Duodenal stricture secondary to IgG4-related chronic sclerosing duodenitis-A case report with review of the literature.

Key Clinical Message: This case highlights the importance of a definite diagnosis of an IgG4-related chronic sclerosing duodenitis based on histological and radiological findings to rule out any malignancy in the mass. While dealing with patients having concentric duodenal thickening resulting in stricture formation, one should think of inflammatory etiology as well. IgG4-related disease is one of these inflammatory disorders where we see soft tissue thickening without a large mass or any associated lymphadenopathy as in our case. Abstract: Immunoglobulin G4-related disease (IgG4-RD) is distinguished as an infiltration of IgG-4-positive plasmacytes involving inflammatory lesions across multiple organs which is accompanied by raised IgG4 levels in the serum. Several inflammatory disorders are recognized as part of the IgG4-RD family based on shared histopathological features, which include Mikulicz's disease, chronic sclerosing sialadenitis, or Riedel's thyroiditis. Our case highlights a distinctive presentation of IgG4-related diseases; a 58-year-old man presenting with duodenal stricture highly suspicious of a duodenal mass/ampullary mass later found to be due to IgG4-related sclerosing duodenitis with negative malignancy on biopsy. We present the diagnostic challenges faced and relevant findings noted.

Pseudoaneurysm of cystic artery stump after laparoscopic cholecystectomy managed successfully with branch hepatic artery embolization using jail technique.

An unusual manifestation caused by cholecystitis, infection, or iatrogenic damage after cholecystectomy is a pseudoaneurysm of the cystic artery. We report this rare illness in a 64-year-old man who visited the emergency room with hematemesis and anemia. The patient initially experienced acute cholecystitis and then underwent a laparoscopic cholecystectomy following which he developed a cystic artery pseudoaneurysm, secondary to infected fluid collection. Based on the patient's history and contrast-enhanced computer tomography abdomen, a diagnosis of pseudoaneurysm of the cystic artery was made. Angioembolization of the hepatic artery branch was performed to occlude the pseudoaneurysm.

The tendency of segmental distribution of hepatic metastasis according to couinaud classification: a comparison of portal versus systemic route of metastatis due to primary colorectal and breast tumors.

Objective: The liver is the commonest site of metastatic disease for patients with colorectal cancer (CRC), with at least 25% of patients developing liver metastasis (LM) during their illness. About 50% of patients diagnosed with metastatic breast cancer develop LM, and 5-12% of these patients develop LM as the main site of breast cancer recurrence. This study aims to determine the frequency of segmental distribution of LM seeding from portal versus systemic routes of dissemination due to primary CRC and breast carcinoma, respectively. Material and methods: This retrospective study was conducted in a tertiary care teaching hospital in Pakistan. Ethical approval was taken from the institutional review board. A total of 587 patients were included in the study with 297 CRC patients with LM and 300 breast carcinoma patients with LM. Segment I involvement was excluded from the calculation because of the dual blood supply. Patients' detailed demographics and other information were collected on a predesigned proforma. The authors evaluated axial and multiplanar reformatted computed tomography images for LM and CRC metastasis. Data analysis was done using SPSS version 25. P value less than or equal to 0.05 was considered statistically significant. Results: A study population of 587 patients was employed that comprised 287 CRC and 300 breast carcinoma patients. There were 179 (30.5%) male and 408 (69.5%) female patients. The mean age of patients was 54.9±13.3. The study revealed that 204 (34.8%) CRC patients showed right lobe (V, VI, VII, VIII) and 83 (14.1%) CRC patients showed left lobe involvement of metastasis while 192 (32.7%) breast carcinoma patients showed right lobe involvement and 108 (18.4%) breast carcinoma patients showed left lobe involvement in metastasis (P=0.02). We also found 40 (6.8%) colorectal and 55 (9.4%) breast carcinoma patients showed left lateral segment (II, III) involvement. Medial segment involvement (IV) was seen in 43 (7.3%) CRC patients and 53 (9%) breast carcinoma patients (P=0.03). Conclusion: The right hepatic lobe is the predominant site of metastasis independent of the portal or systemic route of dissemination in primary carcinoma. Moreover, in left lobe metastasis medial segment (IV) is more affected in CRC while the lateral segment (II, III) is more affected in breast carcinoma.

