Where There Is A Will, There Is A Way: Enhancing Contraceptive Uptake In Pakistan.

OBJECTIVE: To assess the contribution of a series of interventions on contraceptive uptake and reduction in unmet need in areas covered by the Family Advancement for Life and Health project. Methods: The study was conducted from 2008-09 to 2011-12 in 14 districts across Pakistan. The sample comprised all urban and rural households in each district. A total or 40 blocks/villages were selected, with 13 households selected per block/village. Within each household, all married women of reproductive age 15-49 years were interviewed, and their husbands who were present at the time were also interviewed to a maximum of 5 per block. Baseline data was collected in 2008-09, while end line data was collected in 2010-11. Change in family planning uptake attributed to the project interventions were estimated. Besides, a situation analysis of service delivery points was also conducted. Data was analysed using SPSS 21. RESULTS: The panel comprised 5,304 women and 950 husbands. Interventions with the most robust effects were LHWs' home visits, attending women's group meetings, and watching family planning messages on television (p<0.05). The greatest changes were observed in Khyber Pakhtunkhwa province, in urban areas and among younger women (p<0.05). CONCLUSIONS: Investing in public-sector services does pay off in terms of meeting family planning needs, and so do better, wider and clearer communication.

Predictors for Failing the American Board of Radiology Core Examination.

OBJECTIVE. Since the American Board of Radiology (ABR) instituted its new board certification pathway, our residency program has had more residents fail the core examination than was typical with the prior pathway. We performed a single-center retrospective study to evaluate predictors of ABR core examination failure. MATERIALS AND METHODS. Data regarding U.S. Medical Licensing Examination (USMLE) steps 1 and 2, ACR diagnostic radiology in-training examinations, the number of image interpretations, academic degree (doctor of medicine or doctor of osteopathy), status as an American or foreign medical graduate, and Alpha Omega Alpha national medical honor society status were gathered and evaluated through logistic regression and generalized additive logistic regression. Data were gathered for all residents who took the ABR core examination from 2013 to 2017. RESULTS. Six of 30 residents (20%) failed the ABR core examination on the first attempt. The ACR in-training examination scores for 1st- and 3rd-year residents were significantly related to ABR core examination failure (p = 0.027 and p = 0.035, respectively), with significant nonlinearity (p = 0.037 and p = 0.033, respectively). The suggested baseline percentile score was the 30th percentile for 1st-year residents and the 20th percentile for 3rd-year residents. USMLE step 1 and 2 scores were significantly related to ABR core examination failure (p = 0.041 and p = 0.043, respectively), without significant nonlinearity (p = 0.35 and p = 0.09, respectively). However, residents with scores of less than 220 on USMLE steps 1 and 2 seemed to be at risk. CONCLUSION. Low scores on USMLE steps 1 and 2 and 1st- and 3rd-year ACR in-training examinations were associated with ABR core examination failure. If validated more broadly, these cutoffs may serve as predictors of ABR core examination failure and may facilitate identification and remediation of at-risk residents.

Right inferior phrenic artery to right pulmonary artery fistula causing hemothorax: A case report.

Inferior phrenic artery to pulmonary artery fistulae are a rare anomaly seen on CT thorax angiogram when evaluating for certain pulmonary pathological conditions. A 79-year-old man with hemothorax on chest X-ray was evaluated by interventional radiology for embolization of a bleeding vessel. During the procedure, a fistulous connection between the right inferior phrenic artery and right pulmonary artery with signs of extravasation was found and embolized, significantly reducing the size of the hemothorax. This case demonstrates that inferior phrenic artery to pulmonary artery fistulae, a rarely seen vascular anomaly, can result in life-threatening hemothorax.

Dirty Mass sign of abdominal imaging: A case of silent pneumoperitoneum.

Pneumoperitoneum is a common complication after penetrating abdominal trauma, gastric ulcer, or colitis in which free air is present in the peritoneal or retroperitoneal space. Sole pneumoretroperitoneum, which refers to gas in the retroperitoneal space, is a rare entity, and when significant, results in a characteristic radiographic sign known as "Dirty Mass." Common causes include penetrating trauma or perforation of the retroperitoneal portions of the gastrointestinal tract (duodenum, ascending colon, descending colon, and rectum). Our case describes a 59-year-old female admitted for sudden onset RLQ abdominal pain with Dirty Mass sign on abdominal KUB. Early recognition of these key radiographic findings accelerates management and reduces the risk of developing complications.

Exploring urban male non-marital sexual behaviours in Pakistan.

