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   Table of Contents - Current issue
Coverpage
January-March 2021
Volume 11 | Issue 1
Page Nos. 1-61

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REVIEW ARTICLE  

Firibastat, the first-in-class brain aminopeptidase a inhibitor, in the management of hypertension: A review of clinical trials Highly accessed article p. 1
Sara Abdulrahman Alomar, Sarah Ali Alghabban, Hadeel Abdulaziz Alharbi, Mehad Fahad Almoqati, Yazid Alduraibi, Ahmed Abu-Zaid
DOI:10.4103/ajm.ajm_117_20  
An unfortunate subset of hypertensive patients develops resistant hypertension in which optimal doses of three or more first-line antihypertensive drugs fail to sufficiently control blood pressure. Patients with resistant hypertension represent a high-risk and difficult-to-treat group, and such patients are at amplified jeopardies for substantial hypertension-related multi-organ failure, morbidity, and mortality. Thus, there is a pressing requirement to better improve blood pressure control through the pharmaceutical generation of novel classes of antihypertensive drugs that act on newer and alternative therapeutic targets. The hyperactivity of the brain renin-angiotensin system (RAS) has been shown to play a role in the pathogenesis of hypertension in various experimental and genetic hypertensive animal models. In the brain, angiotensin-II is metabolized to angiotensin-III by aminopeptidase A (APA), a membrane-bound zinc metalloprotease enzyme. A large body of evidence has previously established that angiotensin-III is one of the main effector peptides of the brain RAS. Angiotensin-III exerts central stimulatory regulation over blood pressure through several proposed mechanisms. Accumulating evidence from preclinical studies demonstrated that the centrally acting APA inhibitor prodrugs (firibastat and NI956) are very safe and effective at reducing blood pressure in various hypertensive animal models. The primary purpose of this study is to narratively review the published phase I–II literature on the safety and efficacy of APA inhibitors in the management of patients with hypertension. Moreover, a summary of ongoing clinical trials and future perspectives are presented.
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ORIGINAL ARTICLES Top

Implementation of mental health services in conflict and post-conflict zones: Lessons from Syria p. 8
Mohammad Khalid Hamza, Madelyn Hsiao-Rei Hicks
DOI:10.4103/ajm.ajm_141_20  
Objective: We describe the challenges confronted and lessons learned in implementing mental healthcare during the Syrian war to inform effective services for conflict-affected Syrian populations. Materials and Methods: We searched the academic and gray literature. We draw on the experiences of Syrian-American mental health professionals with nine years of experience providing clinical and programmatic mental healthcare in combat settings, siege, internally displaced person camps, and refugee camps. Results: Collaboration with nonprofessional personnel was essential due to the shortage of formally trained mental healthcare professionals in Syria. The use of psychological and diagnostic terms increased stigma, whereas asking about the patient’s identified problem, “suffering,” or “challenges” supported engagement. War-related trauma and horizontal violence commonly affect Syrian children, adolescents, and adults. Resilience and engagement were enhanced by sensitivity to patients’ dignity, religious acceptance, and faith. Conclusions: The Syrian war remains an ongoing public health and humanitarian crisis in which mental healthcare must adapt rapidly to specific needs and resources of the patient and community. Psychiatrists can increase the acceptability and efficacy of their care by being sensitive to Syrian patients’ experiences of horizontal violence, loss of dignity, stigma, worldviews in which religion and faith may be important sources of resilience, and culturally acceptable modes of communication.
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Evaluation of antibiotic prescribing pattern in pediatrics in a tertiary care hospital p. 15
Rinta Mathew, Humera Sayyed, Subhashree Behera, Keemya Maleki, Sunita Pawar
DOI:10.4103/ajm.ajm_73_20  
Background: The irrational use of antibiotics is a global issue and it can lead to morbidity, mortality, and increased health care costs. Hence, proper use of antibiotics is imperative and should be included in the pharmaceutical care plan. Objective: The objective of this study was to evaluate the prescribing pattern of antibiotics for children using WHO core prescribing indicators. Materials and Methods: A prospective, observational study was carried for 6 months in the pediatric department at a tertiary care hospital, Pune. The WHO prescribing indicators were used to evaluate the prescriptions, and the ideal WHO range was considered as a determining factor for rational prescription. Results: A total of 302 patients were included in the study, with a mean patient age of 4.92 ± 4 years. The average number of drugs per encounter was 6.12 (WHO standard is less than 2). The percentage of antibiotics prescribed was 26.3% with an average of 1.63 antibiotics per prescription. Of the 493 antibiotics, 85.59% were injectable which is higher than the WHO standard of 13.424.1%. A near-optimal value of 99.59% antibiotics was prescribed from the hospital formulary which is similar to WHO standards, and the antibiotics prescribed with generic names were 25.76%. The most common class of antibiotics prescribed were cephalosporins and penicillins. Conclusion: Polypharmacy, high injectable use, and non-adherence to generic prescription were common in our tertiary care center. Continuous audits, training, and new treatment protocols are recommended.
