Nayer Jamshed

Ethical issues in electronic health records: A general overview.

Electronic health record (EHR) is increasingly being implemented in many developing countries. It is the need of the hour because it improves the quality of health care and is also cost-effective. Technologies can introduce some hazards hence safety of information in the system is a real challenge. Recent news of security breaches has put a question mark on this system. Despite its increased usefulness, and increasing enthusiasm in its adoption, not much attention is being paid to the ethical issues that might arise. Securing EHR with an encrypted password is a probable option. The purpose of this article is to discuss the various ethical issues arising in the use of the EHRs and their possible solutions.

Alzheimer disease in post-menopausal women: Intervene in the critical window period.

Alzheimer disease (AD) is a crippling neurodegenerative disorder. It is more common in females after menopause. Estrogen probably has a protective role in cognitive decline. Large amount of research has been carried out to see the benefits of hormone replacement therapy with regards to Alzheimer still its neuroprotective effect is not established. Recent studies suggest a reduced risk of AD and improved cognitive functioning of post-menopausal women who used 17 β-estradiol in the critical period. Use of 17 β-estradiol in young and healthy post-menopausal women yields the maximum benefit when the neurons are intact or neuronal stress has just started. Hence intervention in the critical period is key in the prevention or delay of AD in post-menopausal women.

Cardiac tamponade as initial presenting feature of primary hypothyroidism in the ED.

Pericardial effusion is commonly detected in patients with severe hypothyroidism and is typically mild; rarely, it may lead to cardiac tamponade. Cardiac tamponade with myxedema coma as initial presenting feature of previously unrecognized hypothyroidism is rare. This case highlights that previously undiagnosed hypothyroidism can manifest as myxedema coma with shock due to pericardial tamponade particularly in winters because a cold environment can precipitate myxedema.We report an undiagnosed case of primary hypothyroidism who presented to the emergency department for the first time with both cardiac tamponade and myxedema coma. This combination of cardiac tamponade and myxedema coma as the presenting features of primary hypothyroidism has rarely been reported in the literature. The patient was effectively managed with echocardiography-guided pericardiocentesis, levothyroxine, and external rewarming. Cardiac tamponade and myxedema coma as presenting features of previously unrecognized primary hypothyroidism are extremely rare. Urgent bedside echocardiography with pericardiocentesis along with thyroxine therapy is the treatment of choice. It is important to include hypothyroidism as the differential diagnosis in patients with cardiac tamponade and altered level of consciousness especially in winter months.

Successful flexible bronchoscopic management of a large-sized aspirated partial denture.

A 48-year-old male patient presented to the emergency room with a history of chest pain and breathlessness. Chest X-ray demonstrated a large radio-opaque foreign body in relation to the proximal right bronchial tree. The patient subsequently revealed a history of a misplaced denture 4 months previously. Urgent flexible bronchoscopy (FB) examination demonstrated a large partial denture impacted in the right intermediate bronchus, which was removed successfully using a flexible bronchoscope. Although rigid bronchoscopy (RB) is the procedure of choice for large-sized and impacted airway foreign bodies, the present case highlights the utility of FB in airway foreign body removal. In clinically stable patients with foreign body inhalation, FB can be employed initially as it is an outpatient and cost-effective procedure which can obviate the need for administration of general anaesthesia.

Sympathetic crashing acute pulmonary edema

Sympathetic crashing acute pulmonary edema (SCAPE) is the extreme end of the spectrum of acute pulmonary edema. It is important to understand this disease as it is relatively common in the emergency department (ED) and has better outcomes when managed appropriately. The patients have an abrupt redistribution of fluid in the lungs, and when treated promptly and effectively, these patients will rapidly recover. Noninvasive ventilation and intravenous nitrates are the mainstay of treatment which should be started within minutes of the patients arrival to the ED. Use of morphine and intravenous loop diuretics, although popular, has poor scientific evidence.

Hydration therapy: critical intervention in the ED to prevent stroke in evolution after acute ischemic stroke

ous experience in the creation of IO route can successfully perform this practice, even in his/her first experience, provided that he/she properly reads or learns the practice. As a result of this study, which enlightened the use of IO route of administration, demonstrated the usefulness of IO route of administration, revealed the learning curve, and, in addition, aimed to minimize to complications due to the incremental use of IO route of administration, we think that the physicians without a previous experience in this practice can practically and safely create an IO route of administration after the eighth practice, after performing the first 3 or 4 practice under the supervision of experienced physicians.

Toxic brain injury with nitrobenzene poisoning

Acute methemoglobinemia secondary to nitrobenzene ingestion is a rare but well-known clinical entity. It is extremely important to identify such patients as rapid and effective management with methylene blue and other supportive measures will often save these lives. We present a rare and unfortunate case of a girl who developed acute toxic brain injury following nitrobenzene ingestion and succumbed.

