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Khalid Aziz Ansari,1 Marwan Jabr Alwazzeh,2 Feras Ahmed Alkuwaiti,2 Faraz Ahmed Farooqi,3 Noor Al Khathlan,1 Hussain Almutawah,1 Mustafa Alahmed,1 Hussain Alfaraj,1 Ahmed Aljarrash,1 Jaffar Almadhary,1 Sarah Alwarthan,2 Ahmed Mohammed Alsahlawi,2 Abdullah Bandar Almashouf,2 Moammer Alqasim,2 Elaf Alkuwaiti4 1Department of Respiratory Care, College of Applied Medical Science, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 2Department of Internal Medicine, College of Medicine, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 3Department of Dental Education, College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia; 4College of Dentistry, Imam Abdulrahman Bin Faisal University, Dammam, Saudi ArabiaCorrespondence: Khalid Aziz Ansari, Email kaansari@iau.edu.saPurpose: This study investigated the clinical determinants of mortality in hospitalized patients infected with COVID-19.Patients and Methods: A retrospective multicenter large cohort of COVID-19 patients hospitalized between March 2020 and February 2021. We included patients admitted with a confirmed COVID-19 infection with positive COVID-19 through real-time polymerase chain reaction (RT-PCR). SPSS version 25.0 (Armonk, NY: IBM Corp.) was used to analyze the data.Results: Among the study participants (n = 1444), the mean age of the population was 49.22± 17.69 years, of which 63.9% were males (n = 924). Overall, the mean age for non-survivors was 55.65 ± 16.41 years and the length of ICU stay was 13.95 ± 12.4 years. The most common comorbidity among the study subjects was hypertension (HTN) (32.7%), followed by cardiovascular disease (CVD) (10.7%). Patients who were mechanically ventilated (MV) had higher mortality than those who did not require MV (p < 0.001).Conclusion: Our study concluded that old age, the presence of underlying cardiovascular conditions, an abnormal WBC count (leukopenia or leukocytosis), and abnormal blood urea nitrogen (BUN) levels are among the independent predictors of mortality in the Saudi population. These findings may guide health care providers to manage COVID-19 patients more effectively with better outcomes.Keywords: COVID, predictors, KSA, mortality, healthcare

The diagnostic accuracy of tuberculosis can be enhanced by new tests like gamma interferon used in conjunction with tuberculin test but these tests are quite expensive to be conducted on all animals in resource poor countries. The present study was conducted to clarify the usefulness of haematological parameters and changes in serum proteins along with tuberculin test in different animal species. In buffaloes, significantly lower RBC count, WBC count, Hb concentration, neutrophils and eosinophils while significantly higher monocytes percentage along with serum total proteins, albumin and globulins were observed in tuberculin positive reactors. In cattle, significantly lower RBC count, PCV, neutrophils and serum albumin, while lymphocyte percentage was significantly higher in positive reactor animals. In sheep, PCV was lower in positive reactors. In goats, basophils percentage was significantly higher (P = 0.002) in positive reactors. A significant positive correlation of Hb with RBC and PCV in positive reactor buffaloes, goats and sheep was observed. The correlation statistics for differential leukocyte percentage did not differ between positive and negative reactor animals of these species. In cattle and goats, albumin showed significant positive correlation with globulins in negatively reacting animals, while this correlation was non-significant in positive reactor animals. In buffaloes, albumin showed a significant positive correlation with globulins and this correlation was non-significant in negative reactor buffaloes. It was concluded that tuberculosis caused decrease in erythrocyte parameters including RBC count, PCV and Hb concentration, while it caused an increase in monocytes, eosinophils and lymphocytes. [ABSTRACT FROM AUTHOR]

