Identification of appropriate tools to gauge brain functions in a clinical setup of a developing country: A pilot study.

Objective: To identify the most appropriate tools to measure functions of the brain that can be utilized in the clinical setups of developing countries. Methods: This qualitative research with a three-step approach was carried out from January 2022 to May 2022 at the Institute of Basic Medical Sciences, Khyber Medical University, Pakistan. Firstly, literature was searched to identify main brain faculties, then interviews were conducted with regional field experts to identify appropriate scales for the selected functions. Lastly a rubric was filled using interview transcripts and literature. Results: The identified functions were vision, hearing, cognition, motor and emotions. Based on the rubric the best tests were visual fields (17/24), pure tone audiometry (16/24), Mini-Mental State Exam (20/24), Trait Emotional Intelligence Questionnaire (18/24), Romberg's test (19/24) and Manual Muscle Testing (18/24). Conclusion: The clinicians in developing countries can utilize the visual fields, pure tone audiometry, Mini-Mental State Exam, Trait Emotional Intelligence Questionnaire, Romberg's test and Manual Muscle Testing for most efficient, feasible, accurate and cost-effective measurement of brain functions.

A case of Vogt Koyanagi Harada disease in a 16 year old girl.

Vogt Koyanagi Harada (VKH) is an autoimmune disease with widespread systemic manifestations. It typically presents with bilateral sudden painless loss of vision. It is mainly characterized by serous retinal detachment, iridocyclitis and choroidal swelling. The disease is more common in females and maximus incidence occurs in the age group of 30 to 40 years. We present a case of a 16-year-old girl who presented with sudden bilateral painless loss of vision. Fundus examination and OCT scanning confirmed bilateral serous retinal detachment. Patient was started on IV methylprednisolone and the patient showed excellent response with marked improvement in visual acuity. VKH is very uncommon in children and is usually missed. It is important for general practitioners and ophthalmologists to know about this rare cause of painless loss of vision so that it could be managed adequately.

Cerebral Oximetry Use For Cardiac Surgery.

BACKGROUND: Studies have shown maintaining good cerebral perfusion during Cardiac Surgeries is very important in terms of patient outcomes and reducing the hospital stay, which may have its financial and clinical implications. The aim of this review study was to determine the effectiveness of Cerebral Oximetry (Transcranial Near-Infrared Spectroscopy-NIRS to monitor cerebral oxygenation) for Cardiac Surgery and to propose a possible concluding remark about its potential applications, overall clinical value and whether to keep using it or not. METHODS: Medical database and archives including Pubmed, Embase, index medicus, index copernicus and Medline were searched. Different papers were looked upon and each had an argument, scientific evidence and background. Fifteen research papers were selected and brought under review after carefully consideration. RESULTS: The papers were carefully reviewed and findings were given in favour of not using NIRS technique for Cerebral Oximetry in Cardiac Surgery. CONCLUSIONS: This can rightly be concluded from this study that NIRS Cerebral Oximetry does not carry the clinical significance and relevance which was previously thought. The subject under observation needs further studies and research to evaluate the effectiveness of the Cerebral Oximetry Use for Cardiac Surgery.

Pancreatic Duct Stones.

pancreatitis appears to exist in the presence of such calculi upon radiology. Having said that, pancreatic ductal stone due to biliary causes (origin), in face of acute pancreatitis, is rare. To the best of our knowledge this was the first case of its kind presented to our hospital in recent past. A 25-year-old female presented to the emergency department of our hospital with an acute episode of pancreatitis. Computerized tomography (CT) scan, endoscopic retrograde cholangiopancreatography (ERCP) & magnetic resonance cholangiopancreatography (MRCP) concluded acute pancreatitis (AP) with dilated main pancreatic duct left side branches and intra ductal calculi. The findings were not suggestive of any chronic pancreatitis. Conservative treatment was given for the episodic attack of AP. After the episode resolved, an exploration and extraction of the pancreatic ductal calculus was performed successfully. The pancreatic duct stones were removed by lateral pancreaticojejunostomy (partington-rochelle procedure). The patient made a remarkable recovery after the procedure and was perfectly healthy and well-oriented in time and space at 4-months follow up. Acute pancreatitis is an inflammatory condition of pancreas, when, associated with pancreatic duct stones a lateral pancreaticojejunostomy is done, which, results in better outcomes decreasing the mortality and morbidity. Acute pancreatitis due to ductal calculi is rare for which extraction is safe after resolution of the episode of AP. Studies need to be carried out to look for the outcome and the effectiveness of the procedure, when, specifically and specially done for this condition.

Angiofibroma In A 50-Year-Old Patient.

