Challenges in the management of idiopathic pulmonary fibrosis from a low- and middle-income country.

Idiopathic pulmonary fibrosis (IPF) is the most common progressive form of interstitial lung disease (ILD) that leads to gradual deterioration of lung function and ultimately death. Data from low- and middle-income countries (LMIC) on IPF is scarce. In this communication, we report the challenges encountered in managing IPF from Pakistan's largest tertiary care centre. A total of 108 patients with IPF were evaluated at the Aga Khan University Hospital in Karachi, Pakistan from January 2017 to March 2020. A significant concern was that most patients with IPF presented late during their disease. A bigger challenge encountered in clinical practice was the cost and nonavailability of antifibrotic therapy in the country until mid-2020. Successfully addressing these limitations, it is anticipated that better care will be available for the patients suffering from IPF in this part of the world.

Thyroid hemiagenesis with compensatory hypertrophy of the remaining lobe: A case report.

Thyroid hemiagenesis is defined as a failure of one thyroid lobe development. This condition predominantly manifests as an incidental finding during radiological investigation. This paper repor ts the case o f a 53-year-ol d female, a known case of hypertension, who visited the ENT clinic at AKU, a ter tiary ca re centre in Karachi, Pak istan and was hospi talized from 12 th to 1 5th Septembe r 202 1. The patient presented with hemiagenesis of the right thyroid lobe with enlargement of the contralateral lobe resulting in airway compression. She was subjected to excision of the thyroid gland without any intra-operative or postoperative com plicati ons. There were n o complaints o f dyspnoea, stridor or hoarseness during the hospital stay. The patient was discharged and was found to be well on subsequent follow-ups.

Change in mean postoperative pain in patients undergoing tonsillectomy with cold water versus usual practice: A pragmatic trial.

Introduction: Tonsillectomy is one of the most common procedures performed in otolaryngology. There are various methods to perform tonsillectomies (cold and hot). Thermal damage and inflammation of the surrounding tissue using monopolar cautery is said to point to increased pain whereas immediate cooling of the burnt area is thought to reduce pain owing to heat dissipation. Our objective was to determine the difference in mean post-tonsillectomy pain scores among patients irrigated with cold water (4°C) and in patients not irrigated with cold water. Material and Methods: A quasi-experimental trial was conducted from January 2016 to December 2017 at a tertiary care hospital. All tonsillectomies were carried out with monopolar cautery at a power of 20 W. Patients either received cold water irrigation post tonsillectomy of the tonsillar bed (intervention arm) or no irrigation (control arm). The pain score was measured on Days 0, 1, 3, 5, and 7. Pain scores were charted on a visual analog scale on the respective days. Results: Seventy-eight patients were included in the study. The mean age of our patients was 10.26 (4.24) years old in the intervention arm, and 11.95 (4.19) years old in the control arm. It was observed that the pain was significantly lower in patients with cold water irrigation of the tonsillar fossa on Days 1, 3, 5, and 7 (p = 0.001). There were no readmissions postprocedure and none of our patients developed any complications postsurgery. Conclusions: In this trial, we report a reduced pain score at all days of observation in the intervention group. Irrigation of the tonsillar fossa is a safe, cost-effective, and less technically demanding technique that could be employed to reduce postoperative pain. Further studies with randomization, blinding and a larger sample size could further improve on our results.

Auricular leishmaniasis mimicking squamous cell carcinoma of the pinna.

Cutaneous leishmaniasis can occur on any exposed area of the body; however, the pinna is an exceptionally rare site for the disease. Caused by the parasite Leishmania, cutaneous leishmaniasis has a wide range of presentations and thus is very easy to misdiagnose or mistake for a neoplastic lesion. Here, we report the case of a middle-aged male patient presenting with a painful, ulcerated lesion on the left auricle initially suspected to be a malignancy with histopathology eventually revealing a diagnosis of auricular leishmaniasis. The patient received appropriate therapy and was found to be disease free at follow-up. These isolated lesions of the pinna often resemble neoplastic lesions and thus may escape diagnosis for months at a time, increasing patient stress as well as expenditure. In addition, prompt recognition may also help mitigate recurrence of the disease, making it worthwhile to include cutaneous leishmaniasis as part of the differential, especially in endemic areas.

