New Emirates Medical Journal - Volume 2, Issue 1, 2021

The novel coronavirus (COVID-19) pandemic has created an unprecedented global health emergency. This crisis has impacted educational activities worldwide, including India. It is imperative to understand the challenges faced by institutions in imparting resident training when dealing with patients during this pandemic. This correspondence briefly discusses the effect on the cardiology residency program and research activities. It also highlights the measures to impart education safely amid a current pandemic.

Globally, COVID-19 is a viral disease that has become a public health challenge in 2020. COVID-19 is caused by a novel coronavirus, SARS-CoV 2, that was first discovered in the Hubei province of China and it commonly manifests as a respiratory illness but also with symptoms ranging from mild myalgia to severe pneumonia. As our primitive understanding of this novel virus has evolved, COVID-19 has been shown to present in atypical non-pulmonary clinical manifestations, such as diarrhea, acute kidney injury, hepatic and cardiovascular abnormalities, blood coagulation and stroke along with loss of some special senses. We consolidated the publicly available information to precisely summarize the knowledge about the significant non-respiratory clinical manifestations of COVID-19.

Background: The diagnosis of viral causes for flu-like syndromes have positively been impacted by the availability of molecular assays. In recent years, syndromic multiplex panels have been able to give rapid turn-around-times and highly accurate results. We examine the use of this test during the first four months of 2020 during the COVID-19 pandemic.

Methods: A retrospective review of 2145 patient results from a multiplex syndromic flu panel using Biofire RP2 was performed. Cases in which parallel testing for COVID-19 by real-time polymerase chain reaction (RT-PCR) was compared.

Results: 53% of the patients tested identified as a viral agent. 13% of the positive cases were coinfection with more than a single virus. The most frequently detected virus(es) were rhinovirus/enterovirus, followed by coronaviruses (non-MERS, non-COVID-19). One hundred patients had simultaneous testing for COVID-19. Seventeen (17%) had positive COVID-19 by RT-PCR. Three of these patients had coinfection with rhinovirus/enterovirus and COVID-19. The negative predictive value for COVID-19 based on a positive non-COVID agent was 95% in our sample.

Conclusion: Viral syndromic panels are useful for the rapid detection and appropriate treatment of patients. Our results suggest coinfection is infrequent, and we discuss the impact of COVID-19 on patient testing strategy. The use of multiplex panels is useful to provide accurate diagnosis and rule out important pathogens that have different treatment approaches.

Background: Due to the high prevalence and wide distribution of coronaviruses, their large genetic diversity, frequent recombination of their genomes, and increasing human-animal interface activities, novel coronaviruses are likely to emerge periodically in humans owing to frequent cross-species infections and occasional spillover event.

Objective: The aim of this research is to study the short-term morbidities, mortalities and trends of international spread of the COVID-19 outbreak. In addition, to study the explosiveness and aggressiveness of the outbreak and the gaps in response.

Methodology: Outbreak events were observed and followed up over two months. This study used daily statistical reports issued by the World Health Organization, as well as data from different national authorities, regarding mortalities and morbidities from all over the world, with a specific focus on Chinese statistics as the main source of the outbreak.

Results: The current study showed that the number of confirmed COVID-19 infected cases started with 41 cases in early January 2020. The number of cases with COVID-19 kept rising to reach 128000 on March 12, 2020. Moreover, the current study has revealed that the number of deaths was only (1) case in early January 2020 and increased to 25 deaths on January 23, and end up with 170 deaths by the end of January. Deaths have dramatically increased to reach 2462 on Feb 23 and 4717 on March 12. In regards to the geographical spread of the COVID-19 infection outbreak, the number of affected countries increased to 100 by mid- March 2020. The number of fatality cases was 0.0368, compared to 0.533 in recovered cases within two months.

Conclusion: The natural history and course of the current outbreak revealed a highly explosive nature linked to considerable aggressiveness in terms of complications and mortalities, within only two months, and spread to 100 countries worldwide with 80000 cases within only two months. The study forecasted that the peak of the outbreak is not yet attained, and events that are more dramatic may occur worldwide.

Background: Management of rheumatoid arthritis is complicated due to different disease presentations and the multiplicity of drugs. Although most patients are informed about the risks of treatment, there remain possible side-effects, which patients are not informed about to avoid the 'information dump.’ Rheumatologists have to balance what they believe is essential to tell patients versus what reasonable patients believe they need to know to make an informed consent.

Objective: To determine differences in information that the physicians give, regarding the possible side effects of treatment options for rheumatoid arthritis, and what the patients actually want to know.

Methods: To conduct this pilot study, a questionnaire was devised to assess what patients and prescribing rheumatologists, from the Gulf Cooperative Council, consider important for being informed about, including the possible adverse events with biologic drugs in rheumatoid arthritis.

