Duodenal stricture secondary to IgG4-related chronic sclerosing duodenitis-A case report with review of the literature.

Key Clinical Message: This case highlights the importance of a definite diagnosis of an IgG4-related chronic sclerosing duodenitis based on histological and radiological findings to rule out any malignancy in the mass. While dealing with patients having concentric duodenal thickening resulting in stricture formation, one should think of inflammatory etiology as well. IgG4-related disease is one of these inflammatory disorders where we see soft tissue thickening without a large mass or any associated lymphadenopathy as in our case. Abstract: Immunoglobulin G4-related disease (IgG4-RD) is distinguished as an infiltration of IgG-4-positive plasmacytes involving inflammatory lesions across multiple organs which is accompanied by raised IgG4 levels in the serum. Several inflammatory disorders are recognized as part of the IgG4-RD family based on shared histopathological features, which include Mikulicz's disease, chronic sclerosing sialadenitis, or Riedel's thyroiditis. Our case highlights a distinctive presentation of IgG4-related diseases; a 58-year-old man presenting with duodenal stricture highly suspicious of a duodenal mass/ampullary mass later found to be due to IgG4-related sclerosing duodenitis with negative malignancy on biopsy. We present the diagnostic challenges faced and relevant findings noted.

Improved Diagnostic Confidence Imparted by Radiologists in Radiology Reports After Educational Interventions on Reporting Styles.

Background Radiology reports are important medico-legal documents facilitating communication between radiologists and referring doctors. Language clarity and precision are crucial for effective communication in these reports. Radiology reporting has changed with the evolution of imaging technology, prompting the adoption of precise terminology. Diagnostic certainty phrases (DCPs) play an important role in communicating diagnostic confidence in radiology reports. Objective The aim of this study was to evaluate the use of DCPs in radiology reports, before and after targeted educational interventions. Materials and methods The study was approved by the Aga Khan University Hospital's Ethical Review Committee and includes cross-sectional radiology reports. It involved three cycles of retrospective evaluation, with educational interventions in between to improve the use of DCPs. Results The study found a dynamic shift in the use of DCPs during the three cycles. Initially, intermediate-certainty phrases prevailed, followed by an increase in high-certainty phrases and a drop in low-certainty phrases. Later cycles showed a significant decline in DCPs and an increase in the use of definitive language. Across all subspecialties, there was a consistent decrease in intermediate- and low-certainty DCPs. Conclusion The study validates the transformative impact of educational interventions on the use of DCPs in radiology reports. The radiology reports frequently used DCPs with intermediate to low diagnostic certainty with improvement in the subsequent cycles of the study after educational interventions. It emphasizes the significance of continuing education to ensure the use of precise nomenclature.

'Bubbles and esophagus: A tale of unexpected and otherwise unexplained pain'.

Boerhaave's syndrome is a potentially fatal emergency, typically induced by forceful retching, which leads to increased intra-esophageal pressure. It commonly presents with vague symptoms such as chest pain or more classic symptoms like subcutaneous emphysema and vomiting. We present an unusual case of Boerhaave syndrome secondary to rapid and excessive intake of carbonated drinks in a 22-year-old male, who presented to our emergency department with atypical symptoms of fever and shortness of breath. Imaging studies showed left-sided hydropneumothorax with an esophageal pleural fistula, and multidisciplinary teams were involved in the patient's management.

Correlation of Grades of Non-alcoholic Fatty Liver on Ultrasound With Blood Parameters.

Introduction Non-alcoholic fatty liver disease (NAFLD) is the most prevalent liver condition worldwide. NAFLD has been associated with metabolic syndrome and its symptoms, such as type 2 diabetes, hypertension, dyslipidemia, and obesity. Ultrasound is widely used to grade hepatic steatosis, being the most cost-effective, non-invasive, and readily available modality without radiation exposure. The study aimed to assess the correlation of NAFLD grade as seen on ultrasound with blood parameters in a Pakistani population. Materials and methods The included patients were those who were diagnosed with fatty liver disease on ultrasound and whose laboratory tests were available within two weeks of the ultrasound. Two seasoned radiologists rated the severity of NAFLD after looking over ultrasound scans. Consecutive sampling technique was used to minimize selection bias. The degree and direction of the linear relationship between the NAFLD grade and each biochemical parameter were measured using the Pearson correlation coefficient. Results There were 207 patients in all who had been identified with NAFLD on ultrasound, the majority of whom had grade II NAFLD and were in their sixth decade of life. According to Pearson's analysis, the grade of NAFLD had larger positive associations with triglycerides, total cholesterol, low-density lipoprotein, and fasting blood sugar. High density lipoprotein and C-reactive protein were found to have a negative correlation with the grade of NAFLD. Conclusion The findings of the study highlight the correlation between NAFLD grade on ultrasonography and specific blood parameters, implying that managing these biochemical indicators may help to improve hepatic steatosis.