BACKGROUND: In Pakistan, sexual practices outside marriage are proscribed by law. We aimed to assess the range and magnitude of non-marital sexual behaviours of urban men, focusing on men having sex with men. METHODS: In this cross sectional survey undertaken in six cities of Pakistan, we interviewed 2400 men aged 16-45 years selected through a multistage systematic sampling design. Sexual behaviours were assessed through a structured questionnaire. Multivariable analysis was used to identify association between various individual level characteristics and probability of engaging in sexual activities involving men. RESULTS: Nearly one-third (29 percent) reported having had non-marital sex in their lifetime. Of these men 16 percent reported premarital sex, while 11 percent reported engaging in both pre- and extramarital sex. Only two percent reported exclusive extramarital sex. In total 211 respondents, 9 percent reported ever having had sexual relations with men. While 62 respondents, 2.6 percent reported exclusive sex with males. Factors that were significantly associated with MSM behaviours were being less than 27 years (adjusted OR 5.4, 95% CI 3.8-7.7, p < 0.000), less than 10 years of schooling (adjusted OR 2.1, 95% CI 1.4-3.2, p < 0.000), being unemployed (adjusted OR 2.7, 95% CI 1.6-4.3, p < 0.000), being exposed to pornographic materials (adjusted OR 4.8, 95% CI 3.0-7.7, p < 0.000) and being a migrant (adjusted OR 2.1, 95% CI 1.3-3.4, p < 0.002). Factors significantly associated with exclusive homosexual behaviour were having sexual debut at a younger age i.e. 16-22 years (adjusted OR 12.5, 95% CI: 3.8-40.7, p < 0.000), being unemployed (adjusted OR 8.8, 95% CI: 3.0-26.0, p = 0.000), having had exposure to pornographic materials (adjusted OR 3.3, 95% CI: 1.5-7.2, p = 0.002). CONCLUSIONS: To prevent the spread of STI's in Pakistan, preventive interventions should focus on reaching out to young uneducated men offering them with appropriate counselling and skills to adopt "safe sex practices" through workplace orientation sessions; while for youth in schools, life skills education be included in the curriculum. Through public-private partnership stigmatised groups should be reached through established community networks and provided with information on accessing voluntary counseling and treatment centres.

A comprehensive review of transvenous obliteration techniques in the management of gastric varices.

Bleeding gastric varices (GVs) is a life-threatening complication of portal hypertension, with higher morbidity and mortality rates compared with bleeding esophageal varices (EVs). The endovascular techniques for the management of GVs are mainly transjugular intrahepatic portosystemic shunt (TIPS) and transvenous obliteration of the GVs. Transvenous obliteration techniques can be an alternative or an adjunct to TIPS for treatment of GVs, depending on the clinical scenario, and are less invasive than TIPS. However, these procedures are associated with increased portal pressure and related complications, mainly worsening of the EVs. In this article, the different techniques of transvenous obliteration of GVs, their indications, contraindications, and outcomes are discussed.

Traumatic omental variceal rupture-treatment with transjugular portosystemic shunt (TIPS) and embolization.

Bleeding ectopic varices is an uncommon but life-threatening complication of portal hypertension that requires a high clinical index of suspicion for early diagnosis and management. Transjugular intrahepatic portosystemic shunt is a safe and effective treatment option for bleeding ectopic varices. However, due to a high re-bleeding rate despite a patent shunt and reduced portosystemic gradient, adjunctive measures directed at embolization of the varices should be attempted. Herein, we report a case of bleeding omental varices after traumatic injury in a cirrhotic patient presenting with hemoperitoneum and hemorrhagic shock.

Localized nasopharyngeal amyloidosis: A case report.

Amyloidosis is a rare condition on its own but finding localized amyloidosis of a site such as the nasopharynx is an extremely rare condition with very few cases described in the literature. The condition occurs due to the accumulation of misfolded proteins in the extracellular space disrupting the cell architecture and causing eventual dysfunction. In this case report we discuss the pathophysiology, symptoms, and imaging findings of a patient initially thought to have giant cell arteritis, but who was found on CT to have a mass later determined to be localized nasopharyngeal amyloidosis. Evaluation will require biopsy as it is the gold standard, but there are many other tests and even reasons to consider the use of interventional radiology to sample other tissues rather than the primary target site for amyloid deposition in conjunction with nuclear imaging.

Attending Reviews of Residents Correlate with ABR Qualifying (Core) Examination Failure.