Results: A total of 20 patients and 13 physicians completed the questionnaire. Physicians routinely discussed the increased risk of infections (100%), skin rashes at injection sites (92%),falling white blood cell counts, and alterations in liver enzymes (84%). Patients were less interested in learning about infections (72%) and more interested in learning about rare complications, such as an increased risk of heart failure and cancer (81%), which doctors were less likely to discuss.

Conclusion: There is a discordance between what doctors inform patients about and what patients want to know regarding the risks of biologic therapy in rheumatoid arthritis. This information gap can have a significant legal implications in routine practice if a patient develops a rare side effect of which they have not been informed. We propose a solution of both verbal and signed informed consent to bridge the gap.

Background: Cardiac auscultation is a frequent first step in diagnosing heart disorders. However, the lack of dependability of ordinary auscultation in the hands of inexperienced clinicians remains a problem.

Objectives: We sought to develop an inexpensive system for digital cardiac auscultation (digital phonocardiography) using a Windows laptop computer, freely downloadable software and an inexpensive USB microphone.

Description: The system, based on the free open-source Audacity software package, offers advanced features such as phonocardiogram storage and retrieval, low-pass and high-pass waveform filtering and variable-speed signal playback with pitch preservation.

Results: Sample results for both raw and digitally filtered phonocardiograms are provided.

Conclusion: An innovative laptop-based phonocardiogram system offering advanced features can be easily produced at minimal cost.

Aim: Raising awareness of healthcare providers about headache and early morning vomiting in children.

Background: Intracranial cystic hydatid disease (Echinococcosis) is a rare worldwide disease caused by encysted larvae of the dog tapeworm Echinococcus granulosa. Human is the intermediate host of this parasite and CNS involvement occurs in only 3%. Clinically, the cyst causes a seizure, increased intracranial pressure and/or focal neurological deficit. Surgical removal of the intact cyst by the Dowling technique is the treatment. A 4-year-old girl was referred to a neurosurgery clinic with a history of headache and early morning vomiting over the previous 2 months. Neurological examination revealed right hemiparesis and bilateral papilloedema. Emergency brain CT-scan revealed a huge intracranial cystic lesion with midline shift. Emergency craniotomy was done and the cyst was removed intact without complication and sent for histopathological examination. The patient was discharged from the hospital with full recovery.

Introduction:Aplasia Cutis Congenita (ACC) is a rare congenital disorder characterized by the absence of skin and adjacent tissue that usually affect the scalp. A large scalp defect in ACC with adjacent tissue anomalies is associated with high morbidity and mortality. The management of these lesions can be challenging. The treatment can be either conservative, surgical, or combined.

Case: A full-term newborn girl delivered with a huge scalp defect. The dura mater was exposed but intact and there was no Cerebrospinal Fluid (CSF) leakage. She also had bilateral talipes equinovarus and terminal reduction of multiple toes in the left foot. Genetic testing was positive for Adam Oliver Syndrome. Conservative medical management was initiated at birth and continued until discharge at 4 weeks of age. The patient had a regular follow-up with plastic surgery and neurosurgery teams. At 11 months old, the defect became smaller, hairless with good granulation tissue, but still soft and compressible.

Conclusion: Large scalp midline ACC is a rare, but potentially devastating disease when involved adjacent tissue. The choice of treatment is not straightforward and it is mainly based upon the size, depth, and the risk of pre and post-treatment complications. Conservative management still is an option with very complex ACC.

Background: Post-transplant Lymphoproliferative Disorders (PTLD) are a well known late complication after solid organ transplantation, including renal transplant. Among others, graft failure due to reactivation of BK polyomavirus in the grafted kidney is also a well-recognized complication but tends to present early in the first several months after transplant.

Case: Here we present the case of PTLD Burkitt's Lymphoma (BL-PTLD) in a renal transplant patient who was successfully treated with multiagent chemo-immunotherapy but later developed BK polyomavirus nephropathy (BKVN) with graft failure only after completion of her systemic therapy for lymphoma and 7 years after the transplant. Relevant literature is reviewed.

Conclusion: In this case, reactivation and progression of BKVN were most likely associated with immunosuppression from chemo-immunotherapy for her BL–PTLD, unlike early graft failures associated with BKVN.