Wandering spleen with acute torsion mimicking an adnexal mass.

Wandering spleen manifests when the splenic ligaments are underdeveloped, or become lax, thereby allowing the spleen to relocate from its anatomical site to more distant areas. During such movements, torsion of the long splenic peduncle is common, which can lead to symptoms of acute abdomen and further complications such as infarction. It is typically seen in children and young females. Our report presents a case of a 22-year-old female presenting to the ER with complaints of severe pain in the abdominal region. On ultrasound, there was suspicion of an adnexal mass, which was later confirmed to be a misplaced spleen in the lower abdomen, with torsion, fat stranding, and splenic vein thrombosis, as revealed by enhanced CT abdomen and pelvic MRI. It was followed by an emergency splenectomy. As wandering spleen presents nonspecifically and is a rare condition, it is important to consider wandering spleen when patients present similarly to this case, to prevent misdiagnosis and to deliver surgical treatment quickly to preserve the spleen.

Dynamic Resource Optimization for Energy-Efficient 6G-IoT Ecosystems.

The problem of energy optimization for Internet of Things (IoT) devices is crucial for two reasons. Firstly, IoT devices powered by renewable energy sources have limited energy resources. Secondly, the aggregate energy requirement for these small and low-powered devices is translated into significant energy consumption. Existing works show that a significant portion of an IoT device's energy is consumed by the radio sub-system. With the emerging sixth generation (6G), energy efficiency is a major design criterion for significantly increasing the IoT network's performance. To solve this issue, this paper focuses on maximizing the energy efficiency of the radio sub-system. In wireless communications, the channel plays a major role in determining energy requirements. Therefore, a mixed-integer nonlinear programming problem is formulated to jointly optimize power allocation, sub-channel allocation, user selection, and the activated remote radio units (RRUs) in a combinatorial approach according to the channel conditions. Although it is an NP-hard problem, the optimization problem is solved through fractional programming properties, converting it into an equivalent tractable and parametric form. The resulting problem is then solved optimally by using the Lagrangian decomposition method and an improved Kuhn-Munkres algorithm. The results show that the proposed technique significantly improves the energy efficiency of IoT systems as compared to the state-of-the-art work.

Alveolar bone loss and root resorption in mesialized second molars in mandibular first molar extraction cases as compared to contralateral non-extraction side in young adults: A retrospective cross-sectional study.

INTRODUCTION: The alveolar bone loss (ABL) and external apical root resorption (EARR) depict the safety of mesialization of mandibular second molars into the extraction space of mandibular first molars. The aim of this study was to evaluate the ABL and EARR after closure of mandibular first molar extraction space by mesialization of second molar on extraction side (ES) as compared to the contralateral non-extraction side (NES). MATERIAL AND METHODS: A retrospective cross-sectional study was carried out using the pre and posttreatment orthodontic records of young adults with complete set of permanent dentitions treated with extraction of unilateral mandibular first molar and non-extraction treatment on the contralateral side. All patients underwent mini-implant supported mesialization of second molar on ES. The ABL and EARR of second molar on ES and contralateral NES were measured on digital orthopantomograms. The ABL and EARR of second molars on ES and contralateral NES were compared using independent sample t-test. RESULTS: A total of 36 subjects (14 males and 22 females) were included in the study. The mean treatment duration for molar mesialization was 28.75±8.05months. The mean crown and root movements of mandibular second molar on ES were 10.94±1.25mm and 9.04mm±1.14mm, as compared to 0.91±1.01mm and 0.77±0.83mm on contralateral NES, respectively. The mean ABL and EARR at mandibular second molar were found to be significantly greater on the ES than the contralateral NES (P<0.001 and<0.05, respectively). A total of seven patients (19.4%) experienced ABL≥1mm on ES as compared to none in the contralateral NES. EARR of>2mm of at least one root was found in seven patients (19.4%) in ES as compared to four (11%) in contralateral NES. CONCLUSION: There was small but statistically significant difference in the ABL and EARR of mesialized mandibular second molar at first molar ES as compared to the contralateral NES. For majority of patients this difference was small but few isolated cases experienced severe ABL and EARR.

High-altitude cerebral edema manifesting as T2/FLAIR hyperintensity and microbleeds in the white matter on MRI brain.

