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Introduction: Stroke is the second leading cause of death worldwide, with more than a third of these deaths occurring in low-middle income countries, including most of Latin America (LATAM). However, the stroke care systems in LATAM are limited compared to high-income countries. Telestroke is an electronic communication system to deliver medical services from one site to another. Despite the optimal results increasing intravenous thrombolysis and endovascular therapy rates, its use in LATAM is scarce. Objective: The study aims to describe the current state of telemedicine (TM) and telestroke (TS) clinical applications in LATAM. Methodology: We conducted a systematic review of the literature according to PRISMA guidelines in PubMed/MEDLINE, Cochrane-Library, and Google-Scholar. The search was limited to English/Spanish languages using the search terms “telemedicine,” “telehealth,” “teleneurology,” “telestroke,” “Latin America.” In addition, we included randomized control trials, meta-analyses, observational cohorts, and literature reviews. Results: We identified 1,396 articles. After the screening and assessment for eligibility, 37 articles satisfied the inclusion criteria and revealed mixed results. The search showed that TM is widely used in different internal medicine subspecialties in LATAM than TS in Neurology. For example, the term “telemedicine” revealed 1,149 articles, and “telestroke” only 170 articles. Most of the articles reported the feasibility of TS (n=35), but the controlled comparison of TS with conventional services was barely reported (n=2). Brazil (n=7), Chile (n=4), Colombia (n=7), and Mexico (n=4) are the countries with the highest number of TS publications in LATAM. Conclusions: The use of TS is underdeveloped in LATAM compared to TM. Therefore, the collaboration of health authorities and non-governmental institutions is essential to continue building stroke care systems with TS in LATAM.

Background: Aortic arch atherosclerotic plaques of >4mm thickness, evaluated by a transesophageal echocardiogram (TEE) correlate with embolic ischemic stroke. Computed tomography angiography (CTA) of the neck, routinely done during stroke evaluation, is an alternative for the evaluation of aortic arch plaque. We hypothesized that CTA evaluation of the aortic arch plaque is comparable to TEE. Methods: We prospectively measured thickness, extent through different parts of the aortic arch (ascending, arch, and descending aorta), location of the maximal plaque thickness, calcification, mobility, and presence of thrombus in the aortic arch plaque on CTA neck and TEE exams in non-consecutive stroke patients from the hospital database. All measurements were done independently by 2 radiologists for the CTA of neck and 2 cardiologists for TEE. Paired t-test was used for mean difference and Wilcoxon signed-rank test for median difference between TEE and CTA. Results: Of 63 patients who had both CTA and TEE, 31 (mean age ± SD; 54 ± 14.46 years) were included in this analysis; as in 32 patients, aortic arch was not included on the CTA neck. Although maximal plaque thickness was comparable for both methods (CTA 3.0 ± 1.10 vs TEE 3.18 ± 2.54, p=0.68), CTA more commonly showed the extent of the plaque throughout all areas (ascending, arch, and descending) of the aorta (CTA: 25/31 vs TEE: 15/31, p Conclusion: Both CTA and TEE are useful for aortic arch evaluation in stroke patients, contributing different information. Future investigations in a larger prospective cohort are warranted.