Role of Probiotics in Patients with Allergic Rhinitis: A Systematic Review of Systematic Reviews

Abstract Introduction Allergic rhinitis (AR) is estimated to affect up to 30% of the world population. With the rise in cases, newer treatment modalities have been explored. Probiotics have shown to reduce symptoms of AR and improve quality of life. A few systematic reviews have been published aiming to assess the role of probiotics in AR. Objectives To consolidate the recent evidence with an overview of systematic reviews by extracting data regarding subjective outcomes (from quality of life questionnaires, the Total Nasal Symptom Score, the Total Ocular Symptom Score, the Daily Total Symptom Score, the incidence of AR, and the Rhinitis Total Symptom Score) and objective outcomes (levels of antigen-specific immunoglobulin E [IgE], total IgE, interleukin 10 [IL-10], interferon gamma [IFNG], eosinophil, and the T helper 1/T helper 2 [Th1/Th2] ratio). Data Synthesis We conducted a literature search on the PubMed, EBSCO CINAHL, EBSCO Dentistry & Oral Sciences Source, and Cochrane Library up to April 14, 2020. The qualitative assessment was performed using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR-2) tool. A total of 419 titles were screened, and 3 systematic reviews met our eligibility criteria. Probiotics in the treatment of AR have been shown to improve quality of life, the total nasal and ocular symptom scores, the daily total symptom scores and Th1/Th2 ratio. No difference was ascertained for rhinitis total symptom score, and the rates of antigen-specific IgE, total IgE, IL-10, INFG and eosinophil. Conclusion The present review showed that there is considerable evidence that probiotics are useful in the treatment of AR. Further randomized trials targeting the limitations of the currently-available evidence can help ascertain the usefulness of probiotics in cases of AR.

Role of Probiotics in Patients with Allergic Rhinitis: A Systematic Review of Systematic Reviews.

Introduction Allergic rhinitis (AR) is estimated to affect up to 30% of the world population. With the rise in cases, newer treatment modalities have been explored. Probiotics have shown to reduce symptoms of AR and improve quality of life. A few systematic reviews have been published aiming to assess the role of probiotics in AR. Objectives To consolidate the recent evidence with an overview of systematic reviews by extracting data regarding subjective outcomes (from quality of life questionnaires, the Total Nasal Symptom Score, the Total Ocular Symptom Score, the Daily Total Symptom Score, the incidence of AR, and the Rhinitis Total Symptom Score) and objective outcomes (levels of antigen-specific immunoglobulin E [IgE], total IgE, interleukin 10 [IL-10], interferon gamma [IFNG], eosinophil, and the T helper 1/T helper 2 [Th1/Th2] ratio). Data Synthesis We conducted a literature search on the PubMed, EBSCO CINAHL, EBSCO Dentistry & Oral Sciences Source, and Cochrane Library up to April 14, 2020. The qualitative assessment was performed using the Assessing the Methodological Quality of Systematic Reviews (AMSTAR-2) tool. A total of 419 titles were screened, and 3 systematic reviews met our eligibility criteria. Probiotics in the treatment of AR have been shown to improve quality of life, the total nasal and ocular symptom scores, the daily total symptom scores and Th1/Th2 ratio. No difference was ascertained for rhinitis total symptom score, and the rates of antigen-specific IgE, total IgE, IL-10, INFG and eosinophil. Conclusion The present review showed that there is considerable evidence that probiotics are useful in the treatment of AR. Further randomized trials targeting the limitations of the currently-available evidence can help ascertain the usefulness of probiotics in cases of AR.

Sudden sensorineural hearing loss: A rare presentation of dengue fever.

Sudden Sensorineural Hearing Loss (SSNHL) is described as a hearing loss of at least 30db in three frequencies in pure tone audiogram over 3 days or less. The cause may be infectious, vascular, systemic immune-mediated or idiopathic. Multiple viral infections have been associated with SSNL. However, dengue fever, which is an RNA viral disease that is directly transmitted by a mosquito of genus Aedes, has been reported to present with SSNHL only thrice in existing literature to the best of our knowledge. There are multiple different proposed mechanisms of SSNHL in viral infections and multiple viruses have been proven to cause hearing loss. However, dengue virus is not one of them. In majority of cases of SSNHL, the exact cause is very difficult to determine. We report the case of a gentleman who had unilateral SSNHL after dengue fever.

Hormone receptors AR, ER, PR and growth factor receptor Her-2 expression in oral squamous cell carcinoma: Correlation with overall survival, disease-free survival and 10-year survival in a high-risk population.

