Journal of the Asian Medical Students Association
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Harmonizing Hearts: Investigating Cardiac Resynchronization Therapy’s Potential in Left Bundle Branch Block Management
Full text linkThis literature review examines the role of cardiac resynchronization therapy (CRT) in treating left bundle branch block (LBBB) in patients with adult congenital heart disease (ACHD). This study focused on CRT implantations over the past decade, excluding patients under 18 years old, those undergoing concomitant cardiac surgery, and studies lacking reported outcomes. CRT, based on biventricular pacing, aims to rectify ventricular dyssynchrony by pacing the right ventricle endocardially and the left ventricle epicardially.
Clinical guidelines prioritize biventricular pacing for patients with LVEF ≤ 35%, LBBB QRS morphology, and indications for ventricular pacing or high-degree atrioventricular block. Historically, studies like MUSTIC and PATH-HF laid the groundwork for assessing CRT's safety and efficacy. PATH-HF notably demonstrated LV reverse remodeling post-CRT, improving functional capacity and quality of life. Trials like COMPANION and CARE-HF further solidified CRT's role in managing heart failure, reducing mortality and HF events.
Understanding LV function variability regarding AV delays is crucial for optimizing device therapy .In the first case, a 45-year-old female undergoing CRT-D upgrade experienced a fatal cardiac arrest due to an inadvertent atrial lead puncture into the adjacent aortic wall. Post- mortem findings revealed underlying myocarditis, complicating the situation. This highlights the importance of meticulous procedural planning and patient selection, particularly considering anatomical factors like atrial wall thinness and proximity to the aorta. In the second case, a 71-year-old woman with severe dilated cardiomyopathy and a history of mitral valve replacement underwent dual-chamber ICD implantation. Utilizing the NAVHS algorithm, RV-septal pacing was optimized to achieve septal preexcitation and significantly shorten QRS duration. This demonstrates how NAVHS can improve outcomes for patients with conduction anomalies in heart failure by optimizing pacing techniques. Lastly, two patients with severe heart failure underwent upgrades from ICDs to CRT-D due to deteriorating clinical states. Venography revealed occluded subclavian veins, prompting innovative procedural approaches involving left extra-thoracic subclavian punctures. Utilizing the Groshong central line kit facilitated lead placement and wound closure. These findings underscore the significance of tailored strategies in CRT-D implantations for patients with venous occlusion, aiming to improve patient outcomes in advanced heart failuremanagement. In conclusion, CRT represents a cornerstone in managing heart failure, offering significant benefits in cardiac function, symptoms, and patient outcomes. Ongoing research aims to refine CRT techniques and improve patient responses to therapy
The Microbiota-Gut-Brain Axis: Role in Alzheimer’s Disease
Full text linkBackground
Alzheimer’s is a progressive brain disorder mostly in older adults causing cognitive decline. The Microbiota-Gut-Brain Axis is a recent discovery as a cause of AD along with build-up of Aβ plaques, tau protein hyperphosphorylation, neurofibrillary tangle accumulation. This axis acts as a two-way communication system allowing the gut to influence via neural, endocrine, immune, and metabolic signalling.The theory has been researched as a possible target for drug development because of the profuse evidence linking the gut microbiota to the onset of AD.
Objective
To investigate the contribution of the key players of Microbiota-Gut-Brain Axis in relation to Alzheimer’s disease pathogenesis and treatment.
Method
A thorough literature review has been conducted to study the impact of gut microbiota on development of neurocognitive symptoms in AD. Articles were selected from PubMed, Google Scholar, Research Gate, and Science Direct and all articles were restricted from the year 2019 to 2024.