Background: An increased level of interleukin-17A and interleukin-18 in the serum and intestinal mucosa of celiac disease patients reflecting the severity of villous atrophy and inflammation was documented. Thus, the objective of this study was to evaluate the concentrations of salivary-17A, interleukin-1 beta, and interleukin-18 in patients with celiac disease who are on a gluten-free diet, both with and without periodontitis, and to compare these levels with those in healthy individuals., Methods: The study involved 23 participants with serologically confirmed celiac disease (CD) and 23 control subjects. The CD patients had been following a gluten-free diet (GFD) for a minimum of 1 year and had no other autoimmune disorders. The research involved collecting demographic data, conducting periodontal examinations, gathering unstimulated whole saliva, and performing enzyme-linked immunosorbent assays to measure salivary interleukin-17A, interleukin-1 beta, and interleukin-18 levels. Spearman's correlation analysis was utilized to explore the relationships between CD markers in patients on a GFD and their periodontal clinical findings., Results: The periodontal findings indicated significantly lower values in celiac disease patients adhering to a gluten-free diet compared to control subjects ( p = 0.001). No significant differences were found in salivary IL-17A, IL-18, and IL-1B levels between celiac disease patients and control subjects. Nevertheless, the levels of all interleukins were elevated in periodontitis patients in both the celiac and control groups. The IL-1 Beta level was significantly higher in periodontitis patients compared to non-periodontitis patients in the control group ( p = 0.035). Significant negative correlations were observed between serum IgA levels and plaque index (r = -0.460, p = 0.010), as well as gingival index (r = -0.396, p = 0.030) in CD patients on a gluten-free diet., Conclusion: Celiac disease patients on gluten-free diet exhibited better periodontal health compared to control subjects. However, increased levels of salivary IL-17A, IL-18 and IL-1B levels were associated with periodontitis. Additionally, serum IgA level was significantly inversely associated with periodontitis clinical manifestations and with salivary inflammatory mediators in CD patients on GFD., Competing Interests: The authors declare that they have no competing interests., (© 2024 Madi et al.)

Background: Successful root canal treatment is influenced by the apical extent of root canal preparation and the eventual root canal filling. Achieving the full working length until the apical constriction, which is usually 0.5 - 1 mm shorter than the anatomical apex, is crucial. Electronic apex locators were used to detect the working length more accurately. There are six generations of electronic apex locators in the market. The selection of the appropriate irrigation with each apex locator for accurate working length determination is not fully investigated. Methods: The actual working lengths of 120 freshly extracted human single-rooted teeth were measured and compared with their working lengths using 3 rd generation (Root ZX) followed by 6 th generation (Raypex 6) apex locators in dry medium, presence of 5.25% sodium hypochlorite, and 2% chlorhexidine, without coronal pre-flaring and after coronal pre-flaring using the same irrigating media. Data were collected, tabulated, and afterward analyzed using one-way ANOVA with post-hoc to evaluate the significant difference in average working length between actual working length, Root ZX, and Raypex 6 apex locator working lengths accuracy. Results: The significant results were shown in roots that were coronally pre-flared and their working lengths were measured in a dry medium using Raypex 6 apex locator. While using the Root ZX apex locator, the most accurate results were shown in roots that were coronally pre-flared and their working lengths were measured while using a chlorhexidine irrigating solution. Conclusions: It is concluded that it is very important to know the specific irrigating medium to be used with each specific electronic apex locator to achieve the most accurate working length results., Competing Interests: No competing interests were disclosed., (Copyright: © 2023 Rifaat S et al.)

