Retrospective Diagnosis of Ca Thyroid on Thyroid Pertechnetate Scan -A part of Routine Post Thyroidectomy Work up For Nontoxic Multi Nodular Goiter.

Unsuspected thyroid cancer can be detected in multinodular goiter (MNG) where the risk of malignancy is 7-9%. Fine needle aspiration (FNAc) is performed in case of suspicious findings on ultrasound. With benign FNAC results there is no need for surgery unless the patient has pressure symptoms or cosmetic concerns, but the risk of overlooked malignancy is always present. We present the case of a patient with unexpected detection of papillary thyroid cancer on thyroid scan.

Prevalence of HPV types in HIV-positive and negative females with normal cervical cytology or dysplasia.

The burden of HPV varies by country and HIV status. The study aimed to evaluate HPV types prevalent in HIV-positive females compared with HIV-negative females in the local population of the federal capital territory in Pakistan. METHOD: The selected female population consisted of 65 already diagnosed HIV-positive females and 135 HIV-negative females. Cervical scrap was collected and analyzed for HPV and cytology. RESULTS: The prevalence of HPV in HIV-positive patients was 36.9%, higher than HIV-negative patients (4.4%). 12.30% had cervical cytology interpreted as "LSIL" and 87.69% had cytology interpreted as "NIL." The high-risk type was detected in 15.39% while 21.54% showed low-risk HPV types. Among the high-risk types, HPV18 (6.15%), HPV16 (4.62%), HPV45 (3.07%), HPV33 (1.53%), HPV58 (3.07%), and HPV68 (1.53%) were found. In patients with LSIL, high-risk HPV accounts for 62.5%. Risk factors, such as age, marital status, educational status, residence, parity, other STDs, and contraceptives, were analyzed to find the correlation with HPV infection Age ≤35 years (OR 1.21, 95% CI, 0.44-3.34), illiterate and incomplete secondary education (OR 1.08, 95% CI, 0.37-3.15), and those reported not to use contraceptives (OR: 1.90; 95% CI: 0.67-5.42) have an association for increased risk of HPV infection. CONCLUSION: HPV18, HPV16, HPV58, HPV45, HPV68, and HPV33 were identified among high-risk HPV types. High-risk HPV was detected in 62.5% of low-grade squamous intraepithelial lesions. The data is useful for health policymakers to develop a strategy for HPV screening and prophylactic vaccination to prevent cervical cancer.

Extraosseous soft tissue uptake-in Multiple Myeloma.

Tc-99m Methylene Diphosphonate (MDP) bone scintigraphy has been used for the assessment of benign as well as malignant skeletal conditions. Non-osseous radiotracer uptake on bone scan is an unusual finding. It is usually performed for metastatic bone disease, and is generally not an indication in multiple myeloma, as osteolytic lesions typically show no radiotracer uptake. Despite this, substantial number of multiple myeloma patients undergo bone scintigraphy due to their presentation imitating a metastatic bone disease. We describe a case of multiple myeloma, where extra osseous uptake in lung and diffuse hepatic, has been noted on bone scan.

Role of Synonymous Mutations in the Evolution of TEM ß-Lactamase Genes.

