Nouman Safdar Ali

Spontaneous Coronary Artery Dissection: A Case Series of 9 Patients With Literature Review:

Spontaneous coronary artery dissection is an increasingly recognized nonatherosclerotic cause of acute coronary syndrome. Reports regarding the prognosis and natural history of this disease are limited. In addition to the diagnostic difficulty, this condition poses a significant therapeutic challenge due to the lack of specific management guidelines. We present here a case series of 9 patients with spontaneous coronary artery dissection. Additionally, this article reviews the incidence, clinical characteristics, risk factors, diagnostic modalities, therapeutic approaches, and patterns of recurrence in patients with spontaneous coronary artery dissection.

Left Ventricular Pseudoaneurysm: An Overview of Diagnosis and Management

Left ventricular pseudoaneurysm is a rare but life-threatening disorder that is frequently reported secondary to myocardial infarction or cardiac surgery. In this article, we chronicle the case of a patient with no prior risk factors who presented with a 2-week history of nonexertional atypical left chest pain. Apical 2-chamber transthoracic echocardiography revealed an unexpected outpouching of basal inferoseptal wall of the left ventricle, which had a narrow neck and relatively wide apex. The patient was diagnosed with left ventricular pseudoaneurysm and medical therapy was initiated. He refused to undergo the surgical intervention and subsequently, he was discharged from the hospital in stable condition. This article illustrates that physicians should be vigilant for atypical presentations of left ventricular pseudoaneurysm, and a high index of suspicion should be maintained for this stealth killer while performing appropriate diagnostic imaging. Additionally, we review the currently available approaches to diagnosis and management in these patients.

Hepatitis B virus reactivation following imatinib therapy: A comparative review of 9 cases

Patients undergoing cytotoxic or immunosuppressive therapy for cancer have an established predilection for hepatitis B virus reactivation; however, the risk associated with newer molecularly targeted agents has not been well investigated. Imatinib, a small molecule tyrosine kinase inhibitor, induces rapid and sustained clinical benefit by inhibiting a number of signaling pathways, including BCR-ABL and c-KIT. We report the case of a patient who developed hepatitis B virus reactivation while receiving imatinib therapy for gastrointestinal stromal tumor. Furthermore, a structured literature search of the medical databases consisting of MEDLINE and PubMed was performed using the terms “hepatitis B”, “reactivation”, and “imatinib”. The search identified nine case reports only. The data on patients’ characteristics, epidemiology, clinical features, comorbid conditions, diagnosis, and management are summarized. Imatinib-associated hepatitis B virus reactivation was reported in seven patients with chronic myeloid leukemia, one with desmoid tumor, and one with gastrointestinal stromal tumor. This review serves to outline our current understanding of the epidemiology, risk factors, and pathophysiology of chronic hepatitis B virus reactivation secondary to imatinib therapy as well as the current approaches to diagnosis and management of this condition. We aim to increase awareness about this possible association and advocate for hepatitis B virus screening prior to imatinib therapy, especially in patients who are at increased risk for chronic hepatitis B virus infection.

Comparison of Knowledge and Attitudes of Medical and Dental Students towards HIV/AIDS in Pakistan

The number of new human immunodeficiency virus (HIV) cases is increasing in Pakistan while it has seen a decline globally. A survey conducted recently has found that 132,000 people in Pakistan suffer from HIV. This study aims to check the levels of knowledge and attitudes about HIV/acquired immunodeficiency syndrome (AIDS) among medical and dental students. This cross-sectional study was designed and conducted at Combined Military Hospital Lahore Medical College and the Institute of Dentistry (CMH LMC) in Lahore, Pakistan in 2016. Students enrolled in the courses of the MBBS and BDS were included in this study. The questionnaire consisted of three sections: demographics, knowledge and attitude. A total of 414 students completed the questionnaire and out of them, 286 were medical students while the rest were dental students. The mean ± standard deviation score for the students was 10.02 ± 4.37 out of 17 for knowledge related to HIV and AIDS. For acceptable attitude towards AIDS and patients afflicted with the disease, an outcome of 1.93 ± 0.75 out of 4 was observed. The results of this study indicate lack of knowledge about HIV, especially about the modes of transmission and prevention techniques. Therefore, regular interactive workshops and seminars, besides teaching sessions, focused lectures on HIV/AIDS, need to be conducted.

Lafora Disease Masquerading as Hepatic Dysfunction

Lafora disease is fatal intractable progressive myoclonic epilepsy. It is frequently characterized by epileptic seizures, difficulty walking, muscle spasms, and dementia in late childhood or adolescence. We chronicle here an unusual case of an asymptomatic young male soccer player who presented with elevated liver enzymes. Neurological examination was unremarkable. The diagnostic workup for hepatitis, infectious etiologies, autoimmune disorders, hemochromatosis, Wilsons disease, alpha-1 antitrypsin deficiency, and other related diseases was inconclusive. He subsequently underwent an uneventful percutaneous liver biopsy. Based on the pathognomonic histopathological findings, Lafora disease was considered the likely etiology. The present study is a unique illustration of this rare disorder initially manifesting with abnormal liver enzymes. It underscores the importance of clinical suspicion of Lafora disease in cases with unexplained hepatic dysfunction. Prompt liver biopsy and genetic testing should be performed to antedate the onset of symptoms in these patients.