Diagnostic laboratory tests are frequently overused in healthcare entities, leading to an increased strain on laboratory resources, additional workload, and wastage of resources. Continuous monitoring of test ordering behavior is crucial to evaluate clinical necessity. This cross-sectional study aimed to estimate the necessity of ordering clinical chemistry tests in the cardiology clinic of a tertiary center in Saudi Arabia. We retrieved medical records of patients diagnosed with cardiovascular problems admitted at the cardiology clinic in 2020. The frequency and percentages of the ordered tests were calculated upon admission and follow-up, and the difference between necessary and unnecessary tests was compared for each category. Test ordering assessment included cardiac, renal, and liver functions, blood gases, thyroid and diabetic profile, iron indices, hormones, water and electrolytes, and inflammatory markers. The results showed a large number of clinical chemistry tests ordered without clinical necessity. While the number of necessary tests was significantly higher than that of unnecessary tests, 21% of the tests ordered between June-December 2021 at the center were unnecessary. Further studies are necessary to identify driving factors and develop strategies to reduce the overutilization of diagnostic laboratory tests in clinical practice. Eliminating this phenomenon will reduce the risk of unnecessary medical interventions and associated costs, improve patient outcomes, and reduce the overall burden on the healthcare system., Competing Interests: The authors declare no conflict of interest., (©2023 JOURNAL of MEDICINE and LIFE.)

Porphyrias, particularly acute intermittent porphyria (AIP), are rare, inherited disorders of heme synthesis. On the other hand, systemic lupus erythematosus (SLE) is an uncommon autoimmune disease that affects women predominantly. The coexistence of AIP and SLE is rare. We report a case of concomitant diagnosis of AIP and SLE in a 21-year-old woman who presented with recurrent acute abdominal, chest, and back pain associated with nausea and vomiting, followed by arthralgia, multiple joint pain, and rash. Investigations revealed severe hyponatremia related to SIADH (syndrome of inappropriate antidiuretic hormone secretion) with a positive SLE antibody panel and a positive urine screen for porphobilinogen. Molecular test confirmed the diagnosis of AIP with a pathogenic mutation in the HMBS gene.

This study aimed to measure the level of vaccine hesitancy among the Saudi population using the WHO Vaccine Hesitancy Scale (VHS). A cross-sectional study using a modified vaccine hesitancy scale (VHS) was conducted among Saudi Arabian residents between April 4 and May 24, 2021. The relationship between participants' willingness to uptake COVID-19 vaccines and their demographics, awareness of COVID-19, and health status was evaluated. The chi-square test was employed to compare categorical variables and logistic regression for the associations of demographical characteristics with acceptance of the vaccine. We received a total of 1657 completed responses. 1,126 participants (68%) were vaccinated, of which 19% were vaccinated with one dose only, and 49% were fully vaccinated (with two doses). Safety concerns and worries about side effects were higher among the hesitant group (p<0.001). 96% of the participants from the willing group were not hesitant to have the vaccine, whereas in the same group, 70% thought they had good health and the vaccine was not needed. Logistic regression analysis revealed that participants with chronic diseases had lower odds of being willing to be vaccinated (OR=0.583, p-value 0.04). The study findings suggest key factors associated with COVID-19 vaccine hesitancy in the Saudi population and can help public health authorities plan strategies to minimize vaccine hesitancy and improve awareness about vaccine acceptance., Competing Interests: The authors declare no conflict of interest., (©2022 JOURNAL of MEDICINE and LIFE.)