Nonsynonymous mutations are well documented in TEM ß-lactamases. The resulting amino acid changes often alter the conferred phenotype from broad spectrum (2b) conferred by TEM-1 to extended spectrum (2be), inhibitor resistant (2br), or both extended spectrum and inhibitor resistant (2ber). The encoding blaTEM genes also deviate in numerous synonymous mutations, which are not well understood. blaTEM-3 (2be), blaTEM-33 (2br), and blaTEM-109 (2ber) were studied in comparison to blaTEM-1blaTEM-33 was chosen for more detailed studies because it deviates from blaTEM-1 by a single nonsynonymous mutation and three additional synonymous mutations. Genes encoding the enzymes with only nonsynonymous or all (including synonymous) mutations plus all permutations between blaTEM-1 and blaTEM-33 were expressed in Escherichia coli cells. In disc diffusion assays, genes encoding TEM-3, TEM-33, and TEM-109 with all synonymous mutations resulted in higher resistance levels than genes without synonymous mutations. Disc diffusion assays with the 16 genes carrying all possible nucleotide change combinations between blaTEM-1 and blaTEM-33 indicated different susceptibilities for different variants. Nucleotide BLAST searches did not identify genes without synonymous mutations but did identify some without nonsynonymous mutations. Energies of possible secondary mRNA structures calculated with mfold are generally higher with synonymous mutations, suggesting that their role could be to destabilize the mRNA and facilitate its unfolding for efficient translation. In summary, our data indicate that transition from blaTEM-1 to other variant genes by simply acquiring the nonsynonymous mutations is not favored. Instead, synonymous mutations seem to support the transition to other variant genes with nonsynonymous mutations leading to different phenotypes.

Role of M.tuberculosis protein Rv2005c in the aminoglycosides resistance.

Tuberculosis is an airborne infectious disease caused by Mycobacterium tuberculosis which threatens the globe. Aminoglycosides {Amikacin (AK) & Kanamycin (KM)} are WHO recommended second-line anti-TB drugs used against the treatment of drug-resistant tuberculosis. Aminoglycosides target the steps of protein translation machinery of M.tuberculosis. Several mechanisms have been put forward to elucidate the phenomena of aminoglycosides resistance but our knowledge is still insufficient. The aim of the study was to understand the involvement of Mycobacterium tuberculosis universal stress protein (Rv2005c) in aminoglycosides resistance and virulence. To establish the relationship of universal stress protein Rv2005c with AK & KM resistance, Rv2005c was cloned, expressed in E.coli BL21 using pQE2 expression vector and antimicrobial drug susceptibility testing (DST) was carried out. STRING-10 was also used to predict the interacting protein partners of Rv2005c. DST showed that the minimum inhibitory concentration of induced recombinant cells (Rv2005c) were five and four folds shifted with AK and KM E-strips, respectively. STRING-10 showed the interacting protein partners of Rv2005c. Overexpression of Rv2005c leads to shifting in MIC which might be signifying its involvement in the survival/resistance of Mycobacteria by inhibiting/modulating the effects of AK and KM released from the E-strips. Interactome also suggests that Rv2005c and its interacting protein partners are cumulatively involved in M.tuberculosis resistance, stresses, and latency.

Virtual Screening and Experimental Testing of B1 Metallo-ß-lactamase Inhibitors.

The global rise of metallo-ß-lactamases (MBLs) is problematic due to their ability to inactivate most ß-lactam antibiotics. MBL inhibitors that could be coadministered with and restore the efficacy of ß-lactams are highly sought after. In this study, we employ virtual screening of candidate MBL inhibitors without thiols or carboxylates to avoid off-target effects using the Avalanche software package, followed by experimental validation of the selected compounds. As target enzymes, we chose the clinically relevant B1 MBLs NDM-1, IMP-1, and VIM-2. Among 32 compounds selected from an approximately 1.5 million compound library, 6 exhibited IC50 values less than 40 µM against NDM-1 and/or IMP-1. The most potent inhibitors of NDM-1, IMP-1, and VIM-2 had IC50 values of 19 ± 2, 14 ± 1, and 50 ± 20 µM, respectively. While chemically diverse, the most potent inhibitors all contain combinations of hydroxyl, ketone, ester, amide, or sulfonyl groups. Docking studies suggest that these electron-dense moieties are involved in Zn(II) coordination and interaction with protein residues. These novel scaffolds could serve as the basis for further development of MBL inhibitors. A procedure for renaming NDM-1 residues to conform to the class B ß-lactamase (BBL) numbering scheme is also included.

Short term clinical outcomes of Everolimus-eluting stents in patients with stable angina pectoris.

