Use of National Institute for Health and Care Excellence head injury guidelines among patients with delayed presentation after head trauma can lead to missed traumatic brain injury: a 5-year institutional review.

Introduction: In 2014, traumatic brain injury (TBI) caused 3 million ER visits, hospitalizations, and deaths in the US. The National Institute for Health and Care Excellence (NICE) guidelines, initially generated using data from patients presenting within 24 h of head trauma, are used to determine the need for head computed tomography (CT) scan in patients after 24 h. The authors wanted to determine the proportion of CT scans for head trauma performed at our center in late presenters (>24 h after head trauma), the incidence of intracranial pathology in early (24 h) versus late (>24 h) presenters, and the sensitivity of the NICE guidelines for TBI in these two subpopulations. Methods: A retrospective chart review was conducted at a tertiary care center in Karachi. All people (>16) who had a head CT for head trauma from 2010 to 2015 were included. Age, sex, primary diagnosis, comorbid disorders, mechanism-of-injury, duration (in hours) from head trauma to presentation, site, and extent of injury (injury severity scale), hospital stay, number and details of surgical procedures, CT scan findings, other injuries, and mortality were recorded. Means were compared using the Independent Sample t-test, while categorical variables were compared using χ2. Multivariate logistic regression analyses were used to identify TBI predictors. Results: The authors found 2009 eligible patients; seven were excluded due to incomplete medical records. The final statistical analysis comprised 2002 head trauma patients. Overall, 52% of early and late presenters had severe injuries, and 2.3% died. 32.2% of patients with head trauma had CT after 24 h. Early presenters were 46.7% traumatized, while late presenters were 63%. The NICE guidelines were 93% sensitive for early presenters and 83% for late presenters with traumatic intracranial injury. Conclusion: Patients coming to the emergency department after 24 h of head trauma are a large proportion of the overall head trauma population. The NICE guidelines for late-presenting head injuries are less sensitive and may overlook intracranial injuries if imaging is not performed.

Paediatric posterior reversible encephalopathy syndrome: is there an association of blood pressure with imaging severity and atypical magnetic resonance characteristics?

BACKGROUND: Posterior reversible encephalopathy syndrome (PRES) is relatively uncommon in paediatric patients; however, its pathophysiology remains obscure. OBJECTIVE: The aims of this study were to find an association or correlation between (1) blood pressures and (2) imaging severity and the presence of atypical imaging features in children with PRES. MATERIALS AND METHODS: We performed a retrospective cross-sectional evaluation in children diagnosed with PRES. We reviewed radiologic findings along with each patient's clinical profile and outcome. We categorised imaging severity into mild, moderate and severe, and assessed the MR imaging pattern, enhancement and diffusion restriction for each child. We assessed both associations and correlations between variables using the chi-square test, Cramer V and Kendall tau b. RESULTS: A total of 63 children met the inclusion criteria (31 boys; mean age 9.7 years). A total of 42 children (67%) had an elevated blood pressure. Imaging showed parieto-occipital lobe involvement pattern in 24 (38%) children, frontal lobe pattern in 25 (40%) and cerebellar involvement in 12 (19%). Three (5%) had haemorrhage, 15 (24%) had contrast enhancement and 19 (30%) had positive diffusion restriction (cytotoxic oedema). We found no statistically significant association between imaging severity and blood pressures (P=0.11), nor any association between blood pressure and atypical imaging findings such as diffusion restriction (P=0.1), enhancement (P=0.11) or haemorrhage (P=0.33). CONCLUSION: According to our results, there is no statistically significant association or correlation between blood pressure and either imaging severity or atypical imaging features in children with PRES. Further prospective studies are warranted.

Assessment of the normal pediatric pineal gland - MR findings of a single centre; A retrospective study.

OBJECTIVE: To analyse the size and morphology of the normal pineal gland in the paediatric age group using magnetic resonance imaging. METHODS: The retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of patients aged <18 years who had magnetic resonance imaging done between 2007 and 2017. Pineal size was estimated measuring its largest anteroposterior and supero-inferior diameters on sagittal T2-weighted sequences on any slice with maximal diameter. The width of pineal gland was measured on axial or coronal T2 sequences. The volume, morphology and enhancement patterns of the gland were also assessed. Data was analysed using SPSS 21. RESULTS: Of the 200 patients, 116(58%) were males and 84(42%) were females. The overall mean age was 7.8±5.5 years. The mean anteroposterior dimension was 4.85±1.46mm, height 3.31±0.95mm, width 4.16±1.19, and volume 39.54±38.12 mm3. Mean size of cyst was 2.77±1.4mm (range: 1.2-7.5mm). No significant differences in the pattern of enhancement were found in different age groups (p>0.05). CONCLUSIONS: Comprehensive knowledge of the size of the typical pineal organ is useful for radiologists in the identification of pineal gland anomalies and the exclusion of neoplastic lesions.

Interobserver Reliability of the RENAL Nephrometry Scoring System: Experience From a Developing Nation.