Photoaging is not only the main cause of skin aging caused by exogenous factors, it is also related to a variety of skin diseases and even malignant tumors. Excessive and repeated exposure to ultraviolet radiation, especially UVA induces oxidative stress, DNA damage, inflammation, and collagen and elastin degeneration, ultimately leads to skin photoaging, manifested by skin redness, coarse wrinkles, and pigmentation even skin cancer. There has been a large demand of effective prevention and medications but approaches in the current management of photoaging are very limited. In the previous study, we found that a non-coding circular RNA circ&#95;0011129 acts as a miR-6732-5p adsorption sponge to inhibit the reduction of type I collagen and the denaturation and accumulation of elastin in UVA-induced HDF cells photoaging model. However, in vivo instability and efficient delivery to the target cell of circRNA is a major challenge for its clinical application. Therefore, improving its stability and delivery efficiency are desired. In this study, we proposed a strategy of delivering circ&#95;0011129 with small extracellular vesicles (sEVs) from human adipose-derived stem cells (hADSCs) to intervene in the photoaging process. The results showed that sEVs from hADSCs in 3D bioreactor culture (3D-sEVs) can prevent photoaging. Consequently, by overexpressing circ&#95;0011129 in hADSCs, we successfully loaded it into 3D-sEVs (3D-circ-sEVs) and its protective effect was better. Our studies provide a novel approach to preventing skin photoaging, which has important clinical significance and application value for the development of non-coding RNA drugs to treat skin photoaging. We first screened out hADSCs-derived sEVs with excellent anti-oxidant effects. We then compared the sEVs collected from traditional 2D culture with 3D bioreactor culture. By miRNA-seq and GEO data analysis, we found that miRNAs in 3D-sEVs were enriched in cell activities related to apoptosis, cellular senescence, and inflammation. Subsequently, we prepared circ&#95;0011129-loaded 3D-sEVs (3D-circ-sEVs) by overexpressing it in hADSCs for the treatment of photoaging in vitro. We proved that 3D-circ-sEVs can interfere with the process of cell photoaging and protect cells from UVA radiation damage, as well as in a H2O2-induced oxidative stress model.

Background & Objectives: The novel coronavirus (SAR-CoV-2) pandemic has revolutionized medical education worldwide. Most medical schools have adopted the online teaching and assessments. Students attending modified clerkships and assessments under the stress of the pandemic, perform and score differently when compared to normal clerkships. We aimed to identify the impact of COVID-19 on final year MBBS students' EOC (End of Clerkship) examination by comparing them with their scores prior to the COVID and with scores of the previous final year., Methods: This cross-sectional study was conducted at Shifa College of Medicine. Final year MBBS students' scores of years 2019 and 2020 were included. Students' EOC MCQ and OSCE scores were compared in pre-COVID and COVID affected rotations of the same year and with the previous year (2019). Data were analyzed in SPSS version 21, means scores were calculated, and one-way ANOVA was applied. Pearson correlation was calculated for correlation assessment of MCQ and OSCE scores., Results: There were 118 students. The mean EOC, OSCE, and MCQ scores in rotations one to four were 72.8±6.4, 73.3± 8.1, 71.6± 7.4, 72.7± 6.7 and 44.4± 8, 47.2± 8.4, 46.1± 8.2, 48.8± 8.1, respectively. One-way ANOVA results before and after COVID lockdown were statistically insignificant (p=0.3) for OSCE and significant for MCQ in the final year class of 2020 (p=0.001). The Pearson correlation assessment between MCQ and OSCE scores (n=416) had a significant positive correlation (r=0.42, p=0.000). The overall comparison between scores of the final year class of 2019 and 2020 showed significant improvement in Surgery and Obstetrics/Gynae scores in 2020., Conclusion: During the COVID pandemic, the final year students' performance in EOC MCQ and OSCE over all remained unaffected., (Copyright: © Pakistan Journal of Medical Sciences.)

Background: Currently, world is suffering from a respiratory disease names as COVID-19. This is a novel coronavirus (n-CoV), a new strain which has not been previously identified in humans and it has spread in more than 100 locations internationally due to which it is termed as "public health emergency of international concern" (PHEIC) by the World Health Organization So far, no study done as yet to assess whether the dental workforce is aware about the facts and myths related to Covid-19 awareness., Objective: This study aims to analyze and compare the level of awareness about the facts and myths related to COVID-19 amongst faculty, dental students and prep year students of the College of Dentistry (COD) as part of an awareness campaign., Methods: An awareness test about COVID-19 was designed using information from the World Health Organization's (WHO) Myth Busters Awareness webpage. The questionnaire was administrated online to faculty and students, of the College of Dentistry and preparatory year students who had applied for the admission to the dental college using a secure enterprise online assessment platform (Blackboard). The tests were administered over a period of three months from March to June 2020. A written informed consent was obtained., Results: The online COVID-19 awareness test was administered to 810 participants, out of which 325 (40%) were prep year students, 429(53%%) were dental students, and 56 (7%) were faculty members. Analysis of the results showed that 86% of the Faculty were able to correctly identify the facts and the myths related to COVID-19 followed by 81% of the prep year students and 74% of the dental students. Preparatory year student's knowledge related to COVID-19 was found to be high when compared to dental students (26.47±4.27, 23.67±6.2). Student to faculty knowledge score did not differ significantly (p = 0.808)., Conclusion: This study reports about a successful pilot test conducted to assess the perceived knowledge about facts and myths related to corona virus amongst the dental workforce., Competing Interests: The authors have declared that no competing interests exist.