Findings
Research indicates that alterations in the bacterial makeup of the digestive tract, particularly a decrease in Firmicutes and an increase in Bacteroidetes species, may have an impact on brain activity. Certain microbial secretory products, such as lipopolysaccharides and short-chain fatty acids, play antagonistic effects on neuroinflammation. Neurotransmitter production and signalling in vagus nerve and the enteric nervous system, involved in controlling both brain-based cognitive behaviour and the physiological processes of the stomach can be influenced by microbial neurotransmitters and neuroactive metabolites. The preservation of host homeostasis also heavily depends on the intestinal epithelial barrier and the blood-brain barrier's functioning. Other key participants include microglia and astrocytes, which produce proinflammatory cytokines and engage in phagocytosis, causing neuroinflammation and provoking onset of symptoms.
Conclusion
Recent preclinical research on humans and animals suggests that dysbiosis in the gut microbiota plays a major role in AD progression. As a result, modifying these factors has potential as a therapeutic and preventative strategy to reduce symptoms or slow the disease’s course
Fecal Microbiota Transplantation: A Solution for Recurrent Clostridium difficile Infections?
Full text linkIntroduction
Clostridioides difficile (previously called as clostridium difficile) is a bacterium that affects individuals with imbalance in their gut health, also known as dysbiosis, causing an infection that can lead to varying symptoms from diarrhea, abdominal pain, to severe damage to the colon. The mainstay treatment for recurrent Clostridioides difficile infection (rCDI) are antibiotics, but this comes with the risk of exacerbating the dysbiosis already present. Once an individual is affected by a Clostridioides difficile infection, 20%-30% are seen to have a recurrence of the infection if treated with antibiotics initially, and 60% have an increased rate of recurrence after the second time. Fecal microbiota transplantation (FMT) is a procedure involving the transfer of a healthy individual’s fecal microbes to those with rCDI. FMT has been shown high rates of efficacy in the treatment of those especially with rCDI, where observational studies have shown almost 90% of the cases were cured but further clinical trials must be conducted in order to prove its complete benefits.
Method
We used PubMed, Medline, EMBASE, CINAHL, and PEDro to perform a critical review of the literature based on a system of original research studies published between November 2014 and April 2023 that reported the effects of FMT for individuals suffering from rCDI.
Result
FMT was seen to effectively treat rCDIs, surpassing standard therapies. The cure rates ranged between 76% to 100%, with lower mortality. FMT achieved higher resolution and fewer recurrences than vancomycin or rectal bacteriotherapy. Donor FMT showed to yield superior outcomes, with fresh donor products being the most effective than frozen or lyophilized FMT product obtained via colonoscopy. The safety profile showed that FMT was well tolerated, and adverse events were minimal.
Conclusion
In conclusion, FMT emerges as a highly effective treatment for rCDIs. Fresh or frozen donor stool, administered via colonoscopy, yields superior outcomes compared to lyophilized or autologous FMT, or standard vancomycin regimen. The safety profile has also proven that FMT provides a superior treatment pathway for individuals with rCDIs. Further studies are still required to confirm long-term safety and efficacy, but it could possibly be the new mainstay treatment for those suffering from rCDIs
Exploring Omentum as an Alternative Site for Islet Cell Transplantation in Type 1 Diabetes Mellitus: Procedure and Benefits
Full text linkAbstract
Treating T1DM has advanced with pancreatic islet transplantation, which is performed by the infusion of islets into the hepatic portal system. They entail high-risk factors after transplantation, such as portal vein thrombosis or an increase in portal pressure, prompting exploration of alternative sites such as the omentum.
Introduction
T1DM is an autoimmune response targeting insulin-producing β-cells, resulting in the absence or near absence of circulating C-peptide. Hepatic portal infusion of the β-cell system aids glycemic control, making the liver the primary site for transplantation, but carries the risk of portal vein thrombosis, elevation of portal pressure followed by uncontrolled bleeding, and loss of islet due to IBMIR when encountered with the recipient's blood. Alternative sites, including the omentum, peritoneum, spleen, renal subcapsule, and gastric submucosa, can be used, out of which the omentum stands out as it offers advantages such as accessibility, ample surface area, high vascularization, and portal venous drainage, making them attractive for islet transplantation.
Method
This literature review involved a comprehensive search through databases such as PubMed and Google Scholar using timelines from 2020 to 2024 using keywords like T1DM, Islet Cell Transplantation, Alternative Transplant Site, Liver, and Omentum.