Introduction: A paucity of studies exists about the influence of Parkinson’s Disease (PD) in the length of stay (LOS) among patients admitted with acute ischemic stroke (AIS). We seek to identify if a prior history of PD impacts the LOS of AIS patients, and to establish the factors associated it. Methodology: We analyzed data of the NIS from the Healthcare Cost and Utilization Project (HCUP) from 1998 to 2017, using a negative binomial regression to assess sociodemographic factors and hospital characteristics associated with LOS in AIS patients with PD. Results: A total of 835,380,672 hospitalizations were identified with discharge diagnosis of AIS. The cohort was divided into 2 groups based on presence of history of PD during the same admission. 12,799,437 of AIS patients had discharge records with a secondary diagnosis of PD. Non-Parkinson’s disease cohort had longer hospital stay (Incidence Rate Ratio IRR 1.02 (95% CI 1.01-1.03). An increased LOS was observed in males compared to females (IRR 1.03 (1.00-1.03)); Black (IRR 1.17 (95% CI 1.16-1.18)), Hispanics (IRR 1.13 (95% CI 1.11-1.14)) and Asians (IRR 1.22 (95% CI 1.19-1.26)) when compared to whites, Medicaid when compared to Medicare (IRR 1.37 (95% CI 1.34-1.41)). Higher Elixhauser index corresponded to longer LOS (IRR 1.14 (CI 1-14-1.14)). In terms of hospital factors, Urban teaching hospital was associated with longer LOS when compared to rural hospital (IRR 1.18 (95% CI 1.16-1.19)), Northeast compared to West region hospital areas (IRR 1.3 (95% CI 1.27-1.33)). Decreasing LOS was seen over the course of last 20 years. Conclusion: Admission for ischemic stroke tended to result in longer length of stay among non-Parkinson’s patients. Patient characteristics are a greater source of variability in length of stay than Parkinson’s disease status.

BackgroundWe present a case report of a patient who developed severe reversible cerebral vasoconstriction syndrome, which was worsening despite typical interventional and supportive care. We administered a stellate ganglion block (SGB) and monitored the vasospasm with transcranial Doppler measurements.Case reportA 25-year-old woman was admitted with recurrent headaches and neurological symptoms, which angiography showed to be caused by diffuse, multifocal, segmental narrowing of the cerebral arteries leading to severe ischemia in multiple regions. Typical treatment was initiated with arterial verapamil followed by supportive critical care, including nimodipine, intravenous fluids, permissive hypertension, and analgesia. Vasospasm was monitored daily via transcranial Doppler ultrasound (TCD). After symptoms and monitoring suggested worsening vasospasm, an SGB was administered under ultrasound guidance. Block success was confirmed via pupillometry, and repeat TCD showed improved flow through the cerebral vasculature. Improvement in vascular flow was accompanied by a gradual reduction in acute neurological symptoms, with the patient reporting no headaches the following morning.ConclusionsFor patients with reversible cerebral vasoconstriction syndrome who develop severe signs or symptoms despite typical treatment, sympathetic blockade may be a possible rescue therapy. This may extend to other causes of severe vasospasm as well, and further study is needed to determine if the SGB should be included in routine or rescue therapy.

Objectives: To study the bacteriological profile of enteric fever and their antibioticsensitivity pattern to commonly used antibiotics in view of emerging resistance at Civil HospitalKarachi (C.H.K.) and provide a guideline for making a protocol for empirical antibiotic therapywhere culture facilities are not available. Methodology: Design: Descriptive laboratory Basedstudy. Place and Duration of study: The study was conducted from 1st January, 2010 till 30thJune, 2012 at the Central Lab, Civil Hospital Karachi. Patients and Methods: A cross sectionalanalysis was done on a total of 37,805 blood specimens sent for C/S from the entire inpatient andoutpatient departments to the central lab, CHK. All blood cultures were inoculated in thioglycolatebroth and incubated at 37° for 7 days. Positive blood cultures were processed, colonies wereidentified using standard biochemical tests and antibiotic susceptibility was checked by Kirby-Bauer disc diffusion method as per CLSI criteria. Results: Out of these specimens, 430 sampleswere found positive for the salmonella strains, among them 395 (91.86%) were Salmonella typhiand 35 (8.14%) were Salmonella paratyphi A. Salmonella infection was more common in male(55.85%) and more prevalent in children under 10 years of age (34.88%). The resistance patternfor Amoxicillin, Chloramphenicol, Co-trimoxazole, was (29%), (41%) and (5%) respectively;while the resistance was found to be higher in the commonly prescribed drugs belonging to firstand second generation of cephalosporins and flouroquinolones. Conclusion: Amoxicillin andChloramphenicol, the first line of drugs for the treatment of enteric fever are losing their efficacyand most of the organisms have developed resistance. Also, resistance against the second lineof therapy, involving the use of cephalosporins and quinolones is rapidly emerging.