Background:  Online learning or E-learning are approaches to broadcasting teaching by the means of internet technology and software applications. Kingdom of Saudi Arabia is likewise embarking on the rapid growth in online education. The purpose of this study is to investigate the student's perceptions regarding online teaching and learning during COVID 19. Methods:  An online computer-based cross-sectional study was conducted between May and June 2020. A pre-validated questionnaire was used and administrated to health sciences students studying at Dammam Universities through online software QuestionPro. Results:  Out of total 281, 68% of the participants were females (n=188) while 31.9% (n=88) were male students with an average age of 23.1(4.5) years. Overall, 176 (62%) of the students expressed their satisfaction with online learning. Conclusion:  Findings will help academicians to identify strengths, areas of improvement, and encourage faculty to think deeply to restructure course learning objectives, teaching techniques to engage students and improve learning process., Competing Interests: No competing interests were disclosed., (Copyright: © 2021 Aziz Ansari K et al.)

Objective:  The aims of this study were to investigate the awareness, knowledge, and attitudes of Pakistani medical and dental undergraduate students toward COVID-19 during the surge of its outbreak., Materials and Methods:  The multicentered, cross-sectional study was carried out nationwide among undergraduate medical and dental students. A convenience sampling technique was used. A self-developed online questionnaire was pretested to be completed by the participants. It was distributed using social media. The survey was comprised of questions related to demographics, health status, general hygiene perception, understanding, and the learning attitudes of the students. Comparisons of the knowledge scores and the attitude responses with the demographic information were done using the independent t -test, one-way ANOVA, and Chi-square, as appropriate., Results:  Of the 937 total respondents, 353 (38%) were males and 582 (62%) were females; two students did not mark their gender. Of these, 680 (73%) were dental students and 257 (27%) were medical students. The mean knowledge score of the female dental students (5.15 ± 1.08) was significantly higher than that of the male students (4.87 ± 1.09). Overall, the mean knowledge score was statistically higher among the medical students in comparison to the dental students (5.21 ± 1.15, 5.05 ± 1.09; p = 0.054), respectively., Conclusion:  The medical and dental students were both aware of the importance of the use of a mask. The medical students had a greater awareness regarding the mode of transmission, symptoms, and origin of COVID-19. However, the dental students showed better understanding of the use of surgical masks and the correct protocol for hand washing. Social media was considered the main source for COVID-19 related information., Competing Interests: None declared., (European Journal of Dentistry. This is an open access article published by Thieme under the terms of the Creative Commons Attribution-NonDerivative-NonCommercial-License, permitting copying and reproduction so long as the original work is given appropriate credit. Contents may not be used for commercial purposes, or adapted, remixed, transformed or built upon. (https://creativecommons.org/licenses/by-nc-nd/4.0/).)

