A 74-year-old man with past history of near syncope presented with frequent periods of second-degree atrioventricular block (2° AVB). An electrophysiological study revealed prolonged atrial-His and His-ventricular (HV) intervals and frequent His bundle (H) extrasystoles. The latter manifested in the surface electrocardiogram as premature atrial, junctional, or ventricular beats, as well as 2° AVB that mimicked Wenckebach or Mobitz II block. Procainamide markedly suppressed H extrasystole. However, because of the presence of prolonged HV interval and history of presyncope, a permanent pacemaker was inserted. The case illustrates the varied manifestation of H extrasystole and presents guidelines for management.

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Objective: To study the effect of reducing the duration of rifampicin therapy in the treatment of Chronic Central Serous Chorioretinopathy. Methods: This is interventional study conducted in Layton Rahmatullah Benevolent Trust, Free Base Eye Hospital Korangi, Karachi from February 2017 - December 2018. This randomized controlled comparative study included two groups, Groups-A comprised of 48 eyes of 40 cases with Chronic Central Serous Chorioretinopathy who were given reduced dose of oral rifampicin i.e. 600mg for one month, and Group-B consisted of 43 eyes of 40 controls with Chronic Central Serous Chorioretinopathy who were given reduced dose of oral rifampicin i.e. 300mg once daily for three months as previously stated in literature. To access the effect of therapy in both the groups, pre-treatment visual acuity on the logMAR and Optical Coherent Tomography (OCT, Heidelberg spectralis) for CMT were performed and repeated on the 1st and 3rd month post-treatment. Patients were also followed for 6 months to access any recurrence. Results: On comparing the two groups, Group-A had improvement in VA and CMT after one month therapy of Rifampicin, Pre-treatment mean VA in Group-A was 0.85 ± 0.19 as compared to the pre-treatment mean VA in Group-B i.e. 0.74+/- 0.208, while the pre-treatment mean CMT was 609.0 ± 178.29 µm in Group-A, and 600.0 +/- 155.09 µm in Group-B respectively. After 1 month of therapy, the visual status, and CMT in Group-A was 0.29+/- 0.21 and 311.6 +/- 89.9, while Group-B, VA was 0.598 +/- 0.23 (p value 0.001%) and CMT was 512.30 +/- 148.37 (p-value 0.001%). Rifampicin was continued in Group-B till three months, and patients were re-accessed but there was no difference in VA and CMT statically. During the 3rd and 6th months of follow up no relapses were reported. Conclusion: This comparative study showed that the group receiving oral rifampicin 600mg for one month showed better outcome at one month and third month than the group receiving oral rifampicin at a dose of 300mg once daily for three months. This gives a better compliance and lower the risk of drug induced side effects. doi: https://doi.org/10.12669/pjms.35.6.990 How to cite this:Loya H, Ghoghari H, Rizvi SF, Khan A. Effect of altering the regime of oral rifampicin therapy in the treatment of persistent central serous chorioretinopathy. Pak J Med Sci. 2019;35(6):1687-1690. doi: https://doi.org/10.12669/pjms.35.6.990 This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/3.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Coronary artery disease is one of the leading causes of death worldwide, and ST-elevation myocardial infarction (STEMI) is one of its most serious manifestations. While STEMI itself is an ominous sign, there are other sinister electrocardiogram (EKG) patterns that are associated with increased morbidity and mortality, one of which is STEMI with right bundle branch block (RBBB). Blood supply to the right bundle comes from the left coronary circulation. Intuitively, RBBB in the setting of anterior wall myocardial infarction would indicate more extensive myocardial involvement and thus portend a worse prognosis. This case presents the significance of the association of new RBBB with critical lesions of the left anterior descending artery (LAD), therefore a low threshold for emergent coronary angiography and percutaneous coronary intervention (PCI).A 63-year-old man with a known history of non-insulin-dependent diabetes mellitus (NIDDM), hypertension, and hypertriglyceridemia non-compliant with medications presented to the emergency department (ED) after a visit with his primary care physician, with a chief complaint of exertional substernal chest pain for a one-week duration. His EKG on arrival showed significant ST-segment elevation with an atypical EKG pattern showing RBBB in V1-V2 with ST depression in reciprocal leads. Cardiac biomarkers showed an initial troponin I value of 0.441 ng/mL. Due to his persistent, worsening chest pain and associated nausea with episodes of vomiting, he was taken for an emergent cardiac catheterization that revealed a 100% lesion in his proximal LAD. The procedure was complicated by the development of cardiogenic shock requiring intra-aortic balloon pumps and vasopressors. A successful primary PCI was performed with drug-eluting stent (DES) to the 100% lesion in the proximal LAD and DES to the 80% lesions in the mid LAD, with 0% residual stenosis after the intervention. There was thrombolysis in myocardial infarction (TIMI) 0 flow pre-procedure and TIMI 3 flow post-intervention. Left ventriculography revealed anterolateral akinesis, apical akinesis, and diaphragmatic hypokinesis with an estimated ejection fraction (EF) of 20%. Transthoracic echocardiogram was repeated prior to discharge. Left ventricular (LV) systolic function was normal by visual assessment, and EF was noted to be ~55%. The patient continued on dual antiplatelet therapy and the rest of goal-directed medical therapy for coronary artery disease postprocedure.New-onset RBBB in the patient with typical STEMI in the context of ischemic symptoms should raise suspicion of critical proximal LAD coronary occlusion. It is increasingly being recognized as one of the significant EKG patterns for occlusive myocardial infarction associated with the worst outcome and mortality, highlighting the need to pay critical attention to these patients. Given the poor prognosis of these patients in the setting of acute myocardial infarction (AMI), it is essential to minimize the delay in initiating reperfusion therapy as they can potentiall...

An 84 year-old man with history of recurrent dizziness presented with first degree atrio-ventricular block (1° AVB) and periods of 2:1 AVB. An electrophysiological study revealed a predominant 1:1 AV conduction with markedly prolonged AH interval and frequent His bundle extrasystoles (H). A properly timed H could induce periods of 2:1 AV nodal block and 1:1 AV conduction could only resume following another properly timed H. Procainamide suppressed H. However, because of persistence of the patient symptoms, a permanent pacemaker was eventually inserted. The case illustrates a hitherto not described manifestation of H.