BACKGROUND & OBJECTIVE: Everolimus-eluting stents, compared with bare metal stents, reduced the risk of restenosis in clinical trials with strict inclusion and exclusion criteria. The objective of this study was to determine the three months clinical outcomes of Everolimus Eluting Stents in patients with stable angina pectoris in Pakistani population. METHODS: It was a descriptive cross-sectional study and the data was collected from Catheterization Laboratory Cardiology Department Lady Readings Hospital Peshawar. Our study included all the patients with stable coronary artery disease who had received Everolimus eluting stents from August, 2013, to April, 2014. Total study duration was 09 months. The primary end points were the rate of target vessel revascularization, myocardial infarction at three months. All those patients who received Everolimus coronary stents were recalled after three months from the index procedure and enquired about target vessel revascularization (TVR), myocardial infarction and hospitalization over the last three months. Data analysis was done using SPSS version 16. RESULTS: Our study included 378 patients with stable ischemic heart disease who underwent revascularization with Everolimus eluting stent. These patients were followed up for a period of 3 months for target vessel revascularization(TVR) and myocardial infarction(MI). Mean age was 57.04±9.307, males were (72%). Left Anterior Descending (LAD) and Left circumflex (LCx) were the predominant vessels vascularized. Mean length of Everolimus eluting stent was 21.91± 4.6 while mean diameter of stent was 2.90±0.248. Thirteen (3.4%) patients had TVR and 14 (3.7%) patients had MI during three months follow up after PCI. TVR and MI were prevalent in patients who received longer Everolimus stents as compared to those who received shorter stents at three months, and the difference between the two was statistically significant. CONCLUSION: Short-term results from this study suggest that real-world outcomes among 378 patients are comparable to those reported in other registries and trials, and safety outcomes as measured by rates of TVR, MI were low. The long-term safety of Everolimus-eluting stents needs to be ascertained in large, randomized trials.

M. tuberculosis ferritin (Rv3841): Potential involvement in Amikacin (AK) & Kanamycin (KM) resistance.

Tuberculosis is an infectious disease, caused by one of the most successful human pathogen, Mycobacterium tuberculosis. Aminoglycosides, Amikacin (AK) & Kanamycin (KM) are commonly used to treat drug resistant tuberculosis. They target the protein synthesis machinery by interacting with several steps of translation. Several explanations have been proposed to explain the mechanism of aminoglycoside resistance but still our information is inadequate. Iron storing/interacting proteins were found to be overexpressed in aminoglycosides resistant isolates. Iron assimilation and utilization in M. tuberculosis plays a crucial role in growth, virulence and latency. To establish the relationship of ferritin with AK & KM resistance ferritin (Rv3841/bfrB) was cloned, expressed and antimicrobial drug susceptibility testing (DST) was carried out. Rv3841/bfrB gene was cloned and expressed in E. coli BL21 using pQE2 expression vector. Etest results for DST against AK & KM showed that the minimum inhibitory concentration (MIC) of ferritin recombinant cells was changed. Recombinants showed two fold changes in MIC with AK and three fold with KM E-strips. Overexpression of ferritin reflect the MIC shift which might be playing a critical role in the survival of mycobacteria by inhibiting/modulating the effects of AK & KM. String analysis also suggests that ferritin interacted with few proteins which are directly and indirectly involved in M. tuberculosis growth, Iron assimilation, virulence, resistance, stresses and latency.

Temporal Comparative Transcriptome Analysis on Wheat Response to Acute Cd Toxicity at the Seedling Stage.

