A Normotensive Case of Pheochromocytoma With Unusual Presentation of Abdominal Pain.

Multiple endocrine neoplasia (MEN) is an inherited, autosomal dominant condition characterized by primary parathyroid hyperplasia, medullary thyroid neoplasm, and pheochromocytoma. It most commonly presents with medullary thyroid cancer and less frequently with other complaints. Pheochromocytoma can also manifest through gastrointestinal complaints such as abdominal pain, nausea, and constipation. We present a normotensive case of pheochromocytoma, initially featuring abdominal pain and vomiting, which was later found to be associated with neck swelling and medullary thyroid cancer. The patient underwent an adrenalectomy and has continued to visit our endocrinology clinic for ongoing monitoring and treatment of iatrogenic hypoparathyroidism and hypothyroidism. A brief review is also provided.

Overcoming Challenges: Doxycycline as an Alternative Treatment for Hyponatremia in Managing Syndrome of Inappropriate Secretion of Anti-diuretic Hormone (SIADH) in Small Cell Lung Cancer (SCLC): A Case Report.

Hyponatremia, a common complication in small cell lung cancer (SCLC), can arise from various causes such as cancer itself, its treatment, paraneoplastic syndrome-induced SIADH secretion (syndrome of inappropriate anti-diuretic hormone secretion), and brain metastasis. While fluid restriction is the initial approach, refractory cases require pharmacological intervention in managing hyponatremia secondary to SIADH. This case report presents doxycycline as an alternative treatment option for a patient with refractory hyponatremia and SCLC with brain metastases, resulting in improved serum sodium levels. However, the use of doxycycline was associated with acute pancreatitis, prompting its discontinuation without establishing a definitive causal relationship. This case report highlights the importance of alternative treatments in resource-limited settings and emphasizes personalized care for hyponatremia in SCLC patients. Doxycycline can be an option, but safety and effectiveness require further study.

Insulinoma Mimicking Psychiatric Illness: A Covert Endocrine Tumor.

Insulinomas are rare neuroendocrine tumors with an annual incidence of four cases per million people in the general population. They have varied presentations making their diagnosis a challenging task necessitating a thorough patient assessment to ascertain early detection of this clinical entity by treating physicians. Insulinomas are characterized by the presence of Whipple's triad comprising of hypoglycemic symptoms, biochemical demonstration of hypoglycemia, and improvement of those symptoms after glucose administration. Biochemical detection of insulinoma by supervised 72-hour fasting test with plasma glucose, insulin, C-peptide, and proinsulin level measurements remains the gold standard of diagnosis. In this report, we present an interesting case of delayed diagnosis of pancreatic insulinoma. He was treated for more than six years as a psychiatric illness before receiving the correct diagnosis and treatment. Herein, a middle-aged man with a history of recurrent episodes of altered talk and confusion that resolved after eating something sweet. Biochemical investigations were suggestive of endogenous hyperinsulinemia. Pancreatic insulinoma was localized by a computed tomography scan. The patient underwent surgical resection of the tumor with complete resolution of his symptoms.

Radiation therapy outcomes of patients with pituitary macroadenoma.

Pituitary adenomas are one of the most common benign intracranial tumors, which are normally treated with surgery along with radiation therapy and medication such as dopamine agonist in prolactinoma. The aim of the present study was to evaluate the outcome of patients with pituitary macroadenoma who underwent radiation therapy. For the present retrospective study, a total of 75 patients with pituitary macroadenoma who received radiation therapy were included. Data was acquired from the electronic medical record system of the hospital. Mean ± standard deviation of the quantitative variables, such as age and sizes of the tumors, were reported. In addition, frequencies and percentages were presented for all categorical variables. To compare the frequency distribution in radiation therapy characteristics between functional and non-functional tumors, the χ2 test or Fisher's exact test was applied, where appropriate. Kaplan-Meier survival curve was drawn to assess the progression free survival proportion. P≤0.05 was considered to indicate a statistically significant difference. In the present study, all patients (n=75) with pituitary macroadenoma were treated with radiation therapy (RT). The mean age was 38.55±1.36 years and the majority of the patients were male (43; 57.3%). The mean tumor size was 3.84±1.43 cm. In total, 66.7% were non-functional tumors whereas 33.3% were functional tumors that produce hormones in excess [growth hormone (72%), prolactin (16%), both growth hormone and prolactin (8%) and adrenocorticotropic hormone (4%)]. The overall outcome was revealed to be 92% achieving local tumor control and 28% achieving biochemical control. Hypopituitarism (38.7%) and visual acuity deterioration (9.3%) were the most common complications observed following RT. The overall progression-free survival at 2 years was 92%. In conclusion, the data of the present study suggested that local tumor control in non-functional and functional pituitary macroadenoma can be well managed with RT. However, biochemical control to normalize hormones overproduction in functional pituitary macroadenoma was not as effective as local tumor control.