Phenolics drive the global economy, but they also pose threats to soil health and plant growth. Enzymes like peroxidase have the potential to remove the phenolic contaminants from the wastewater; however, their role in restoring soil health and improving plant growth has not yet been ascertained. We fractionated efficient peroxidases (MPx) from leaves of an invasive species of Mesquite, Prosopis juliflora, and demonstrated its superiority over horseradish peroxidase (HRP) in remediating phenol, 3-chlorophenol (3-CP), and a mixture of chlorophenols (CP-M), from contaminated soil. MPx removes phenolics over a broader range of pH (2.0-9.0) as compared with HRP (pH: 7.0-8.0). In soil, replacing H 2 O 2 with CaO 2 further increases the phenolic removal efficiency of MPx (≥90% of phenol, ≥ 70% of 3-CP, and ≥90% of CP-M). MPx maintains ~4-fold higher phenolic removal efficiency than purified HRP even in soils with extremely high contaminant concentration (2 g phenolics/kg of soil), which is desirable for environmental applications of enzymes for remediation. MPx treatment restores soil biological processes as evident by key enzymes of soil fertility viz. Acid- and alkaline-phosphatases, urease, and soil dehydrogenase, and improves potential biochemical fertility index of soil contaminated with phenolics. MPx treatment also assists the Vigna mungo test plant to overcome toxicant stress and grow healthy in contaminated soils. Optimization of MPx for application in the field environment would help both in the restoration of phenolic-contaminated soils and the management of invasive Mesquite., Competing Interests: Declaration of competing interest Authors declare no competing interests of any kind. All authors declare lack of any financial and personal relationships or interest with other people or organizations having any influence on the present work., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

The need for cardiac device implantation in patients receiving deep brain stimulation (DBS) is increasing. Despite the theoretical risk of the two systems interacting, there are no clear guidelines for cardiologists carrying out cardiac device implantation in this population. We performed a review of the literature and describe 13 case reports in which patients have both DBS and a cardiac pacemaker or ICD implanted. Except for one early study, in which an ICD shock reset the deep brain stimulator, no significant interactions have been reported. We discuss the potential interactions between DBS and cardiac devices, and provide practical advice for implanting cardiologists. We conclude that, provided that specific precautions are taken, cardiac device implantation is likely to be safe in patients with DBS., Competing Interests: Disclosure: The authors have no conflicts of interest to declare.

Canine babesiosis is an important tick-borne protozoal disease of dogs that poses major health problem worldwide. Farm dogs in rural areas are the companion animals, that not only watch the livestock herds but also guard the house of the owners. Each farmer keeps his companion dog to get all the services. In our study, a total of 450 blood samples of farm dogs from three different ecological zones (Southern, Central and Northern regions of the province; Punjab) of Pakistan, were collected to examine through microscopy and PCR. Examination of thin blood smears revealed an overall prevalence of 12.8% (58/450) of canine babesisal parasites. However, PCR analysis revealed 46.8% (211/450) and 7.3% (33/450) samples positive for B. gibsoni and B. vogeli, respectively. The amplicons of 671 bp and 590 bp were amplified for the detection of B. gibsoni and B. vogeli, respectively through PCR. The results of multivariate analysis showed that the occurrence of canine babesiosis is higher in the Central Punjab and younger age of the dogs, while breed and sex of the host were not significantly associated with the occurrence of the disease. Mixed infection of B. gibsoni and B. vogeli was observed only in 3 dogs each in district Kasur and Rawalpindi. Our study is the first report to observe the occurrence of canine babesiosis in rural dogs in Pakistan through PCR.