Cadmium (Cd) is a non-essential and toxic metal that accumulates in plant's tissues and diminishes plant growth and productivity. In the present study, differential root transcriptomic analysis was carried out to identify Cd stress-responsive gene networks and functional annotation under Cd stress in wheat seedlings. For this purpose, the Yannong 0428 wheat cultivar was incubated with 40 µm/L of CdCl2·2.5H2O for 6 h at three different seedling growth days. After the quality screening, using the Illumina Hiseq 2000 platform, more than 2482 million clean reads were retrieved. Following this, 84.8% to 89.3% of the clean reads at three time points under normal conditions and 86.5% to 89.1% of the reads from the Cd stress condition were mapped onto the wheat reference genome. In contrast, at three separate seedling growth days, the data analysis revealed a total of 6221 differentially expressed genes (DEGs), including 1543 (24.8%) up-regulated genes and 4678 (75.8%) down-regulated genes. In total, 120 DEGs were co-expressed throughout all the growth days, whereas 1096, 1088, and 2265 DEGs were found to be selectively up-/down-regulated at 7d, 14d, and 30d, respectively. However, the clustering of DEGs, through utilizing the Kyoto Encyclopedia of Genes and Genomes (KEGG), revealed that the DEGs in the metabolic category were frequently annotated for phenylpropanoid biosynthesis. In comparison, a considerable number of DEGs were linked to protein processing in the endoplasmic reticulum under the process of genetic information processing. Similarly, in categories in organismal systems and cellular processes, DEGs were found in plant hormone signal transduction pathways, and DEGs were identified in the plant-pathogen interaction pathway, respectively. However, DEGs in "endocytosis pathways" were enriched in environmental information processing. In addition, in-depth annotations of roughly specific heavy metal stress-response genes and pathways were also mined, and the expression patterns of eight DEGs were studied using quantitative real-time PCR. The results were congruent with the findings of RNA sequencing regarding transcript abundance in the studied wheat cultivar.

A decade of machine learning-based predictive models for human pharmacokinetics: Advances and challenges.

Traditionally, in vitro and in vivo methods are useful for estimating human pharmacokinetics (PK) parameters; however, it is impractical to perform these complex and expensive experiments on a large number of compounds. The integration of publicly available chemical, or medical Big Data and artificial intelligence (AI)-based approaches led to qualitative and quantitative prediction of human PK of a candidate drug. However, predicting drug response with these approaches is challenging, partially because of the adaptation of algorithmic and limitations related to experimental data. In this report, we provide an overview of machine learning (ML)-based quantitative structure-activity relationship (QSAR) models used in the assessment or prediction of PK values as well as databases available for obtaining such data.

Antibody Response to SARS-CoV-2 in Relation to the Contributing Factors in COVID-19 Patients.

Human health has always been challenged by variety of viral infections, but severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has surpassed all previous viral diseases and emerged as a major health challenge around the globe. Real-time polymerase chain reaction (PCR) is the gold standard for the diagnosis of SARS-CoV-2 and serological assay provides a compliment to diagnosis after second week of infection. The aim of the study is the characterization of antibody response to SARS-CoV-2 in the blood sample of diagnosed coronavirus disease 2019 (COVID-19) patients, and its potential association with factors such as age, gender, time, and symptoms. Serum from 248 confirmed SARS-CoV-2 patients was investigated for antibodies. Elecsys anti-SARS chemiluminescent immune assay was performed for the detection of nucleocapsid-specific antibodies. Association of antibody response with gender, age, and time after onset of symptoms was analyzed. Among 248 PCR positive SARS-CoV-2 patients, 214 (86.3%) have virus-specific antibody signals. Antibodies positivity rate was higher in male patient patients as compared with female patients (90.8% vs. 79.2%, p = 0.009). Patients aged 30-40 years had the highest antibody positivity rate as compared with other groups (89.10%, p = 0.04). Patients age group >60 years had a lower positivity rate (75%, p = 0.04). The increasing trend in the antibodies detection with time was observed, maximum positive antibodies response rate observed at 8 weeks. Patients were categorized on the basis of clinical symptoms into asymptomatic, mild, and moderate; 17.7% were asymptomatic, 60.5% showed mild symptoms, and 21.8% showed moderate symptoms of the disease. Males were seen to be more asymptomatic as compared with females (i.e., 59.1% to 40.9%). The serological test for SARS-CoV-2 has a high sensitivity at >2 weeks after the positive PCR result or onset of illness. In addition, the serological response differs among patients based on gender, age, as well as time between the onset of symptoms or PCR confirmation and sample collection for the study of antibody response.