Prolactinoma: Clinical Characteristics, Management and Outcome.

Aim Prolactinoma, a prolactin (PRL) secreting functioning pituitary tumor, is the most common of all pituitary adenomas (PA) accounting for 40-60% and dopamine agonists (DA) are the cornerstone of treatment. The aim of this study was to review the clinical presentation, treatment modalities and therapeutic outcomes of patients with prolactinomas in the South Asia region. Methods This retrospective study was conducted in the Endocrinology Department of Shaukat Khanum Memorial Cancer Hospital and Research Centre from December 2011 till December 2019. Medical records were used to retrieve for patient's demographics, clinical features at diagnosis, PRL levels and size of prolactinoma on MRI at diagnosis and after start of dopamine agonists and outcome of medical management. Results A total of 107 patients were included in this study. Mean age at diagnosis was 35 (22-54) years for men and 32 (18-50) years for women and 66.4% (71) of the patients were females. Our study included 38 (35.5%) microadenoma, 50 (46.7%) macroadenoma and 19 (17.8%) giant adenomas. At presentation, the most common symptom among females was menstrual irregularity/amenorrhea seen in 73.2% of females and among males was visual disturbance (80.6%). A significant reduction in PRL levels was seen within six to 12 months of treatment. Mean PRL levels decreased from 3162.8 ng/ml to 1.52 ng/ml. A notable decrease in tumor size was seen with medical management, mean adenoma size decreased from 2.18 cm to 1.04 cm. With cabergoline (CAB) 83.3% biochemical cure was seen compared to bromocriptine (BRC) which has 60.4%. The radiological response rate in CAB and BRC groups was 65.45% and 60%, respectively. Complete resolution of adenoma was seen in 13 patients (nine were microadenoma, two macro and two giant adenomas). The prolactin level at diagnosis was positively correlated with maximum tumor diameter (r = 0.469, P = 0.001). Two patients developed cerebrospinal fluid (CSF) rhinorrhea and the defect was repaired in both patients. Median follow-up duration was 40 (12-288) months. Conclusion Clinical presentation and demographics of prolactinoma are the same in our region when compared to the rest of the world. Cabergoline is superior to bromocriptine in prolactin normalization and tumor shrinkage but still bromocriptine is being used in a significant number of patients in low-income countries as first-line due to its low cost.

Efficacy of Radioiodine Therapy in Patients With Primary Hyperthyroidism: An Institutional Review From Pakistan.

Background Radioactive iodine (RAI) is the treatment of choice for most patients with primary hyperthyroidism. The most common etiologies of hyperthyroidism are Graves' disease (GD), toxic adenoma (TA), and toxic multinodular goiter (TMNG). A single dose of RAI is usually sufficient to cure hyperthyroidism. The aim of this study was to assess the effectiveness of RAI therapy for patients diagnosed with primary hyperthyroidism. Methods and materials Patients diagnosed with hyperthyroidism who received RAI therapy between 2008 and 2018 were included in the study. The data was acquired from the hospital's electronic medical record system. Following the RAI treatment, a cure was defined as the development of euthyroidism or hypothyroidism after a single fixed-dose without antithyroid medication within one year of RAI therapy. In addition, a simple logistics regression model was used to identify the prognostic factors that may lead to better outcomes. Results A total of 112 patients diagnosed with hyperthyroidism with a mean age of 47 ± 14 were included in this study. The majority of the patients were female, 79 (70.5%). Within one year of RAI therapy, 84 (75%) patients achieved a cure that is either hypothyroid or euthyroid status. RAI dose was higher in responsive patients (18.50 ± 4.10 millicurie [mCi] versus 16.50 ± 4.10 mCi) than in non-responsive patients. The mean RAI doses were 16.05 ± 2.99 mCi in GD, 19.81 ± 4.40 mCi in TMNG, and 20.50 ± 3.30 mCi in TA, with a statistically significant p-value of 0.001. In the univariable logistic regression model, RAI dose was a significant prognostic factor of the responsive group (OR: 1.15, CI [1.01-1.31], p-value 0.03). Conclusion Our data presented that RAI therapy is effective for primary hyperthyroidism. We achieved remission with a single fixed-dose in the majority of patients. Most of our patients were cured within three months of RAI therapy. In addition, the RAI dose was higher in the responsive group as compared to the non-responsive group.

