A 42-year-old male presented with a history of presyncope. There was no postural hypotension or neurological cause for syncope. Electrocardiogram (ECG) only showed non-specific ST-T changes in inferior leads. Echocardiogram, exercise stress test and 24 hours holter monitoring were all normal. Computed tomography (CT) angio was done and are shown in the panels above. Q: What is the diagnosis? Answer: refer to page 71

A 34-year-old male with diabetes mellitus presented with diabetic ketoacidosis. He was treated with insulin. Echocardiography and cardiac enzymes (CKMB and troponin I) were normal. Routine electrocardiogram (ECG) was done and is shown in the above panel. Q: What is the ECG diagnosis? What are the possible diagnoses you would consider? 1: Acute ST segment elevation myocardial infarction (STEMI) 2: Hyperkalemia 3: Brugada Syndrome 4: Normal ST-T changes in a young person Answer: refer to page 69

(Refer to page 48) Answer: Brugada syndrome The patient did not have any cardiac symptoms or any cardiac enzyme changes suggestive of an acute myocardial infarction (AMI). Although not always present, the finding of reciprocal ST segment depression in opposing leads favours myocardial infarction. This was also not present in the patient’s ECG. Echocardiogram did not show any regional wall motion changes that could be seen in patients with myocardial infarction. Thus the probability of this patient having AMI based on the ECG alone is very unlikely.

(Refer to page 50) Answer: Anomalous coronary artery Panel (a) shows the right coronary artery traveling between the aorta (posterior) and pulmonary artery (anterior).

Stroke or cerebrovascular accident is common and is most commonly embolic or haemorrhagic. A common source of embolism is the heart and as such echocardiogram is an essential investigation. However, clinicians need to be aware of rare sources of embolism. We report a rare and interesting case of a 61-year-old Caucasian man who presented with stroke and on evaluation was found to have a large thrombus coiled striding over a patent foreman ovale into the right and left atrium consistent with a 'thrombus in transit'. The origin of the thrombus was later confirmed to be from the left saphenous vein. This case highlights an interesting case of 'thrombus in transit'.
Stroke ; Myxoma ; Foramen Ovale, Patent ; Embolism, Paradoxical

Myxomas are the most common type of primary cardiac tumour with 86% occurring in the left atrium. Right atrial myxomas is far less common. Patients usually present with progressive dyspnoea, fever, weight loss, right-sided heart failure, or pulmonary embolisation. We report the case of a 55-year-old man who presented with progressive dyspnoea and signs of right heart failure secondary to a large right atrial myxoma, which was diagnosed with a bedside transthoracic echocardiogram. This was successfully removed surgically.
Atrial Myxoma ; Dyspnea ; Heart Failure ; Treatment Outcome

We evaluated the performance of MGIT 960 system in terms of recover rate, detection time of mycobacteria and contamination rate from various human clinical specimens and compared it with already in use BACTEC 460 TB system and conventional LJ medium. This is the first reported study on MGIT 960 and its comparison with BACTEC 460 system in Pakistan. A total of 260 different clinical specimens received for the culture of mycobacteria were dealt during the six months study period. All the specimens were digested and decontaminated according to the standard N-acetyl-Lcysteine NaOH method. All the processed specimens were inoculated on both the liquid systems and solid medium and incubated for six weeks and eight weeks consecutively. A total of 44 mycobacterial isolates (Mycobacterium tuberculosis, n=43; Mycobacteria other than tuberculosis, n=1) were recovered from 260 clinical specimens. The recovery rate of M. tuberculosis complex was 97.6% on BACTEC MGIT 960 system and 93.0% on BACTEC 460 system and 83.7% on LJ medium. The mean detection time of mycobacteria on BACTEC MGIT 960 system was 11.2 days in smear positive cases, 14.2 days in smear negative cases and 14.8 days in smear positive cases on BACTEC 460 system. Contamination rates were 9.6% and 5.6% and 3.4% for BACTEC MGIT 960, BACTEC 460 system and LJ medium respectively. The non-radiometric, fully automated BACTEC MGIT 960 system has better diagnostic ability as compared with radiometric, semi-automated BACTEC 460 system and LJ medium, so it can be used as a reliable alternative in over burden laboratories.

The efficacy and safety of oral versus vaginal misoprostol for elective induction of labor in post date multigravida with an unfavourable cervix was compared over a period of one year in the Bahawal Victoria Hospital, Bahawalpur, Pakistan. Eightyeight multigravida post date women were divided into two groups and given 50 mg misoprostol orally and 50 mg intravaginally, respectively. The induction to onset of significant uterine contractions and delivery intervals were lower in the first group (7.8 h vs. 8.9 h) when compared to (10.4 h vs. 12 h). The first group had a higher rate of Caesarean section (7% vs. 4%; p>0.05), uterine hyperstimulation (9% vs. 5%; p>0.05), uterine tachysystole (23% vs. 14%; p>0.05) and neonatal admissions to intensive care unit (12% vs. 4%; p>0.05) when compared to second group. Fifty mg oral misoprostol has the potential to induce labor as safely and effectively as the intravaginal route.