BackgroundNon-adherence to dietary recommendations, exercise and prescribed drug regimens, in coronary heart disease (CHD) patients following coronary artery bypass grafting (CABG), is a major health care issue worldwide.Aims and objectivesThe primary objective of this study was to investigate the frequency and predictors of non-adherence to lifestyle changes and medication among CHD patients after undergoing CABG surgery.MethodThe sample of this cross sectional descriptive study was 265 patients who underwent isolated primary CABG. Participants who met the eligibility criteria were provided with a pre-coded questionnaire 4 weeks or more after surgery. Adherence was assessed on the basis of patient's self-report. Significance of results was analyzed using Chi square test.ResultsRoughly half of the patients were non-adherent to dietary recommendations (n = 120, 45.3%) and exercise (n = 109, 41.1%) while about one third (n = 69, 26%) were non-adherent to prescribed medications. Unwillingness to adopt a new lifestyle and more than one social gathering per week, were found to be statistically significant predictors of non-adherence to diet (p-values < 0.001). Reluctance to follow exercise regimen, busy schedule, and fear that exercise will aggravate heart issues were commonly reported as reasons for non-compliance to exercise. As for non-adherence to medication, forgetfulness, affordability of drugs and too many medications to take were important predictors.ConclusionNon-adherence to lifestyle modifications and medication is an emerging problem worldwide. It is essential for medical health professionals to discuss these predictors and address them individually. Our findings highlight the need for a healthy physician and patient relationship.

Institutional investors are the key investors in stock markets. Stock markets are influenced by these giants. We investigate the comparative institutional ownership structure in financial and non-financial corporations. Institutional ownership structures are foreign, domestic, state, and private institutional ownership, which are examined against the corporate performance of 40 firms listed in Pakistan Stock Exchange from 2006 to 2016. Panel regression is applied to observe the results. Varied impacts for every category of institutional ownership in financial and non-financial firms are evident. The findings of the study are robust, and potential investors can use this study for their future investment plans. Investor institutions can decide their future investment directions in Pakistan.

Figure 1. (A-B) Non-contrast CT abdomen and pelvis done upon initial presentation showing findings suggestive of bowel wall thickening in the ascending colon and cecum concerning for colitis in axial (A) and coronal (B) planes. (C-E) Repeat non-contrast CT abdomen/pelvis in axial (C) and sagittal (D, E) planes which showed increase in colonic distention within the transverse colon measuring up to 7cm (C, E) and increased distention within the cecum and ascending colon (D) concerning for toxic megacolon.

Cocaine is considered a leading non-opioid cause of drug overdose in the US. It acts as a sympathomimetic and increases the amount of catecholamines, thereby increasing the risk of ventricular irritability and resultant arrhythmias. Its sodium (Na) channel blockage is the principal mechanism behind the Brugada pattern on an electrocardiogram (ECG), which is often transient but is indistinguishable from that of Brugada syndrome, the autosomal dominant channelopathy.We are presenting a case of a 32-year-old male with a history of cocaine and nicotine abuse, who sought medical attention for sudden-onset palpitations and pressure-like chest pain after having snorted an impressive amount of cocaine. His ECG depicted a classical Brugada pattern with ST-elevation with T inversion in V1; however, previous ECGs were normal without ST changes, signifying the Brugada pattern unmasked by cocaine use. Other investigations including stress tests and nuclear imaging were equivocal. His symptoms as well as the ECG pattern reverted to baseline signifying the presence of Brugada phenotype in the absence of channelopathy.Hence, as a sodium channel blocker, cocaine may unmask latent Brugada syndrome in asymptomatic patients without a family history. Recognizing Brugada syndrome on ECG is vital to avoid misdiagnosis and mistreatment of the patient with and without a genetic predisposition.

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Introduction: Bezoars are solid masses of indigestible materials that accumulate in the gastrointestinal tract (GIT). They are classified according to their content and sites in the GIT. We present a case of large bowel partial obstruction secondary to bezoar, attributable to chronic opioid use. Case Description/Methods: A 65-year-old male with a history of hypertension, occasional constipation with unremarkable colonoscopy 2 years ago, spinal stenosis with fully functioning activity on chronic opioid use for 10 years, presented with worsening abdominal pain and distension with small bowel movements for 5 days. He reported nausea with no vomiting. Physical exam showed normal vital signs and distended soft abdomen with no tenderness or guarding. CT abdomen showed 10 x 6 cm partially obstructing bezoar in the proximal transverse colon, with decompressed distal colon, and with no small bowel obstruction (Figure). He was started on different laxatives and enemas for 3 days with no improvement. Colonoscopy showed a large obstructing stoolball (Figure ) that was not getting fragmented by polypectomy snares, tripod forceps, or water piks. Surgical removal of the bezoar was then performed with primary anastomosis. He remained stable and was discharged on Senna with instructions for a followup colonoscopy, and to avoid opioids. Discussion: Bezoars are uncommon causes of GIT obstruction. They are classified according to their content into phytobezoars (indigestible food particles), trichobezoars (hair and food particles), and pharmacobezoars (concretions of different medications). They commonly occur in the stomach, however; they can occur in any part of the GIT. Bezoars' common risk factors are altered GIT anatomy or motility such as post abdominal surgery, diabetic gastropathy, Guillain-Barre syndrome, bedridden state, and medications with intestinal hypokinetic effects. Chronic opioid use is the culprit risk factor in our patient. GIT obstruction is a common complication of bezoars although it rarely occurs in the colon. A plain radiograph is usually the first diagnostic modality, however; a CT abdomen is often needed. Management varies from medical to endoscopic or surgical according to the bezoar's size and the associated complications. Our patient was treated surgically after failed medical and colonoscopic treatment. This raises the importance of the concomitant use of stimulant laxatives with opioids and avoiding chronic opioid use in unnecessary conditions to prevent such complications.[2057] Figure 1. On the left, the CT abdomen shows a large proximal transverse colon bezoar. On the right, the colonoscopy shows a large stoolball.

Immune thrombocytopenia (ITP) is a bleeding disorder characterized by a decreased number of platelets. It is an immune system-mediated condition, with formation of antibodies against a structural platelet antigen. Although the pathogenesis remains elusive, primary disease is idiopathic and comprises 80% of cases. However, quite a few secondary causes have been established including Helicobacter pylori, varicella-zoster virus and cytomegalovirus. A few cases with an incidental association with herbal medications have been reported, but this causality has not been studied in detail. Here we present the case of 38-year-old African-American woman who presented with symptomatic thrombocytopenia, with a platelet count of 5 K/µl 1 week after she had consumed herbal tea containing Rumex crispus (yellow dock) and Arctium lappa (burdock). The association between unstudied herbs and ITP needs further research, given the widespread use of these substances and ongoing public uncertainty about their benefits.

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