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The prognostic effect of brain natriuretic peptide levels on outcomes of hospitalized patients with COVID-19 Highly accessed article p. 20
Yazan Abdeen, Ahmad Kaako, Mohammad Alnabulsi, Amira Okeh, William Meng, Richard Miller
DOI:10.4103/ajm.ajm_169_20  
Natriuretic peptides are biomarkers of myocardial stress and are frequently elevated among patients with severe respiratory illnesses, typically in the absence of elevated cardiac-filling pressures or clinical heart failure. Elevation of brain natriuretic peptide (BNP) or NT-proBNP is associated with worse outcomes among patients with Acute Respiratory Distress Syndrome (ARDS). We conducted a retrospective cohort study based on a comprehensive review of Electronic Medical Records (EMRs) of patients with Coronavirus Disease 2019 (COVID-19) to evaluate whether BNP on admission has prognostic value on mortality and hospital length of stay (LOS) among patients admitted with confirmed COVID-19 along with the inclusion of additional prognostic variables. Overall, 146 patients were included after analyzing 230 patients’ EMR and excluding potential confounding factors for abnormal BNP. Our statistical analysis did not show a statistically significant association between BNP level and mortality rate (P = 0.722) or ICU LOS ( P = 0.741). A remarkable secondary outcome to our study was that impaired renal function (GFR<60) on admission was significantly associated with an increased mortality rate (P = 0.026) and an increased ICU LOS (P = 0.022). Although various studies have presented the predictive role of pro-BNP among patients with respiratory distress in the past years, our study did not find BNP to be an accurate predictive and prognostic factor among patients with COVID-19 in our study population. Renal impairment and high Acute Physiology and Chronic Health Evaluation (APACHE) II scores on admission, on the other hand, have demonstrated to be strong predictors for COVID-19 morbidity and mortality. This study could represent an introduction to more prominent multicenter studies to evaluate additional prognostic factors and minimize the ordering of nonspecific testing.
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Impact of a division-wide bundle on hospital-acquired Clostridioides difficile cases, antibiotic days of therapy, testing appropriateness, and associated financial costs p. 27
Elizabeth Wenqian Wang, Ashlee Weekley, Jennifer McCarty, Hoonmo Koo, Bradley Lembcke, Mayar Al Mohajer
DOI:10.4103/ajm.ajm_193_19  
Introduction: Updated international guidelines recommend the use of a two-step algorithm (glutamate dehydrogenase [GDH] or nucleic-acid amplification test [NAAT] plus toxin) rather than NAAT alone for the diagnosis of Clostridioides difficile (formerly Clostridium difficile) infections. The goal of our project was to evaluate the impact of a new bundle on the rate of hospital-acquired C. difficile infections (CDIs), hospital-acquired CDI standardized infection ratio (SIR), antibiotic days of therapy (DOT), and financial cost. Materials and Methods: The new bundle was implemented in April 2018. This bundle was implemented across five hospitals in Catholic Health Initiatives (CHI) Texas Division. The bundle included a switch from NAAT to a two-step process (GDH and toxin). We placed the new test in an order panel which included enteric isolation and required indications for C. difficile testing. We used quarterly data pre- and post-intervention to calculate SIR and DOT. Results: In the pre-intervention period, 15.5% of the total 3513 C. difficile NAAT was positive. In the post-intervention period, 5.7% of a total of 2845 GDH and toxin assays was positive for both GDH and toxin (P < 0.0001). SIR, which adjusts for denominator and change in testing methodology, also dropped from 1.02 to 0.43. The estimated cost associated with positive C. difficile cases dropped from 1,932,150 USD to 1,113,800 USD with an estimated yearly cost saving of 794,150 USD. Compliance with enteric isolation improved from 73.1% to 92.5% (P = 0.008). Conclusion: The new testing bundle led to a marked reduction in hospital-acquired CDI and unnecessary treatment, reduction in C. difficile testing, an increase in compliance with enteric isolation, and significant cost savings.