A fatal case of menthol poisoning

Menthol is a monocyclic terpene alcohol, which is present naturally in peppermint and can be synthesized artificially as well. Generally, it is considered as very safe and has wide usage in medicine and food. There are case reports of toxicity due to excessive consumption of menthol, but a fatal intoxication has never been reported in the medical literature. We present a case of fatal menthol intoxication in a worker, who accidently got exposed when he was working in a peppermint factory. Emergency physicians must keep in mind this extremely rare manifestation of menthol poisoning. All necessary precaution should be taken to reduce its intake or exposure, as it has no specific antidote. Early recognition and supportive treatment of this poisoning is the key for a successful outcome.

Severe hypoglycemia masquerading as cerebellar stroke

Hypoglycemia is a common presenting feature of diabetes in the emergency department. Cardiovascular and neuroglycopenia features are well documented in the literature. We here report a case of 55-year-old female who came to our emergency with clinical features suggestive of cerebellar stroke. Laboratory investigations revealed severe hypoglycemia. The cerebellar signs and symptoms improved completely with intravenous dextrose infusion. Her MR imaging and Doppler of carotid and vertebrobasilar arteries were noncontributory. Hypoglycemia causes behavioral changes, confusion, loss of consciousness, and seizures. It is also well known to cause hemiplegia and aphasia. Hypoglycemia presenting as cerebellar stroke is rarely reported in the literature. This case highlights an uncommon manifestation of a common clinical condition. Physician must rule out hypoglycemia in every stroke patients.

Severe hypoglycemia as a presenting feature of aluminum phophide poisoning

To the Editor: Aluminium phosphide (AlP) is a highly effective insecticide. It is known as a suicide poison because of high mortality and easy over-the-counter availability. It has no specific antidote. Fatal dose for an average-sized individual is 150 to 500 mg. The mortality rate is very high varying from 60% to 80%.1 Death occurs due to toxic myocarditis, multi-organ failure, and profound shock. Its toxicity is due to the release of phosphine (PH3), which occurs when it comes in contact with moisture or gastric juice. PH3 is a mitochondrial toxin. Hyperglycemia following AIP ingestion has been described as poor prognostic factor.2 Mild hypoglycemia has already been reported, but severe hypoglycemia as presenting feature of AlP poisoning is extremely rare.3 We report a case of a 19 year-old male who came to our emergency in deep coma and profound shock, about 7-and-a-half hours after ingestion of 1 (3 g) tablet of AlP. On investigation, he had severe metabolic acidosis with pH 6.86, blood sugar of 15 mg/dL, oxygen saturation of 70%, and serum lactate of 13 mmol/L. The electrocardiogram revealed T-wave inversion in leads II, III, and aVF with ST elevation in VI with sinus tachycardia. His Troponin I level was 0.36 μg/L. The patient was immediately intubated for mechanical ventilation and was treated with 2 boluses of 50% dextrose (50 mL each) intravenously, followed by 10% dextrose as a continuous infusion. His repeat blood sugar level was 110 mg/dL and continued to remain normal thereafter. Despite normalization of blood glucose, there was no change in neurological status of the patient. After initial stabilization, the patient received gastric lavage with aliquot of 50 mL sodium bicarbonate and 50 mL coconut oil through nasogastric tube. He was also given 4 g magnesium sulphate intravenously as a bolus followed by 2 g magnesium sulphate intravenously at every every 6 hours, adequate fluid boluses and 100 mL of 8.4% sodium bicarbonate along with double inotropic support. The patient also received N-acetylcysteine. Despite extensive supportive care, patient died after 30 hours of ED presentation. PH3 poisoning following AlP ingestion develops rapidly, and the majority (95%) of deaths occur within 12 to 24 hours because of cardiovascular dysfunction, intractable hypotension, and multi-organ dysfunction. Changes in blood glucose levels are well known following AIP ingestion. It has been previously observed that elevation, reduction, and lack of effect on blood glucose level can occur in AlP poisoning.4 Mild hypoglycemia is common in AlP poisoning; however, severe hypoglycemia is extremely rare. A probable relation exists between AlP and severe hypoglycemia based on Naranjo Scale. Several mechanisms have been suggested for hypoglycemia in AlP poisoning. Inhibition of hepatic gluconeogenesis and glycogenolysis, damage to adrenal cortex along with decreased cortisol, and glucagon and epinephrine production may precipitate hypoglycemia. Release of insulinlike growth factor in response to severe shock also contributes to hypoglycemia.5 Studies have shown that non-survivors in AlP poisoning had significantly higher blood glucose level than survivors, and these studies concluded that hyperglycemia prognosticates higher mortality. AlP causes rapid onset of shock, severe metabolic acidosis, cardiac dysrhythmias, and ARDS. Various studies have concluded that hyperglycemia, high SAPS II and high APACHE II score, hypotension, acidosis, leukocytosis, hyperuricemia, ECG abnormalities, low Glasgow coma scale, acute renal failure, low prothrombin time, methemoglobinemia, use of vasoactive drugs, lack of vomiting after ingestion, and use of mechanical ventilation are markers of poor prognosis. However, instead of hyperglycemia, which is a poor prognostic factor, severe hypoglycemia was present in our case, which could be one of the poor prognostic factors. To conclude severe hypoglycemia is extremely rare following acute AIP poisoning. Similar to hyperglycemia, hypoglycemia could also be a predictor of mortality and should be included in the poor prognostic marker in AIP poisoning.