Left paratesticular mass mimicking polyorchidism: A case report

We report a rare case of primary scrotal lipoma in a 20-year-old patient which clinically mimics a left triorchidism. The patients presented with the left testicular swelling and the ultrasonography of the scrotum revealed an inhomogeneous hyperechoic mass with an inconclusive report. The left scrotal hemi exploration was planned, and intraoperatively, it was found to be a paratesticular mass with an equivalent size corresponding to the left testicle, separate from the left testicle. The histopathology confirms the lipomatous swelling. The post-operative period remains uneventful and the patient has been on follow-up for the past 1 year with no relapse

Self-penile amputation and castration: A rare and life-threatening form of genital self-mutilation

Self-castration and penile amputation are rare life-threatening types of genital self-mutilation. The microsurgical technique of penile replantation is the gold standard; however, there are conflicting reports of successful macrosurgical penile replantations. Being rare, this condition may even be mistaken as criminal genital mutilation. The surgical management of penile amputation evolves over a few case reports and case series; therefore, it is prudent to publish such rare phenomena to make more awareness among the clinicians to initiate prompt and effective treatment. We report a case of self-multiple penile amputations and castration in a 70-year-old man suffering from bipolar disorder who also had failed macrosurgical penile replantation. To the best of our knowledge, this is the first case of self-multiple penile amputation with castration reported in the literature. Although ours is a single case experience, yet the macrosurgical replantation in multiple penile amputations is likely to be unsuccessful

An Observational Study between Snodgrass Urethroplasty and Modified Mathieu’s Repair in the Management of Distal Penile Hypospadias

Background: Objectives: An Observational Study Between Tubularized incised plate urethroplasty (Snodgrass) and Modified Mathieu’s repair in the management of distal hypospadias. Study Design: An Observational And Comparative Study. Place and Duration: Department of general surgery GMC Srinagar from Jan 2015 to December 2016. Methods: A total of fifty patients, upto 15 years of age were included in the study. Patients of Distal Penile Hypospadias with significant chordae and history of previous surgery were excluded. Patients were selected in two groups,25 each by randomization. In each group. Group I had Snodgrass and Group II had Modified Mathieu’s repair. Operative time was noted for both the procedures separately. Patients were followed for subsequent outcome. Complications were noted as immediate postoperative (within 24 hours), delayed post-operative (within 72 hours) and on follow up. Results: The mean duration of surgery was significantly lower for Tubularized incised plate urethroplasty (Snodgrass) as compared to Mathieu’s repair and the overall complications were more in modified mathieu’s repair. Conclusion: The overall complication rate and operative time were significantly lower in Tubularized Incised Plate urethroplasty (Snodgrass), Therefore we recommend this repair as a primary treatment for distal penile hypospadias.

Frequency of diabetes in non St elevation myocardial infarction

Objective: To determine the frequency of diabetes mellitus in non ST segment elevation myocardial infarction

Study Design: Cross-sectional

Place and Duration of Study: The study was carried out at the Armed Forces Institute of Cardiology [AFIC] Rawalpindi, from Apr 2010 to Oct 2010

Material and Methods: In this study three hundred fifty two patients with non ST elevation myocardial infarction [NSTEMI] who fulfilled the inclusion criteria were studied while they were admitted to the hospital. They were divided into diabetic and non diabetic groups. Frequency of age, gender, rising levels of cardiac biochemical markers, plasma glucose and HbA1c were seen in both diabetic and non diabetic patients. Results were obtained by using chi-square method and independent t-test

Results: Out of 352 patients of NSTEMI 193 were diabetics. The study population was categorized in three groups according to age as; 30-45, 46-60, and 61-75 years respectively. It was found that 46-60 years group was most frequently affected with frequency of 46.1%, p<0.001 with male predominance as 67.9% and females as 32.1%. Cardiac biochemical markers were raised with mean for CK 528.51 U/L SD +/- 275.82 and CK MB 79.39 U/L SD +/- 32.5, p<0.001 respectively. Raised fasting plasma glucose was found in 189 patients mean 8.74 mmol/L SD +/- 1.52, p<0.001 and elevated HbA1c seen in 187 patients mean 7.94% SD +/- 0.83, p<0.001

Conclusion: Despite modern therapies for unstable angina [UA]/NSTEMI diabetes is an independent cardiovascular risk factor, therefore we need aggressive strategies to manage the high risk group of patients

Effect of silymarin therapy on liver aminotransferase in non-alcoholic fatty liver disease

Objective: The present study evaluated the effects of silymarin on blood glucose, blood lipids and liver amino-transferase [AST and ALT] in Non-alcoholic fatty liver disease [NAFLD]

