Radionuclide Esophageal Transit Scintigraphy in Primary Hypothyroidism

BACKGROUND/AIMS: Esophageal dysmotility is associated with gastrointestinal dysmotility in various systemic and neuroregulatory disorders. Hypothyroidism has been reported to be associated with impaired motor function in esophagus due to accumulation of glycosaminoglycan hyaluronic acid in its soft tissues, leading to changes in various contraction and relaxation parameters of esophagus, particularly in the lower esophageal sphincter. In this study we evaluated esophageal transit times in patients of primary hypothyroidism using the technique of radionuclide esophageal transit scintigraphy. METHODS: Thirty-one patients of primary hypothyroidism and 15 euthyroid healthy controls were evaluated for esophageal transit time using 15–20 MBq of Technetium-99m sulfur colloid diluted in 10–15 mL of drinking water. Time activity curve was generated for each study and esophageal transit time was calculated as time taken for clearance of 90% radioactive bolus from the region of interest encompassing the esophagus. Esophageal transit time of more than 10 seconds was considered as prolonged. RESULTS: Patients of primary hypothyroidism had a significantly increased mean esophageal transit time of 19.35 ± 20.02 seconds in comparison to the mean time of 8.25 ± 1.71 seconds in healthy controls (P < 0.05). Esophageal transit time improved and in some patients even normalized after treatment with thyroxine. A positive correlation (r = 0.39, P < 0.05) albeit weak existed between the serum thyroid stimulating hormone and the observed esophageal transit time. CONCLUSIONS: A significant number of patients with primary hypothyroidism may have subclinical esophageal dysmotility with prolonged esophageal transit time which can be reversible by thyroxine treatment. Prolonged esophageal transit time in primary hypothyroidism may correlate with serum thyroid stimulating hormone levels.

Ultrasound is here to stay

Only in a few decades, ultrasonography has revolutionized the diagnostic approach in many of the medical specialties. Although the obstetricians were the first ones to use it to the advantage of the patients, many other medical and surgical specialties followed them. Anesthesiologists were not very late in this race, and they soon studied and found its multiple uses in the practice of anesthesiology, interventional pain management, intensive care, trauma and resuscitation. Huge cost on the ultrasound machines, administrative inertias and lack of adequate training facilities have been the main obstacles in adopting this modality to its full potential in non-developed countries. It's the need of the time that cheaper but adequate versions of the machines are developed and due stress is laid on the professional training in its use at all postgraduate training courses

Investigation of Cs-137 in the environmental soil segments of the Peshawar and Nowshera districts of Khyber Pakhtunkhwa, Pakistan

Background: Radioactive contamination in soil arises due to various activities of human being, such as nuclear energy generation, use of radioisotopes in industrial applications, science, technology, medicine and release of radiation in nuclear weapon tests

Materials and Methods: The two districts [Peshawar and Nowshera] of Khyber Pakhtunkhwa, Pakistan were selected for the study of anthropogenic Cs-137 assessment. A total of 102 soil samples were collected from different locations of these two districts of Khyber Pakhtunkhwa

Results: The activity concentration of Cs-137 was determined by gamma ray spectrometry using a high purity germanium detector coupled with a PC. The highest values for Peshawar and Nowshera found were 44.1+/- 4.6 Bq/kg and 27.9 +/- 4.3 Bq/kg, respectively

Conclusion: The presence of Cs-137 shows that the areas under study have gained some fallout, however, the activity concentrations of Cs-137 found in the surveyed area were nominal and do not pose any potential health hazard to human beings?

Malignant hyperthermia: survival without dantrolene - a case report

We encountered a case of malignant hyperthermia in a 52 year old male undergoing open reduction/internal fixation of humerus fracture under general anesthesia. Isoflurane has been reported as a potent triggering agent of malignant hyperthermia. Dantrolene remains the gold standard for treating this life threatening syndrome but it is not available in many countries including Pakistan. However, we successfully managed our patient by timely recognition of this syndrome and administering prompt and effective symptomatic treatment

Loop-mediated isothermal amplification [RT-LAMP]: a new approach for the detection of foot-and-mouth disease virus and its sero-types in Pakistan