RATIONALE AND OBJECTIVES: Since the American Board of Radiology (ABR) instituted the new system of board certification, there has been much discussion as to the test's validity. We decided to evaluate if subjective evaluation of resident performance correlated with ABR Qualifying (Core) Examination performance at this single institution. MATERIALS AND METHODS: Data regarding resident evaluation scores by attending physicians and passage of board examinations was gathered regarding residents who had taken the ABR Qualifying (Core) Examination from 2013 through 2019 for a total of 42 residents, eight of whom failed the ABR Qualifying (Core) Examination on their first attempt. A univariate analysis comparing scores with resident passage or failure of the ABR Qualifying (Core) Examination on the first attempt and analyses correcting for class year only and class year and number of evaluations was performed. RESULTS: The non-weighted average evaluation score of years 1, 2, and 3 was 80.24% for those who failed the ABR Qualifying (Core) Examination and 83.71 % for those who passed. On univariate analysis along with analyses correcting for class year only and class year along with number of evaluations, there was a statistically significant correlation with decreased evaluation scores averaged over the three years of residency and failure of the ABR Qualifying (Core) Examination (p = 0.0102, p = 0.003, and p = 0.0043). The statistical significance held for the average numerical score in each individual year of training in all analyses except for year 1 of the univariate analysis (p = 0.1264). CONCLUSION: At the studied institution, there was a statistically significant correlation between lower subjective faculty evaluation scores and failure of the ABR Qualifying (Core) Examination.

Herpes Simplex Virus-2 infection amongst urban male population in Pakistan.

OBJECTIVE: To describe the prevalence of Herpes Simplex Virus-2 (HSV-2) infection among males in six major cities of Pakistan. METHODS: A cross sectional behavioural and biological survey of urban male population aged 16-45 years was conducted in Rawalpindi, Lahore, Karachi, Faisalabad, Peshawar and Quetta to measure the prevalence of five sexually transmitted infections and assess sexual behaviours. Respondents were selected through a multistage sampling technique. In each city 10 blocks demarcated by the Population Census Organization were selected based on probability proportional to socio-economic status. In each block 40 men were selected through systematic sampling with a random start. In total 2400 men were administered a behavioural questionnaire and 2396 provided biological specimens for laboratory testing. RESULTS: This paper discusses the overall and city wise prevalence of HSV-2 infection. The overall prevalence of HSV-2 infection in the six cities was 3.4 percent (95% CI 2.8-4.3). City wise the highest prevalence was reported in Karachi 6 percent (95% CI 4.1-8.8), followed by Lahore and Quetta at 4.3 percent (95% CI 2.7-6.7), and Faisalabad at 2.5 percent (95% CI 1.4-4.5). The lowest prevalence was in Rawalpindi at 1.8 percent (95% CI 0.9-3.6). CONCLUSION: Empirical evidence from this study suggests that there is city wise variation in the prevalence of HSV-2 infection across the major cities in Pakistan. Based on possible link between HSV-2 and HIV, future HIV control strategies must also focus on the better management of HSV-2 infections in Pakistan.

Uterineintravenous leiomyomatosis with cardiac involvement.

Intravenous leiomyomatosis is a histologically benign smooth muscle tumor that arises either by direct extension of a uterine leiomyoma into the adjacent veins or by vascular intimal smooth muscle proliferation. Herein, we report the case of a 60-year-old female who was noted to have suspected cardiac mass on elective echocardiography done electively for abnormal electrocardiographic findings. Computed tomography and cardiac magnetic resonance indicated the presence of an intravenous leiomyoma originating from the uterus and extending to the inferior vena cava and right atrium. The patient was managed with a single-stage surgery involving cardiopulmonary bypass and excision of the right atrial mass, excision of the inferior vena cava tumor thrombus, and total abdominal hysterectomy and bilateral salpingo-oophorectomy.

TIPS to the rescue: Preoperative Transjugular Intrahepatic Portosystemic Shunt (TIPS) placement in a patient with caput medusae and colon cancer.

Abdominal surgery in patients with cirrhosis and portal hypertension remains a challenge due to higher risk of morbidity and mortality. Preoperative elective transjugular intrahepatic portosystemic shunt (TIPS) is increasingly being used in these patient population. Herein, we report a case of 65-year-old male with biopsy-proven ascending colon cancer and cirrhosis. As a sequalae of portal hypertension, patient also had large caput medusae which posed significant challenge to the surgical approach for resection of the colon cancer. The patient was managed initially with placement of TIPS to decompress the portal pressures and caput medusae and allow safe surgical field for curative resection of the colon cancer. Following this, the patient underwent uneventful laparoscopic right hemicolectomy.

Multidetector Computed Tomography (MDCT) Angiography in the Pre-Procedural Assessment of Patients Undergoing Transcatheter Aortic Valve Replacement.