Juvenile Angiofibroma (JNA) is a benign tumour that tends to bleed and occur in the nasopharynx with most cases occurring in pre-pubertal and adolescent males 10-20 years. We present the case of a 50-year-old male shopkeeper who consulted the ENT out patients' department (OPD) of Khyber Teaching Hospital (KTH) with the chief complaint of right sided nasal obstruction for the last 2.5 months which was associated with two episodes of epistaxis and diplopia which started 2 months back. He complained of right sided frontal and periorbital pain for the last 15 days. Past medical and surgical history was insignificant. Computerized Tomography (CT) scan without contrast and magnetic resonance imaging (MRI) showed finding consistent with a pedunculated tumour like growth. After baseline investigations, surgery was done and a Wilson's incision was given and the mass was excised and sent to the lab for histopathological report which showed angiofibroma. The age of the patient shows that this is a very rare case of angiofibroma. Dissection of such tumours is important as they have propensity to bleed. Excision along with biopsy is the method of choice. Proper surgical techniques and use of better medical technology are required to make and early diagnosis. Further studies/case reports around the world would assert our findings that a nasopharyngeal angiofibroma can also be found in middle aged men.

Eales Disease.

Eales disease is an eponym after a British ophthalmologist Henry Eales. The aetiology behind Eales disease is ill-understood and stands controversial. Various systemic diseases associated with peripheral retinal revascularization and Retinal vasculitis could imitate the proliferative and inflammatory phases of Eales' disease, respectively. We present a case of a 30 years old female patient with Eales disease and discuss the clinical features, treatment plan and its outcome in our patient. Tuberculosis appears to be the cause of Eales disease but the relation is yet to be established and clinically proven. Steroid therapy is usually the main stay of treatment with tapering doses of systemic corticosteroids. Other interventions are vitrectomy, photocogulation or cryotherapy.

Pleomorphic Adenoma Of Minor Salivary Glands.

Pleomorphic adenoma is the most common benign tumour of salivary glands which is Known for its wide pleomorphic architecture. It accounts for 45-75% of all salivary gland neoplasm. It can involve major as well as minor salivary glands. Among minor salivary glands (5-10% of cases) the palate lip, nasal cavity, pharynx, larynx and trachea are the most common sites. Diagnosis is made with biopsy along with histopathology. Wide excision with biopsy and removal of underlying extension of tumour is the treatment of choice. Sixty years old farmer presented with painless swelling in the upper lip for the last 8 years. History revealed recurrent mass in the midline of upper lip with no other complaints. He was operated 3 times for this complaint in the past. Belonging to poor socioeconomic status no biopsy records were found. On examination 3×4 cm hard and mobile mass was found. Lymph nodes of head and neck and parotid gland revealed no enlargement. Surgery by wide excision was planned. After baseline investigation surgery was done and the mass sent for histopathology. Biopsy reports showed pleomorphic adenoma on unusual site. Dissection of salivary gland tumour is important as they have propensity to metastasize. Wide local excision along with biopsy is the method of choice. Proper surgical techniques are required to avoid recurrence.

A New Clinical Sign In Meningitis-Jamil's Sign.

BACKGROUND: This study explored a new clinical sign in meningitis: neck stiffness in lateral position, also known as Jamil's sign. METHODS: A patient was placed in the left lateral position. The examiner held the patient's occiput with his left hand and the chin with his right hand. Then, the examiner performed a manoeuvre by fully extending and then fully flexing the neck. By doing so, the examiner was able to get ample time and range of movement to judge the tone. The tone was assessed during flexion and extension. If the examiner felt resistance, rigidity, or stiffness while performing this manoeuvre, Jamil's sign was present. Otherwise, it was supple, and Jamil's sign was absent. RESULTS: Of the 419 patients, Jamil's sign was present in 362 patients and absent in 57 patients. Upon lumbar puncture, 361 patients had meningitis, and 58 patients did not have meningitis. Among patients with meningitis, Jamil's sign was present in 357 patients and absent in four patients. Jamil's sign had a sensitivity of 98.89% and a specificity of 91.38. CONCLUSIONS: Due to its high sensitivity and specificity for the diagnosis of meningitis, Jamil's sign obviates the need for unnecessary lumbar puncture, which is performed in doubtful situations of neck stiffness in the supine position.

An Early Presentation Of Supraglottic Laryngeal Paraganglioma: Case Report And Review Of Literature.

A thirty-year-old male presented with progressive hoarseness and dysphagia for solids. Fibre optic laryngoscopy showed a right supraglottic mass. Subsequent CT imaging showed the location and extent of the mass. Biopsy revealed a Paraganglioma with cytokeratin negative and chromogranin positive cells. The mass was subsequently removed without complications. Follow up also showed no complications. Hoarseness and dysphagia resolved following tumour excision.

Case Report: Can we differentiate mesothelioma from inflammatory pericardial constriction preoperatively?

Primary malignant pericardial mesothelioma (PMPM) is a rare cardiac tumor. The patient usually presents with pericardial constriction, usually misdiagnosed and wrongly managed. We present the case of a 21-year-old woman with a history of pericarditis and cardiac tamponade. The patient was referred from a clinic due to nausea, vomiting and ascites with lower extremity edema, soft and watery diarrhea, and right upper quadrant pain. Surgery (sternotomy and partial pericardiectomy) was proposed after looking at the different relevant investigations; it was not until that the patient was operated on that it was established that this wasn't a mere constriction but a malignancy. The patient shortly died after the operation. Pathology made a diagnosis of PMPM. Along with the classical symptoms those who present with level 1 thoracic adenopathy a decision to operate should be very carefully made, this may lead to a misdiagnosis of PMPM which postoperatively results in patient's death.

