for MM (56% respondents incorrect) and that skin cancer is one of the most common cancers (54% respondents incorrect). 73% reported being sunburned at least once during childhood and 40% suffered sunburns at least once this summer, which points to the inadequacy of sun protection. The risk of MM may double if severe sunburns are experienced during childhood. Education system and gender did not affect the knowledge and practices. The popular sources of learning about skin cancer were magazines (52%) followed by television (42%).

CONCLUSION

There is a need for epidemiological studies in Pakistani population regarding skin cancer. For preventing excessive solar exposure which leads to sunburns, we recommend interventions like a Pilot Program for photoprotection education and Sun Awareness Week to improve knowledge and sun protection behavior.

Implementation of a clinical practice guideline for stress ulcer prophylaxis increases appropriateness and decreases cost of care

OBJECTIVE

To develop, implement and evaluate a practice guideline for stress ulcer prophylaxis.

DESIGN

Before-after study.

SETTING

Ten-bed Intensive Care Unit (ICU) and 4-bed Step-down Unit in a teaching hospital.

PATIENTS AND PARTICIPANTS

Fifty patients admitted during 1 year before and 50 patients admitted 3-6 months after introduction of the guideline.

INTERVENTION

Introduction of the practice guideline by dissemination of pocket cards, seminars and "academic detailing".

MEASUREMENTS AND RESULTS

Appropriateness (defined as proportion of days in which the prophylaxis met the criteria in the guideline), incidence of gastrointestinal bleeding and of ventilator-associated pneumonia, length of stay in ICU and in hospital, ventilator days. ICU mortality and medication costs for stress ulcer prophylaxis. After the introduction of the guideline, appropriateness increased from 75.8% to 91.1%, and medication costs decreased from C $2.50/day to C $1.30/day. There were no differences in any clinical outcomes. Predictors of appropriate use or the withholding of prophylaxis were the introduction of the guideline, lack of an indication for prophylaxis and number of days studied.

CONCLUSIONS

Introduction of this guideline was associated with an increase in appropriateness of prophylaxis and a decrease in medication costs.

Cost-effectiveness analysis of potential improvements to emergency medical services for victims of out-of-hospital cardiac arrest

STUDY OBJECTIVE

To measure the incremental cost-effectiveness of various improvements to emergency medical services (EMS) systems aimed at increasing survival after out-of-hospital cardiac arrest.

METHODS

We performed cost-effectiveness analysis based on (1) metaanalysis of effectiveness of the various EMS systems, (2) costing of each component of EMS systems, (3) modeling of the relationship between the proportion of cardiac arrest victims who receive CPR and the proportion of individuals trained, (4) modeling of the relationship between response time interval and the characteristics of the EMS system, (5) measurement of quality of life, and (6) decision analysis to combine the results of the first five components.

RESULTS

The incremental cost-effectiveness ratio for a 48-second improvement in mean response time in a one-tier EMS system yielded by the addition of more EMS providers was $368,000 per quality-adjusted life year (QALY). For improved response time in a two-tier EMS system by the addition of more basic life support (BLS)/BLS-defibrillator (BLS-D) providers to the first tier, the ratio was $53,000 per QALY with pump vehicles or $159,000 per QALY with ambulances. Change from a one-tier EMS to a two-tier EMS system by the addition of initial BLS/BLS-D providers in pump vehicles as the first tier was associated with a cost per QALY of $40,000. Change from one-tier EMS to two-tier EMS by the addition of initial BLS/BLS-D providers in ambulances as the first tier was associated with a cost per QALY of $94,000.

CONCLUSION

The most attractive options in terms of incremental cost-effectiveness were improved response time in a two-tier EMS system or change from a one-tier to a two-tier EMS system. Future research should be directed toward identification of the costs of instituting the first tier of a two-tier EMS system and identification of cost-effective methods of improving response time.

PhacoTmesis

I was extremely delighted to be invited to write a review of PhacoTmesis. However, there is not enough existing literature to review other than a few short articles authored by myself and a few short statements made by some investigators commenting on their short one-time trial of PhacoTmesis. The reason for this is that it has taken Chiron (Clairmont, CA) and myself more than 5 years to develop and evolve the concept and the machine to the level at which it can be used clinically with safety and efficiency prior to making it available to other ophthalmologists to explore its capabilities.

Biochemical properties of Egyptian Cerastes venoms in relation to geographic distribution

Total proteins, electrophoretic analysis, biological lethality, and phospholipase activity of five members of the Cerastes-viper species living along the Nile Valley were investigated. Elevation of environmental temperature was accompanied with high values for these indices. It is concluded that zoological distribution and environmental conditions could influence the overall biological behaviour of snake venoms of the same species.