Pheochromocytoma-Induced Hypertension After Traumatic Brain Injury.

A 23-year-old female presented to the emergency department (ED) after sustaining a motor vehicle accident and subsequent loss of consciousness. In the ED, the patient was hemodynamically stable and was appropriately discharged with a diagnosis of mild traumatic brain injury. The patient presented 10 days post-injury to the outpatient brain injury clinic with complaints of headache, anxiety, and dizziness, with an elevated blood pressure of 160/100 mmHg. Initial head imaging, drug screen, complete blood count, and complete metabolic panel were unremarkable, however, urine and plasma metanephrines were found to be elevated. Abdominal computed tomography imaging revealed a pheochromocytoma, and the patient was adequately treated with medication and adrenalectomy with complete resolution of symptoms. Existing literature has indicated that stress and physical trauma can contribute to the escalation of pheochromocytoma symptoms in previously asymptomatic individuals; here, the stress and trauma stemming from an automobile accident and mild traumatic brain injury may have precipitated the onset of pheochromocytoma symptoms in the patient. Symptoms of pheochromocytoma can align with those commonly observed after traumatic brain injury (TBI), encompassing headaches, anxiety, and dizziness. Our case demonstrates the need for clinicians to consider the presence of pheochromocytoma in a post-traumatic brain injury patient.

An Unfortunate Incident Of A Surgical Swab Left In The Sphenoid Sinus For Eight Years.

Retained foreign bodies are foreign materials which are left accidentally inside a patient's body after a procedure. In this report we present the case of a 57 year old man who presented to the ENT clinic with a history of symptoms stretching over 8 years back to when he underwent a hypophysectomy through the transsphenoidal approach. These symptoms included cacosmia, ageusia, altered taste at times, foul smelling discharge, nasal discharge and dizziness. He had undergone multiple radiological examinations as well as antibiotic courses. It was only after the examination of the nose under general anaesthesia, conducted by the corresponding author that a swab was found in the sphenoid sinus which was left behind from his surgery 8 years ago. Cases of retained foreign bodies are very rare and are easily preventable. This case highlights the importance of adherence to health and safety protocols to prevent such an avoidable complication.

Postpartum maternal tachycardia - diagnostic pitfalls!

PURPOSE OF REVIEW: Maternal tachycardia is a common sign with a multitude of causes. We attempt to look at the most common sinister ones in the postpartum period. RECENT FINDINGS: Current guidelines differ in the definition of maternal tachycardia. It has been associated with adverse outcomes such as increased length of stay as well as higher mortality if there is underlying peripartum cardiomyopathy. Some recent studies look at common investigations and how these apply to peripartum women, such as ECG markers of arrhythmogenesis, reference ranges for PCT and echocardiogram findings during pregnancy prior to diagnosis of peripartum cardiomyopathy. SUMMARY: Physiological changes make it difficult to interpret maternal tachycardia and thus how best to manage it. We propose the idea of a three-step approach for the assessment of patients, aiming to identify causes including tachyarrhythmias, obstetric haemorrhage, sepsis, venous thromboembolism and peripartum cardiomyopathy.The first step 'BEDSIDE' applies to all patients looking at observations, history and examination. The second step 'BASIC', applies to most patients and covers ECG and basic blood tests. The final step 'EXTRA' assesses the need for further investigations including additional blood tests and imaging. By using this model, clinicians and healthcare professionals should be able to rationalise the need for more invasive investigations whilst maintain good high-quality care.

An Atypical Case of Neuroleptic Malignant Syndrome Associated With Ciprofloxacin and Quetiapine.

A 29-year-old male presented to the emergency department with complaints of shortness of breath and numbness in bilateral upper and lower extremities that started a few hours prior to arrival. On physical examination, the patient was afebrile, disoriented, tachypneic, tachycardic, and hypertensive with generalized muscle rigidity. Further investigation revealed that the patient had recently been prescribed ciprofloxacin and restarted on quetiapine. The initial differential diagnosis was acute dystonia, and subsequently, the patient was placed on fluids, lorazepam, diazepam, and later benztropine. The patient's symptoms began to resolve, and psychiatry was consulted. Given the patient's autonomic instability, altered mental status, muscle rigidity, and leukocytosis, psychiatric consultation revealed an atypical case of neuroleptic malignant syndrome (NMS). It was postulated that the patient's NMS was caused by a drug-drug interaction (DDI) between ciprofloxacin, a moderate cytochrome P450 (CYP) 3A4 inhibitor, and quetiapine, which is primarily metabolized by CYP3A4. The patient was then taken off quetiapine, admitted overnight, and discharged the next morning with complete resolution of his symptoms along with a prescription for diazepam. This case highlights the variable presentation of NMS and the need for clinicians to consider DDI when managing psychiatric patients.