Successful disease management requires a rapid and sensitive diagnosis method that can recognize early infection even before the manifestation of its clinical signs. The only available field diagnostic tests for foot-and-mouth disease [FMD] are lateral flow devices, commonly known as chromatographic strips. Low sensitivity and inability to detect FMD virus [FMDV] at the serotype level are limitations of lateral flow devices. Therefore, a reverse transcriptase loop-mediated isothermal amplification [RT-LAMP] was standardized using universal and sero-type specific genes in a single tube. This test does not require sophisticated equipment and can detect FMDV at serotype level in about 60 min. In addition, the sensitivity and specificity of this test is comparable to conventional reverse transcriptase PCR and real time PCR [rRT-PCR]

Intervention of fruit juice in yoghurt preparation

Fruit yoghurt was prepared with the addition of different ratios [5, 10 and 15%] of jackfruit and mango juice. The physical, chemical and microbiological characteristics were analyzed to assess the quality of yoghurt. The physical parameters showed that 5% JFD and 10% MFD came in top position compared to other types of yoghurt or Dahi. The fat and protein contents decreased in both JFD and MFD but not in plain Dahi owing to the lower fat and protein content of fruit juice. Acid contents increased in JFD and MFD due to the high concentrations of fermentable sugars in fruit juice which promotes acid formation. The microbial concentration of fruit Dahi were within standard values, though the H and K Dahi samples contained slightly below standard cocci and bacilli. The findings confirm that the addition of fruit juice up to a certain limit, not exceeding 5-10% of the milk, improved the color, texture, flavor and taste of yoghurt

Frequency of TMJD among medical students vis-a vis non-medical students

The temporomandibular joint [TMJ] is the synovial joint that connects the lower jaw to the base of the skull. Temporomandibular Joint Dysfunction TMJD is the commonest disorder seen with this joint which appears with common signs and symptoms like clicking sounds, limited mouth opening, jaw pain, headaches, earaches, toothaches and other types of facial pain. TMJ disorder is seen to be an increasing problem especially among the students with higher burden of studies and excessive stress during exams

Methods: This study was conducted to determine the frequency of TMJ dysfunction in medical students in comparison to non-medical students and its association with different variables. A structured questionnaire was designed and administered on 80 medical students and 80 non-medical students irrespective of gender, age ranging from 17-25

Results: The data collected was then entered into the SPSS-16 and tabulated into percentages and bar charts. It is seen that the TMJD is seen to be more common among Medical Students [p= 0.001] and has a significant correlation with study hours and stress [p = 0.032 and 0.00] respectively

Conclusion: Frequency of TMJD is more among medical students than non-medical students in regard of tough studies, excessive stress during exams and study hours

Risk factors of oral cancer in Lahore, Pakistan: a case control design

Increase in incidence of oral cancers associated with tobacco and smokeless tobacco products in South Asian countries, especially in Pakistan, is creating an alarming situation

Objectives: Study investigated the association of tobacco, smokeless tobacco and alcohol with oral cancer

Methods: A case control design was used. 118 cases of oral cancer were selected from hospital, matched with 354 controls during April to June 2015. Case to control ratio was 1:3

Results: Mean age of cases was 48.9I +/- 13.24 years, 77.1% being males and 22.9% females. Most of the participants belonged to low socioeconomic status. The association of pan with oral cancer was very significant [p<0.05, OR= 9.755, 95% CI 5.7-16.5]. However, 62/118 cases were non-chewers and developed oral cancer. Pan chewing showed the strongest risk for oral cancer. We also found an increased risk for oral cancer in the consumption of Niswar [p<0.05, OR- 3.941, 95% CI 1.6-9.8], gutka [p<0.05, OR- 4.133, 95% CI 3.5-4.9], supari/chalia [p<0.05, OR-3.291, 95% CI 1.6-6.7] and alcohol [p<0.05, OR-4.789, 95%C1: 1.7-13.6]. Cigarette Smoking habit was present in both case and controls [p>0.05, OR- 1.291, 95% CI 0.8-1.9] indicating the cultural habit prevalent in Pakistan

Conclusion: Our study thus proved strong association between these predisposing factors and the development of oral cancer and the strength of association found to be stronger than in other studies

Knowledge of Saudi female university students regarding cervical cancer and acceptance of the human papilloma virus vaccine