Previous literature has highlighted a high burden of a variety of psychopathologies such as anxiety, depression, and poor sleep quality among Pakistani physicians. These psychopathologies are associated with a poor quality of life and cognitive difficulties, affecting empathy levels, doctor patient relationship, and work performance. It is a cross sectional study in which 300 Pakistani physicians aged 45 and above, were interviewed using a questionnaire comprising hospital anxiety and depression scale, cognitive difficulties scale, and Pittsburgh Sleep Quality Index. All data were analyzed in SPSS v.21. A total of 268 doctors responded (268/300). A total of 72 (26.9%) participants were severely anxious, 31 (11.6%) were severely depressed and 129 (48.1%) respondents were poor sleepers. Hierarchal regression analysis revealed that female gender, increasing age, high PSQI and anxiety scores were significant predictors of cognitive difficulties among the respondents.

Cerebral air embolism (CAE) is a rare, avoidable and potentially fatal iatrogenic complication. Here, we report a case of CAE associated with a central venous catheter in the internal jugular vein that resulted in neurological deficits and generalised epileptic seizures. A 64-year-old man admitted for fasciotomy for compartment syndrome developed CAE with left-sided neurological deficits. The suspected origin was retrograde air flow from the right internal jugular venous catheter. The air spontaneously resorbed without the need for specific therapy, and he made a good recovery. CAE is an infrequent iatrogenic complication that requires prompt diagnosis to avoid significant morbidity and mortality. This case serves as a timely reminder that adverse outcome such as stroke, seizures or death can be avoided by a high index of suspicion and prompt diagnosis. Hyperbaric oxygen is the prime therapeutic measure, but high-quality evidence on its clinical value is lacking.

Herpes simplex virus encephalitis (HSVE) is a medical emergency associated with high mortality and morbidity. Definitive diagnosis is established by history, clinical examination, neuroimaging studies, supportive electroencephalogram (EEG) findings, and cerebrospinal fluid (CSF) analysis. We report a case of HSVE presenting as a stroke mimic in a 76-year-old female with a history of atrial fibrillation on warfarin. She was admitted to our medical intensive care unit with intermittent fever, lethargy, and new onset left-sided hemiparesis. A computed tomography (CT) of the head showed a right middle cerebral artery (MCA) acute ischemic stroke with midline shift and a dense right MCA sign. Brain magnetic resonance imaging (MRI) showed evidence of acute stroke with consideration of herpes encephalitis. CSF analysis was positive for herpes simplex virus (HSV) type one. She recovered with high-dose intravenous acyclovir therapy. Our patient was a diagnostic dilemma, initially being diagnosed with an acute ischemic stroke and yet found to have HSVE, which mimicked an acute ischemic stroke. Delay in treatment may result in devastating clinical outcomes that may include severe cognitive, focal neurological deficits, persistent seizures, and even death. This case highlights the importance of a multidisciplinary approach and the need for increased awareness of an atypical presentation of HSVE among emergency physicians, neurologist, intensivists, and radiologists.

Oropharyngeal cancers are the most common cancers of head neck region, they are placed amongst the top ten malignancies globally and around 40% of all the cancers in South and South East Asia. Patient's personal behaviour impacts causality more than the environmental factors in the pathology and prognosis of this particular cancer. In our country risk factors are based on poor infrastructure of the health care system, illiteracy, poor socioeconomic status, Betel nut and quid, smokeless and smoke tobacco. We recommend that an active precautionary approach is required to restrict the rising incidence in the oral cancers, particularly due to culturally related risk habits and reluctance to seek early healthcare amongst our people. Primary prevention is the need of time.