Implantable cardioverter defibrillators (ICDs) save lives in selected patients at risk of sudden cardiac death. However, in patents suffering with terminal illness, ICD therapy could pose a risk of unnecessary futile shocks which could lead to undignified discomfort in their final days of life. National guidelines advise that patients approaching the end of their natural life should be offered a compassionate choice of having their defibrillator deactivated. Following an actual clinical incident involving a patient receiving avoidable ICD shocks in his final hours, we identified shortcomings in communication and gaps in knowledge about ICD management in end-of-life care. We developed a quality improvement programme targeting training and educational support to general physicians and nurses at our large District General Hospital. A series of interventions were delivered including Grand Round presentation, departmental seminars and publicity posters. In parallel, we introduced a local protocol for implementing ICD deactivation which was published on our intranet for Trust-wide accessibility. Following interventions, we examined the clinical notes of each end-of-life care patient who died with an ICD in situ over a 6-month observation period and recorded the proportion who received consent-guided ICD deactivation versus died with an active ICD in situ because no deactivation discussion had been offered. Before our interventions in 2015, 0 out of 10 eligible patients (0%) received consent-guided ICD deactivation. Six months into our campaign to encourage healthcare workers to undertake advance care planning discussion in 2016, 7 out of 13 eligible patients (54%) received consent-guided ICD deactivation and no patients received shocks in their final month of life. This programme was successful in raising awareness of this emerging issue, improving physician knowledge and delivering patient choice as well as contributing to safe and compassionate end-of-life care., Competing Interests: Competing interests: None declared.

We report an unusual case of an elderly man presenting with a fast-growing large malignant tumour involving the skin overlying his permanent pacemaker site. The fast-growing cutaneous squamous cell carcinoma appeared 2 years after pacemaker implantation. Joint specialist input was required to tackle this complex problem as a wide surgical excision would expose the pacemaker generator risking device infection particularly if the skin graft reconstruction failed. Having established that the patient had minimal pacing needs, it was determined through expedited multidisciplinary discussion that the best option was excision of the lesion with skin grafting of the defect by maxillofacial surgical team and pacemaker generator removal by a cardiologist in a joint surgical procedure. The procedure was successful and uneventful. This case highlights how effective multidisciplinary planning can help achieve a favourable clinical outcome in a patient with a rare case of a squamous cell carcinoma overlying a pacemaker site., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Ltd (unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)

We submit a case of a young patient with known severe left ventricular (LV) systolic impairment who presented with recurrent flash pulmonary oedema (FPO) requiring multiple high-dependency care admissions. Despite extensive optimisation of his underlying heart failure, the presentations remained frequent. Investigations for alternative diagnosis were not approached due to the presence of LV impairment and compliance being questioned. However, deteriorating renal function prompted further investigation with multiple imaging modalities, and an effective diagnosis of bilateral renal artery stenosis secondary to an aortoiliac thrombus was made. At the point of diagnosis, it was felt that rescue of renal function was unfeasible and thus the patient was started on anticoagulation, with initiation of peritoneal dialysis planned. This case highlights the importance of considering alternative diagnoses for the presentation of FPO even in the presence of LV impairment. If this patient had received a prompter diagnosis it is possible that the outcome would have been different., (2015 BMJ Publishing Group Ltd.)

We describe a case of a 74-year-old woman who presented with symptoms of fever and lethargy, associated with an episode of cardiac syncope and exertional shortness of breath (SOB). She was diagnosed with Staphylococcus aureus infective mural endocarditis (IE) and subsequent transoesophageal echocardiogram (TOE) confirmed this diagnosis. As the vegetative mass arose from the septal wall, an unusual location, it caused left ventricular outflow tract (LVOT) obstruction and therefore behaved similarly to a subaortic valvular stenosis. There were no conduction abnormalities on the ECG and no clinical or echocardiographic features of congestive heart failure. The finding of LVOT obstruction explained the unusual presentation with syncope and exertional SOB making this case unique. Owing to the large vegetative mass and thereby its high risk of septic emboli, the patient underwent successful surgical resection of the mass with resolution of the obstruction. She successfully completed intravenous antibiotics and was discharged from hospital., (2015 BMJ Publishing Group Ltd.)