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Dose adjustment of antidiabetic medications in chronic kidney disease p. 33
Matthew Salvatore Snyder, Joshua Fogel, Svetlana Pyatigorskaya, Sofia Rubinstein
DOI:10.4103/ajm.ajm_110_20  
Purpose: The purpose of this study is to identify whether Internal Medicine house-staff (IMHS) have awareness and knowledge about the correct dosage of antidiabetic medications for patients with chronic kidney disease (CKD), as dosing errors result in adverse patient outcomes for those with diabetes mellitus (DM) and CKD. Methods: There were 353 IMHS surveyed to evaluate incorrect level of awareness of medication dose adjustment in patients with CKD (ILA) and incorrect level of knowledge of glomerular filtration rate level for medication adjustment (ILK-GFR) for Glipizide, Pioglitazone, and Sitagliptin. Results: Lack of awareness and knowledge was high, with the highest for Pioglitazone at 72.8%. For ILA, the percentages were: Pioglitazone: 72.8%, Glipizide: 43.9%, and Sitagliptin: 42.8%. For ILK-GFR, the percentages were: Pioglitazone: 72.8%, Glipizide: 68.3%, and Sitagliptin: 65.4%. Conclusions: IMHS have poor awareness and knowledge for antidiabetic medication dose adjustment in patients with DM and CKD. Both Electronic Medical Rerecord best practice advisory and physician–pharmacist collaborative drug therapy management can enhance safe drug prescribing in patients with CKD. In addition, IMHS’s practice for antidiabetic medication dose adjustment was better with Nephrology exposure. A formal didactic educational training during medical school and residency for antidiabetic medication dose adjustment in patients with DM and CKD is highly encouraged to prevent medication dosing errors and to more effectively and safely allow IMHS to manage complex treatment regimens.
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BRIEF REPORTS Top

USMLE step 1 pass/fail: The impact on international medical graduates p. 40
Mohammad Al-Akchar, Mohsin Salih, Zaher Fanari
DOI:10.4103/ajm.ajm_154_20  
On February 12th, 2020, and after a yearlong discussion, the National Board of Medical Examiners (NBME) announced that the reporting of the U.S. Medical Licensing Examination (USMLE) step one exam will transition to pass/fail reporting system and is expected to kick in as early as 2022. The decision was met with various responses, especially by the IMG community. In this paper, we discuss this change and its effect on IMG trainees and their selection process.
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Homemade cardiac and vein cannulation ultrasound phantoms for trauma management training in resource-limited settings p. 42
Ameer AI-Hadidi, Mukarram Amine, Amir Batman, Wael Hakmeh
DOI:10.4103/ajm.ajm_196_20  
Ultrasound has become an essential skill for trauma management in resource-limited areas. Prohibitive costs of commercial ultrasound phantoms limit the abilities of many hospitals to adequately train health-care providers. We assessed the utility of homemade phantoms in a wartime setting. Thirty physicians and technicians enrolled in a medical training course, sponsored by the Syrian American Medical Society (SAMS). Ultrasound simulation models were created onsite by using psyllium, gelatin, a hotel coffee maker, and Pyrex dishes. Lamb hearts were used to teach visual diagnosis and subsequent drainage of pericardial effusions. Penrose drains were used to teach vein identification and cannulation under dynamic ultrasound guidance. Two phantoms with a total of 14 penrose drains were created, serving 30 health-care providers. Feedback from participants was positive and within one month of the course, two cases of pericardial tamponade were diagnosed and surgically treated in the largest trauma hospital operated by SAMS. Context: In resource-limited environments, ultrasound phantoms (models) are cost-prohibitive. Aims: We assessed the utility of homemade phantoms in a resource-limited wartime setting to train Syrian physicians and technicians in vein cannulation and limited cardiac ultrasonography. Settings and Design: Thirty physicians and technicians enrolled in a medical training course, sponsored by SAMS. Methods: Ultrasound simulation models were created onsite by using psyllium, gelatin, a hotel coffee maker, and Pyrex dishes. Lamb hearts were used to teach visual diagnosis and subsequent drainage of pericardial effusions. Penrose drains were used to teach vein identification and cannulation under dynamic ultrasound guidance. Two phantoms with a total of 14 penrose drains were created, serving 30 health-care providers. Statistical Analysis Used: N/A Results: Feedback from participants was positive and within one month of the course, two cases of pericardial tamponade were diagnosed and surgically treated in the largest trauma hospital operated by SAMS. Conclusions: Homemade ultrasound phantoms are a promising cost-effective means for meeting an educational gap in ultrasound training, particularly for resource-limited hospitals and possibly more broadly in residency education.