Case Report: A Challenging Clinical Problem of Calcitonin-Negative Medullary Thyroid Cancer Diagnosis and Surveillance.

Medullary carcinoma of the thyroid is a rare neuroendocrine carcinoma that originates from the malignant proliferation of parafollicular C cells. In almost 100% of the cases, medullary carcinoma of the thyroid is associated with high levels of calcitonin and carcinoembryonic acid (CEA). Both carcinoembryonic antigen and calcitonin are used for the diagnosis and surveillance of medullary carcinoma of the thyroid. Calcitonin-negative medullary carcinoma of the thyroid is an extremely rare entity that is characterized by classic medullary carcinoma of the thyroid morphology without raised serum calcitonin levels. We describe the case of a middle-aged lady who presented with a few-month history of neck swelling associated with compressive symptoms. CT of the neck showed a large right thyroid nodule with central necrosis and retrosternal extension to the superior mediastinum. There was also a 360-degree encasement of the right common carotid artery. She underwent fine needle aspiration (FNAC) of the right thyroid nodule, and histopathology showed typical features of medullary carcinoma of the thyroid. Immunohistochemical staining for calcitonin and carcinoembryonic antigen was negative but positive for other neuroendocrine markers, i.e., synaptophysin and chromogranin A. Serum calcitonin and carcinoembryonic antigen levels were also in the normal range. So, a rare diagnosis of calcitonin-negative medullary carcinoma of the thyroid was made. As the disease was inoperable because of vascular encasement, a plan for external beam radiation therapy (ERBT) to the neck was made. Medullary carcinoma of the thyroid with normal serum levels of calcitonin is a very rare entity, with only a few cases reported in the literature. In this case report, we have presented a rare case of medullary thyroid carcinoma (MTC) with normal-range serum calcitonin levels, how it was diagnosed, and how to follow up postoperatively.

Dopamine Agonist-Induced Cerebrospinal Fluid Rhinorrhoea: A Case Report.

Introduction: Prolactinomas are the most common pituitary adenomas. Medical therapy with dopamine agonists (DAs) is the mainstay of treatment and rarely requires surgical manipulation. Patients may rarely present with cerebrospinal fluid (CSF) rhinorrhoea after starting therapy with DA in case of massive or invasive prolactinomas. Case Description: We present a case of a 29-year-old lady with invasive prolactinoma who presented with CSF rhinorrhoea after a month of starting bromocriptine therapy with the development of meningitis and warranting early surgical repair. Practical Implications: Patients with macroprolactinoma should be closely monitored initially after starting on DA to avoid life-threatening complications.

Perceived stress and monetary burden among thalassemia patients and their caregivers.

OBJECTIVE: To find the perceived stress level and monetary burden in the thalassemia patients and their caregivers related to thalassemia treatment sessions. METHODS: A descriptive cross sectional study was conducted at Rawalpindi Thalassemia Centre and Military Hospital Rawalpindi of six months' duration from November 2016 to April 2017. A total of 87 sample size was calculated by using WHO sample size calculator. Participants were inducted through purposive sampling technique from thalassemia centers. A validated standardized Cohen's Perceived Stress score was used. Data were entered and analyzed in SPSS 22. RESULTS: Mean age of the participants was 30.42 ± 14.53 years. There were 30 (34.2%) males and 57 (65.8%) females. There were 39 (51.3%) patients and 48 (48.7%) caregivers. The mean income per month of the participants was 48706.9 ± 39492.68 PKR. The mean total expenditure per treatment session was 48706 ± 4037.12 PKR. Among the patients, there were 15 (38.5%) who were having average stress, while 4 (10.3%) were having moderate stress while 45 (51.7%0 were having severe stress. Among the caregivers, 10 (20.8%) were having mild stress, 13 (27.1%) were having moderate stress while 25 (52.1%) were having severe stress. The stress among the two groups was not statistically significant (p=0.066). CONCLUSION: More than half of the patients and caregivers were having a high perceived stress levels and there was a significant association between the two groups. The monetary burden was a lot to bear by the patients and the cost of treatment session most expensive.

Revealing Maximal Diameter of Upper Limb Superficial Vein with an Elevated Environmental Temperature.

