Autopsy Techniques in Patients With History of Radiofrequency Ablation for Atrial Fibrillation

Context.— Esophageal fistula formation is one of the most feared complications of radiofrequency catheter ablation. This procedure and its many variations, such as the “maze,” are becoming the mainstream treatment for atrial fibrillation owing to limitations of antiarrhythmic drugs. The incidence of this complication rate has been reported to be from 0.01% to 1%. Objective.— To delineate the importance of using the en bloc Letulle method of dissection for identifying esophageal fistulas for cases with a history of radiofrequency catheter ablation. Design.— Six autopsy cases with a history of radiofrequency catheter ablation for atrial fibrillation were selected from 1736 autopsies performed between 2009 and 2020. Results.— The initial presenting symptoms included neurologic symptoms, chest pains, epigastric discomfort, and sepsis. Transesophageal echocardiogram of 4 cases showed no evidence of thrombus or vegetation, however, 2 cases had evidence of atrial esophageal fistula. The autopsy findings included 5 atrial esophageal fistulas and 1 esophagopericardial fistula. Atrial esophageal fistulas were small and could be detected without difficulty when the en bloc Letulle technique was used and would have been easily missed by the Virchow method. The immediate causes of the deaths were myocardial ischemia, septic emboli to brain and heart, hypovolemic shock secondary to exsanguination, stroke, and coagulopathy. Conclusions.— To date, this is the largest collection of autopsy cases showing esophageal fistula associated with prior radiofrequency catheter ablation. The Letulle dissection method is preferable in this setting.

Leptospirosis: A Rare Cause of Acute Hepatitis

Leptospirosis is a zoonotic infection caused by the pathogenic Leptospira interrogans. Humans acquire the infection either through direct contact with the urine of infected animals, commonly rats or indirect contact of contaminated water or soil. It is a rare cause of acute hepatitis in the UK with fewer than 100 reported cases a year and hence diagnosis is commonly delayed. A 51-year-old fit Caucasian gentleman was admitted with a one-week history of painless jaundice, dark urine and pale-coloured stools. This was associated with feeling unwell, anorexia, nausea and intermittent epigastric discomfort. He binges on alcohol on a weekend. He works as a telephone engineer which occasionally exposes him to sewage water. On clinical examination, he was icteric with mild right hypochondriac tenderness. Liver biopsy was performed and histologically it was suggestive of leptospirosis. He was started on a five-day course of intravenous ceftriaxone followed by two days course of oral doxycycline. His IgM leptospirosis result finally came back as positive. Due to the rarity of leptospirosis in the UK, the serological testing of leptospirosis is only performed in the Rare and Imported Pathogens Laboratory in Porton Down, Salisbury leading to a delay in getting the result. The patient underwent an invasive procedure which can be avoided if the leptospirosis serology was ordered early and result available quickly. Fortunately, the patient made a full recovery after two months. Leptospirosis should be considered in an individual with acute hepatitis and a history of exposure to sewage.International Journal of Human and Health Sciences Supplementary Issue-2: 2021 Page: S22