Result
Islet encapsulation in a semi-permeable hydrogel membrane permits the passage of oxygen, glucose, insulin, and nutrients while preventing immune cell attachment and antibodies towards the graft, resulting in a delay in rejection. Studies in insulin-dependent rats demonstrate the efficacy of encapsulated islet transplantation in restoring glycemic control. There are two types of encapsulation: macroencapsulation and microencapsulation, the latter being more frequently used
Conclusion
T1DM is an autoimmune disorder causing β-insulin-producing cells of the pancreas to undergo destruction. From all the collected data, omentum presents as a promising alternative site for unpurified or encapsulated islet transplantation with reduced complications. However, its limitations are the inability to acquire multiple transplants, ruling out the site for laparotomy. Relaparotomy is seen to be associated with pain, incisional hernia, ileus, and a higher risk of wound infection. This necessitates more clinical evidence to improve the safety, efficacy, and suitability of the omentum as the preferred site
Understanding the Invisible Threat: The Progressive Escalation of Antibiotic Resistance in Pakistan
Full text linkAntibiotic resistance is a global health problem and is quickly becoming a growing health concern in Pakistan. Rapidly increasing resistance to antibiotics in the recent years has significant implications for the public health and the healthcare systems. Resistance develops when bacteria acquire certain characteristics which render antibiotics previously effective obsolete. The primary cause of antibiotic resistance is the excessive and often times inappropriate use of antibiotics. Antibiotics are often prescribed by healthcare workers without proper diagnostic tests and this misuse is contributing to the development of resistant strains. Lack of awareness and lack of access to healthcare in some regions of Pakistan prompt patients to search for quick solutions to their various illnesses. Antibiotics resistance has the potential to become a health crisis for the already crippling healthcare system of Pakistan. Therefore, a multifaceted approach must be adapted quickly to mitigate this issue. The distribution and sale of antibiotics should be controlled through implementation of strict regulations. Proper public awareness campaigns should be used as targeted interventions, to create a sense of responsibility in the general public about the prudent use of antibiotics.
 
Metastatic Epithelioid Sarcoma- A Case Report
Full text linkIntroduction
Epithelioid sarcoma (ES) is a rare soft tissue sarcoma distinguished by epithelioid cell nodules that are immunoreactive to CD34, cytokeratins (CKs), and epithelial membrane antigen. (1) It is commonly found in young adults with a mean age of incidence of 35 years and manifests as a result of SMARCB1/INI1 deficiency or other proteins of the SWI/SNF complex. (2)
Background
Commonly misdiagnosed as infected warts, ulcers, or abscesses, (3) it represents less than 1% of all soft tissue sarcomas, (4) with a prevalence of 0.4 per 1 million population. (5) Despite vigorous multimodal therapies, it has a fatal outcome in ∼50% of cases. (6)
Case
A 23 year old adult male diagnosed with epithelioid sarcoma presented with a several weeks’ history of worsening pain and limited movement in the left lower limb, general weakness and decreased working ability. Inspection revealed a necrotic area measuring 10-7-7 cm on the left ankle. Tumors were palpated in the left popliteal fossa and the left groin. Imaging results of PET-CT scan of the whole body, CT scans of the pelvis and lower limb revealed regional metastatic disease. An above the knee amputation, along with inguinal lymph node dissection was decided as the definitive course of treatment.