Study Design: Randomized Placebo Controlled [double blind] Trial

Place and Duration of Study: This study was carried out at Consultant Clinic Cant area Hyderabad andDepartment of Medicine, Isra University Hospital Hyderabad from April 2012 to August2013

Materials and Methods: A sample of 64 subjects [33 cases and 31 controls] was selected for evaluating effects of silymarin. Subject selection observed the inclusion and exclusion criteria. Subjects with aspartate transaminase [AST] and alanine transaminase [ALT]>1.2 of normal were included. NAFLD diagnosis was confirmed by ultra-sonography. NAFLD cases were given silymarin[140 mg x2 tablets] daily for duration of 3 months. Controls received placebo. AST and ALT were checked after three months. Data variables were analyzed by SPSS version 21.0

Results: Mean +/- SD of aspartate transaminase [AST] and alanine transaminase [ALT] before intervention were found as 73.2 +/- 9.7 vs. 69.3 +/- 17.6 IUL[-1][p<0.021] and 92.1 +/- 19.4 vs.83 +/- 15.6 IUL[-1]in cases and controls [p < 0.0001] respectively. After three months the AST and ALT were found reduced compared to baseline. AST and ALT were found as 39.3 +/- 7.5 IUL[-1]and ALT to 39.3 +/- 10.9 IUL[-1]35.9 +/- 11.7 IUL[-1]and 83 +/- 15.6 IUL[-1]in cases and controls respectively. Blood lipids and blood glucose also showed statistically significant differences [p=0.0001]

Conclusion: Silymarin improves blood glucose, blood lipids and liver amino transferase in non-alcoholic fatty liver disease

Pictorial review of intrathoracic manifestations of progressive systemic sclerosis

Intra-thoracic manifestations of progressive systemic sclerosis [PSS] are not well known particularly the imaging features, which forms the basis of accurate and timely diagnosis. The aim of this study is to familiarize the physicians and radiologists with these features. The diagnosis can remain elusive because of the non-specific nature of symptoms which mimic many common conditions. Thus, the diagnosis of PSS can be missed leading to continuous morbidity if the correct imaging is not pursued. The authors examined the records of rheumatology patient referrals of over a 5 year period. A hundred and seventy patients with systemic sclerosis and mixed connective tissue disorders were chosen for detailed study of the imaging available, which form the basis of this review. The images included conventional chest radiographs, digital radiographs computed radiography [CT] and high resolution computed tomography [HRCT]. Where applicable computed pulmonary angiography [CTPA] and radionuclide scans were also interrogated

Urinary incontinence- patient's physical, mental and oral health analysis

Urinary incontinence can be distressful and may affect the quality of life to a great extent. Common types of UI are stress incontinence, urge incontinence and mixed incontinence. UI is more prevalent in older people and more frequently diagnosed in females than males. Efforts are made to investigate the primary disorder which causes incontinence, as UI is mostly secondary to an underlying medical condition. This study included patients diagnosed with UI and was conducted during one year period extending from February 2013 to January 2014. The data also constituted of a self-administered questionnaire to access the patient's knowledge regarding their disease. Ethical consent was obtained from the hospital where data were collected and oral and written consents were taken from all the participants prior to their participation. The study included 332 patients with a response rate of 73.7%. Overall, 254 males and 278 females participated. 64.9% of the male participants had urge incontinence followed by 26.6% having stress incontinence, while only 8.44% of the males were diagnosed with mixed incontinence. In females 77.2% had stress incontinence followed by urge incontinence [15.1%] and only 7.3% had Mixed urinary incontinence. 24% of males and 44.3% of females believed that pelvic exercises can prevent or treat UI. 34.6% of the total participants [40% females,27.9% males] had an understanding that weak anatomy contributes to the development of UI. Stress incontinence is more common in women, while the dominant type in men is urge continence. All patients, especially pregnant women should be provided information regarding UI in order to efficiently cope up with the condition if encountered