Dominant negative mutations affect oligomerization of human pyruvate kinase M2 isozyme and promote cellular growth and polyploidy.

This study was designed to understand the mechanism and functional implication of the two heterozygous mutations (H391Y and K422R) of human pyruvate kinase M2 isozyme (PKM(2)) observed earlier in a Bloom syndrome background. The co-expression of homotetrameric wild type and mutant PKM(2) in the cellular milieu resulting in the interaction between the two at the monomer level was substantiated further by in vitro experiments. The cross-monomer interaction significantly altered the oligomeric state of PKM(2) by favoring dimerization and heterotetramerization. In silico study provided an added support in showing that hetero-oligomerization was energetically favorable. The hetero-oligomeric populations of PKM(2) showed altered activity and affinity, and their expression resulted in an increased growth rate of Escherichia coli as well as mammalian cells, along with an increased rate of polyploidy. These features are known to be essential to tumor progression. This study provides insight in understanding the modulated role of large oligomeric multifunctional proteins such as PKM(2) by affecting cellular behavior, which is an essential observation to understand tumor sustenance and progression and to design therapeutic intervention in future.

Diagnosis and Management of Diffuse Large B-Cell Lymphoma: Society of Medical Oncology, Pakistan Society of Hematology, and Pakistan Society of Clinical Oncology Joint Clinical Practice Guideline.

Diffuse large B-cell lymphoma (DLBCL) is the commonest non-Hodgkin lymphoma encountered by hematopathologists and oncologists. Management guidelines for DLBCL are developed and published by countries with high income and do not cater for practical challenges faced in resource-constrained settings. This report by a multidisciplinary panel of experts from Pakistan is on behalf of three major national cancer societies: Society of Medical Oncology Pakistan, Pakistan Society of Hematology, and Pakistan Society of Clinical Oncology. The aim is to develop a practical and standardized guideline for managing DLBCL in Pakistan, keeping in view local challenges, which are similar across most of the low- and middle-income countries across the globe. Modified Delphi methodology was used to develop consensus guidelines. Guidelines questions were drafted, and meetings were convened by a steering committee to develop initial recommendations on the basis of local challenges and review of the literature. A consensus panel reviewed the initial draft recommendations and rated the guidelines on a five-point Likert scale; recommendations achieving more than 75% consensus were accepted. Resource grouping initially suggested by Breast Health Global Initiative was applied for resource stratification into basic, limited, and enhanced resource settings. The panel generated consensus ratings for 35 questions of interest and concluded that diagnosis and treatment recommendations in resource-constrained settings need to be based on available resources and management expertise.

Can Radiation Therapy Quality Assurance Improve Nasopharyngeal Cancer Outcomes in Low- and Middle-Income Countries: Reporting the First Phase of a Prospective International Atomic Energy Agency Study.