Discussion
For further evaluations and support of clinical decision-making, scientific publications from the last 10 years were reviewed using the keyword ‘Epithelioid sarcoma’ on PubMed by applying appropriate filters. It has two distinct variants: classic ES and proximal ES. The former is usually observed in distal extremities manifesting as a subcutaneous or deep dermal mass, with uniform epithelioid cells having central necrosis, while the latter usually favors proximal limbs, limb girdles and midline of the trunk with more atypical cells of variable rhabdoid morphology. (7) In addition to having a high recurrence rate and localized lymph node metastases, ES is renowned for its aggressive behavior, leading to an expected survival of about a year. Wide surgical resection is accepted as a reliable treatment of localized ES. Alternative approaches include administration of doxorubicin, tazemetostat and immunotherapy (8)
Conclusion
Treatment selection depends on characteristics of the disease, staging upon presentation, regional lymph node involvement, presence of comorbidities, and the patient's performance status. (9) The likelihood of a misdiagnosis can be reduced, resulting in prompt and efficient management of epithelioid sarcoma, by identifying common misinterpretations of ES and putting strategies like immunohistochemical staining, multidisciplinary collaboration, and raising awareness among healthcare professionals into practice
KRAS Therapeutics: Identification of novel scaffolds for Dynamic Drugging Pockets of Oncogenic G12D Mutant Kirsten Rat Sarcoma protein
Full text linkAs a proto-oncogene, Kirsten rat sarcoma 2 viral oncogene homolog (KRAS) mutations can cause prolonged activation, leading to abnormal cell proliferation and subsequently development of a variety of human cancers. Therefore, the continuous efforts dedicated to fight against cancer through the discovery of anticancer leads is very significant. We report the identification of 2 novel scaffolds and their derivatives against KRAS G12D mutant protein. We used an integrated pharmacophore-based scaffold screening approach to select the optimum feature quintessential for scaffold stability. The scaffold nucleus was computationally grown using in-house tools. The library is screened, simulated, and analyzed. Intensive PCA analysis was performed, and conformational abundance was analyzed against the full-scale pharmacophore and molecular free states. We report five novel molecules with scores at par with the known FDA approved molecule. These molecules show preferential binding to the GDP-bound state of K-Ras and block the carboxylic group of the aspartatesp at 12th position. Compared to the retrospective analysis of the proposed molecules with the 12G variant, the leads show a considerable conformational density and Gibbs free energy difference. Overall, the reported novel molecules performed significantly ascompared to the known drug reference molecule of KRAS-G12D
Examining the Influence of Seasonal Changes on Mood: An Analytical Cross-Sectional Study of Local and Foreign Medical Students at Grodno State Medical University
No full textBackground
Seasonal affective disorder (SAD) is known to cause negative effects on a person's life. This is more prevalent in the higher latitudes. Interestingly foreigners migrating to higher latitudes from lower latitudes had higher prevalence rate of SAD comparative to the indigenous population at that latitude.
Purpose of Study
There is a scarcity of research conducted on SAD among medical students. So, we aimed to examine the effect of seasonal mood variations among foreign (international) medical students relocating to regions with higher latitude and compare it to the changes of local medical students of that country.
Methods
This cross-sectional study was conducted in the Grodno State Medical University involving both local and foreign medical students. A pre-formed Google form with PIDS-SA was used for data collection. This data were then analyzed using Epi Info 7.6.2.0 Software.
Results
There were mood changes with seasons in both student populations (Foreign 70.2%, Local 64.2%). When considering the criteria to diagnose SAD, 11.3% were affected with SAD in Winter. Foreign students had 4 times more likelihood of been affected with Winter SAD relative to the local medical students. (OR=4.12, p 0.04). There were no cases of summer SAD in this sample.
Conclusion
Increased vulnerability of foreign students to SAD upon relocating to higher latitudes presents an additional challenge to a medical student’s life. Raising awareness, teaching coping mechanisms and ensuring treatment access will foster a supportive environment for both local and foreign students’ wellbeing.
Key words
Seasonal Affective Disorder, Medical Students, Undergraduate Students, Eastern Europe, Local and International Students, Latitud
Assessing the Cardiovascular Impact of Intermittent Fasting on Type 2 Diabetes Mellitus Patient : A Systematic Review
Full text linkIntroduction
For those with type 2 diabetes mellitus (T2DM) and other medical disorders, intermittent fasting (IF) has drawn interest as a possible treatment option for cardiovascular disease. The review embraces a range of research, including umbrella reviews and network meta-analyses, emphasizing the possible advantages of IF on weight loss, insulin sensitivity, cardiovascular markers, betterment in blood pressure, lipid profiles, and inflammatory markers, which are pivotal factors in reducing the risk of cardiovascular diseases.