Histological changes in human gallbladder mucosa due to cholelithiasis

To observe the histological changes in gallbladder mucosa due to Cholelithiasis. Observational study. This study was carried out at Department of Surgery, Anatomy and Pathology of Isra University Hospital and Institute of Biochemistry Sindh University Jamshoro. Sixty nine cases of Cholelithiasis undergoing surgery were included in this study. After operation the gall bladders were obtained and fixed in 10% formalin. Gall bladder stone were obtained and their analysis was done in the Institute of Biochemistry Sindh University Jamshoro. Gross examination of gall bladders was done and for microscopy after hematoxylin and eosin staining, sections were obtained from the fundus, body and neck of the gallbladder. Additional sections were taken from grossly abnormal looking areas. Data was analyzed by using SPSS version 16.0. Chi square test was used to determine statistical significance between categorical groups [p<0.5]. It was observed that size of gall bladder were normal in 41 [59.4%], increased in 20 [29.0%] and shrunken in 08 [11.6%] cases. The mucosal changes seen in Cholelithiasis include, Cholestrolosis in 18 [26.08%], ulceration 07 [10.1%], atrophy 12 [17.4%] and lymphocytic infiltration in 67 [97%] cases. Cholelithiasis produced a series of histopathological changes in the gallbladder mucosa. These changes have no relation with type of gall stone

Atypical radiological manifestations of thoracic sarcoidosis: a review and pictorial essay

Thoracic sarcoidosis is a common disease, with well-described and recognizable radiographic features. Nevertheless, most physicians are not familiar with the rare atypical often-confusing manifestations of thoracic sarcoid. Although these findings have been previously reviewed, but more recent advances in imaging and laboratory science, need to be incorporated. We present a review of literature and illustrate the review with unpublished data, intended to provide a more recent single comprehensive reference to assist with the diagnosis when atypical radiographic findings of thoracic sarcoidosis are encountered. Thoracic involvement accounts for most of morbidity and mortality associated with sarcoidosis. An accurate timely identification is required to minimize morbidity and mortality. It is essential to recognize atypical imaging findings and relate these to clinical manifestations and histology

Accelerated 2 hour regimen of streptokinase for pulmonary embolism

To assess the safety and efficacy of accelerated 2 hour regimen of streptokinase [SK] in acute massive pulmonary embolism. The primary end point of study was immediate hemodynamic improvement and safe discharge from the hospital. Quasi-experimental study. Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD], March 2010 to Sept 2010. Twenty five patients referred to AFIC-NIHD Rawalpindi with recent symptoms [<5 days] suggestive of acute massive pulmonary embolism were considered for entry into the study. On confirmation of acute massive pulmonary embolism, they were thrombolysed with 1.5 million units of streptokinase over two hours followed by unfractionated heparin infusion intravenously at a dose of 1,000 IU/h. They were observed for immediate hemodynamic and clinical improvement and followed up till discharge from the hospital. Safety of Streptokinase was assessed by observing for major bleed [requiring blood transfusion]/fatal bleeding/intracranial haemorrhage confirmed on CT scan or anaphylaxis secondary to accelerated regimen. Mean age of the patients was 55 years [range 24 to 85 years] and 60% [15] were males and 40% [10] were females. CT pulmonary angiogram in all 25 cases confirmed massive pulmonary embolism. Streptokinase 1.5 million units were given to all 25 patients in infusion form over a period of 2 hours followed by unfractionated heparin infusion at 1000 IU/hour. No bleeding complication was observed in any of these cases. Eighteen [72%] patients showed immediate hemodynamic and clinical improvement but 28% [7] expired on the same day. Average hospital stay of the patients was 6 days. Mortality of patients with massive pulmonary embolism is high even after thrombolysis. Accelerated 2 hour regimen of streptokinase can be routinely used in patients with massive pulmonary embolism without obviously compromising efficacy or safety but further randomized controlled trials to compare the two SK regimens are required to better predict the efficacy and outcome of the two regimens

Double stick approach for chronic total occlusion of coronary arteries

To describe experience of double stick access to arterial system with contralateral injection of the opposite artery to visualize the distal cross filling vessel when a totally occluded vessel has no antegrade flow. A Quasi-experimental study. Armed Forces Institute of Cardiology / National Institute of Heart Disease Rawalpindi from Jan 2009 to Aug 2010. Retrospective analysis of 20 coronary angiograms performed for CTO at the cardiac catheterization laboratory of AFIC/NIHD were included in the study. Double stick access was gained through femoral artery in the groin 1cm apart. Twenty patients with chronic total occlusions underwent PCI with contralateral injection technique. Out of them 70% were male and 30% were female. The mean age was 53.65 years. Multivessel coronary artery disease was seen in 45% of patients. Left anterior descending artery lesion was present in 60%, while right coronary artery lesion in 40%. There was no LCX lesion. Single wire was used in 55% of cases while 40% required a second wire which was stiffer and heavier than the previous one. Pilot 50 was successful in 70% and 10% required cross it 200. Predilation was done in all cases using multiple balloons. DES was used in 93.75% cases of CTO. The procedure was successful in 80% while in 20% it was unsuccessful. There was no death during the procedure, nor any other periprocedural or access site complications. We conclude that double stick approach with contralateral injection is a safe and effective way to cross total occlusion