Insufficient attention towards caregivers has resulted in the emergence of psychological and health complaints. Affliction tethers more towards spouses as compared to parents and females as compared to males. The role of sibling care givers was found to be no different from parents or spouses. Marital relationships were found to suffer the most, with the caregiver leaving the traumatic brain injury (TBI) patient in his time of need. The Brief Symptom Inventory (BSI) and family assessment device (FAD) predicted a correlation between patient variables and caregiver discontent. The Blacks/Hispanics proved to cope better with stress and their caregiver roles as compared to Whites. Time elapsed since the injury was found to relieve distress, while the surprising severity of the injury has no recorded impact. Social support or rather a lack of it has been seen to have an impact on family homeostasis, which can further be deteriorated by substance abuse by the patient. The therapeutic intervention found to be most advantageous was the D'Zurilla and Nezu social problem-solving model. Current evidence suggests that emphasis should be given on proper education and encouragement of caregivers before discharge of TBI patients from hospital to reduce the incidence of stressors. Additionally, counseling sessions should be led by professionally led support groups for dealing with psychological symptoms and peer-led group to eliminate social insecurities of caregivers.

Muhammad Nabeel Shafqat,1 Muhammad Aadil,2 Maria Shoaib31Department of Medicine, University of Medical Sciences “Serafin Ruiz de Zarate” Villa Clara (UCMVC), Villa Clara, Cuba; 2Department of Psychiatry, Rush University Medical Center, Chicago, IL, USA; 3Department of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, PakistanWe read with great interest the currently published article written by Pederson and Brook1 entitled “Sleep disturbance linked to suicidal ideation in postural orthostatic tachycardia syndrome”. Awareness of postural orthostatic tachycardia syndrome (POTS) has increased in recent years. However, sleep disturbance has not been thoroughly investigated as a cause of increased suicidal risk in patients with POTS. We would like to applaud the authors on conducting this novel cross-sectional study to understand and highlight the potential relationship between sleep disturbances and increased risk of suicide in patients suffering from POTS.1View the original paper by Pederson and Brook.

Background There is a steep increase in the consumer use of complementary alternative medicine (CAM), with many users unaware of the need to inform their health care providers. Various predictors including psychosocial factors such as beliefs and behavior have been accounted for preference toward CAM use, with varying results. Methods This study investigates the belief and attitude regarding preference toward CAM use among the Malaysian population by using a questionnaire-based, cross-sectional study. Results A large majority of the 1,009 respondents admitted to taking at least one type of CAM (n=730, 72.3%). Only 20 (1.9%) respondents were found to have negative beliefs (total score 36). A total of 507 (50.2%) respondents were categorized as having a negative CAM attitude, while 502 (49.8%) respondents were categorized as having a positive CAM attitude. It was demonstrated that there was a positive correlation between belief and attitude score (ρ=0.409, P

Munchausen syndrome (MS) was first reported in 1951 by Richard Alan John Asher as a factitious disorder. It is a condition in which the patient intentionally produces symptoms to assume a sick role and gain medical attention. Underdiagnosis of this disorder results in the unnecessary use of medical resources, i.e. unnecessary medical tests and evaluations. This makes it one of the most challenging diagnosis in any medical set up. We present this rare case of a patient with chronic factitious disorder who presented to the emergency with hematemesis. The patient was successfully treated with psychotherapy with no recurrence. It is the need of the hour to create awareness amongst the medical and nonmedical population about factitious disorders so that they can easily be diagnosed and treated with efficiency. Further research is needed to find the risks leading to this syndrome and discover the cultural and social aspects of this disease, which may help us explore treatment strategies and avoid unnecessary tests and treatment.​.

Maria Shoaib,1 Muhammad Taimoor Khan2 1Department of Medicine, Dow Medical College, Karachi, Pakistan; 2Department of Neurology, Charleston Area Medical Center/West Virginia University, Charleston, WV, USAWe read this article, “Altered emotional recognition and expression in patients with Parkinson’s disease” by Jin et al1 with great interest and appreciate the novel information provided on altered emotional processing in pre-deep brain stimulation (DBS) Parkinson’s disease (PD) patients and we would like to add our feedback on the role of DBS on nonmotor and emotional components of PD.View the original paper byJinand colleagues.&nbsp