Oral squamous cell carcinoma (OSCC) comprises most of head and neck neoplasms and is one of the highest-ranking and lethal cancers in Pakistan due to prevailing mouth habits. Several types of receptors act as prognostic markers and targets for therapy in some cancers, but their application in OSCC is largely unexplored. This study aimed to evaluate the expression of hormonal receptors and Her-2 in OSCC patients and correlate it with 10-year, overall and disease-free survival. To achieve this objective, immunohistochemistry for Her-2, AR, ER and PR was performed on 100 formalin-fixed paraffin-embedded primary OSCC specimens. Receptor expression was correlated with mouth habits and clinicopathological features and patient survival was analyzed using Kaplan-Meier method and Cox regression univariate analysis. We observed that in 100 patients, there were 57 males and 43 females. Immunopositive Her-2 expression was observed in 21% of patients, AR in 13%, ER in 3% and 0% for PR. Patients with betel quid/areca nut mouth habits had significantly absent Her-2 expression (P = 0.035). Also, Her-2 negative patients were also negative for AR expression (P = 0.002). Her-2 positive patients had poor 10-year survival (P = 0.041). A trend of low survival and high recurrence rate was observed in AR positive patients, but this was not significant (P = 0.072). No statistically relevant correlations were seen in the case of ER and PR. In conclusion, Her-2 may be a valuable marker for predicting long-term prognosis of OSCC patients.

Body Mass Index and Diabetes Mellitus May Predict Poorer Overall Survival of Oral Squamous Cell Carcinoma Patients: A Retrospective Cohort From a Tertiary-Care Centre of a Resource-Limited Country.

Introduction: Oral squamous cell carcinoma (OSCC) is one of the highest-ranking cancers among both genders in Pakistan. Obesity is linked to a much higher risk for developing multiple cancer types. Individuals with Diabetes mellitus (DM) face an increased risk for developing oral cancer. Hence, the objective of this study was to identify the effect of obesity and DM on the prognosis of OSCC patients. Methods: This retrospective cohort analysis was conducted on 386 patients diagnosed and treated for OSCC at The Aga Khan University Hospital, Karachi, Pakistan. Patient information was obtained from hospital medical records. Obesity was defined as having a body mass index (BMI) of ⩾25 kg/m2 according to the WHO Asian cut-offs for BMI. Patient BMI was correlated with diabetes status, clinicopathological features and overall survival. Kaplan-Meier survival analysis was performed, along with univariate and multivariate cox regression analysis to test the effect of obesity and diabetes on overall survival. Results: In a set of 386 patients, there were 296 males (76.7%) and 90 females (23.3%). The mean BMI was 24.4 (SD ± 5.25) and 42.7% of patients were found to be obese (⩾25 BMI). 64 patients (16.6%) were diabetic. The risk of death was significantly higher in underweight patients (P = .035) compared with normal weight individuals. Diabetics had a higher mean BMI compared with non-diabetics. However, DM was not a statistically valid predictor of survival. Conclusion: Underweight OSCC patients were at a higher risk of death compared with normal weight OSCC patients.

Myoepithelioma of the Parotid Gland: A Case Report and Literature Review.

Tumors of the salivary glands are rare and have various histo-pathological subtypes. The overall incidence is 2.5-3 per 100,000 patients per year. Myoepithelioma of the parotid gland is very rare with an incidence of only 1-1.5% among all salivary gland tumors. The diagnostic criteria for benign myoepithelioma were laid down on the basis of the work of Barnes and Sciubba. A 30-year-old lady presented to our university with a mass slowly increasing in size. There were no aggravating and/or relieving factors found. On examination a 3 × 3 cm diffuse swelling was found around the right pre auricular area. Fine Needle Aspiration Cytology (FNAC) was performed. The findings were suggestive of a pleomorphic adenoma. The patient underwent a right sided superficial parotidectomy to remove the tumor. The final histopathology report revealed the tumor to be a myoepithelioma. Myoepithelioma is a benign salivary gland neoplasm formed almost entirely of myoepithelial cells arranged in a sheet, island or cord-like fashion. On CT scans, it presents as a well-circumscribed homogenous lesion with lobulated or smooth margins. Myoepitheliomas may also have nodules that enhance under contrast and areas of linear bands that do not. The recommended treatment for a myoepithelioma is complete surgical excision with wide margins. It has a very low recurrence rate compared to the 15-18% recurrence rate for pleomorphic adenomas. Utilization of immunohistochemical staining is of utmost importance in suspected myoepithelioma cases to ensure proper treatment and follow-up. Myoepitheliomas are rare tumors which must be included in the differential if a patient presents with a tumor of characteristics similar to those described above. Immunohistochemistry and electron microscopy are useful tools for the diagnosis of myoepitheliomas.