Zidovudine Induced Pancytopenia: A Case Study

Zidovudine is the oldest anti-retroviral agent that is in clinical use. It’s common adverse effects are headaches (42-62.5%), nausea (46-61%), anorexia (11-20%), vomiting (6-25%), anemia (1.1-29%), granulocytopenia (1.8-37%) and neutropenia (3%). This study is to increase awareness of Zidovudine induced pancytopenia. This is an observational type of case report of a 40 year old man with known complaints of HIV on anti-retroviral therapy since 8 years who came with complaints of easy fatigability since 1 year which was aggravated since 1 week, epigastric discomfort, constipation since 2 weeks, chest pain retrosternal in position which was radiating to both upper limbs, sweating, palpitations, decreased appetite since 1 week and cough with expectoration. He was given tablet ZLN (Zidovudine 300 mg + Lamivudine 150 mg + Nevirapine 200 mg) twice daily regularly for the past 8 years. His last CD4 count was 300 cell/mm3. He had pallor. His laboratory results were: hemoglobin (6.6 g/dL), TLC (2400/μL), platelets (18,000/μL), neutrophil (36%) and MCV (107.4fL). He was diagnosed with pancytopenia (dimorphic anemia + leucopenia + thrombocytopenia) and neuropathic pain. It was confirmed to be Zidovudine induced pancytopenia by objective analysis and Naranjo score suggesting “probable” interpretation. Pancytopenia improved after withholding Zidovudine along with Oxcarbazepine. Suggestion was made to change his anti-retroviral regimen once his counts improve. Tenofovir + Lamivudine (or Emtricitabine) + Efavirenz is the preferred first line combination therapy according to latest WHO guidelines (2013 and 2015). In case Zidovudine is used in first line combination therapy (2009 WHO guidelines), physicians should monitor for its toxicity. A clinical pharmacist can help in such situations by creating awareness among prescribers regarding latest WHO and other recommended guidelines, checking whether the prescriptions follow these guidelines and also by monitoring patients for toxicities. Keywords: Zidovudine, Drug induced pancytopenia, Adverse drug reaction

Severe Abdominal Pain as a Presentation of Lead Poisoning: a Case Report

Background: Lead poisoning is a rare but serious disease. The clinical manifestations of lead poisoning are various and nonspecific such as abdominal pain, headache, dizziness, nightmare, fatigue and so on. Rapid diagnosis of lead poisoning is challenging because it does not have special symptoms and the morbidity is very low.Case presentation: A 31-year-old woman presented with epigastric discomfort without any obvious cause. The patient was diagnosed with lead poisoning, as the blood levels of heavy metals were detected and the lead was 463.17ug/L, which was very high (normal value was less than 100 ug/L). The patient was treated with intravenous drip of calcium sodium edentate and got better. The patient achieved good recovery and there was no recurrence.Conclusion: Lead poisoning is a rare disease and easy to be misdiagnosed as acute abdomen disease when present with abdominal pain. Lead poisoning should be considered when common causes of abdominal pain are excluded, especially patients with anemia and abnormal liver function. The diagnosis of lead poisoning is mainly replied on the blood or urine lead concentrations. Then we should firstly cut off the contact with lead and use metal complexing agent to facilitate lead excretion.

Barriers to Physical Activity Among Pregnant Women During Pregnancy

Introduction: Co-morbidities such as obesity, gestational diabetes and pregnancy induced hypertension during pregnancy can be dangerous to the mother and foetus. Regular physical activity during pregnancy not only maintains maternal and foetal wellbeing, but it also maintains physical fitness and brings various health benefits. However, many women reduce their physical activity levels during pregnancy.Objectives: Thus, this study aimed to identify the barriers that could prevent pregnant mothers from doing physical activities.Methods: This is a cross-sectional study involving 168 pregnant women aged 18 to 35 years between gestational age 12 to 35 weeks in a primary health clinic in Kuantan, Pahang. Their socio-demographic characteristics were recorded, and barriers for physical activity assessed through a set of pre-tested questionnaire.Descriptive statisticswere used to describe the sociodemographiccharacteristics and the barriers.Results: The mean (SD) age was 28.0 (3.6) and majority of them were of Malay ethnicity from B40 group. Two thirds (74.4%) had tertiary education and 66.7% were working mothers. More than half (53.0%) of the participants wereoverweight and obese.Moreover, 58% of the participants had leg cramp and 63.1% felt fatigue. Almost 80.4% had backache and 46.4% had epigastric discomfort.Conclusion: Barriers such as leg cramp, backache, fatigue and epigastric discomfort could prevent pregnant women from conducting physical activities. Opportunistic recommendation by physician and concerns on the physical activity should be addressed.International Journal of Human and Health Sciences Supplementary Issue: 2021 Page: S23