To assess the level of knowledge regarding cervical cancer and the acceptance of the human papilloma virus [HPV] vaccine among Saudi female students in health colleges. This cross-sectional study of a convenient sample encompassed 1400 students in Health Colleges at Princess Nora Bint Abdul Rahman University, Riyadh, Saudi Arabia was conducted between December 2013 and February 2014. A self-administrated questionnaire was distributed to all participants. Data collected included socio-demographic data, knowledge of cervical cancer risk factors and clinical presentation, Pap smear, and HPV vaccine acceptance. The questionnaire reliability as tested by Cronbach's alpha was 0.82. The response rate was 89.9%, and data analysis revealed that 95.7% of students had poor knowledge level. The Pap smear was poorly recognized as a screening tool, with 46.7% of students having heard of the test. Senior and medical students had a significantly higher knowledge score. Father's health profession, high monthly income, and presence of cervical cancer among family members or friends increased the level of knowledge. Vaccine acceptance is influenced by its price, approximately 80% of students thought that an affordable vaccine price should not exceed 300 Saudi Riyals. Perceived barriers to the vaccine were fear of injections and vaccine side effects. There is a lack of knowledge and misinformation regarding cervical cancer, Pap smear, and HPV as a major risk factor for cancer of the cervix. These data can be used as a benchmark to formulate effective awareness programs

Saudi guidelines for the diagnosis and management of COPD

The Saudi Thoracic Society [STS] launched the Saudi Initiative for Chronic Airway Diseases [SICAD] to develop a guideline for the diagnosis and management of chronic obstructive pulmonary disease [COPD]. This guideline is primarily aimed for internists and general practitioners. Though there is scanty epidemiological data related to COPD, the SICAD panel believes that COPD prevalence is increasing in Saudi Arabia due to increasing prevalence of tobacco smoking among men and women. To overcome the issue of underutilization of spirometry for diagnosing COPD, handheld spirometry is recommended to screen individuals at risk for COPD. A unique feature about this guideline is the simplified practical approach to classify COPD into three classes based on the symptoms as per COPD Assessment Test [CAT] and the risk of exacerbations and hospitalization. Those patients with low risk of exacerbation [<2 in the past year] can be classified as either Class I when they have less symptoms [CAT < 10] or Class II when they have more symptoms [CAT >/= 10]. High-risk COPD patients, as manifested with >/= 2 exacerbation or hospitalization in the past year irrespective of the baseline symptoms, are classified as Class III. Class I and II patients require bronchodilators for symptom relief, while Class III patients are recommended to use medications that reduce the risks of exacerbations. The guideline recommends screening for co-morbidities and suggests a comprehensive management approach including pulmonary rehabilitation for those with a CAT score >/= 10. The article also discusses the diagnosis and management of acute exacerbations in COPD.

Targeting the PI3K-AKT-mTOR signaling network in cancer / 癌症

The phosphoinositide 3-kinase-AKT-mammalian target of rapamycin (PI3K-AKT-mTOR) pathway is a frequently hyperactivated pathway in cancer and is important for tumor cell growth and survival. The development of targeted therapies against mTOR, a vital substrate along this pathway, led to the approval of allosteric inhibitors, including everolimus and temsirolimus, for the treatment of breast, renal, and pancreatic cancers. However, the suboptimal duration of response in unselected patients remains an unresolved issue. Numerous novel therapies against critical nodes of this pathway are therefore being actively investigated in the clinic in multiple tumor types. In this review, we focus on the progress of these agents in clinical development along with their biological rationale, the need of predictive biomarkers and various combination strategies, which will be useful in counteracting the mechanisms of resistance to this class of drugs.

Frequency of impaired glucose tolerance and diabetes mellitus in subjects with fasting blood glucose below 6.1 mmol/L [110 mg/dL]

The diagnosis of diabetes mellitus by the available criteria is controversial and relies heavily on fasting glucose results. This cross-sectional study in 2010-2011 aimed to measure the frequency of impaired glucose tolerance and diabetes mellitus in 127 subjects having fasting blood glucose < 7.0 mmol/L and to measure the agreement between different standard diagnostic criteria. Subjects presenting to a laboratory for analysis of fasting blood glucose for excluding diabetes meilitus underwent a 2-hour 75 g oral glucose challenge. A total of 40.6% of subjects with fasting blood glucose from 5.6-6.0 mmol/L had abnormal glucose regulation on the basis of the gold standard glucose challenge. Agreement between American Diabetes Association and World Health Organization diagnostic criteria was only fair [kappa =: 0.32]. Abnormalities of glucose metabolism including impaired glucose

Hemiplegia caused by inadvertent subclavian artery double-lumen catheterization

Arterial puncture during central venous catheterization [CVC] is a relatively rare complication that may have devastating consequences. We present a case of left sided hemiplegia after inadvertent, unidentified right subclavian artery double-lumen catheterization in a 60 years aged male who had to undergo central venous catheterization for hemodialysis. The patient had had hemodialysis from the same intra arterial route thrice. Twenty days later, he was successfully managed in OR by removal of the catheter from his artery and manual compression for 20 minutes to control the bleeding