High-altitude cerebral edema is a rare type of acute mountain illness characterized by consciousness disruption and truncal ataxia. Here we discuss a 40-year-old nondiabetic, nonsmoker male who went on a tour to Nanga Parbat. On returning home, the patient developed symptoms of headache, nausea, and vomiting. His symptoms worsened with time and he developed lower limb weakness and shortness of breath. Later, he underwent a computerized tomography chest scan. On the basis of CT scan findings, the doctors decided that the patient was suffering from COVID-19 Pneumonia despite having negative COVID-19 PCR tests multiple times. Later, the patient presented to our hospital with similar complaints. MRI of the brain revealed T2/fluid-attenuated inversion recovery hyperintense and T1 hypointense signals in the bilateral semioval centrum, posterior periventricular white matter, and corpus callosum genu, body, and splenium. These abnormal signals were discovered to be more evident in the corpus callosum's splenium. Moreover, susceptibility-weighted imaging revealed micro hemorrhages in the corpus callosum. This verified the diagnosis that the patient is suffering from high-altitude cerebral edema. Within 5 days, his symptoms resolved and he was discharged with full recovery.

Testicular choriocarcinoma with small bowel metastasis and active gastrointestinal bleeding.

Testicular choriocarcinomas make up less than 1% of all germ-cell tumors and are highly malignant, attributable to hematogenous spread. While the most common sites of metastasis are the lungs and liver, metastatic spread to the gastrointestinal tract is rare wherein patients may present with GI distress or even an upper GI bleed. In this report, we present a case of known testicular choriocarcinoma in a 40-year-old male who presented to the emergency room with severe anemia and a suspected upper GI bleed.

Color doppler ultrasound for diagnosis of testicular carcinoma: A comparison with gold standard histopathology.

Introduction: Testicular carcinoma is the most common cancer among males aged 15-34 years. The known risk factors for testicular cancer include undescended testis (cryptorchidism), testicular dysfunction, perinatal factors and prior history of cancer in one testis. We aimed to determine the diagnostic accuracy of color doppler ultrasound in diagnosis of testicular carcinoma using histopathology as GOLD STANDARD. Method: ology: A cross sectional study was conducted from July 2015 to Feb 2016 at the Department of Radiology, Jinnah Post Graduate Medical Center, Karachi. 311 subjects were selected through inpatient/outpatient or emergency department. Patients were evaluated for testicular carcinoma by color doppler ultrasound on Toshiba nemio. Finding of color doppler ultrasound was compared with histopathology. True positive, true negative, false positive, false negative as per operational definition was determined. Results: Mean age of the patients of the study was 41.76 ± 8.11 (30-50) and mean and SD of Duration of symptoms was 5.5 ± 3.5 (4-15) months. Of 175(56.27%) subjects diagnosed as testicular carcinoma on CDUS, only 160(48.55%) were subsequently found to have testicular carcinoma. sensitivity of CDUS in diagnosing scrotal diseases was 88.8% while specificity was 78.1%. Conclusion: We conclude that CDUS is an excellent, safe, and reliable method for evaluating patients with testicular carcinoma. It helps to improve patient's management, especially by preventing unnecessary surgical exploration. It is also convenient and easy to perform. But it has its own limitations, and requires adequate expertise and experience. Its results are also equipment dependent.

Safety and Adequacy of Ultrasound-Guided Percutaneous Renal Biopsy in Children: A Single-Center Experience.

Background Ultrasound-guided percutaneous renal biopsy (PCRB) is a commonly used technique to obtain renal tissue for histopathological diagnosis in children and adolescents. The objectives of this study include determining the indications for renal biopsy, documenting the safety and efficacy of ultrasound-guided PCRB, and documenting its complications along with histopathological findings in children. Methodology The Ethical Review Committee approved this cross-sectional study. Data of all children with either nephrotic or nephritic syndrome from January 2017 to September 2020 (at The Kidney Center Post Graduate Training Institute Karachi) who underwent ultrasound-guided PCRB were collected and analyzed. An ultrasonic examination was performed both before and after the biopsy. Results During the research period, 104 individuals underwent PCRB. The average age of the children biopsied was 7.44 ± 4.12 years (range = 1-17 years). The most prevalent reason for biopsy was nephrotic syndrome. Almost 94% of PCRBs were effective. Post-biopsy complications were detected in 16 cases, with peri-nephric hematoma being the most prevalent. Conclusions In children, ultrasound-guided PCRB can safely be performed under sedation in experienced hands with an automated biopsy gun needle. The use of real-time ultrasound guidance as well as the automated biopsy gun ensures good outcomes.