Guidelines for the role of FDG-PET/CT in lung cancer management

Fluoro-2-deoxy-D-glucose [FDG]-positron emission tomography [PET] and PET/computed tomography [FDG-PET/CT] is regarded as a standard of care in the management of non-small-cell lung carcinoma [NSCLC] and is a useful adjunct in the characterization of indeterminate solitary lung nodules [SLN], and pre-treatment staging of NSCLC, notably mediastinal nodal staging and detection of remote metastases. FDG-PET/CT has the ability to assess locoregional lymph node spread more precisely than CT, to detect metastatic lesions that would have been missed on conventional imaging or are located in difficult areas, and to help in the differentiation of lesions that are equivocal after conventional imaging. Increasingly FDG-PET/CT is employed in radiotherapy planning, prediction of prognosis in terms of tumor response to neo-adjuvant, radiation and chemotherapy treatment. Evidence is accumulating of usefulness of PET/CT in small cell lung cancer.

Initial experience of fractional flow reserve in 30 patients with moderate coronary artery lesions at armed forces institute of cardiology

To evaluate our initial experience of Fractional Flow Reserve [FFR] for decision making in coronary revascularization in moderate lesions. A descriptive study. Armed Forces Institute of Cardiology/National Institute of Heart Diseases from August 2009 to August 2010. A total of 30 consecutive patients who underwent FFR at AFIC/NIHD from August 2009 to August 2010. These were the cases in which decision regarding PCI was difficult on visual assessment alone as experienced operators differed in their opinion. A 0.014" FFR wire was used and pressure gradients across the lesions were noted A total of 30 patients with 44 moderate lesions on coronary angiography were evaluated in our initial experience. Amongst these, 27 [61.4%] LAD lesions were studied [20 lesions had an FFR > 0.80 while 7 [15.9%] had an FFR 0.80 or less]. Seven [15.9%] lesions of LCX were evaluated [5 had an FFR > 0.80 and 2 had 0.80 or less]. Seven [15.9%] lesions were of RCA [4 had an FFR >0.80, 3 had 0.80 or less]. One case of LMS lesion was found to be non-critical. Two [4.5%] vein graft lesions were included of which one was found to be angiographically critical, [FFR 0.72]. Out of the total 44 lesions studied 14 [31.82%] lesions were critical with an FFR 0.80 or less, which were stented. Thus 30 stents were saved. This reduced the cost, as well as the un-necessary hazards and risks associated with PCI and the issue of difference in opinion was put to rest. We thus conclude that FFR is a very important tool in guiding the interventionist for planning PCI in moderate lesions

Procedural analysis of patients with stent thrombosis [ST]

To analyze the procedural details of patients presenting as ST and undergoing PCI. Descriptive study. Armed Forces Institute of Cardiology - National Institute of Heart Diseases [AFIC-NIHD] from Jan 2007 to Dec 2010. A descriptive, single center study done at AFIC Rawalpindi from Jan 2007 to Dec 2010. During this period patients with prior stenting who presented to AFIC E/R with acute ischaemic symptoms with ECG changes and had angiographically confirmed ST were studied. Their procedural details [index PCI and ST procedure] were analyzed. Over this four year study period, 7694 coronary angioplasties were carried out and 12871 stents [10633 DES and 2238 BMS] were implanted. Amongst these, 32 patients [28 males and 4 females] later had angiographically confirmed ST and were treated with PCI. Mean age was 51.57 years. Dual antiplatelet therapy [DAPT] non-compliance was not a contributory factor in our study. Coronary distribution involved in ST included 20 cases of LAD, 7 of LCX and 5 of RCA territory. Thirteen [40%] patients had overlapping stents, 11 [34.4%] had direct stenting. Average diameter of stents with ST was 2.86 mm and the average length was 24.17 mm. Incidence of ST was higher in BMS as compared to DES [p0.003]. Of these 32 patients, 14 [43.75%] were treated with further stenting whereas 18 [56.25%] underwent POBA only. Telephonic follow up after second PCI was possible in only 15 cases, out of which five [33.33%] deaths were reported on the day of thrombotic procedure. ST has a high mortality and there was an overall higher frequency of ST in BMS compared to DES. Acute and subacute ST were mainly related to BMS whereas late ST was more common in DES. However PCI technique i.e direct stenting and overlapping stents, was a major predictor of stent thrombosis

Pulmonary vascular complications of chronic liver disease: pathophysiology, imaging, and treatment