Method
In accordance with a cohort study, people who fast on alternate days for six months routinely cut their caloric intake by about 28.5%. This was coupled to decreased levels of low- and very-low-density lipoproteins as well as circulating lipids, such as triglycerides, but no changes in high-density lipoprotein plasma levels were observed. Additionally, alternate-day fasting improved a number of cardiovascular health parameters, including pulse pressure, pulse wave velocity, systolic and diastolic arterial blood pressures, and resting heart rate. Short-term alternate-day fasting significantly lowered the Framingham Risk Score, which calculates the 10-year risk of developing cardiovascular disease, even though it had no effect on blood lipid levels. Although the literature currently in publication offers hope for the beneficial effects of IF on cardiovascular health outcomes, there are disparity in the findings of these studies, entailing additional research to determine the best fasting schedules and long-term effects of IF. The combination of IF with regular exercise provides added value in lowering cardiovascular risk and strengthening overall health outcomes.
Result
Furthermore, considering other approaches such as IF in the management of these diseases and the avoidance of related cardiovascular problems is vital given the prevalence of prediabetes and T2DM. To validate the results and evaluate the efficacy of IF in a variety of populations, more randomized controlled trials are requisite.
Conclusion
To sum up, there is a chance to improve cardiovascular health and alleviate the worldwide burden of cardiovascular illnesses by enforcing intermittent fasting. To best apply IF as a therapeutic intervention for people at risk of cardiovascular disorders and to elucidate the reasons behind its effects on cardiovascular risk factors, more research is required
From Pneumonia to Cardiac Crisis: Unravelling the Intricacies of a Rare Clinical Sequence in a 53-year-old female
Full text linkPneumonia is a common respiratory infection, but its complications can be severe, including ARDS and cardiac dysfunction such as stress cardiomyopathy. This case highlights the challenges in managing such complex presentations and underscores the importance of prompt diagnosis and intervention. This case report describes a rare sequence of events beginning with community-acquired pneumonia progressing to acute respiratory distress syndrome (ARDS) and culminating in stress cardiomyopathy. The patient's clinical course underscores the intricate interplay between respiratory and cardiac pathologies, exacerbated by an initial exposure to a communal gathering. A previously healthy 53-year-old female attended a funeral gathering and subsequently developed symptoms consistent with pneumonia, upon presentation to the hospital with symptoms of shortness of breath - grade 3, fever for 6 days, productive cough, throat pain, chest pain, and an episode of sweating. Differential diagnosis included screening for both influenza and COVID-19 due to the ongoing pandemic. Investigations revealed paradoxical motion and mild mitral regurgitation on 2D echocardiogram, along with tachycardia and acute myocardial infarction on electrocardiogram. Biofilm array respiratory testing confirmed influenza A, Haemophilus influenzae, and Klebsiella pneumoniae infections. The patient progressed to septic shock with multiple organ dysfunction syndrome (MODS). The treatment strategy focused on upgrading antibiotics, judicious fluid administration, tapering vasopressor support, and closely monitoring bronchoalveolar lavage (BAL) results. Hemodynamic instability required vasopressor support with norepinephrine and vasopressin. Oxygenation significantly improved, but the patient exhibited a systemic inflammatory response syndrome (SIRS) with febrile spikes and persistent tachycardia. Metabolic acidosis was managed while maintaining adequate urine output. The patient’s condition was closely monitored, and follow-up assessments revealed persistent global hypokinesia with severe left ventricular dysfunction. The management approach focused on addressing both respiratory and cardiac complications, with an emphasis on tailored antibiotic therapy and hemodynamic optimization. This case underscores the need for a multidisciplinary approach to managing complex clinical presentations, particularly in the context of pneumonia-associated ARDS and stress cardiomyopathy. Early recognition and aggressive intervention are essential to improve outcomes in such critically ill patients