Introduction The RENAL (radius, exophytic/endophytic properties, nearness of tumor to the collecting system or sinus in millimeters, anterior/posterior, location relative to polar lines) nephrometry score (RENAL-NS) has been described as a structured and quantifiable method to describe a renal tumor's relevant anatomic features as they relate to the complexity of the lesion. We aim to evaluate a tumor's RENAL-NS and to assess the reproducibility of the score among different observers. Methods This retrospective study included 49 patients diagnosed with renal cell carcinoma (RCC) who had complete computed tomography (CT) data, RENAL-NS, and histopathology results. All patients underwent renal surgery/intervention at our center between January 2008 and December 2018. The radius of the lesion, exophytic/endophytic properties, nearness to the collecting system, anterior or posterior description, and location relative to the polar lines was used to calculate the score. Tumor complexity was graded as low, intermediate, or high. Two body imaging radiologists evaluated the data independently. Results Interobserver agreement for each of the RENAL-NS parameters, respectively, and overall complexity was calculated. The total agreement was 82%, 51%, 84%, 69%, 73%, and 90%, corresponding to Kappa values of 0.72, 0.33, 0.44, 0.49, 0.58, and 0.83, respectively. The radius, nearness to the collecting system, and total complexity showed the best agreement. Exophytic properties of the lesion showed the least agreement. For cases that were discordant in terms of the final score, no major implications in surgical planning were observed. Conclusion The results of this study show that the RENAL-NS is a useful tool to assess the anatomical features of renal tumors and it is easily reproducible, even for less experienced radiologists in a developing nation.

Spontaneous Uterine Rupture Secondary to Morbidly Adherent Placenta in an Unscarred Uterus.

We report a case of spontaneous uterine rupture in a primigravida with an unscarred uterus, which was secondary to morbidly adherent placenta proven on surgery and histology. Although rare, uterine rupture should be considered as a differential diagnosis of acute abdominal pain in pregnancies, especially when associated with free fluid, even with the absence of vaginal bleeding. Abnormal placentation is associated with spontaneous antepartum uterine rupture even in early pregnancy. Most cases in the literature have advocated emergency hysterectomy to arrest life-threatening hemorrhage.

Polypoid Adenomyoma of the Uterus.

Polypoid adenomyoma is a rare uterine endometrial polypoid tumor of mixed epithelial and mesenchymal origin. Although the clinical and pathologic features of polypoid adenomyomas have been described extensively, imaging findings for these tumors have not been frequently reported in the literature. On imaging, their features may be confused with prolapsed leiomyomas or malignancy. Hemorrhagic cystic spaces in a prolapsed uterine tumor within the vagina should raise consideration of a diagnosis of polypoid adenomyoma. Such blood-containing cystic spaces would be unusual findings in leiomyomas and malignancy. Diagnosing polypoid adenomyoma is vital because it can potentially be managed by hysteroscopic resection, unlike an ordinary form of adenomyosis.

Usefulness of Delayed Films of Contrast Enema for Detecting Hirschsprung's Disease.

Background Contrast enema (CE) in Hirschsprung's disease (HD) provides a road map to surgeons by ascertaining the transition zone (TZ) and helps in pre-surgical planning. In our institute, we use CE as the initial investigation for HD and carry on till the whole colon is fully distended, followed by a 24-hour abdominal film which is also a part of the international protocol. The main aim of this study was to evaluate the usefulness of this 24-hour delayed film in detecting HD, compare it with gold-standard biopsy results, and to evaluate other imaging features of contrast enema for diagnosis of HD in our tertiary-care hospital in Pakistan.  Methods This retrospective study was conducted at the Department of Radiology, Aga Khan University Hospital, Karachi. Records of pediatric patients referred for radiological evaluation of symptoms and signs suspicious of HD during the years 2007-2017 were reviewed. A delayed film was labeled positive if the contrast was not completely evacuated when the residual contrast was present till transverse colon and not beyond. Specificity and sensitivity along with positive and negative predictive values were calculated for each finding according to rectal biopsy, taken as the gold standard. Results In all, 82 patients met the inclusion criteria out of 111 cases, as they had both biopsy results and delayed 24-hour films. HD was confirmed using rectal biopsy in 56 (43 patients were males and 13 were females) of 82 cases. The most sensitive radiological finding was the transition zone with a sensitivity of 91.07%. The rectosigmoid index was the second most common finding on contrast enema with a sensitivity and specificity of 91.07% and 83.93%, respectively. In all, 59% patients had a positive delayed 24-hour film and were confirmed with having HD on biopsy. The sensitivity, specificity, and positive predictive value of delay in contrast evacuation after 24 hours in our study was 81.25%, 90.91%, and 97.50% respectively. Conclusion Contrast enema examinations along with the 24-hour delayed film with mid transverse colon cut-off are optimal for initially investigating HD in a developing nation, and our results show that it correlates well with biopsy. However, rectal biopsy still remains the gold standard for diagnosis.

Intramedullary cavernoma with extralesional haemorrhage.