To review the pathogenesis of pulmonary vascular complications of liver disease, we discuss their clinical implications, and therapeutic considerations, with emphasis on potential reversibility of the hepatopulmonary syndrome after liver transplantation. In this review, we also discuss the role of imaging in pulmonary vascular complications associated with liver disease

Cetirizine and loratadine - comparing their antagonist effects on isolated trachea of rabbit

To study and compare the antagonist effects of Cetirizine and Loratadine on histamine induced contractions of isolated trachea of rabbit. Comparative controlled invitro experimental study. This study was conducted at The Department of Pharmacology and Therapeutics, Basic Medical Sciences Institute [BMSI] Jinnah Postgraduate Medical Center [JPMC] Karachi, for the period of six months. Isolated tracheal smooth muscles of twenty four rabbits were used. Fresh Kreb's nutritional solution was prepared for each subject. Tracheal smooth muscles were exposed to standard dilution of Histamine, and then they were challenged with serial dilutions [10 [-18]to 10 [-3]gm. /ml] of Cetirizine and Loratadine separately. Responses as rate and amplitudes of contractions were recorded by 7B Grass Polygraph machine. Cetirizine inhibit the rate of histamine induced contractions of tracheal muscles from 0.85 to 12.33% and amplitude from 0.0 to 82.69%, as concentration of drugs increased. While Loratadine inhibit the rate of histamine induced tracheal contractions from 0.85 to 10.59% and amplitude from 6.5 to 76.82% as concentration of drugs increased. Cetirizine found more potent than Loratadine as inhibitor of histamine induced contraction in isolated tracheal smooth muscles of rabbit. Basic Sciences

calcified lung nodule: what does it mean?

The aim of this review is to present a pictorial essay emphasizing the various patterns of calcification in pulmonary nodules [PN] to aid diagnosis and the pathogenesis where it is known. The imaging evaluation of PN is based on clinical history, size, distribution and the gross appearance of the nodule as well as feasibility of obtaining a tissue diagnosis. Imaging is instrumental in the management of PN and one should strive not only to identify small malignant tumors with high survival rates but to spare patients with benign PN from undergoing unnecessary surgery. The review emphasizes how to achieve these goals. One of the most reliable imaging features of a benign lesion is a benign pattern of calcification and periodic follow-up with computed tomography showing no growth for 2 years. Calcification in PN is generally considered as a pointer toward a possible benign disease. However, as we show here, calcification in PN as a criterion to determine benign nature is fallacious and can be misleading. The differential considerations of a calcified lesion include calcified granuloma, harmartome, carcinoid, osteosarcoma, chondrosarcoma and lung metastases or a primary bronchogenic carcinoma among others. We describe and illustrate different patterns of calcification as seen in PN on imaging

Imaging lung manifestations of HIV/AIDS

Advances in our understanding of human immunodeficiency virus [HIV] infection have led to improved care and incremental increases in survival. However, the pulmonary manifestations of HIV/acquired immunodeficiency syndrome [AIDS] remain a major cause of morbidity and mortality. Respiratory complaints are not infrequent in patients who are HIV positive. The great majority of lung complications of HIV/AIDS are of infectious etiology but neoplasm, interstitial pneumonias, Kaposi sarcoma and lymphomas add significantly to patient morbidity and mortality. Imaging plays a vital role in the diagnosis and management of lung of complications associated with HIV. Accurate diagnosis is based on an understanding of the pathogenesis of the processes involved and their imaging findings. Imaging also plays an important role in selection of the most appropriate site for tissue sampling, staging of disease and follow-ups. We present images of lung manifestations of HIV/AIDS, describing the salient features and the differential diagnosis

Angina pectoris; role of trimetazidine

To assess the clinical efficacy, cost effectiveness and side effect profile of trimetazidine in the management of stable angina pectoris. An open label, uncontrolled study was conducted in 200 patients with stable angina in armed forces institute of cardiology, Rawalpindi Pakistan. Patients were treated for 4 weeks with modified release trimetazidine tablet [35 mg] twice daily in addition to their conventional therapy. As compared to base line trimetazidine significantly reduced the number of angina episodes per week from 10 to 3 [p<0.005], improved exercise duration time on standard exercise tolerance test [ETT] [410 vs. 370 sec; p<0.01], time to onset of typical angina [380 vs. 290 sec; p<0.05], time to 1mm or more ST segment depression [340 vs. 290 sec; p<0.01]. There was no drop out of patients due to side effects or non compliance. These results indicate that trimetazidine is effective and well tolerated when used in combination with existing antianginal therapy in patients with angina pectoris