IgG4-related inflammatory pancreatic head pseudotumor mirrors pancreatic head tumor: A novel case series with a review of the literature.

Key Clinical Message: In this noteworthy case series regarding pancreatic pseudo tumors, we intend to spread knowledge among physicians for the diagnostic and therapeutic approach and eventual disease prognosis. Abstract: Inflammatory pseudotumor of pancreatic head greatly mimics pancreatic head tumor. One of them is IgG4-related pancreatic disease, which is commonly mistaken as neoplastic disease on imaging. In our novel case series, we report three cases of IgG4-related pancreatic head pseudotumor with patients ranging from 35 to 72 years of age. Patients presented with jaundice and abdominal pain. Alongside initial laboratory workup, abdominal CTs and serum IgG4 levels were also obtained. Imaging features in conjunction with IgG4 levels confirmed the diagnosis of IgG4-related autoimmune pancreatitis. Pancreatic pseudotumors are notorious for being often reported as real tumors. Through our noteworthy case series, we intend to highlight the imaging features and laboratory markers that are crucial in such cases to avoid invasive procedures.

Concordance Between Resident and Attending Radiologist in Reporting Pneumothorax on Intensive Care Unit and Emergency Room Chest Radiographs.

Introduction Pneumothorax is a common medical emergency and has potentially life-threatening consequences, so it is important for radiology residents and consultants to know its radiographic appearance so that timely diagnosis and appropriate management can be done. Patients with pneumothorax have nonspecific complaints, and clinical examinations are not confirmatory. The chest X-ray is easily available and has high accuracy in the detection of pneumothorax. The aim of this study is to determine the agreement between the on-call radiology resident and the attending radiologist in the diagnosis of pneumothorax on chest radiographs. Materials and methods This cross-sectional study was performed in the Department of Radiology at Aga Khan University Hospital, Karachi. After approval from the ethical review committee (ERC), the study was carried out. A total of 174 patients were included in the study. The resident interpreting the radiograph commented on the pneumothorax and recorded it on the "Comments" section of the picture archiving and communication system (PACS). Further entries were made in the department's "Panic Logbook." Subsequently, the final report by the attending radiologist was tallied, and the decision of both the resident and the attending radiologist regarding the presence or absence of pneumothorax was compared for interobserver agreement. Results Of the 174 patients, 139 (79.9%) were male and 35 (20.1%) were female. The mean age of the patients was 45.6 ± 12.4 years. Pneumothorax was reported by the resident in 164 (94.25%) cases, while the attending radiologist reported it in 167 (96%) cases. The remaining 4% of cases were ultimately diagnosed on a CT scan of the chest performed at the request of the primary team; they were too small to be detected on a chest radiograph. The most common side involved was the right side, with 112 (64.4%) cases, followed by the left side with 55 (31.6%) and both sides with five (2.9%), while in two cases, pneumothorax was not reported by the resident and the attending radiologist. The position of the pneumothorax was as follows: apex in 80 (46%), base in 56 (32.2%), and along the lateral border of the lung in 93 (53.4%). Concordance between the resident and the radiologist was found to be 92.5% (kappa = 0.20; p = 0.008). Stratification for age, gender, the position of pneumothorax, and the level of residency was also carried out. Conclusion In our setting, there was a high level of agreement (92.5%) between the resident and the attending radiologist in reporting pneumothorax on chest radiographs (kappa = 0.20; p = 0.008).

Endovascular Embolisation of Pulmonary Arteriovenous Malformation Using Amplatzer Vascular Plugs.

Pulmonary arteriovenous malformation (PAVMs) are abnormal communications between pulmonary arteries and veins. The rarity of their occurrence, coupled with the risks they pose, including brain abscess, embolic stroke, and myocardial infarction, mandates that they should not be overlooked in the differential diagnosis of patients presenting with haemoptysis, dyspnea, clubbing, cyanosis, hypoxemia, or epistaxis. We present the case of a 41-year-old local female who presented to our hospital as an outpatient with decreased oxygen saturation (SpO2) of 70%-80% for the past two years with a final diagnosis of PAVM. The initial baseline workup showed polycythemia with a hemoglobin level of 19 mg/dL and raised hematocrit. She had extensive workup in the past two years for her polycythemia including gene mutation testing and cardiac workup which all turned out normal. Her chest X-ray (CXR) showed right lung opacity which was initially considered to be infective but it did not respond to antibiotic treatment. Later on, a CT scan of the chest was performed and findings were typical of a large PAVM which had two feeding arteries. The patient was referred to a cardiothoracic surgeon who sent the patient to the interventional radiology section for endovascular management. The embolization procedure was then performed and both feeders were successfully embolised. After the procedure, the patient's SpO2 levels were restored to 95%-96%, and no post-procedure complications were noted.

Adequacy of Completion of Computed Tomography Scan Request Forms at a Tertiary Care Center in Pakistan: A Clinical Audit.