Primary Hydatid Disease Of Chest Wall.

Hydatid disease-a parasitic medical condition caused by echinococcus, is one of the oldest diseases known to mankind. Primary hydatid disease of the chest wall is very rare and only nine cases have been reported so far in the literature. This study presents a case of primary hydatid chest wall in a patient with right infraclavicular swelling that increased in size suddenly. A 35 year-old lady presented to the Surgical Unit of Khyber Teaching Hospital with a two and a half year history of right infraclavicular chest wall lump which increased in size abruptly Upon investigation the Computed tomographic (CT) scan of the chest showed a complex multiseptated hypodense lesion in the right pectoralis muscle with no involvement of underlying clavicle or rib. She was booked for exploration under general anaesthesia electively. The lump revealed multiple daughter cysts with the characteristics of germinal layers and ecto cysts of hydatid cysts. The patient had a stable recovery in the postoperative period and was sent home on medical treatment. On follow up she was fine; the wound had healed and there was no swelling in the surgical site. Primary hydatid disease of the chest wall is a very rare disease, so this case is a piece of good evidence to consider hydatid cyst in the differential diagnosis of any cystic mass in any part of the body, especially in endemic areas. Radical peri-cystectomy followed by chemotherapy with albendazole is all that is needed for the treatment.

Intraorbital, Infratemporal And Intracranial Extensions As The First Presentation Of Follicular Thyroid Carcinoma.

Metastatic skull deposits from follicular thyroid carcinoma are rare, and let alone this being the primary presenting symptom with no history of thyroid cancer is exceptionally rarer. A 40-yearold female patient presented with a mass in the temporal and occipital region of the skull. Fine needle aspiration cytology confirmed multiple fragments of a neoplasm composed of variably sized follicles lined by tumour cells having pleomorphic hyperchromatic nuclei. Further workup revealed Follicular thyroid carcinoma and subsequently, total thyroidectomy was done. Skull resection was not possible due to the extensive nature of disease and patient was advised radioactive iodine ablation therapy but couldn't survive past 4 months.

Plasma Cell Leukaemia: A Rare Yet Aggressive Plasma Cell Dyscrasia With A Very Poor Response To Conventional Therapy.

Plasma cell leukaemia (PCL) is a very rare plasma cell dyscrasia with a significant number of monoclonal plasma cells in the peripheral blood. It is diagnosed by the presence of ≥ 2x109 /L plasma cells in the blood or by plasma cells making up ≥20% of the leukocyte count. It can arise from a leukemic transformation of multiple myeloma, or more commonly it can be primary. Regardless of its origin, it carries a very dire prognosis. It responds very poorly to the traditional chemotherapy regimens used for multiple myeloma. We present the case of a 50 years old female who presented to our hospital with a complicated UTI and severe generalized body aches. She was diagnosed as a case of plasma cell leukaemia and was treated with cyclophosphamide and dexamethasone, however she failed to go into remission. Her condition deteriorated and she ultimately passed away 1.5 months after diagnosis. The recommended treatment for PCL is aggressive combination chemotherapy followed by stem cell transplantation. However, there is no consensus regarding the treatment of plasma cell leukaemia, and treatment should be individualized based on the patient profile. Once diagnosed, the prognosis is poor.

Resolution Of Gestational Gigantomastia With Termination Of Pregnancy.

Less than 100 cases of gestational gigantomastia have been described in literature. The aetiology and risk factors are not well-established. Various treatments have been used with some consensus. We present the case of a 47-year-old female who presented to us with bilateral gigantomastia in her 16th week of gestation. She had massively enlarged breasts which were very painful. Relevant laboratory investigations were normal. An incisional biopsy done prior to, and two trucut samples at presentation to us, showed normal breast tissue proliferation. In the absence of adequate pain control, it was decided to electively terminate the pregnancy and give a trial of tamoxifen. She made a rapid recovery following termination without requiring the use of tamoxifen.

Pregnant Lady With Undiagnosed Hodgkin's Disease Presenting As Secondary Sclerosing Cholangitis.

Hodgkin's lymphoma. A 25 years old lady, 34 weeks primigravida was referred from the Emergency Department to the Medical Unit Khyber Teaching Hospital-MTI, Peshawar with four weeks of fever, progressive jaundice, pruritus, night sweats and weight loss. LFTs showed cholestatic picture, ERCP showed scanty intrahepatic giving beading and autumn tree appearance typical of sclerosing cholangitis. CBD was normal. Doppler U/S of hepatic and portal vein reported normal. She was started on steroids, ursodeoxycholic acid and antibiotics 3rd generation cephalosporins to which she did not respond well. This prompted a Liver biopsy which showed Hodgkin's disease having mixed cellularity. She was shifted to specialized oncology unit for further management where she died of irreversible liver damage. This is a rare case of secondary sclerosing cholangitis in Hodgkin's lymphoma of liver and the first case reported to our Hospital.