Left Ventricular Non-compaction Cardiomyopathy (LVNC) is a rare disorder characterized by abnormal myocardial trabeculations and deep intertrabecular recesses. Diagnostic criteria for LVNC are controversial. Echocardiography remains the primary modality for diagnosis, but there is growing evidence that it may fail in early diagnosis due to its limitation in accurately visualizing the apical and lateral wall trabeculations. This case report describes the use of Cardiac Magnetic Resonance (CMR) imaging to diagnose early LVNC in a young patient where echocardiography had failed. The patient presented with recurrent palpitations and an unremarkable past medical history. The echocardiography results showed only mild hypokinetic changes of the apex, but more than 4,000 ventricular ectopic beats were recorded by Holter monitoring. CMR was performed to exclude myocarditis and cardiomyopathy, and non-compaction ratio measurements met the diagnostic criteria for LVNC. Treatment with a combination of a low-dose ACE inhibitor and a ß-blocker was started and the patient reported almost complete resolution of his symptoms.

The dentist must look for extra canals while performing endodontic treatment. Patients presenting with three canals in maxillary second premolar is a rare phenomenon, and in particular, bilateral maxillary premolars having three canals is very rare. In these patients, accurate preoperative radiographs with multiple angulations are useful in diagnosis. Good clinical and radio-graphic skills are required in the successful diagnosis and treatment of these cases. This article describes an uncommon case of endodontic treatment of bilateral maxillary premolars with three canals.

Acute appendicitis in elderly continue to be a diagnostic dilemma as it raises both the suspicion of malignancy and increased risk of morbidity and mortality. Cancers of the appendix are rare and most of them are found accidentally on appendectomies performed for acute appendicitis. When reviewed, the majority of the tumors were carcinoid, adenoma, and lymphoma. Adenocarcinomas of appendix are only 0.08% of all cancers and the treatment remains controversial. This paper presents a case of 75-year-old female presented to the emergency (ER) with signs and symptoms mimicking acute appendicitis. Laparoscopic appendectomy was planned after a CT scan was done as it was suggesting acute appendicitis. The specimen then was sent for pathology lab and a diagnosis of adenocarcinoma of the appendix was made.

Background: Myocardial Infarction with Non-Obstructive Coronary Arteries (MINOCA) is a syndrome with different causes, characterized by clinical evidence of myocardial infarction with normal or near-normal coronary arteries on angiography.

Case Presentation: Here we describe an interesting case of a 29 year old male known to have bioprosthetic aortic valve replacement who presented with chest pain suggestive of the acute coronary syndrome, with rising troponin levels but having a normal coronary angiography and a cardiac magnetic resonance imaging showing evidence of myocardial infarction thus suggestive of MINOCA.

Conclusion: This case illustrates the increasing clinical role of cardiac magnetic resonance imaging in modern cardiology and its ability to detect a final diagnosis in patients with MINOCA and also raise the possibility of recurrent embolic phenomena to the epicardial vessels from bioprosthetic valves, which might be challenging to prove.

Background: Traumatic duodenal perforation is a serious injury and is a result of major trauma and insult to the body. The management is difficult due to associated injuries and these children often need major resuscitation. The standard surgical treatment of traumatic duodenal perforation is laparotomy and repair of duodenal perforation. In children, laparoscopic repair of duodenal perforation is reported in only a few cases.

Case: A repair of a near-complete duodenal transaction is not reported in the pediatric population. Herein, we report a case of an eight years old child who had a road traffic accident, and sustained multiple injuries and duodenal perforation, as confirmed by radiological evaluation including CT abdomen. The child was resuscitated, and later laparoscopy was performed, which showed gross bruising of the abdominal wall and a near-complete transaction at the level of 3rd part of the duodenum.

Conclusion: Laparoscopic repair of the duodenum was performed using interrupted polyglycolic sutures. The child had a smooth post-op recovery and was discharged home in stable condition. At one-year follow-up, the child remained well and symptom-free. This case highlights the role of the safety of laparoscopic surgery in abdominal trauma and duodenal perforations.

 Introduction: This is a report of immediate endoscopic balloon dilatation for incomplete pyloromyotomy in idiopathic hypertrophic pyloric stenosis.

Case Report: A two-months old boy presented with 6 weeks of projectile vomiting, failure to thrive and severe physiologic disturbance. Following investigation and resuscitation, he underwent laparoscopic pyloromyotomy. Recovery was delayed due to ongoing projectile vomiting. Contrast studies showed persisting proximal pyloric obstruction. On the third post-operative day, endoscopic balloon dilatation of the residual proximal pyloric stenosis was successful, with immediate tolerance of feeds.

Discussion: We describe the presenting features of his case, the technical details of our management and a review of the relevant literature.

The goals of cleft palate surgery are an effective barrier between the nasal and oral air passages leading to functional outcomes in terms of speech, feeding and hearing for the affected child. But unfortunately, these goals are sometimes not easily attained and complicated by Cleft Palate Fistulas (CPFs), which adversely affects not only the child but also the parents. The principles of cleft palate surgery include a two-layer, tension-free, watertight closure with preservation of the greater palatine neurovascular pedicle. This article aims to give a broad review of the current perspectives in the management of this distressing complication.