Diagnostic Accuracy Of Contrast Enhanced Ct For Detection Of Renal Cell Carcinoma Taking Histopathology As Gold Standard.

BACKGROUND: Renal cell carcinoma being the commonest primary renal malignancy of adulthood accounts for approximately 80-90% renal malignant lesions. The purpose of radiological imaging modalities when devising the treatment options for renal masses is crucial as it significantly influence the clinical outcome and prognosis of the disease. Subjective impression by a radiologist for diagnosing a mass lesion is known to be critical and its precision is improved by contrast enhanced CT as demonstrated by certain retrospective analyses. We aimed to ascertain the diagnostic accuracy of contrast enhanced computed tomography to diagnose renal cell cancers by verifying through histopathology reported diagnoses. METHODS: This Cross-sectional (validation) study was carried out in Radiology and Urology departments of Ayub Teaching Hospital; Abbottabad, from 1st November 2020 to 30th April 2022. The study population included all admitted symptomatic patients with age range 18-70 years of either gender. The patients were subjected to detailed clinical examination and history and an ultrasound and contrast enhanced CT abdomen and pelvis. CT scans were reported under supervision of single consultant radiologist. Data was analysed in SPSS version 20.0. RESULTS: Mean age of the patients was 38.88±11.62 years ranging from 18-70 years and mean duration of symptoms was 54.64±49.171 ranging from 3-180 days. All of the total 113 patients underwent contrast enhanced CT scan and later operated to confirm the diagnoses by histopathology. The comparison yielded true positive (TP) cases to be 67, True Negative (TN) 16, False Positive (FP) 26, and 4 False Negative (FN) as per CT scan diagnoses. CT scan had a diagnostic Accuracy of 73.45% with 94.37% sensitivity and 38.10% specificity. CONCLUSIONS: Contrast-enhanced CT has a high sensitivity for making the diagnosis of renal cell carcinoma; however, its specificity is low. A multidisciplinary approach is necessary to overcome the low specificity. Therefore, collaboration between radiologists and urologic oncologists should be considered while devising treatment plan for patients.

Drug Reaction With Eosinophilia and Systemic Symptoms Syndrome in a Patient Taking Lamotrigine: A Case Report Based Literature Review.

A 29-year-old patient presented to the hospital with worsening generalized rash for the last two days from a mental health facility. The patient was commenced on lamotrigine two weeks earlier, and he developed fever and generalized macular rash on his body. His blood tests showed deranged liver function tests (LFTs) and clotting with raised eosinophil count, and he was treated for lamotrigine-induced drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome. The patient was commenced on prednisolone 50 mg once daily with a proton pump inhibitor cover, and lamotrigine was suspended on advice from Dermatology. The patient showed improvement after 3-4 days of treatment. His skin biopsy showed prominent suppurative granulomatous folliculitis, mild perivascular chronic inflammation, and red blood cell extravasation, including the rare eosinophil. He was weaned off from prednisolone by 5 mg weekly and had complete resolution of symptoms.

Left Heart and Systemic Arterial Circulation Air Embolus During CT-Guided Lung Biopsy.

A transthoracic needle biopsy (TTNB) of the lung, commonly referred to as a "lung biopsy," is a commonly performed procedure in Interventional Radiology. It is usually associated with well-known risks including pneumothorax and hemothorax. One of the rare and lesser-known risks of TTNB, however, is a phenomenon called an air embolism. The term "air embolism" alone may be somewhat ambiguous, as it could indicate i) air entering the systemic veins, or ii) air entering the pulmonary veins. Here, we present a case of an air embolus entering the pulmonary veins. The pulmonary veins naturally drain into the left side of the heart (left atrium and ventricle) which provides oxygenated blood to the major arteries of the body including the coronary, carotid, and major abdominal visceral branches. Therefore, an air embolism in this vasculature can lead to potentially devastating hemodynamic consequences downstream.