Background Coronary heart disease is the leading cause of death worldwide and accounts for 13.7% of deaths in countries like Pakistan. Its association with stress has not been well considered in our setup. Patients with coronary artery disease admitted for coronary artery bypass grafting may have a high prevalence of stress that might increase the risk of adverse outcomes. Methods 60 patients with coronary artery disease admitted to the Civil Hospital Karachi for coronary artery bypass graft surgery from January 1 to March 31, 2012, were evaluated using a stress evaluation scale. Results Stress of varying degrees was found to be a significant independent risk factor in patients with coronary heart disease. Analysis of our collected sample of patients with stress showed 60% with high stress ( p = 0.025) and 36.7% moderate stress ( p = 0.0025). An appreciable relationship was found between stress and patient age, sex, body mass index, blood group, and the incidence of myocardial infarction. Conclusion Our study found evidence of an independent causative association between psychological stress and coronary heart disease, of a similar order to the more conventional coronary heart disease risk factors.

Background Breast cancer is treated with many different modalities, including chemotherapy that can be given as a single agent or in combination. Patients often experience adverse events from chemotherapy during the cycles of treatment which can lead to economic burden. Objective The objective of this study was to evaluate costs related to chemotherapy-related adverse events in patients with metastatic breast cancer (mBC) in an integrated health care delivery system. Methods Patients with mBC newly initiated on chemotherapy were identified and the first infusion was defined as the index date. Patients were ≥18 years old at time of index date, had at least 6 months of health plan membership and drug eligibility prior to their index date. The chemotherapy adverse events were identified after the index date and during first line of chemotherapy. Episodes of care (EOC) were created using healthcare visits. Chart review was conducted to establish whether the adverse events were related to chemotherapy. Costs were calculated for each visit, including medications related to the adverse events, and aggregated to calculate the total EOC cost. Results A total of 1,682 patients with mBC were identified after applying study criteria; 54% of these patients had one or more adverse events related to chemotherapy. After applying the EOC method, there were a total of 5,475 episodes (4,185 single episodes [76.4%] and 1,290 multiple episodes [23.6%]) related to chemotherapy-related adverse events. Within single episodes, hematological (1,387 EOC, 33.1%), musculoskeletal/pain related (1,070 EOC, 25.6%), and gastrointestinal (775 EOC, 18.5%) were the most frequent adverse events. Patients with adverse events related to single EOC with anemia and neutropenia had the highest total outpatient costs with 901 EOC ($81,991) and 187 EOC ($17,017); these patients also had highest total inpatient costs with 46 EOC ($542,798) and 16 EOC ($136,768). However, within multiple episodes, hematological (420 EOC, 32.6%), followed by infections/pyrexia (335 EOC, 25.9%) and gastrointestinal (278 EOC, 22.6%) were the most frequent adverse events. Conclusion The economic burden related to chemotherapy adverse events in patients with mBC is substantial.

Muhammad Nabeel Shafqat,1 Muhammad Aadil,2 Maria Shoaib3 1Department of Medicine, University of Medical Sciences “Serafin Ruiz de Zarate” Villa Clara (UCMVC), Villa Clara, Cuba; 2Department of Psychiatry, Rush University Medical Center, Chicago, IL, USA; 3Department of Medicine, Dow Medical College, Dow University of Health Sciences, Karachi, PakistanWe read with great interest the recently published article “Sleep apnea and the subsequent risk of Parkinson disease: a 3-year nationwide population-based study” by Chou et al.1 The study is a step forward in understanding the underlying pathophysiology of Parkinson’s disease, the authors have deduced sleep apnea as one of the possible risk factors.View the original paper by Chou and colleagues.

Purpose Research has consistently found that the proportion of medical students who experience high levels of psychological distress is significantly greater than that found in the general population. The aim of our research was to assess the levels of psychological distress more extensively than has been done before, and to determine likely predictors of distress and well-being. Subjects and methods In 2013, students from an Australian undergraduate medical school (n=127) completed a questionnaire that recorded general demographics, hours per week spent studying, in paid work, volunteer work, and physical exercise; past and current physical and mental health, social support, substance use, measures of psychological distress (Kessler Psychological Distress Scale, depression, anxiety, stress, burnout); and personality traits. Results Females were found to have higher levels of psychological distress than males. However, in regression analysis, the effect of sex was reduced to nonsignificance when other variables were included as predictors of psychological distress. The most consistent significant predictors of our 20 indicators of psychological distress were social support and the personality traits of emotional resilience and self-control. Conclusion The findings suggest that emotional resilience skills training embedded into the medical school curriculum could reduce psychological distress among medical students.