A Study On Efficacy Of Corneal Collagen Cross Linking In Progressive Keratoconus.

BACKGROUND: Keratoconus is a progressive, noninflammatory, bilateral ectatic corneal disease, characterized by paraxial stromal thinning and weakening that leads to corneal surface distortion. The objective of this research was to determine the effectiveness and safety of collagen crosslinking in progressive keratoconus, with keratometry (Kmax) value of 50 diopters or above. It was a retrospective study, conducted at Bodla Eye Care (BEC) and Multan Medical and Dental College, Multan (MMDC) from May 2018 to November 2019. METHODS: In this research 52 eyes were studied. The best-corrected visual acuity, uncorrected visual acuity, maximum keratometry, mean keratometry value, and thinnest corneal thickness before surgery and 12 months after Cross-linking were observed. A Galeili G6 by Zeimer ophthalmic system was used to measure the clinical parameters. Dresden protocol was followed in this study. A written ethical approval was obtained and research was conducted under the light of declaration of Helsinki. RESULTS: The average logarithm of the minimum angle of resolution (logMAR) of the uncorrected visual acuity decreased from 0.66±0.41 D to 0.49±0.40 D (p=0.012), while the mean thinnest point thickness of the cornea decreased from 435.31 37.91 µm to 419.41±70.12 µm (p=0.004) after 12 months. The decreases in the mean logMAR of the BCVA, Kmax and Kmean values were not analytically important (p>0.05) at the 12-month follow-up 94.2% positive results were obtained. CONCLUSION: Collagen cross-linking treatment was safe and maintained both the visual acuity and tomographic parameters at the one-year follow-up in eyes.

SARS-CoV-2: big seroprevalence data from Pakistan-is herd immunity at hand?

PURPOSE: Seroprevalence surveys from different countries have reported SARS CoV-2 antibodies below 20% even in the most adversely affected areas and herd immunity cannot be predicted till more than half of the population gets the disease. The purpose of this survey was to estimate the magnitude of community-based spread of the infection, associated immunity, and the future prospects and proximity to a 'herd community'. METHODS: The study was undertaken as a cluster randomized, cross-sectional countrywide survey. This largest community-based seroprevalence data of SARS-CoV-2 were collected between 15th and 31st July, 2020 from seven randomly selected cities belonging to the three most populous provinces of Pakistan. The FDA approved kit of ROCHE was used for detection of SARS-CoV-2 antibodies. RESULTS: Serum samples of 15,390 participants were tested for SARS CoV-2 antibodies with an overall seroprevalence of 42.4%. The seroprevalence ranged from 31.1% to 48.1% in different cities with the highest in Punjab province (44.5%). In univariable analysis, the odds of seropositivity was higher in men compared to women (OR: 1.10, 95% CI: 1.01-1.19, P < 0.05). In multivariable analysis, the risk of being seropositive was lower (OR 0.72, 95% CI: 0.60-0.87, P < 0.01) in younger group (≤ 20 years) than in those aged above 60 years. CONCLUSION: The study concluded that despite a reasonable seroprevalence, the country is yet to reach the base minimum of estimations for herd immunity. The durability of immunity though debated at the moment, has shown an evidenced informed shift towards longer side.

Predicting Down syndrome and neural tube defects using basic risk factors.

Congenital anomalies are not only one of the main killers for infants but also one of the major causes of deaths under 5. Among congenital anomalies, Down syndrome or trisomy 21 (T-21) and neural tube defects (NTDs) are considered the most common. Expectant mothers in developing countries may not have access to or may not afford the advanced prenatal screening tests. To solve this issue, this paper explores the practicality of using only the basic risk factors for developing prediction models as a tool for initial risk assessment. The prediction models are based on logistic regression. The results show that the prediction models do not have a high balanced classification rate. However, these models can still be used as an effective tool for initial risk assessment for T-21 and NTDs by eliminating at least 50% of the cases with no or low risk. Graphical Abstract Prenatal Risk Assessment of Trisomy-21 and Neural Tube Defects.