PURPOSE: Most new nasopharyngeal cancer cases occur in low-income and middle-income countries, and these patients experience poorer overall survival than that of new nasopharyngeal cancer cases in high-income countries. The goal of this research project is to determine whether the introduction of a radiation therapy quality assurance program can ultimately improve outcomes for nasopharyngeal cancer patients in lower-income and middle-income countries. This study reports the results of the first phase of the International Atomic Energy Agency Coordinated Research Project (325-E3-TM-47712). METHODS AND MATERIALS: This prospective study has 2 phases. Phase 1 is a survey of radiation therapy resources, patient characteristics and treatment, and results of radiation therapy quality assurance performed by the expert panel. An educational workshop reviewing phase 1 results for each center was completed before accrual of patients for phase 2. The ultimate aim of the study is to compare the first and second cohort of patients to see if quality assurance can result in fewer major protocol deviations and a 15% improvement in patients' 3-year progression-free survival. RESULTS: Of 14 participating centers, 13 (93%) had computed tomography simulators and linear accelerators (LINAC) with intensity modulated radiation therapy (IMRT) capacity, median 3 LINAC (range, 1-13), and median 10 radiation oncologists (range, 5-51). The annual number of nasopharyngeal cancer cases irradiated was median 54 (range, 10-627). Five of 14 centers (36%) had no local radiation therapy quality assurance. For the current phase 1 study, 134 patients were evaluated, 82.1% had MRI staging, 99.3% had metastatic workup, 65.6% undifferentiated histology, 51% stage 3 and 49% stage 4. Radiation therapy quality assurance revealed 81 (60.4%) of 134 patients had major protocol violations in gross tumor volume and high dose planning target volume contours and/or dosimetry, 28.4% patients had borderline plans, 15 (11.2%) acceptable, and only 6 (4.2%) had inevitable compromise due to tumor extent. CONCLUSIONS: This is the first International Atomic Energy Agency study to address the fundamental issue of treatment quality rather than altered treatment regimens. The high rate of unacceptable radiation therapy plans is a major concern, and we hope phase 2 will show a significant reduction and improved patient outcomes.

Long-term survivor of brain metastases from malignant melanoma.

Malignant melanoma is notorious for distant metastases. Median survival for stage IV melanoma is 6-10 months and 5 year survival is less than 5%. Median survival for melanoma with brain metastases is even lower i.e. 2 to 9 months. Here a case is reported who was treated for melanoma of sole of left foot with ipsilateral inguinal adenopathy and brain metastases in 2001 and is still surviving disease-free after a lapse of 8 years.

Does BMI affect cholesterol, sugar, and blood pressure in general population?

BACKGROUND: Higher BMI in child hood is also associated with an increase risk for coronary heart disease in adulthood. Impaired glucose tolerance is highly prevalent in children and adolescents with severe obesity. Positive correlations between BMI and glucose, lipids and BP have previously been reported. The objective of this study was to find the correlation of BMI with cholesterol and sugar level in general population. METHODS: This study was a part of 'Peshawar Heart Study', performed at Cardiology Department, Lady Reading Hospital, Peshawar in 2008-2009. Individuals with different ages, gender, professions, socioeconomic class were randomly selected from general population. Random blood sugar and cholesterol was measured with strip method. Height and weight of each individual was recorded and BMI calculated. All individuals were asked about any current medical illness and whether they were performing any exercise or not. Using SPSS-13, descriptive statistics were used for frequencies. Bivariate correlations were used for measuring correlation between BMI, sugar and cholesterol. Partial correlations were used to factor out the effect of other variables. RESULTS: A total of 2,270 individuals, 1,798 (79.2%) male and 472 (20.8%) female were examined. Mean age was 38.47 +/- 12.66. Mean BMI was 26.38 +/- 4.97. Mean RBS was 113.7 +/- 47.145. Mean cholesterol was 168.47 +/- 28.23. Exercise was performed by 929 (40.90%) individuals. Diabetes was present in 113 (5.0%) and history of high cholesterol in 25 (1.1%) persons. When bivariate correlation analysis were done systolic BP, diastolic BP, RBS and cholesterol had positive correlation with BMI [correlation coefficient of 0.317 (p < 0.000), 0.319 (p < 0.000), 0.125 (p < 0.000) and 0.205 (p < 0.000) respectively]. These variables also showed a positive correlation among themselves. After factoring out the effects of age, exercise, gender and current medical status on the above correlations, the correlation of RBS and cholesterol with BMI decreased to 0.025 (p = 0.232) and 0.135 (p < 0.000) respectively and between sugar and cholesterol decreased to 0.018 (p = 0.401). CONCLUSION: In general population BMI is positively correlated with RBS and cholesterol. With the effect of age, sex, exercise and current medical status, this correlation is reduced.

Indeterminate Prediction of Hepatitis C Virus Genotype by Commercial Real-Time Polymerase Chain Reaction Assay Resolving by Sequencing to Avoid the Consequence of Inaccurate Typing.