Introduction A lot of radiation exposure to a population comes from medical sources. Clinicians must justify the need for radiology procedures on a request form to prevent unnecessary scans and radiation exposure. Moreover, the properly-filled form will help to identify the patient correctly and provide clinical details to make a radiological diagnosis. Objective The purpose of the study was to audit the computed tomography (CT) scan request forms and find out the adequacy of completion of the request forms at Bahawal Victoria Hospital, Bahawalpur, Pakistan. Materials and methods We scrutinized 300 CT scan request forms received at the tertiary care center, Bahawal Victoria Hospital. We checked the adequacy of filling of different fields in the request forms like name, address, clinical and surgical history, and the name of required examination. We also looked for the missing subjects in the CT request form currently used in our hospital like the contact numbers of the patient and the doctor, the identity of the requesting doctor, renal function tests (RFTs), last menstrual period (LMP), and history of allergy. The results were analyzed using Statistical Package for the Social Sciences 20 (SPSS 20) (IBM, NY, USA) and Microsoft Office Excel Worksheet (Microsoft Corporation, NM, USA). Results The name of the patient was present in 100% of the request forms, surname in 27.66%, age in 73.33%, gender in 64.33%, date in 91.66%, bed number in 37.90%, address in 1% and the name of required examination in 99.6%. Information about diagnosis included clinical history in 50.66%, past surgical history in 1%, laboratory investigations in 1%, and clinical examination in 8.66% of the forms. All the forms had the name and signature of the referring consultant, but only 10.33% forms contained the identity of the requesting junior doctor. More than half of the request forms for CT scan provided RFTs. We found no record of the allergy, LMP, and the contact number of the doctor and the patient. Conclusion The information provided in the CT scan request forms was inadequate. The practice of filling these forms needs to be improved to protect the patients from unnecessary radiation exposure.

The Spectrum of Beta-thalassemia Mutations in Couples Referred for Chorionic Villus Sampling at Bahawal Victoria Hospital, Bahawalpur.

Introduction The prevalence of beta-thalassemia mutations is different in various castes, regions, and ethnic groups. By knowing this prevalence, we can conduct a targeted screening of only the high-risk population and only for the specific mutations that are prevalent in each group. Objective The purpose of this study was to determine the regional, caste-wise, and ethnic spectrum of beta-thalassemia mutations in couples referred for a prenatal diagnosis. Methods A cross-sectional analytical study was conducted at the thalassemia unit, Bahawal Victoria Hospital, Bahawalpur, from October 1, 2015, to May 15, 2018. After obtaining informed consent, chorionic villus sampling (CVS) was performed in 144 women having a gestational age of 12 to 16 weeks. We took blood samples of the couples. A chromosomal analysis for 13 mutations was done at Punjab Thalassaemia Prevention Programme (PTPP), Lahore. The researchers filled a questionnaire with all the details of couples like ethnicity, caste, and region. Results The most common mutation was Fr 8-9(+G), accounting for 29.8%, followed by IVS 1-5(G-C), which was 28.9%. We did not find three mutations in any chromosome. Fr 8-9 (+G) was the most common mutation among Punjabis and Pakhtoons. IVS 1-5 (G-C) was the most common mutation among Saraikis and Urdu-speaking people. In Rajputs, Arains, Jatts, and Pathans, Fr 8-9 (+G) was the most common mutation. IVS 1-5 (G-C) was the most common mutation among Sheikhs, Balochs, Syeds, and Miscellaneous. IVS 1-5 (G-C) was the most common mutation in the Bahawalpur division and Ghotki (Sindh) while Fr 8-9 (+G) was the most common mutation in the Multan division. The p-value of all the results was <0.001. Conclusion There is an ethnic, caste-wise, and regional distribution of mutations. We can conduct a targeted screening of the population and provide counseling about chorionic villus sampling by using this local data.

The Frequency of Hepatitis C and its Risk Factors Among Health Care Providers at Tehsil Headquarter Hospital, Hasilpur, Pakistan.

Introduction Hepatitis C has emerged as a big challenge for Pakistan. Health care providers are at increased risk of being infected due to tremendous exposure. Aim The purpose of this study was to find the prevalence of hepatitis C, its risk factors especially its occupational risk factors and preventive measures practiced by health care providers of Tehsil Head Quarter Hospital, Hasilpur, Pakistan. Materials and methods Blood samples were collected, and rapid chromatography strips were used for diagnostic purpose. A questionnaire was used for data collection. After analyzing the data, results were summarized. Results The prevalence of Hepatitis was 5.17%. Those who used gloves were 67.24%. A history of needle stick injury was present in 47.41%, and 49.13% knew about the spread of Hepatitis C Virus (HCV). Just 18.96% knew about the treatment plan, and 19.83% had attended a workshop on preventive measures of infectious diseases in healthcare settings. Conclusion The frequency of HCV among health care providers is high. Awareness programs and training workshops should be mandatory to increase knowledge about hepatitis C prevention. It will decrease the incidence of hepatitis C infection among health care workers.