BACKGROUND: Agitation occurs frequently among criticaly il patients admitted to the intensive care unit (ICU). We aimed to evaluate the frequency, predisposing factors and outcomes of agitation in trauma ICU. METHODS: A retrospective analysis was conducted to include patients who were admitted to the trauma ICU between April 2014 and March 2015. Data included patient's demographics, initial vitals, associated injuries, Ramsey Sedation Scale, Glasgow Coma Scale, head injury lesions, use of sedatives and analgesics, head interventions, ventilator days, and ICU length of stay. Patients were divided into two groups based on the agitation status. RESULTS: A total of 102 intubated patients were enrolled; of which 46 (45％) experienced agitation. Patients in the agitation group were 7 years younger, had significantly lower GCS and sustained higher frequency of head injuries (P<0.05). Patients who developed agitation were more likely to be prescribed propofol alone or in combination with midazolam and to have frequent ICP catheter insertion, longer ventilatory days and higher incidence of pneumonia (P<0.05). On multivariate analysis, use of propofol alone (OR=4.97; 95％CI=1.35–18.27), subarachnoid hemorrhage (OR=5.11; 95％CI=1.38–18.91) and ICP catheter insertion for severe head injury (OR=4.23; 95％CI=1.16–15.35) were independent predictors for agitation (P<0.01). CONCLUSION: Agitation is a frequent problem in trauma ICU and is mainly related to the type of sedation and poor outcomes in terms of prolonged mechanical ventilation and development of nosocomial pneumonia. Therefore, understanding the main predictors of agitation facilitates early risk-stratification and development of better therapeutic strategies in trauma patients.

The introduction of laparoscopic cholecystectomy has stimulated a renewed interest in the anatomy of Calot’s triangle 1. This triangle is a focal area of anatomical importance in cholecystectomy and a good knowledge of its anatomy is essential for both open and laparoscopic cholecystectomy 2, 3. This triangle was described by Calot in 1891 as bounded by the cystic duct, the right hepatic duct and lower edge of liver 4. In its present interpretation the upper border is formed by the inferior surface of the liver with the other two boundaries being the cystic duct and the common hepatic duct 2,5. Its contents usually include the right hepatic artery (RHA), the cystic artery, the cystic lymph node (of Lund), connective tissue and lymphatics 5,6. The cystic artery is a branch of the RHA and is usually given off in Calot’s triangle 7. Anatomic variations in Calot’s triangle are common. Variations in cystic artery anatomy, based on its origin, position and number are well described 3, 8 because of its importance in avoiding inadvertent bleeding and its consequences. The reported incidence of these variations is from 25 to 50 % in various studies 3,9 with the magnified laparoscopic view having increased the frequency of recognition of these variations. The methods of retraction used in the laparoscopic procedure gives a different view of the area, thus introducing the term ‘laparoscopic anatomy’7. Accurate knowledge of cystic artery anatomy and its variations can reduce the likelihood of uncontrolled intraoperative bleeding, an important cause of iatrogenic extra hepatic biliary injury and conversion to open cholecystectomy 3, 7, 8. The incidence of conversion to open surgery due to vascular injury is reported to be 0-1.9% and its mortality 0.02% 3, hence these variations should stay in surgical conscience to prevent procedure related morbidity. We aim to present the variations in cystic artery seen in laparoscopic cholecystectomy in our patient population.

Left atrial intramural hematoma is a very rare complication of radiofrequency ablation procedures. A patient with tachyarrhythmia underwent radiofrequency catheter ablation. Echocardiography performed the following morning showed a large mass in the left atrium, suggestive of intramural hematoma formation. The patient was in a stable condition; therefore, it was decided that follow-up should be conservative and her anticoagulation therapy was continued. The size of the hematoma decreased significantly over the following 50 days. This case highlights a rare complication of a complex catheter ablation procedure in the left atrium that was managed via a noninvasive approach, with which all interventionists should be familiar.
Catheter Ablation* ; Catheters* ; Echocardiography ; Follow-Up Studies ; Heart Atria ; Hematoma* ; Humans ; Tachycardia