LONGEST LAD ENDARTRECTOMY RECORDED AND DOCUMENTED TILL DATE IN AFIC/NIHD

As the world advances, living standards are getting changed with inclination more toward sedentary life style and junk food, we are seeing a worldwide increased incidence of coronary artery disease. A 73 year of age gentleman with progressive shortness of breath NYHA-II/III since last 6 months and epigastric discomfort with effort angina CCS-III. Was having no other co-morbidities, except of 35 pack years of smoking. On evaluation his Coro-angiogram revealed Diffuses TVCAD with Lad diffusely diseased throughout its middle course >90%, LCX 80%, RCA mid-Course critical discrete lesion of 90%. His 2D, TTE showed normal valvular apparatus and ejection fraction of 55%. Literature review further furnishes the fact that LAD is most commonly being affected by atheroma formation hence making it the most common site for endartrectomy, though peri-operative MI is still a grave concern, but half dose protamine slow reversal of the heparin and keeping ACT at 150-160 sec greatly reduces the incidence of peri-operative MI.

Limited Wedge Resection of a Duodenal Gist in a Patient with Intermittent Melena

Gastrointestinal Stromal Tumors account for 1% - 2% of all gastrointestinal (GI) tract tumors. Among GISTs, duodenal localization occurs in less than 5% and usually presents with upper GI bleeding. A 45-year-old man presented in the outpatient department with complaints of epigastric discomfort, intermittent melena and undocumented weight loss for the preceding 3 months. Initial upper GI endoscopy showed mild duodenitis and no other upper GI pathology. For unexplained symptoms, a CT Scan was performed which demonstrated a well-defined solid lesion along the second part of the duodenum. An endoscopic ultrasound (EUS)-guided biopsy of a subepithelial lesion at D2 was performed. Immunohistochemistry findings were suggestive of GIST. Wedge resection of the duodenal mass was done. Duodenal GIST should be considered as a differential in cases of GI bleeding when other differentials have been ruled out. Limited resection of duodenal GIST should be considered over pancreaticoduodenectomy, in case of small size tumors.

Comparison of Varying Bolus Doses of Oxytocin in Patients Undergoing Caesarean Spinal Delivery

Objective: To determine the lowest effective bolus dose of oxytocin to produce adequate uterine tone during elective caesarean delivery avoiding side effects. Study design and setting: A study was conducted at Rawal General and Dental Hospital, from 10th Oct, 2018 to 27th May, 2019. Methodology: Patients undergoing elective cesarean spinal delivery were randomly divided by computer generated numbers(n=155) into 5 groups A, B, C, D and E receiving 0.5, 1, 3, 5 and 10 units of injection oxytocin as bolus respectively after delivery of baby. Uterine contraction was assessed by gynecologist by manual palpation of uterus on a linear scale. Value of 8 was considered adequate and 8 inadequate uterine tone respectively. Heart rate, non-invasive blood pressure and oxygen saturation were noted before and after oxytocin bolus. All patients received oxytocin infusion. The primary outcome measure was the assessment of uterine tone at 2 minute of oxytocin bolus. The secondary outcome variables included shortness of breath, chest discomfort, top-up bolus administered, hemodynamic variables, epigastric discomfort and oxytocin related effects (tachycardia, epigastric discomfort and hypotension). Results: The use of 5 units oxytocin (group-D) showed most optimal uterine contractions, 61.3% in comparison to commonly used 10 units bolus dose (group-E) 48.4% with minimal side effects like, less tachycardia(12.9% versus 72.9%) and hypotension (12.9% versus 32.3%), no top-up bolus dose was required in 54.8% cases and no complain of epigastric discomfort was observed. Conclusion: Low doses of oxytocin are effective in terms of uterine contraction with minimal side effects

An Asymptomatic Renal Mass

Advancement in imaging techniques has now made it possible for small renal tumors to be detected incidentally. This has led to the use of minimally invasive techniques for treatment of these cases. A 40 year-old woman was diagnosed to have a small renal mass after routine abdominal ultrasonography for epigastric discomfort. Computed tomography scan was used to characterize the mass, and an elective partial nephrectomy was successfully carried out. The procedure is safe, less morbid, and has good oncological outcome. Bangladesh Journal of Urology, Vol. 19, No. 1, Jan 2016 p.49-52