Optimization of Biostimulants Application for Phenology and Quality of Oats

Abstract In modern agriculture the use of biostimulants not only reduces the cost of production but also increase yield and quality of crops without harming environment. The response of fodder oat to biostimulants was evaluated in a pot experiment using four biostimulants at different concentrations i.e Moringa leaf extract at ratio of 1:10, 1:20, 1:30, 1:40, 1:50, Sea weed extract at 1%, 2%, 3%, 4%, 5%, Thiourea at 100 ppm, 200 ppm, 300 ppm, 400 ppm, 500 ppm and Chitosan at 25 ppm, 50 ppm, 100 ppm, 125 ppm, 150 ppm. Oat crop was treated with biostimulants using foliar application, at two growth stages i.e tillering and booting. Data on various agronomic and quality parameters were recorded and analyzed. Results showed that biostimulants significantly affected phenology and quality of oat. The highest green fodder yield (872.32 g) was observed in the pots treated with 2%Solution of seaweed extract similarly highest dry matter yield was also highest at 170.85 g Interestingly crude protein was highest for thiourea at 400 ppm. In each biostimulant following doses stood out both in terms of yield and quality. In case of moringa leaf extract the ratio of 1:40with 900 g per pot yield and 9.43 % protein, for sea weed extract 2% was better than other doses with 981 g yield and 9.17% protein, for thiourea the 400 ppm was better than other concentrations as it shows highest yield (872.32 g) and crude protein (9.52%) and for chitosan 100 ppm was comparatively better in performance with 964.98 g yield per pot and 9.35% CP. It is concluded from our study that biostimulants improve fodder oat yield and quality.

Personalized Text Messages and Automated Calls for Improving Vaccine Coverage Among Children in Pakistan: Protocol for a Community-Based Cluster Randomized Clinical Trial.

BACKGROUND: A major reason for poor childhood vaccine coverage in developing countries is the lack of awareness among parents and caregivers regarding the need for immunization and the importance of completing the entire series of vaccines. Short message service (SMS)-based interventions have been quite effective in different programs such as smoking cessation, treatment adherence, health care scheduled appointment attendance, antenatal care attendance, and compliance to immunization. However, there are limited data from low- and middle-income countries on the role of SMS and automated call-based messages and interventions to improve routine immunization (RI) coverage. OBJECTIVE: The primary objective of this study is to evaluate whether automated mobile phone-based personalized messages (SMS or automated call) can improve RI uptake at 6, 10, and 14 weeks of age per the expanded program immunization schedule, compared with a usual care control group. Secondary objectives include assessing the effects of different types of automated SMS text or calls on RI coverage at 20 weeks of age. METHODS: This is a mixed methods study using a clustered randomized controlled trial with 4 intervention arms and 1 control arm, augmented by qualitative interviews for personalizing the message. The study is being conducted in Pakistan (an urban site in Karachi and a rural site Matiari). In Karachi, 250 administrative structures are taken as 1 cluster, whereas in Matiari, a catchment area of 4 Lady Health Workers is considered as 1 cluster. The intervention targets families to receive weekly 1-way or 2-way (interactive) personalized automated SMS or automated phone call messages regarding vaccination. Possible barriers to vaccination are assessed in each family at the time of inclusion to determine the type of personalized messages that should be sent to the family to increase the chance of a positive response. Finally, in-depth interviews using purposive sampling are conducted before and after the trial to determine the family's vaccination experience and related factors. RESULTS: All study participants for the cluster randomized trial were enrolled by January 14, 2019. Study exit interviews at 20-weeks follow-up visits will be completed by June 2019. CONCLUSIONS: The results of this study will be useful to understand the respective effects of SMS text messages versus automated phone-based communication to improve RI coverage and timelines. Moreover, information regarding families' perceptions of vaccination and the daily life challenges for timely visits to the vaccine clinic will be used for developing more complex interventions that use mobile phone messages and possibly other approaches to overcome barriers in the uptake of correct and timely immunization practices. TRIAL REGISTRATION: ClinicalTrials.gov NCT03341195; https://clinicaltrials.gov/ct2/show/NCT03341195 (Archived by WebCite at http://www.webcitation.org/78EWA56Uo). INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/12851.

Assessment of flatulence causing agents in Chickpea (Cicer arietinum L.) and their possible removal

Abstract Flatulence and fullness of stomach is one of the most common problem associated with chickpea primary due to presence of some oligosaccharides and phenols. In this investigation Desi and Kabuli varieties were compared for these oligosaccharides and phenolic compounds. Furthermore, the effect of different processing and cooking methods such as soaking, cooking and germination in the reduction of these antiphysiological factors were are also studies. Maximum tannic acid (0.90 ± 0.20%) was observed in Parbat and C-44 while minimum (0.60 ± 0.04%) in Karak-2. Stachyose contents ranged between 1.10 ± 0.05 (Karak-3) to 1.42 ± 0.02% (Parbat) while raffinose was 0.63 ± 0.05(Karak-3) to 0.81 ± 0.02% (Dasht). The highest tannic acid content was reduced up to 50% in C-44 by cooking of 72 hours germinated seeds. Stachyose and raffinose contents were completely removed after 72 hours germination. Present studies revealed that cooking after germination is the most effective method to reduce the anti-nutritional factors of chickpea. Individually, soaking and cooking also contributed to the loss of the same factors but to a lesser extent.