BACKGROUND: Chronic lymphocytic leukemia (CLL) exhibits profound heterogeneity in its clinical course. Its clinicohematological and cytogenetic features play a significant role in determining the clinical course and in predicting the treatment response and prognosis. In this context, 17p deletion is known to predict a poor prognosis, as these cases are refractory to conventional therapy. This study aimed to evaluate the clinicohematological characteristics, outcomes, and prognostic factors among CLL patients with and without del 17p in Pakistan. METHODS: This prospective observational study was conducted at the Department of Haematology, Armed Forces Institute of Pathology (Rawalpindi, Pakistan) between January 2013 and December 2017. Patients were diagnosed based on the International Workshop on Chronic Lymphocytic Leukaemia IWCLL criteria, their clinicohematological parameters were recorded, and cytogenetic analyses were performed. The time from diagnosis to treatment and the 2-year overall survival rate were also evaluated. RESULTS: We evaluated 130 CLL cases, including 24 patients (18.5%) with del 17p, who included 18 men (75%) and 6 women (25%). The median age was 68 years. Binet stage C was detected at the presentation in 16 patients (67%). Treatment was administered to 14 patients (70%) at a median interval of 11 months (range, 0–28 mo) after diagnosis. The overall response rate was 64.3%, the median event-free survival was 9 months (range, 1–23 mo), and the 2-year overall survival rate was 65%. CONCLUSION: Del 17p is relatively common in Pakistan, and patients harboring this deletion had poor treatment response and survival outcomes.
Arm ; Cohort Studies* ; Cytogenetic Analysis ; Cytogenetics ; Diagnosis ; Disease-Free Survival ; Education ; Female ; Humans ; In Situ Hybridization, Fluorescence ; Leukemia, Lymphocytic, Chronic, B-Cell* ; Male ; Observational Study ; Pakistan* ; Pathology ; Population Characteristics ; Prognosis ; Prospective Studies ; Survival Rate

The angiotensin converting enzyme (ACE) is a strong candidate gene for myocardial infarction (MI). Insertion-deletion dimorphism in intron 16 of this gene has been inconclusively found to be associated with it. Several new polymorphisms in the ACE gene have been identified and among these, a dimorphism in exon 17, ACE G2350A, has a significant effect on plasma ACE concentrations. To assess the value of genotyping the ACE G2350A dimorphism in a genetically homogeneous population, we carried out a case-control study of dimorphism G2350A for a putative association with MI among Pakistani nationals. We investigated a sample population of 370 Pakistanis, comprising 163 controls, and 207 patients with clinical diagnosis of acute MI (AMI). ACE G2350A alleles were visualized by assays based on polymerase chain reaction and restriction endonuclease analysis. Frequencies of G alleles were 0.68 among controls and 0.72 among AMI patients. The ACE G2350A dimorphism showed no significant association with MI (c2=0.90, 2 df, P=0.64), plasma levels of homocysteine (P=0.52) or with serum levels of folate (P=0.299). The results indicate that ACE G2350A polymorphism is not associated with risk of myocardial infarction in the Pakistani population investigated here.
Adult ; Aged ; Exons/*genetics ; Female ; Genetic Predisposition to Disease ; Genetics, Population ; Genotype ; Humans ; Male ; Middle Aged ; *Mutation ; Myocardial Infarction/blood/*genetics ; Peptidyl-Dipeptidase A/blood/*genetics ; *Polymorphism, Genetic ; Predictive Value of Tests

OBJECTIVETo determine the presence of Babesia bovis (B. bovis) in large ruminants in southern Punjab and its effect on hematological and serum biochemical profile of host animals.

METHODSBlood samples were collected from 144 large ruminants, including 105 cattle and 39 buffaloes, from six districts in southern Punjab including Multan, Layyah, Muzaffar Garh, Bhakar, Bahawalnagar and Vehari. Data on the characteristics of animals and herds were collected through questionnaires. Different blood (hemoglobin, glucose) and serum (ALT, AST, LDH, cholesterol) parameters of calves and cattle were measured and compared between parasite positive and negative samples to demonstrate the effect of B. bovis on the blood and serological profile of infected animals.

