Explore the vast range of titles available.

The S1Q3T3 electrocardiographic (ECG) pattern is commonly described in patients with acute pulmonary embolism (PE). However, it is a nonspecific, nonsensitive ECG finding associated with right heart strain that can be found in other acute presentations as well. Most of these acute diseases are of cardiac or pulmonary origin and pathophysiology. Acute abdominal pathologies are not well-known etiologies for this characteristic ECG pattern. We present a case of postoperative colonic dilation and ileus that showed up as acute, new atrial fibrillation (AF) associated with the S1Q3T3 pattern and that resolved after the resolution of the ileus symptoms.

Abstract Many perspectives have been offered on what induces policy failures, which have been numerously called malignity, policy volatility, ill-intentioned policy behavior, abuse of public authority, prioritizing the interests of specific influential or identity interests, subverting policy goals and targets, and rent-seeking. Such a dark side of policy design is seen in India’s rollout of decentralization for natural resources. A discussion on malignant policy designs across states and sectors highlights the importance of understanding the political economy of institutional designs. This article points out that failing to account for the political economy of policy design for decentralization results in malignant designs. It also provides insights into developing policy designs to mitigate the influences of the erstwhile beneficiaries of centralization. The article brings insights from decentralization designs within a political economy framework and discusses mechanisms to mitigate malignant decentralization designs. It points to key policy design and implementation moments that create malignant behavior. It shares comparative instances where policies have been adapted to curb such behavior and strengthen devolutionary decentralization. It details how well-intended national policies towards devolutionary decentralization are intertwined with state and sub-state-level micro-politics of institutional design and decentralization.

In the literature, multiple radiological signs of clinically important congenital cardiovascular abnormalities have been described which are named as per the object they resemble. These signs are very useful in learning. The Gooseneck sign is a sign seen in left ventricle catheter angiography in case of an atrioventricular septal defect. This sign has not been demonstrated on a cardiac computed tomography (CT) so far, to the best of our knowledge. We present a case showing cardiac CT pictorial equivalent of angiographic Gooseneck sign.

Background Polypharmacy is common in older persons, and some of the prescribed drugs may be potentially inappropriate medications (PIMs), whose risks outweigh their benefits. It is therefore necessary to review medication intake of older patients and deprescribe the ones that are not appropriate. Although there are many tools for deprescribing, none of these have been developed for the Indian context, where there is widespread use of fixed dose combinations (FDCs), medicines from different systems of medicines, and different levels of healthcare. Also, some of the medications listed in existing tools are not marketed in India, while some which are commonly prescribed in the country are not listed in the tools. We therefore undertook to develop a deprescribing tool for the older persons in India. Methods A draft deprescribing tool was developed through a modified Delphi consensus process by 18 panellists. Item level content validity index (I-CVI) and scale level content validity index (S-CVI) were calculated from the Delphi round 1 and 2 responses. In addition, face and content validity of the tool was carried out by 6 experts and content validity ratio (CVR’) and I-CVI were calculated. Results Our draft Deprescribing tool included 63 drugs/groups organized in three sections-drugs/drug groups to avoid generally in all older patients (39 items), herb-drug interactions (5 interactions) and drugs which should be avoided in renal dysfunction (15 allopathic and 4 herbal medicines). After Delphi process and tool validation, ten drugs/drug groups were removed due to CVR’ value < 0.62 or I-CVI value < 0.67, and recommendations and/or alternatives were modified for nine drugs/groups, so that the final the tool includes 52 items – 30 drugs/drug groups to be avoided in all older persons, 7 herb-drug interactions and 15 drugs to be avoided in renal dysfunction. The scale-level content validity index (S-CVI) was 0.87 for the entire tool, which is higher than the generally acceptable 0.8. Conclusion A deprescribing tool containing drugs/drug groups commonly prescribed and relevant for the older persons in India, including important herb-drug interactions, and restricted to drugs available and prescribed in India, has been developed through the Delphi process followed by tool validation.