Management of Orthostatic Hypotension: A Literature Review

In the older population, especially the hospitalized patients who are prone to dehydration and hypovolemia, orthostatic hypotension (OH) presents as a debilitating disease. How different pharmacological and non-pharmacological interventions affect the incapacitating symptoms (falls and episodes of syncope), morbidity, and mortality related to OH has become a topic of debate. OH can predispose to ischemic heart disease (IHD). A non-pharmacological approach consisting of mobilization, early lifestyle changes, and therapeutic maneuvers is the first choice in the management of these patients. Individuals with persistent symptoms require pharmaceutical therapy to increase blood volume and peripheral vascular resistance. This article summarizes the management of OH that is vital to cope with the needs of the growing geriatric populations.

American Heart Association High Blood Pressure Protocol 2017: A Literature Review

Hypertension is the most prevalent clinical symptom arising from various cardiovascular disorders. Likewise, it is considered a precursor or sequelae to the development of acute coronary artery disease and congestive heath failure (CHF). Hypertension has been considered a cardinal criterion to determine cardiovascular function. According to the World Health Organization (WHO) global observatory data, hypertension causes more than 7.5 million deaths a year, about 12.8% of the total human mortality. Similarly, the Center for Disease Control (CDC) states that 35% of the American adults have been estimated to have a persistently high blood pressure, which makes it about one in every three adults. Hypertension is a modifiable symptom that can be managed through pharmacological and non-pharmacological methods and standard protocols set forth by the American Heart Association (AHA). With new findings from various clinical trials related to the management of hypertension, new developments and recommendations have been made to update the previously established protocols for hypertension. This article aims to discuss and dissect the modern updates of hypertension management as comprehensively elaborated in the 2017 Hypertension Clinical Practice Guidelines.

Small Bowel Perforation Secondary to Esophageal Stent Migration: A Comparative Review of Six Cases

Esophageal stent placement is used to treat benign strictures, esophageal perforations, fistulas and for palliative therapy of esophageal cancer. Although it is a safe and effective method, complications are increasing the morbidity and mortality rate. Small bowel perforation as a result of esophageal stent migration is a remarkably rare occurrence. We report one case from our clinical experience and undertake a review of the previously reported cases retrieved from the PubMed. A total of six cases were found accessible. Abdominal pain was the common clinical presentation. The mean time from stent placement to perforation was 3.4 months (range, two weeks to 12 months). The jejunum was the frequently perforated portion of the small bowel. Surgical intervention was the mainstay of treatment. This comparative review illustrates that clinicians should remain vigilant for small bowel perforation in patients with esophageal stent placement. Further studies are required to delineate the magnitude and scope of this association.

Pseudo-Wellens’ syndrome secondary to concurrent cannabis and phencyclidine intoxication

Wellens’ syndrome is an electrocardiographic pattern of T-wave changes associated with critical stenosis of the proximal left anterior descending artery, signifying imminent risk of an anterior-wall myocardial infarction. The Wellens’ electrocardiographic pattern can also be noted in several cardiac and non-cardiac diseases. We chronicle here a unique case of a patient who presented with atypical left chest pain and dizziness for 6 hours. His pain started after he smoked phencyclidine-laced cannabis. Cardiac panel demonstrated normal troponin T levels. Electrocardiogram showed sinus rhythm with new deep biphasic T-wave inversions in anterolateral leads. Coronary angiography showed no pathological processes. Subsequently, ECG changes resolved coincidentally with the resolution of chest pain. He was eventually diagnosed with pseudo-Wellens’ syndrome. This paper illustrates that physicians should be vigilant for Wellens’ syndrome mimicked by acute phencyclidine and cannabis intoxication. Additionally, we present a review of various aetiologies of pseudo-Wellens’ syndrome, especially in patients with substance abuse.

Brucellosis in renal transplant recipients: a comparative review of 5 cases

Although brucellosis in renal transplant recipients is rare, we studied the clinical characteristics of this infection in this patient population due to the significantly increased number of renal transplantations performed over the past few decades. We report one case from our experience and undertake a review of the previously reported cases retrieved from the PubMed. A total of 5 cases of brucellosis in renal transplant recipients were found to date. The mean time from transplantation to diagnosis of brucellosis was 4.7 years (range, 4 months to 13 years). Blood culture and detection of anti-Brucella antibodies were frequently used diagnostic investigations. Treatment with appropriate antibiotic regimen led to a clinical cure and marked improvement in Brucella titre in all the patients. This review illustrates that clinicians should remain vigilant for this infectious aetiology following renal transplantation. Further studies are required to delineate the magnitude and scope of this association.