Intramedullary cavernomas are rare lesions constituting 5 to 12% of all intramedullary tumours. They are more recognized after introduction of magnetic resonance imaging and detection rates have improved by advance techniques. They may be solitary or multiple or may have associated cranial lesions. They may present with gradual neurological decline or with acute loss of spinal function. In addition neurological deficit depends on the location of the lesion within the spinal cord. We are reporting the case of a 45 year old male who presented with neck pain and progressive right arm weakness with numbness. MRI cervical spine with contrast showed intramedullary lesion with peripheral T2 hypointense rim and extralesional haemorrhage consistent with cavernoma. Patient underwent successful surgery and his symptoms markedly improved with mild residual grip weakness in right hand.

Improving Adolescent Sexual and Reproductive Health: A Systematic Review of Potential Interventions.

Adolescents have special sexual and reproductive health needs (whether or not they are sexually active or married). This review assesses the impact of interventions to improve adolescent sexual and reproductive health (including the interventions to prevent female genital mutilation/cutting [FGM/C]) and to prevent intimate violence. Our review findings suggest that sexual and reproductive health education, counseling, and contraceptive provision are effective in increasing sexual knowledge, contraceptive use, and decreasing adolescent pregnancy. Among interventions to prevent FGM/C, community mobilization and female empowerment strategies have the potential to raise awareness of the adverse health consequences of FGM/C and reduce its prevalence; however, there is a need to conduct methodologically rigorous intervention evaluations. There was limited and inconclusive evidence for the effectiveness of interventions to prevent intimate partner violence. Further studies with rigorous designs, longer term follow-up, and standardized and validated measurement instruments are required to maximize comparability of results. Future efforts should be directed toward scaling-up evidence-based interventions to improve adolescent sexual and reproductive health in low- and middle-income countries, sustain the impacts over time, and ensure equitable outcomes.

A 360-degree evaluation of the communication and interpersonal skills of medicine resident physicians in Pakistan.

BACKGROUND: To provide high-quality patient care, effective communication and interpersonal skills are necessary for physicians. A 360-degree evaluation of residents in the department of medicine was conducted to assess their interpersonal and communication skills. The measurement properties and utility of the multi-source ratings were investigated. METHODS: A cross-sectional assessment of a cohort of Internal Medicine residents was conducted at the Aga Khan Medical University in Pakistan. Every resident (n = 49) was evaluated by eight raters, including physicians, nurses and unit staff. Each resident also completed a self-evaluation. Evidence to support the validity of the ratings was gathered by exploring performance differences amongst more- and less-experienced providers. Analysis of variance (ANOVA) was employed to test for differences in mean scores, both for rater type and experience (residency year). Generalizability theory was employed to estimate the reliability of the ratings. RESULTS: We received 367/441 (83.2%) completed forms. There was a significant effect attributable to rater source (F = 5.2, P < 0.01). There were no significant differences in mean scores for residents at different levels of training. The mean resident self-assessment scores were significantly lower than those provided by faculty (P < 0.01). Based on eight raters, the reliability of the ratings was moderate (ρ2 = 0.39). DISCUSSION: The 360-degree evaluation technique can be used to measure the communication and interpersonal skills of residents. It can also provide important data to guide resident feedback. Health care providers and staff who interact with residents on regular basis can, as a group provide moderately consistent judgments of their abilities.

Congenital diaphragmatic hernia presenting in the sixth decade mimicking pneumonia.

Congenital diaphragmatic hernia presentation in adults is extremely rare. Patients who present with late diaphragmatic hernias complain of a wide variety of symptoms and diagnosis can be difficult. We report a case of a 64 year old male who presented with a six month history of cough, shortness of breath and weight loss. The most common strategy to treat a Bochdalek hernia is via a thoracotomy or laparotomy or both. In our patient the repair was performed with a thoracotomy.

Intrauterine growth retardation--small events, big consequences.

Intrauterine growth retardation refers to a rate of growth of a fetus that is less than normal for the growth potential of a fetus (for that particular gestational age). As one of the leading causes of perinatal mortality and morbidity, intrauterine growth retardation has immense implications for the short term and long term growth of children. It is an important public health concern in the developing countries. Health statistics encompassing parameters for maternal and child health in the Indian subcontinent have shown improvement in the past few years but they are still far from perfect. Maternal health, education and empowerment bears a strong influence on perinatal outcomes including intrauterine growth retardation and should be the primary focus of any stratagem targeted at reducing the incidence of intrauterine growth retardation. A concerted liaison of various medical and social disciplines is imperative in this regard.

Ruptured hydatid cyst presenting as pneumothorax.

Patients with echinococcus infection are mostly asymptomatic. The documented rates of simple pneumothorax in patients with pulmonary hydatidosis ranged from 2.4% - 6.2%. We report a case of a forty-year-old male patient who was referred to our hospital for management of recurrent pneumothorax. A video assisted thoracoscope (VATS) was first introduced which showed a large amount of pus in the pleural cavity and a perforated hydatid cyst. The VATS was converted to an open thoracotomy and decortication was done with removal of the ruptured hydatid. The patient made an unremarkable recovery and was discharged after one week with empyema tubes. The empyema tubes were gradually removed over a period of six weeks. An extraordinary number of management options for pulmonary hydatid disease have been offered. This case report highlights surgical treatment as the management opti.