Context: Fine needle aspiration cytology (FNAC) plays an important role in the diagnosis of breast carcinoma. However, its role as a prognostic tool needs to be explored. This can be achieved by studying its correlation with an established prognostic marker such as axillary nodal metastasis. Aims: This study was undertaken to correlate the cytological features of invasive ductal carcinoma (IDC) of breast with axillary lymph node status. Settings and Design: Tertiary care hospital, retrospective analytical study. Materials and Methods: The study group included 150 cases of IDC of breast diagnosed on FNAC, who had subsequently undergone modified radical mastectomy. Cytologic grades were assigned as per Robinson's grading system. Histopathological sections of axillary lymph nodes were assessed for metastasis. Statistical Analysis Used: The cytologic grade and each feature of the cytologic grade were correlated with the lymph node metastasis using χ2 test. Values of P < 0.05 were considered significant. Result: A statistically significant correlation was noted between cytologic grade of tumor and axillary lymph node metastasis (P < 0.05). In addition, a positive correlation was found between two of the individual features of cytologic grade, namely, nuclear size and cell uniformity with axillary lymph node metastasis (P < 0.05). Conclusion: Robinson's cytologic grade of breast carcinoma correlates well with the presence of axillary lymph node metastasis and hence can be used as a prognostic tool. As there is an increasing trend toward conservative approach to management of breast carcinoma, patients receive preoperative neoadjuvant therapy which may alter the nodal status on the resected specimen. Hence, a high cytological grade of primary tumor, as assessed on FNAC before initiation of therapy, should alert the treating team of the possibility of axillary lymph nodal metastasis.

Intramural duodenal hematoma is an uncommon entity, usually associated with trauma. Spontaneous intramural duodenal hematoma is an even more rare phenomenon reported in patients with anticoagulation therapy, gastrointestinal endoscopy procedure or coagulopathy. We report a case of spontaneous intramural duodenal hematoma in a 30-year-old male as a pancreatitis complication, very few cases have been known in the past and still a lot is to be discovered about this rare hematoma associated with pancreatitis. This condition can have catastrophic consequences and should be managed appropriately.

Cryptococcosis is a major life-threatening fungal infection in patients with severe HIV infection and other immunocompromised states. Lung and central nervous system (CNS) are the most commonly involved organs in disseminated cryptococcosis. Others include skin, prostate, medullary cavity of bones, eyes, heart, liver, etc. Pulmonary cryptococcosis may be misdiagnosed because of comparatively nonspecific clinical and radiological features. We report the case of a 61-year-old male patient who is a known case of gastroesophageal reflux disease (GERD), myasthenia gravis, and steroid-induced diabetes mellitus. He was diagnosed with gangrenous cholecystitis at another institution but refused surgery. At our hospital, he experienced loss of consciousness in the out-patient department (OPD) and was therefore admitted for further evaluation where he was found to have pulmonary cryptococcosis and pancytopenia. Pulmonary cryptococcosis is usually found in HIV-positive immunosuppressed patients. However, sometimes it is also seen in HIV-negative patients, and they tend to have a good prognosis with adequate treatment.

Legionnaires disease is primarily a pneumonic illness with possible multisystem involvement. Major risk factors include immunodeficiency, smoking, alcoholism and chronic obstructive pulmonary disease among others. We report a peculiar case of Legionnaires disease presenting with diarrhea as the chief complaint and no respiratory symptoms throughout the course of disease. The patient had no risk factors for the disease and had no recent travel history or sick contacts. Acute diarrhea is not an uncommon manifestation of Legionnaires disease, although isolated diarrhea symptoms with the absence of concurrent respiratory symptoms and no risk factors for Legionella makes this case a diagnostic challenge, leading to possible delay in appropriate management. We are presenting this case to inform physicians of the possibility of Legionnaires disease presenting as an isolated gastrointestinal involvement with no clinical symptoms of pneumonia at presentation.