Pakistan is ranked second highest after Egypt in hepatitis C virus (HCV) infection. Accurate typing is mandatory to be compliant with the World Health Organization strategy to eliminate HCV infection in 2030. We characterized the HCV genotypes using Abbott real-time polymerase chain reaction assay and indeterminate samples were sequenced. We also investigated the distribution of HCV genotype among different age groups and gender in chronic HCV patients. One thousand thirteen samples were tested for HCV genotyping using Abbott real-time HCV genotyping assay. RNA extraction from plasma was done using the m2000sp platform. The amplification and detection of genotypes was done on m2000rt instrument. The lower limit of detection assay is 500 IU/mL. The indeterminate genotypes were analyzed by sequencing of the NS5B region. We found genotype 1 in 1.68%, genotype 1b in 0.89%, genotype 1a in 0.79%, genotype 2 in 0.6, genotype 3 in 94.37%, genotype 4 in 0.4%, genotype 5 in 0.09%, and indeterminate genotype result were found in 1.18%. Abbott assay could not identify 12 samples of genotype 3 (1.18%) and gave the indeterminate result. It also fails to assign some of the samples of genotype 1 into 1a and 1b. The indeterminate genotypes were resolved by sequencing followed by phylogenetic analysis. Genotype 3 is the predominant genotype and significantly higher in females as compared with males. Genotype 1a is more common in males than in females. Indeterminate HCV genotypes on sequencing analysis identify as genotype 3a and likewise subtype of genotype1 as 1a.

Porocarcinoma: a rare sweat gland malignancy.

Eccrine Porocarcinoma (ECP) is a malignant tumour arising from the intraepithelial ductal parts of the sweat gland. It has also been described as malignant hidroacanthoma simplex, sweat gland carcinoma, malignant intra-epidermal eccrine poroma, eccrine poroepithelioma, dysplastic poroma, malignant syringo acanthoma and porocarcinoma. Treatment with wide local excision but metastatic lesions can be treated with chemotherapy. Here, we present a case report of 52 years old male who presented with a fungating growth on left pre-auricular region that came out to be a case of ECP on histopathological examination.

Hepatic and skeletal metastases from primary intracranial atypical meningioma.

Meningioma constitutes 27% of primary CNS tumours. It rarely metastasizes to distant sites (< 0.1%). Here, we present a case report of primary atypical intracranial meningioma metastasizing to liver and bone after 4 years of surgery and postoperative radiotherapy presenting with multiple episodes of hypoglycemia.

Therapeutic effects of 20 gray radiotherapy over a week in the management of brain metastases.

OBJECTIVE: To determine the therapeutic effects of 20 Gy over a week in the management of multiple brain metastases. Secondly to determine the toxicity profile and survival at 6th month in patients treated with the above-mentioned protocol. METHODS: This was a single arm interventional study, conducted at Nuclear Medicine, Oncology and Radiotherapy Institute (NORI), Islamabad from May 8, 2006 to May 31, 2007. Thirty patients with multiple brain metastases were inducted in this study. Mean age was 52 +/- 11 years. Fifty Four percent were females and 46% males. After initial workup, all were planned for whole brain radiotherapy. 20 Gy was given to whole brain by two parallel opposed, equally weighted lateral fields in five consecutive daily fractions. Dose per fraction was four Gy. All were followed up for six months for survival. Treatment response was categorized in four different categories i.e., > 50%, approximately 50%, < 50% and no response. RESULTS: It revealed that there was significant effect of treatment with 20 Gy radiotherapy as 76% of the patients during and 80% on the last day of therapy showed > 50% response (p < 0.05). Secondly, median survival of the patients after radiotherapy was two months (p < 0.05). No serious toxicity was noted during this therapy. CONCLUSION: Twenty Gy over a week is highly effective in palliation of symptoms due to multiple brain metastases. In comparison with other studies, this protocol had no significant difference in overall survival and acute toxicity.