Transcatheter aortic valve replacement (TAVR) initially emerged as an alternative option to surgical aortic valve replacement (SAVR) for patients with severe aortic stenosis who were considered either inoperable or high-risk for surgery. However, since its advent the role of TAVR has been continuously evolving on the basis of clinical trials which showed that TAVR is non-inferior to SAVR in patients with moderate as well as low-risk for surgery. Because of recent technological advances, multidetector computer tomography (MDCT) is inherently suitable for the pre-procedural assessment of patients being considered for TAVR within a very short imaging time, MDCT can measure the diameter of the aortic annulus, provide detailed information regarding the status of the entire thoracoabdominal aorta, and assess the caliber of the peripheral vasculature used for transcatheter heart valve delivery. This information helps interventionists make optimal pre-procedural decisions and avoid complications. To familiarize non-imaging specialists with the role of MDCT in TAVR, we provide a concise overview of our approach to using this modality for the pre-procedural assessment of TAVR candidates.

The Additional Diagnostic Value of the Three-dimensional Volume Rendering Imaging in Routine Radiology Practice.

Three-dimensional volume rendering (3DVR) is useful in a wide variety of medical-imaging applications. The increasingly advanced capabilities of CT and MRI to acquire volumetric data sets with isotropic voxels have resulted in the increased use of the 3DVR techniques for clinical applications. The two most commonly used techniques are the maximum intensity projection (MIP) and, more recently, 3DVR. Several kinds of medical imaging data could be reconstructed for 3D display, including CT, MRI, and ultrasonography (US). In particular, the 3D CT imaging has been developed, improved, and widely used of late. Understanding the mechanisms of 3DVR is essential for the accurate evaluation of the resulting images. Although further research is required to detect the efficiency of 3DVR in radiological applications, with wider availability and improved diagnostic performance, 3DVR is likely to enjoy widespread acceptance in the radiology practice going forward.

Computed Tomography Imaging Findings of Acute Aortic Pathologies.

Acute aortic syndromes (AAS) encompass a spectrum of life-threatening conditions characterized by acute aortic pain. AAS include acute aortic dissection, intramural hematoma, penetrating atherosclerotic ulcer, and aneurysm rupture. The prognosis of AAS is clearly related to prompt diagnosis and appropriate management. The different types of AAS cannot be reliably differentiated solely based on clinical presentation since the clinical features are indistinguishable. Multidetector-row computed tomography (MDCT) with electrocardiographic gating (ECG-gated MDCT) has been used in the acute emergency setting as a powerful clinical tool, which enables rapid and specific diagnosis of aortic pathologies. ECG-gated MDCT significantly reduces motion artifact and avoids potential pitfalls in the diagnosis of AAS. The aim of this review is to evaluate the role of MDCT imaging in the assessment of AAS and to discuss the differentiation of this spectrum of aortic diseases with reference to the key imaging findings.

Implementation of a triage system in Pakistan: the need of the hour.

In today's world, an effective emergency department (ED) cannot function properly without having a triage system. Though available in various forms, this essentially categorises patients according to the seriousness of their condition and the priority of their need.Pakistan is yet to introduce this system and where it exists, it is in its infancy. A disaster-prone country such as ours, which is frequently faced with both man-made and natural calamities, could benefit tremendously from its introduction. The activity of EDs would be streamlined and precious lives would be saved.

Ascaris lumbricoides and its invasion of the accessory cystic duct: an unusual presentation.

Around the world, Ascaris lumbricoides is the most common helminthic infection. We describe the case of a 25-year-old woman, known to have had Ascaris infestation, presenting with abdominal pain, constipation and jaundice together with fever and tachycardia. There was tenderness in the right hypochondrium and liver function tests confirmed cholestatic jaundice. An abdominal ultrasound showed multiple linear echogenic foci in the distal small intestine along with cholelithiasis and a thick-walled gall bladder with a single stone compressing the common bile duct (Mirizzi syndrome). The patient underwent exploratory laparotomy; more than 100 worms were found inside the small intestine and they were removed by enterotomy and manual decompression. No worm could be palpated within the common bile duct (CBD). Cholecystectomy was performed, during which an accessory cystic duct was noted opening into the common bile duct superiorly to the main cystic duct. A 10 cm live worm was found coming out of it and was removed via forceps. Later on an endoscopic retrograde cholangio-pancreatogram (ERCP) showed a widened ampulla, a mildly dilated common bile duct, but without any filling defects. The patient made an uneventful postoperative recovery being discharged on the ninth day. Worms in an accessory cystic duct have not been report in the medical literature so far.