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CASE REPORTS Top

Spontaneous expectoration of tumor tissue in primary adenocarcinoma lung p. 46
Ramakant Dixit, Mukesh Goyal, Neena Kasliwal, Hasha T Somson, Shreya Agarwal
DOI:10.4103/ajm.ajm_97_20  
Spontaneous expectoration of the tissue fragments in primary lung carcinoma is an extremely unusual event. Expectoration of tumor fragments is a significant event that should not be ignored as it serves itself as a noninvasive tool to diagnose underlying malignancy if such samples are immediately preserved and subjected to histopathological examination. More so, expectoration of a large-sized fragment may provide substantial relief from the breathlessness. Reported here is the case of a middle-aged male patient with adenocarcinoma in the right lung, and mass extended up to trachea, who spontaneously coughed out pieces of tumor tissue.
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Sebaceous carcinoma of the vulva: a case report and review of the literature p. 49
Hind Alharthi, Hala Alnuaim, Ohoud Aljarbou, Haitham Arabi
DOI:10.4103/ajm.ajm_183_20  
Sebaceous carcinoma is a rare malignant cutaneous neoplasm that is most commonly arises in the ocular region. Although it can occur in extraocular sites, sebaceous carcinoma is rarely encountered in the vulva. The use of immunohistochemical staining is very crucial to exclude other differential diagnoses including primary cutaneous and metastatic neoplasms. Unlike ocular sebaceous carcinoma, little is known about the clinical behavior and the prognostic factors in vulvar sebaceous carcinoma. Herein, we present a case of vulvar sebaceous carcinoma in a 27-year-old female, who presented with a labial tumor with lung metastases. To the best of our knowledge, only 11 similar cases were previously reported in the literature.
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Intravascular lithotripsy to treat an underexpanded coronary stent during index procedure: A case report study p. 54
Sherif Seif, Abhishek Kumar, Sanjay Arya, Vellore J Karthikeyan
DOI:10.4103/ajm.ajm_200_20  
Management of heavily calcified lesions during percutaneous coronary intervention (PCI) is often associated with high incidence of complications and long-term adverse outcomes. There is growing evidence of the efficacy of intravascular lithotripsy (IVL) in de novo coronary lesion preparation; however, little experience has been documented within freshly deployed stent underexpansion. We report a 66-year-old male with a marked stent underexpansion despite extensive lesion preparation due to severe underlying calcification. The stent was resistant to balloon postdilatation; therefore, IVL was applied, resulting in excellent stent expansion. IVL could be considered for treating acute stent underexpansion caused by severe underlying calcification.
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Accidental poisoning with aluminum phosphide presenting with excessive cholinergic symptoms with response to atropine: A case report p. 58
Abubakar Muhammad Shakur, Nuhu Abubakar Garba, Ibrahim Ahmadu, Daniel Apollos, Mustafa O Asani, Ibrahim Aliyu
DOI:10.4103/ajm.ajm_156_20  
Accidental poisoning in children, though underreported in our environment, is common and could prove fatal. It is important to identify the primary chemical agent that is responsible for the poisoning. We present a case of accidental ingestion of fish poisoned with aluminum phosphide (AlP) used as rat poisoning by a 14-month-old girl. At presentation, the actual chemical content of the poison was not available and clinical features were suggestive of organophosphate poisoning. She was commenced on atropine together with other treatment, on which she made remarkable improvement. The atropine was continued with complete resolution of symptoms on the third day of admission. We, therefore, report a serendipitous use of atropine in the management of AlP poisoning with successful outcome.
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