Cardiac involvement in sarcoidosis has been reported to be as high as 50% of cases and it is well documented that it is associated with a poorer prognosis. Early recognition and treatment is key to reducing the risk of fatal arrhythmias and heart failure. We report a case of undiagnosed systemic sarcoidosis in a young man who initially presented to the emergency department with complete heart block in the context of preserved biventricular systolic function, and then again with ventricular tachycardia and moderately impaired left ventricular systolic function. We discuss how 18F-fluorodeoxyglucose positron emission tomography with CT was used for accurate diagnosis and how its role in the management of sarcoidosis has expanded with recent evidence suggesting it to be a mainstay of management and disease monitoring in cardiac sarcoidosis., (2015 BMJ Publishing Group Ltd.)

Typical stable angina is a clinical diagnosis based on history. The challenge for GPs in primary care is to identify those patients who are presenting with either possible or typical angina symptoms and refer onwards for specialist assessment in the local Rapid Access Chest Pain Clinic (RACPC). Our initial information gathering study suggested that referring GPs may be cautiously overdiagnosing angina in primary care, potentially resulting in avoidable or unnecessary referrals to RACPC. We sought a practical and cost effective solution to reducing avoidable referrals by assisting GPs with chest pain discrimination. We tested a change of referral form incorporating chest pain symptom scoring to see whether GP referral quality could be improved and then assessed its impact post implementation. GPs that used the chest pain symptom scoring questionnaire were more than twice as likely to correctly discriminate non-cardiac chest pain. Our post implementation study of the new referral form showed that the proportion of referrals to RACPC with diagnosis of non-cardiac chest pain reduced by almost 19%, and there was a statistically significant 30% fall in the total number of referrals to RACPC. This was likely to be driven by the deterrent effect of the novel referral form on avoidable referrals. Fewer avoidable referrals results in shorter wait times for specialist review, reduces the risk of waiting time breach, and improves RACPC efficiency. In summary, chest pain symptom scoring resulted in improved GP discrimination of chest pain, improved referral quality, fewer overall referrals to RACPC and shorter patient wait times. These benefits were achieved without using additional financial resources and without the time or capital expense of training GPs. These findings could assist GPs and Clinical Commisioning Groups to achieve cost savings by reducing avoidable secondary care referrals.

We present an interesting, unusual and complex case of a young man who initially presented with symptoms suggestive of tuberculosis and later developed malignant ventricular arrhythmias. A diagnosis of cardiac sarcoidosis was made only after histological evidence was paired with his presentation of monomorphic ventricular tachycardia. In this case we highlight the current challenges faced in the choice of investigations and diagnostic criteria. Additionally, we have identified the difficulties in treatment and long-term management of such a multisystem disorder. Ultimately by doing so, we hope to encourage clinicians to be aware of making a diagnosis of cardiac sarcoidosis.

Wellens' syndrome refers to specific ECG abnormalities in the precordial T-wave segment, which are associated with critical stenosis of the proximal left anterior descending (LAD) coronary artery culminating in an acute anterior wall myocardial infarction (MI) if the patient is not urgently revascularised. We describe the youngest reported presentation of Wellens' syndrome in a 24-year-old woman with unstable chest pain, characteristic ECG changes and slight troponin biomarker elevation. This was initially unrecognised by the emergency department as unstable coronary syndrome and she subsequently progressed to an anterior non-ST elevation MI (NSTEMI). Her coronary angiogram showed critical narrowing of the proximal LAD which was successfully treated with a drug-eluting stent.

A transradial arterial approach to coronary angiography and percutaneous coronary intervention has become increasingly embraced by cardiologists as it is associated with decreased vascular complications and allows early mobilisation of patients when compared with transfemoral arterial access. Major vascular complication post-transradial access is uncommon. We describe a very rare case of perforation of the costocervical trunk (a branch of the right subclavian artery at the site of the thoracic inlet) presenting shortly after percutaneous transradial coronary intervention. The resulting rapidly expanding cervical haematoma caused airway compromise necessitating emergent intubation in the catheter laboratory recovery area. Transfemoral catheter coil embolisation of the feeder artery was successful in obliterating blood flow to the perforated vessel with eventual resolution of the neck haematoma.