Myths and Misconceptions of Breast Cancer in the Pakistani Population.

Background Breast cancer is one of the most prevalent types of cancer in the female population. The cultural diversity, religious beliefs, myths, and misinformation regarding the disease contribute to diagnostic delays and enhanced burden on the healthcare system. This study aimed to ascertain the extent of knowledge and prevalence of erroneous beliefs and misconceptions regarding breast cancer among Pakistani women belonging to diverse socioeconomic and educational backgrounds. Methodology This cross-sectional study was performed in a tertiary care hospital in Karachi, Pakistan. A total of 350 women were enrolled in the study as a representative female population, and 300 participants were included who met the inclusion criteria. Participants were conveniently interviewed using a pre-piloted questionnaire designed to assess the prevalent myths and misconceptions about breast cancer. The data were analyzed by SPSS version 23 (IBM Corp., Armonk, NY, USA) using descriptive statistics. Results The study findings point to a significant prevalence of erroneous beliefs and a lack of accurate information on breast cancer. The mean age of the participants was 20.8 ± 10.4 years. The majority of the participants belonged to a middle socioeconomic status (70%) and were undergraduates (61.4%). The participants' friends and family members were the most frequent sources of information regarding breast cancer. The most common myth was "breast-feeding offers immunity to breast cancer completely" (76.6%), followed by "breast cancer spreads after biopsy" (63.8%). Participants also believed that breast tissue biopsy can lead to the spread of cancer (63.4%) and that faith healers and alternative medicine can cure breast cancer (47.5%). One-third (33.3%) of the participants considered all lumps to be breast cancer; however, approximately half (41.6%) of the participants thought that only painful lumps were associated with breast cancer. A significant number of participants believed breast cancer to be a result of God's curse (31.4%) or evil eye (38.7%). Conclusions The findings suggest a critical need for community-based breast health education initiatives that take into account Pakistani women's distinctive cultural and societal attitudes and work to dispel common misconceptions about the condition.

Rapid Correction of Hyponatremia With Isotonic Saline Leading to Central Pontine Myelinolysis.

Central pontine myelinolysis (CPM) is a part of the spectrum of osmotic demyelination syndrome (ODS), which is a rare demyelinating disorder due to the rapid correction of low serum sodium. It affects the neurons of the pons but may also involve other extra-pontine sites. The disease is characterized by a wide variety of clinical features ranging from dysarthria, dysphagia, bulbar palsy, quadriplegia, and behavioral and psychiatric disturbances. We present a case of a young female who developed CPM due to rapid sodium correction after vomiting. She presented with quadriplegia and locked-in syndrome. The diagnosis is on the basis of clinical and radiographic features. Magnetic resonance imaging (MRI) of the brain is superior to computed tomography (CT) in detecting changes. It shows hyperintensities on T2-weighted images that are classically known as the trident sign in the region of the pons. The patient was managed supportively, and the family was counseled regarding the poor prognosis of the disease. Unfortunately, she met a fatal fate due to a complication of CPM that is aspiration pneumonia. It is, therefore, imperative to create more awareness regarding the disease, and measures should be taken for its prevention that includes correction of low sodium levels not greater than 10 mmol/L/day.

Anti-synthetase Syndrome: A Diagnostic Dilemma.

Among the various inflammatory myopathies, the anti-synthetase syndrome (ASS) is a rare entity with autoantibodies directed against aminoacyl-transfer ribonucleic acid synthetase. Its clinical spectrum ranges from myopathy and non-erosive arthritis to dyspnea and cough of pulmonary interstitial disease and from hyperkeratotic skin changes to spasms of blood vessels causing Raynaud's phenomenon. We present a case of a 21-year-old female who had been suffering from fever, night sweats, and weight loss for two years and had remained undiagnosed. She came to our hospital with new-onset muscle weakness, small joint arthralgia, and skin changes. Physical examination showed inflammation involving multiple small joints and characteristic hyperkeratotic skin changes in the distal and lateral phalanges of the hands and feet. Raised creatine phosphokinase levels indicated the possibility of myositis along with positive anti-nuclear antibodies, suggesting an autoimmune rheumatic disorder. Inflammatory myositis was later confirmed on biopsy. Further investigations revealed positive anti-Jo1 antibodies. The diagnosis of ASS was made despite the absence of pulmonary signs and symptoms. The patient was promptly started on prednisone and azathioprine. She showed some improvement in muscle weakness at the end of two months and continues to improve albeit slowly. Due to the lack of awareness about the rare disease among the non-rheumatologists, there was a significant delay in the patient's diagnosis. It is, therefore, important for primary care physicians to obtain a comprehensive history and perform a detailed clinical examination to make timely referrals to specialized healthcare professionals.