Dear editor We would like to add our views regarding the paper “Validation of Dengue infection severity score” by Pongpan et al.1 As the paper outlines, the purpose of the Dengue Severity Score is to classify individuals with dengue infection into three levels of severity with clinically acceptable underestimation or overestimation. Dengue virus is transmitted by Aedes mosquitoes, which are sensitive to various environmental conditions including temperature, rainfall, and humidity. These factors are critical to mosquito reproduction and survival, for example, higher temperatures decrease the time required for virus replication and dissemination in the Aedes mosquito.2 The incidence of dengue doubles every decade, it increased from 8.3 million apparent cases in 1990 to 58.4 million apparent cases in 2013.3 Although it is a preventable disease, dengue still has an estimated mortality rate of 20,000 people per year.2 The clinical presentation of dengue infection is characterized by fever, headache, vomiting, muscle and joint pain, as well as rash on the skin. Complicated cases may result in hemorrhagic fever, thrombocytopenia, shock, and death. The World Health Organization classification of dengue fever (2009) includes two separate entities, namely, dengue and severe dengue; however, this has yet to be proven as clinically significant. Very few studies are available, and of them, most are at a secondary or tertiary level of care and not at the level of primary care. Most studies are not carried out in resource-poor settings.4 This World Health Organization gross classification is not practical since dengue epidemic affects a wide range of age groups and manifests as different clinical presentations globally, thus adding diversity to disease spectrum.5 Dengue infection severity score is a handy assessment tool; prerequisite information required for this include patients’ clinical data consisting of their medical history, recorded vitals, complete blood count, history of bleeding episodes with results of tourniquet tests, and recent incidents of plasma leakage determined by assessing hemoconcentration, which shows a 20% increase in hematocrit. In our opinion, utilizing the clinical data in the scoring system would allow for more efficient and cost-effective patient care and may minimize unnecessary hospitalization as patients with a low score are suspected to have dengue fever and could be examined and treated as outpatients, while those with a greater score are suspected of dengue hemorrhagic fever and could be admitted in the hospital. Finally, those with the greatest score, likely to have dengue shock syndrome, could be admitted for immediate monitoring in an intensive care unit. We suggest that the scoring system should be made widely applicable to effectively manage the ongoing changes being currently observed in the virulence factors of dengue virus, for example, a fifth serotype DENV-5 recently discovered in 2015, has been shown to have caused frequent epidemics and life-threatening mortalities.5 We recommend this resourceful and impactful scoring system for efficient hospital care and management of dengue patients.

The objective of this study is to determine the time interval from decision to seek medical help and arrival of the patients to the emergency department (ED). The duration of stay in ED was also calculated. This study also assesses factors responsible delayed presentation to hospital. This prospective study was conducted during day timings (9 am to 3 pm) from May 2012 to August 2012 in ED at Civil Hospital, Karachi. Patients older than 18 years and meeting the inclusion criteria were considered to be eligible for the study. Statistical analysis was done using SPSS version 17. The study sample consisted of 4,226 patients with a response rate of 96.5%. The median decision time was 146 minutes (IQR = 74–339), median transit time was 84 minutes (IQR = 42–188), median physician time was 58 minutes (IQR = 47–103), median diagnostic time was 148 minutes (IQR = 135–192), median transfer time was 155 minutes (IQR = 118–274) and the median ED LOS was 327 minutes (IQR = 209–488). Patient beliefs regarding spontaneous resolution of the symptoms was the most common reason (44.8%) cited for increased time spent in taking decision to seek medical help. Mode of transportation other than ambulance and traffic gridlock were the most common reasons found to be significantly associated with increased transit time (p