Effects of diuretic and vasodilator therapy in meniere's disease

Meniere's disease is recognised by frequent periods of remissions. The available wisdom about the disease and treatment reflects the openion of experienced clinicians, rather than scientific facts. To determine the efficacy of vasodilator and diuretic therapies in the prophylaxis of Meniere's disease. A randomized controlled trial. The study was carried in the ENT Department, Combined Military Hospital, March 2007 to Dec 2009. Subjects and Methods: All new patients [N=120] of clinically diagnosed Meniere's disease were included by consecutive non-probability sampling. Demographic characteristics of the patients were noted and the patients were divided into three groups irrespective of age and sex. Group A was placed on amiloride 5 mg and hydrochlorthiazide 50 mg combination, one tablet daily, the Group B on tablet betahistine hydrochloride 48 milligram in three divided doses and Group C patients on tab multivitamin once daily respectively. The patients were reviewed after 06 weeks. Improvement in vertigo was seen in 77% in group A, in 68% patients in group B and in 45% in group C [p=0.021]. Hearing thresholds improved in 54% in group A, 63% in group B and in 36% in group C [p=0.067]. There was subjective improvement in tinnitus in 54% in group A, 80% in group B and in 37% in group C. Diuretic and vasodilator had a definitive and significant effect in Meniere's disease, in controlling vertigo and tinnitus, when compared with placebo [p<0.05]. Diuretics and vasodilators do have a significant role in the prophylaxis of Meniere's disease

PEG tube insertion: enhanced need for greater selectivity in patient referral

Percutaneous endoscopic gastrostomy [PEG] refers to insertion of a tube into the stomach percutaneously, aided by endoscope and was first described in 1980 by Gauderer. This was devised for feeding the patients who have swallowing problems due to any reason especially neurodisability. There is an enhanced need for greater selectivity in patient referral. Retrospective, single-institution case series. The study was performed in Waterford Regional Hospital, Waterford, Ireland. Jan 2003 to Dec 2007. A total of 203 consecutive patients referred for nutritional support underwent PEG tube insertion during this period. Written informed consent was taken from all the participants or their attendants and the procedure was performed with prophylactic antibiotic and under intravenous sedation. Standard PEG set was used for the procedure. Feeding was started 12 hours after tube placement and care instructions were given. The parameters of study included indications, annual frequency, and overall outcome. A total of 203 patients having a male to female ratio 1:0.7 underwent PEG tube insertion. The age ranged from 26 to 96 years [mean 79+5.17. The mean duration of PEG feeding was 93 [3-785] days. The annual frequency of insertion increased from 19 [9.3%] patients in 2003 to 64 patients [31.5%] in 2007. The length of stay ranged from 1 to 350 days [median 93]. In this cohort, 32 [15.7%] patients died during the same admission. A total of 79 [38.9%] were discharged for home, 92 [45.3%] were discharged back to nursing home care. This study underscores the need for enhanced awareness and protocol-driven selectivity in patient referral for PEG tube insertion

Maternal and perinatal outcome of hypertensive disorders of pregnancy at a tertiary care hospital

To study the frequency of various hypertensive disorders of pregnancy and to determine their maternal and perinatal outcome. Retrospective descriptive study. Department of Obstetrics and Gynecology Unit III, Civil Hospital Karachi, from January 2002 to December 2007. A total of 626 cases were reviewed for age, parity, gestational age, diagnosis, antenatal and intra partum complications, mode of delivery and neonatal outcome. Data was analyzed using SPSS software [version 16]. Total number of deliveries during the study period was 11,718 and there were 626 cases of hypertensive disorders of pregnancy giving a frequency of 5.34%. Pre-eclampsia was seen in 308 [49%], severe pre-eclampsia in 85 [13%], eclampsia in 121 [19.2%], chronic hypertension in 41[6%] and postpartum eclampsia in 21 [3.3%] patients. There were 39 maternal deaths [case fatality rate: 6.23%]. The mean ages for pre-eclampsia, severe pre-eclampsia, eclampsia and chronic hypertension were 28, 27, 24 and 29 [27 years] years respectively. The commonest maternal complication of hypertensive disorders was postpartum hemorrhage in 24 women [4.2%]. This was followed by placental abruption in 9 women [1.6%] and pulmonary edema in 8 women [1.4]. The prevalence of prematurity in pre-eclampsia, severe pre-eclampsia and eclampsia in study population was 14%, 5% and 8.6% respectively. Cesarean section was required for pre-eclampsia, severe pre-eclampsia and eclampsia in 46%, 51% and 61% of patients respectively. The main fetal complications were found to be still birth [14% in pre-eclampsia, 18% in severe pre-eclampsia and 15% in eclampsia] and low birth weight [31% in pre-eclampsia, 49% in severe pre-eclampsia and 52% in eclampsia]. Hypertensive disorders in pregnancy are an important cause of maternal and perinatal mortality and morbidity