Pyoderma Gangrenosum as a Presenting Feature of Takayasu Arteritis.

Takayasu arteritis (TA) is a large vessel vasculitis that involves the aorta and its major branches. The disease has a female preponderance, and it presents with a wide variety of symptoms including skin manifestations, mainly ulcerative nodules, pyoderma gangrenosum, and erythema nodosum-like lesions. We report a case of a 50-year-old female who presented to the outpatient department with multiple ulcerative lesions over both upper extremities and chest. On physical examination, the patient had pulseless upper limbs. Laboratory investigations revealed positive antinuclear antibodies (ANA) and raised inflammatory markers. CT angiography of the aorta showed thickened aortic arch with the obliterated lumen of the left common carotid and left subclavian arteries. A biopsy of the skin lesion revealed surface ulceration and densely inflamed granulation tissue with a fibroblastic proliferation of deeper tissues. The patient had three out of six features of the American College of Rheumatology 1990 (ACR-1990) criteria for the classification of TA and was diagnosed with TA associated with pyoderma gangrenosum. The patient was managed with steroids and immunosuppressants along with gentle wound debridement with grafting of skin wounds. Since TA has varying presentations, its diagnosis is often challenging and requires a combined approach including clinical signs and symptoms, as well as laboratory and radiological workup. The disease also requires long-term follow-up due to its remitting and relapsing course.

Postpartum septic shock presenting as symmetrical peripheral gangrene: A rare entity.

Symmetric peripheral gangrene (SPG) is a rare clinical entity defined as ischemia of peripheral parts of the body without underlying vaso-occlusive disease. Its pathogenesis is unknown, but it is seen from previous reports that SPG is a sequel of underlying Disseminated Intravascular Coagulation (DIC). We report a case of a middle-aged woman who developed high-grade fever followed by painful black discoloration of the digits of four limbs, few days after spontaneous vaginal delivery at home. The patient developed septic shock. However, peripheral pulses were palpable and radiologic and laboratory investigations did not show any evidence of vessel occlusion. The patient had neutrophilic leukocytosis and a deranged clotting profile. Blood culture revealed growth of Staphylococcus Aureus and Pseudomonas Aeruginosa. The patient was diagnosed with SPG due to postpartum sepsis and DIC. She was managed with fluids, antibiotics, aspirin, and heparin but unfortunately, the patient underwent amputation of limbs due to irreversible ischemia. Therefore, prompt diagnosis and management of SPG are crucial to prevent mortality and morbidity.

Primary Cutaneous Actinomycosis: A Diagnostic Enigma.

Actinomyces are Gram-positive, filamentous rods found endogenously as a part of the normal flora and can be acquired exogenously as they are present in the soil. The most common species known to infect humans is Actinomyces israelii. Five forms of the disease have been identified so far, of which the primary infection of the skin is the most uncommon. It is also commonly considered one of the most misdiagnosed diseases. We present a case of a young male diagnosed with primary cutaneous actinomycosis based on a histopathology specimen after multiple failed diagnoses of Madura foot/mycetoma, cutaneous tuberculosis, and malignancy. The patient was successfully treated with antibiotics with the restoration of his functional disability caused by the lesion.

Disseminated Tuberculosis Presenting as Cerebellar Dysfunction and Adrenal Insufficiency in an Immunocompetent Patient: A Rare Coexistence.

Disseminated tuberculosis is more prevalent in immunocompromised hosts; however, it can affect people with intact immune systems. Here, we present a case of an immunocompetent young woman who presented with headache, vomiting, and dizziness for the past two months. There was a history of significant weight loss during this period. Examination revealed postural hypotension and positive cerebellar signs. Imaging of the brain revealed a conglomerate mass in the cerebellar vermis suggestive of tuberculoma. Tubercle bacilli were detected in gastric lavage specimens. Laboratory investigations revealed hyponatremia with low serum osmolality. Further investigations showed low serum cortisol and high adrenocorticotrophic hormone levels. CT of the abdomen revealed atrophy of both adrenal glands. Our patient was diagnosed with cerebellar dysfunction and adrenal insufficiency secondary to disseminated tuberculosis. We started the patient on antituberculous drugs, along with mineralocorticoid and glucocorticoid replacement. Subsequent follow-up showed significant improvement in symptoms. Hence, timely diagnosis of the disease is essential to prevent lethal outcomes.

A Fatal Fate: A Medical Error Leading to Acute Methotrexate Toxicity.