Breast cancer is a frequently occurring malignancy in women. Immunologically, breast cancers can be classified into four subtypes depending on the types of receptors present and their expression profiles. These are estrogen positive, progesterone positive, human epidermal growth factor receptor type 2 (HER2) positive, and triple-negative as identified by immunohistochemistry. This classification is the basis of response to treatment, prognosis, and survival. With the identification of HER2 receptor overexpression, targeted therapies with anti-HER2 agents have been developed. The first-line therapy approved for HER2 positive tumors is trastuzumab and pertuzumab linked to taxane and further treatment with an antibody-drug conjugate to achieve satisfactory outcomes. Tyrosine kinase overexpression can be treated with lapatinib, which has also been approved for improving survival and is used in combination with capecitabine. Acquired resistance in HER2 positive tumors is shown in many cases due to genetic or epigenetic modifications. Therefore, it is very important to plan therapeutic strategies and design effective treatment approaches. For a long time, only two agents, trastuzumab and lapatinib, have been approved by the Food and Drug Administration (FDA) for the treatment of HER2 positive breast cancers. There has been no appropriate treatment for trastuzumab resistance and its failure to reduce tumor growth. Lapatinib was approved by the FDA in 2007 for HER2 positive breast cancer. Three existing therapy options after trastuzumab resistance was proposed by clinicians: continuation of trastuzumab, starting therapy with lapatinib, and the synergistic use of trastuzumab and lapatinib. There have been several effective therapies proposed for HER2 positive breast cancers in correlation with clinical trials. Discovering the mechanisms of trastuzumab resistance would increase its response to therapy and better clinical outcome. Clinicians are being continuously challenged by the resistance mechanisms and bioavailability of the drugs in the treatment of metastatic breast cancers. The addition of new drugs to the chemotherapeutic regimen increases the complexity, burden of side effects, and chances of relapse. Novel anti-HER2 agents have been directed towards therapy making a major paradigm shift.Breast cancer is a frequently occurring malignancy in women. Immunologically, breast cancers can be classified into four subtypes depending on the types of receptors present and their expression profiles. These are estrogen positive, progesterone positive, human epidermal growth factor receptor type 2 (HER2) positive, and triple-negative as identified by immunohistochemistry. This classification is the basis of response to treatment, prognosis, and survival. With the identification of HER2 receptor overexpression, targeted therapies with anti-HER2 agents have been developed. The first-line therapy approved for HER2 positive tumors is trastuzumab and pertuzumab linked to taxane and further treatment with an antibody-drug conjugate to achieve satisfactory outcomes. Tyrosine kinase overexpression can be treated with lapatinib, which has also been approved for improving survival and is used in combination with capecitabine. Acquired resistance in HER2 positive tumors is shown in many cases due to genetic or epigenetic modifications. Therefore, it is very important to plan therapeutic strategies and design effective treatment approaches. For a long time, only two agents, trastuzumab and lapatinib, have been approved by the Food and Drug Administration (FDA) for the treatment of HER2 positive breast cancers. There has been no appropriate treatment for trastuzumab resistance and its failure to reduce tumor growth. Lapatinib was approved by the FDA in 2007 for HER2 positive breast cancer. Three existing therapy options after trastuzumab resistance was proposed by clinicians: continuation of trastuzumab, starting therapy with lapatinib, and the synergistic use of trastuzumab and lapatinib. There have been several effective therapies proposed for HER2 positive breast cancers in correlation with clinical trials. Discovering the mechanisms of trastuzumab resistance would increase its response to therapy and better clinical outcome. Clinicians are being continuously challenged by the resistance mechanisms and bioavailability of the drugs in the treatment of metastatic breast cancers. The addition of new drugs to the chemotherapeutic regimen increases the complexity, burden of side effects, and chances of relapse. Novel anti-HER2 agents have been directed towards therapy making a major paradigm shift.

May-Thurner syndrome, which is also known as iliac vein compression syndrome, is caused when an anatomical variant of the left common iliac vein with a lateral or anterior spur is compressed by the right iliac artery, resulting in thrombosis of the vein. It can present as left deep vein thrombosis which can lead to pulmonary embolism or chronic changes of venous insufficiency in the left lower limb. We report a 27-year-old female with pain abdomen, who was diagnosed to have May-Thurner syndrome.