Vitamin D toxicity in adults: a case series from an area with endemic hypovitaminosis D

Vitamin D deficiency state is endemic to the Kashmir valley of the Indian subcontinent. Physicians often treat patients with high doses of vitamin D for various ailments and on occasion the prescribed doses far exceed the requirements of the patients. Ten cases of hypercalcemia due to vitamin D intoxication are presented with features of vomiting, polyuria, polydipsia, encephalopathy and renal dysfunction. All the patients had demonstrable hypercalcemia and vitamin D levels were high in nine of the 10 cases. The patients had received high doses of vitamin D and no other cause of hypercalcemia was identified. Treatment of hypercalcemia resulted in clinical recovery in nine cases. We conclude that hypervitaminosis D must be considered in the differential diagnosis of patients with hypercalcemia in endemically vitamin D deficient areas. A careful history and appropriate biochemical investigation will unravel the diagnosis in most of the cases

Craniosynostosis: early recognition prevents fatal complications

Background: Craniosynostosis is the premature fusion of cranial vault sutures. The overall incidence is 3–5/10, 000 live births. With multiple craniosynostoses, brain growth may be impeded by the unyielding skull. Most cases of single suture involvement can be treated with linear excision of suture. Involvement of multiple sutures or skull has usually required combined efforts of neurosurgeons and craniofacial surgeons. Methods: On the basis of visible skull deformity all patients were admitted in the Department of Neurosurgery, Liaquat University Hospital, Jamshoro, Pakistan. Patients were examined for signs of raised ICP and other congenital deformities. The records of patients were maintained till follow up. Results: Twenty-seven children were included in this study from 2002 to 2009. Age range was 1–6 years, boys were 18 [66.6%], and girls were 9 [33.3%]. The common suture affected was coronal 12 [44.4%]. Two children with craniostenosis belonged to same family, and all presented with suture involvement. Three [11.1%] deaths occurred due to hypothermia [1], and blood loss [2]. Conclusion: Early diagnosis, expert surgical techniques and per- and postoperative care for bleeding and temperature regulation prevent mortality and morbidity. Keywords: Craniosynostosis, children, skull defects, suture

Liver abscess presentation and management in Saudi Arabia and the United Kingdom

Liver abscess [LA] is a well-described disease in the medical literature; however, information about its characteristics and outcome in the Middle East is lacking. We compared the mode of presentation, risk factors, management and outcome of LA patients in Saudi Arabia with cases from the United Kingdom [UK]. Retrospective review of LA patients from three tertiary care centers [2 from Saudi Arabia and 1 from the UK] over a period of 10 years, from 1995 to 2005. Data collected included demographic characteristics; clinical presentation; biochemical, microbiological and radiological findings; treatment modalities; and outcome. A total of 83 patients were diagnosed with LA, including 48 patients from Saudi Arabia and 35 patients from the UK. The mean [SD] age was 45.2 [20.3] years for those from Saudi Arabia and 55.4 [18.8] years for those from the UK [P=.022]. The majority of the patients were males [70% from Saudi Arabia and 80% from the UK]. Upper abdominal pain and fever were the commonest symptoms, each reported in 87% of the cases. Alkaline phosphatase elevation was the commonest liver function abnormality, seen in 66 [80%] patients. Organisms were isolated in 43 [52%] cases and the majority of these were coliforms [58%]. Amebic liver abscesses occurred in 19 [23%] patients and all of those patients were either from or had traveled recently to the Indian subcontinent. Complete resolution of the abscesses was achieved in 66 [80%] patients with aspiration and/or antibiotics, and 9 [10.8%] patients died. On multivariate analysis, underlying malignancy, hypotension and chest signs at presentation were predictors of poor outcome [P=.008, .029 and .001, respectively]. Successful resolution of LA is achievable in the majority of the cases, although underlying malignancy is associated with poor outcome. Amebic liver abscesses must be considered in patients with a history of travel to endemic areas