Methotrexate is an anti-metabolite, which is commonly utilized as an anti-cancer, anti-rheumatic, and anti-inflammatory drug used to treat a large variety of connective tissue disorders. Methotrexate when consumed at low doses for longer periods usually has a very limited side effect profile, however, accidental ingestion of large methotrexate doses is common which can result in a wide variety of adverse effects and can even result in fatal demise. We, unfortunately, relate the incidence of a 75-year-old female, who unintentionally consumed 200mg of methotrexate instead of methylcobalamin because the pharmacist misunderstood the prescription. The patient presented to the Accident and Emergency (A&E) department of Jinnah Hospital, Karachi, with extensive hemorrhagic oral ulcers, maculopapular dermatitis, and inability to swallow, which further progressed to acute renal insufficiency, neutropenic sepsis, and respiratory distress. The patient was managed with leucovorin rescue therapy, intravenous rehydration, urinary alkalinization, neutropenic protocol, and oxygen support given her respiratory distress, and hemodialysis was arranged for her renal insufficiency. However, despite all these measures the patient met an unfortunate fate and expired. Patients should be given accurate dosage directions, detailed textural information, and audio-visual resources. Additionally, symptoms of toxicity should be explained to all patients. Measures should be taken to minimize such unfortunate events in the future.

Jaundice, Coombs Positive Hemolytic Anaemia, and Liver Failure: An Unusual Trio.

Hepatitis E virus (HEV) is a single-stranded RNA virus with 20 million cases reported worldwide. Infected individuals may either remain asymptomatic or develop acute or even fulminant hepatitis. HEV has been implicated in causing Acute-on-Chronic Liver Failure (ACLF) among patients with underlying cirrhosis. Among the causes of cirrhosis, Wilson's disease is an identified cause that results in an increased accumulation of copper in the liver, brain, and other organs. It is noted that Coombs negative hemolytic anaemia is also seen in the clinical spectrum of Wilson's disease, however, Coombs positivity has not been documented. We present a case of a young female who had an undiagnosed chronic liver disease (CLD). The patient developed acute decompensation with HEV infection along with Coombs positive hemolytic anaemia. Her autoimmune hepatitis screen was negative, so the patient was worked up for other causes of CLD, which led to a diagnosis of underlying Wilson's disease. The patient was started on penicillamine and zinc acetate. However, during the disease, the patient developed acute decompensation and unfortunately expired before her transplant could take place. Our case documentation is of importance as Coombs positivity in patients with Wilson's disease has not been reported before. Attending physicians should be suspicious of Wilson's disease in a patient with Coombs positive hemolytic anaemia when other causes cannot be identified. It is also important to promptly identify any other cause of CLD to educate patients regarding factors leading to acute decompensation and progression to ACLF.

Effect of health education on awareness and practices of breast self examination among females attending a charitable hospital at North Karachi.

OBJECTIVE: To assess the effectiveness of health education as an intervention to promote breast self-examination in a low-resource setting. METHODS: The quasi-experimental study was conducted from January to August 2018 in Karachi after approval by the Jinnah Sindh Medical University, and comprised women from a low resource locality and dividing them into intervention group A and control group B. Demographic data was collected using a pretested questionnaire filled through interviews. Subsequently, group A received health education regarding carcinoma of breast, importance of breast self-examination and monthly motivation through cell phone to perform self-examination. The questionnaire was again filled after 6 months of intervention. Data was analysed using SPSS 20. Group B was given the same health education sessions after the completion of the study. RESULTS: Of the 172 subjects, there were 86(50%) in each of the two groups. In terms of demographic data, the groups were similar (p>0.05). After the intervention, group A showed significant (p<0.001) improvement in knowledge and practice of breast self-examination. There was no change in group B (p>0.05). Being in the intervention group (p=0.001) and level of education (p=0.018) showed positive and negative associations with selfexamination practice. Upon adjusting for age, marital status, family history and education, group A (p=0.001) remained significant, while the level of education (p=0.116) became non-significant. CONCLUSIONS: Designed health promotion programmes with monthly reminders through cell phone improved knowledge and practice of breast self-examination.

Patterns of Peripheral Nerve and Tendon Injury in Hand Trauma Patients in a Tertiary Care Hospital of Pakistan.

Introduction Traumatic injury to peripheral nerves is a major medical problem worldwide. Moreover, injury to the hand and wrist can lead to extreme morbidity and disable the injured for life. In this study, we highlight the most commonly damaged nerves and tendons that get ruptured in different types of hand trauma patients. No recent study has been done to document the etiologies and quantify the patterns of nerve and tendon involvement in hand injuries to the best of our knowledge. Methodology This was a cross-sectional study conducted at the largest trauma center in the city and the Plastic and Reconstructive Surgery ward of Civil Hospital, Karachi. A convenient sampling of 200 patients was done with the help of a preformed, well-structured questionnaire. Patients whose hand was injured solely were included in the study and those with the involvement of the whole limb or other parts of the body were excluded. Results We found that most males between the ages of 11 and 20 years presented predominantly with right-hand injury while working with machines. Nerve injury proved to be a rare occurrence. However, combined nerve injury of the ulnar, median, and radial nerve was seen in poly digit trauma. The median nerve was the most commonly damaged nerve in poly digit trauma. Among the tendon injuries, the incidence of combined tendon injury was the greatest. The flexor digitorum superficialis was the most common tendon injured overall. Conclusion This study significantly states that tendons are frequently injured in hand accidents. Plastic surgeons must also be aware of optimal nerve repair and reconstruction techniques to limit the physical disabilities and economic burden arising from nerve injury of the dominant hand.