Ultrasonography is the primary tool for preoperative analysis of vein morphology for fistula creation in patients with end-stage renal disease. This study examines the effect of environmental temperature on the superficial vein size. Superficial veins of thirteen healthy volunteers were marked at three sites: cephalic vein in left lateral arm near cubital fossa, cephalic vein in left forearm at wrist, and basilic vein in left medial arm near cubital fossa. Mean diameters were recorded using ultrasound probe at 26°C and 43°C. Body temperature was increased using a Bair Hugger blanket. Mean values from the two temperatures were analyzed using paired sample t-test. All three superficial vein sites displayed statistically significant increase in diameter when the temperature was increased from 26°C to 43°C. Paired t-test showed p values of 0.001 for cephalic vein at wrist, 0.01 for cephalic vein near cubital fossa, and 0.01 for basilic vein near cubital fossa. This study proved that environmental temperature exerts a statistically significant effect on vein size measured by ultrasound during preoperative assessment for vascular access. Not to the extent of 43°C, the authors would recommend setting the room temperature higher during ultrasound vascular assessment to avoid underestimating the superficial vein size.

Comparison of articaine and lignocaine for uncomplicated maxillary exodontia.

OBJECTIVE: To compare single buccal articaine injection versus conventional lignocaine buccal and palatal injections for uncomplicated maxillary tooth extractions. STUDY DESIGN: Single blinded randomized control trial. PLACE AND DURATION OF STUDY: The outpatient department of Oral and Maxillofacial Surgery, Armed Forces Institute of Dentistry, Rawalpindi, from February to September 2011. METHODOLOGY: Patients aged 20 - 60 years under simple extraction in the maxillary arch were included in the study. Patients were randomly divided into two groups-A and B toss method. Maxillary teeth were divided into three groups; group-1 (posterior teeth) including first, second and third molars on either side, group-2 (middle teeth) including the premolars and group-3 (anterior teeth) including incisors and canines. Group-A (study group) received buccal infiltration of 4% articaine with 1:200,000 adrenaline and group-B (control group) received buccal and palatal infiltration of 2% lignocaine/HCl with 1:100,000 adrenaline. Faces Pain Scale (FPS) and a Visual Analogue Score (VAS) was used for objective and subjective assessment of per operative pain respectively. RESULTS: A total of 194 patients were included in the study. Group-A comprised of 100 patients while group-B consisted of 94 patients. The mean age of the total sample was 41.12 ± 13.6 years. Statistically significant difference was found for the VAS scores of anteriors (p=0.9), premolars (p=0.2) and molars (p=0.2) for groups A and B. The FPS scores for both groups were also statistically insignificant (p=0.864). CONCLUSION: Buccal infiltration with a single articaine injection and lignocaine buccal and palatal infiltration were equally effective for maxillary exodontia.

Patient communication in radiology: current status of breaking bad news among radiologists and radiology trainees in Pakistan.

Breaking bad news can be an intimidating task for any physician. The aim of this study was to record the practices of breaking bad news to the patients by Pakistani radiologists and trainees. The radiologists and trainees attending the 26th National Radiological Conference in October 2010 in Karachi, Pakistan, were surveyed. The response rate was 76%. The respondents included residents (51%), private practicing radiologists (28%), academic radiologists (13%), and other trainees (8%). Most of the academic radiologists communicated with their patients. The daily frequency of breaking bad news by residents was noted, which was highest in the public teaching hospitals (71%). For severe abnormalities such as malignancy, 50% residents, 55% of the academic radiologists and 74% of the private practicing radiologists were very uncomfortable in disclosure of results. Differences in frequency of communication with patients were noticed with both different training levels, and different settings of practice in a developing country.

Sex-based difference in the perception of exercise and level of physical activity among residents of Karachi City, Pakistan.

OBJECTIVES: To identify sex-based differences in the perception of benefits and barriers toward exercise and to determine the sex- and age-based differences in the level of physical activity (PA) among adult residents of Karachi. METHODS: Three hundred adult individuals were included in cross sectional survey conducted during July-October 2010. Perception of benefits and barriers to exercise and the level of PA were measured through a questionnaire. Differences in the perception of benefits and barriers of exercise and level of PA were calculated with age and sex strata. RESULTS: Women perceived more barriers to exercise than men (P-value < 0.001). In all age strata women have higher ranks for domestic-related physical activity while men have higher ranks for job-related PA. Leisure time PA were significantly lower for females in all age groups. Total PA is also affected by age and socioeconomic status, higher among people having monthly income < 6000 rupees and lower in males > 45 years of age. CONCLUSION: Sex-based differences exists in the level of PA and perception regarding exercise in mega city of Pakistan. There is a need to design programs that influence PA determinants connected to sex to prevent impending epidemic of non communicable diseases.