RESULTS27 out of 144 animals, from 5 out of 6 sampling districts, produced the 541-bp fragment specific for B. bovis. Age of animals (P=0.02), presence of ticks on animals (P=0.04) and presence of ticks on dogs associated with herds (P=0.5) were among the major risk factors involved in the spread of bovine babesiosis in the study area. ALT concentrations were the only serum biochemical values that significantly varied between parasite positive and negative cattle.

CONCLUSIONS: This study has reported for the first time the presence of B. bovis in large ruminant and the results can lead to the prevention of babesiosis in the region to increase the livestock output.

Alanine Transaminase ; blood ; Animals ; Aspartate Aminotransferases ; blood ; Babesia bovis ; genetics ; Babesiosis ; blood ; epidemiology ; parasitology ; Blood Glucose ; analysis ; Buffaloes ; Cattle ; Cattle Diseases ; blood ; epidemiology ; parasitology ; Cholesterol ; blood ; India ; epidemiology ; L-Lactate Dehydrogenase ; blood ; Polymerase Chain Reaction ; RNA, Protozoan ; blood ; RNA, Ribosomal ; blood ; Surveys and Questionnaires

A multi-centred study was designed to collect dengue epidemiologic data from government and registered private hospitals/clinics and maintained archive of frozen specimens in bio-bank to be used for future dengue epidemic control program, and assess the epidemiology of dengue fever (DF) by evaluating biochemical and oxidative status of patients. ELISA IgM antibodies test was done to confirm DF. From August 2010 to December 2011, 101 confirmed blood samples of DF patients referred to pathology lab of Jinnah Hospital Lahore were subjected to the epidemiologic assessment by evaluating the biochemical and physiological indices and alterations of circulating antioxidants. Clinical features of DF patients and effect of fever on blood components and serum proteins of liver were recorded. The hospital stay in DF, dengue hemorrhagic fever (DHF) and dengue shock syndrome (DSS) showed significant difference. Significant increases in serum alanine amino transferase (ALT) (P=0.000), aspartate amino transferase (AST) (P=0.000), alkaline phosphatase (ALP) (P=0.000), malondialdehyde (MDA) along with significant decreases in total protein (TP) (P=0.000), reduced glutathione (GSH) (P=0.000), superoxide dismutase (SOD), catalase (CAT) (P=0.000), and sialic acid contents (P=0.016) were observed. A positive correlation existed between bound sialic acid levels, liver enzymes and circulating antioxidants (r=0.656, P=0.016). In the present study, alterations of circulating antioxidants in DF suggest that DF might be a metabolic response to an acute, self-limiting tropical viral infection, and a consequence of the viral inflammatory process.
Adult ; Antioxidants ; metabolism ; Biomarkers ; blood ; China ; Dengue ; classification ; diagnosis ; metabolism ; Diagnosis, Differential ; Female ; Humans ; Immunoglobulin M ; metabolism ; Male ; Middle Aged ; Young Adult

Objective: To determine epidemiological, molecular characterization, and potential risk factors of human brucellosis. Methods: This descriptive study was carried out in the clinical setting in Iran between 2017 and 2018. A total of 297 participants enrolled in the study. The sample size was calculated based on the occurrence rate of brucellosis in different areas. Patients were assessed using serological tests and conventional culture methods. Phage and multiplex PCR methods typed all of Brucella isolates. Potential risk factors of disease were determined. Results: A total of 141 of 297 (47.5%) Brucella strains were isolated and all of them were detected as Brucella melitensis biovar 1. Based on serologic titers, high culture positivity was recorded at 1/640 titer (P< 0.006). The risk factors for brucellosis were patients older than 40 years (OR=2.23, 95%CI: 1.4-3.55, P=0.001), animal keeper (OR=7, 95%CI: 1.51-32.41, P=0.005), housewife (OR=8.76, 95%CI: 1.85-41.37, P=0.002), farmer (OR=6.42, 95%CI: 1.21-33.97, P=0.019), and contact with animal (OR=1.31, 95%CI: 0.60-2.85, P=0.005). Conclusions: To the best of our knowledge, this is the first comprehensive report from Iran presenting the detection of Brucella species by the multiplex PCR. Brucella melitensis biovar 1 is still the dominant causative agent in Iran. The consumption of unpasteurized dairy products, living in rural areas, and animal contact were risk factors of brucellosis.