A Rare Case of Malignant Infantile Osteopetrosis Presenting as Frontal Lobe Hemorrhage.

Osteopetrosis comprises a group of rare inherited disorders of the bones characterized by a common radiographic finding of increased bone thickness. The disorders vary genetically as well as clinically, and range in severity from mild manifestations to fatal complications based on the type of the disorder. Malignant infantile osteopetrosis (MIOP) is a less common, more severe form of the disease with most affected individuals surviving up to only the first few years of life if left untreated. We present a previously diagnosed case of the malignant infantile type who was brought to our attention for convulsions. Antiepileptic medications were started along with supportive therapy. CT scan revealed a large frontal lobe hemorrhage, which was suspected as a possible cause of the seizures, other than the progressively worsening hypocalcemia. Laboratory investigations also revealed pancytopenia and blood cultures positive for staphylococci, which were treated accordingly. Genetic testing and hematopoietic stem cell transplantation could not be performed due to financial constraints and the rapidly deteriorating condition of the patient. Unfortunately, the baby expired two weeks from the day of admission. This case highlights a rare and grave clinical manifestation of MIOP and brings to attention the significance of bone marrow transplantation as the only curative therapy of the disease.

Gastric Tuberculosis.

Gastric tuberculosis is a very rare disease posing a diagnostic challenge to physicians, pathologists and radiologists. It usually occurs in females aged 25 to 45 years. Symptoms include epigastric pain, vomiting, fever, weight loss, upper gastrointestinal (GI) bleed and gastric outlet obstruction. High index of suspicion and endoscopic or endoscopic ultrasound guided biopsies may help in making an early diagnosis, particularly in patients with non-healing gastric ulcers. We report a case of gastric tuberculosis in a 55-year male, who presented with persistent vomiting, epigastric pain and significant weight loss. His upper GI endoscopy finding with histopathology results favoured the diagnosis of gastric tuberculosis. He was successfully treated with antituberculous regimen.

Predicting the Relationship Between Breastfeeding and Gross Motor Milestones Development: The Practice and Prevalence of Breastfeeding in Metropolitan Areas of Sindh, Pakistan.

Objective Breastfeeding is known to be beneficial for the health of both the child and the mother. The primary aim of this study is to assess the effect of lactation on the development of gross motor milestones. The evaluation of breastfeeding practices and the frequency of lactation among mothers living in the urban city of Karachi, Pakistan, is the secondary aim of this study so that interventions can be made to improve breastfeeding practices. Methods A cross-sectional study was conducted using a well-designed questionnaire. A population of 360 mothers living in Karachi, Pakistan, with children aged between two and six years, was selected. The questionnaire included demographic data, the duration of breastfeeding, the age of milestone development, and the educational and financial status of the mothers. The relationship between the duration of breastfeeding and the development of gross motor milestones was analyzed using the Pearson chi-square test via Statistical Package for the Social Sciences (SPSS) version 22.0. A p-value < 0.05 was rendered significant. Descriptive statistics were applied to calculate the frequency of the varying duration of breastfeeding among mothers with respect to their socioeconomic status and educational class. Results The study revealed that 68.6% of children were breastfed for four months or more with supplementary feed or solids started at four months or later (prolonged exclusive). Along with this, 6.4% were breastfed only before two months (short duration), 5.6% had been breastfed beyond two months but ceased before four months (intermediate duration) while 14.7% were breastfed for four months or more with supplementary feed or solids started before four months (prolonged partial). Mothers belonging to low (67.7%), moderate (67.5%), and higher (72.2%) socioeconomic status (SES) preferred to breastfeed for a prolonged exclusive duration. With respect to education, uneducated mothers (72.6%), mothers with primary education (63.6%), secondary education (65.90%), and tertiary education (68.6%) also breastfed for a prolonged exclusive duration. No statistically significant correlation was found between gross motor milestone development and the duration of breastfeeding (p-value > 0.05). Conclusion Breastfeeding was found to have an insignificant impact on the development of gross motor milestones despite the fact that mothers, irrespective of educational background and socioeconomic status, were found to be breastfeeding for a prolonged exclusive duration.