Environmental Remediation and Application of Nanoscale Zero-Valent Iron and Its Composites for the Removal of Heavy Metal Ions: A Review.

The presence of heavy metals in the industrial effluents has recently been a challenging issue for human health. Efficient removal of heavy metal ions from environment is one of the most important issues from biological and environmental point of view, and many studies have been devoted to investigate the environmental behavior of nanoscale zerovalent iron (NZVI) for the removal of toxic heavy metal ions, present both in the surface and underground wastewater. The aim of this review is to show the excellent removal capacity and environmental remediation of NZVI-based materials for various heavy metal ions. A new look on NZVI-based materials (e.g., modified or matrix-supported NZVI materials) and possible interaction mechanism (e.g., adsorption, reduction and oxidation) and the latest environmental application. The effects of various environmental conditions (e.g., pH, temperature, coexisting oxy-anions and cations) and potential problems for the removal of heavy metal ions on NZVI-based materials with the DFT theoretical calculations and EXAFS technology are discussed. Research shows that NZVI-based materials have satisfactory removal capacities for heavy metal ions and play an important role in the environmental pollution cleanup. Possible improvement of NZVI-based materials and potential areas for future applications in environment remediation are also proposed.

Extrathyroidal uptake from thyroid carcinoma on 99mTc-pertechnetate scintigraphy.

Three cases of imaging with 99mTc-pertechnetate (99mTcO4) and unusual positive lymph node uptake in the neck are reported hereby. Two cases were later diagnosed to be well-differentiated thyroid carcinoma, (DTC) with nodal metastasis. The third was a confirmed case of carcinoma thyroid that had presented with mass in the neck soon after surgery, being prepared for ablative dose of radioactive iodine (131I). All three were young females under 40 years of age. These 3 cases signify that extra thyroidal areas of uptake on a routine thyroid scan with 99mTcO4 can some time be due to thyroid carcinoma with regional metastases. Foci of metastasis in patients with DTC may be incidentlly detected with 99mTcO4 scan. Multinodular goiter with palpable lymph node should always be investigated for exclusion of malignancy. The patients underwent near total thyroidectomy and radical neck dissection; histopathology confirmed the scan findings.

The intracellular uptake of CD95 modified paclitaxel-loaded poly(lactic-co-glycolic acid) microparticles.

The CD95/CD95L receptor-ligand system is mainly recognised in the induction of apoptosis. However, it has also been shown that CD95L is over-expressed in many cancer types where it modulates immune-evasion and together with its receptor CD95 promotes tumour growth. Here, we show that CD95 surface modification of relatively large microparticles >0.5 µm in diameter, including those made from biodegradable polylactic-co-glycolic acid (PLGA), enhances intracellular uptake by a range of CD95L expressing cells in a process akin to phagocytosis. Using this approach we describe the intracellular uptake of microparticles and agent delivery in neurons, medulloblastoma, breast and ovarian cancer cells in vitro. CD95 modified paclitaxel-loaded PLGA microparticles are shown to be significantly more effective compared to conventional paclitaxel therapy (Taxol) at the same dose in subcutaneous medulloblastoma (∗∗∗P < 0.0001) and orthotopic ovarian cancer xenograft models where a >65-fold reduction in tumour bioluminescence was measured after treatment (∗P = 0.012). This drug delivery platform represents a new way of manipulating the normally advantageous tumour CD95L over-expression towards a therapeutic strategy. CD95 functionalised drug carriers could contribute to the improved function of cytotoxics in cancer, potentially increasing drug targeting and efficacy whilst reducing toxicity.

Unilateral blindness as a presenting symptom of lung cancer treated with erlotinib.

A non-smoker young man presented to the ophthalmologist with loss of vision in his left eye. Clinical work-up revealed metastatic deposits in left retina. Broadened workup also showed metastatic disease in the skull and brain. The search for the primary concluded on the histopathological evidence of Non-Small Cell Lung Carcinoma (NSCLC) in the upper lobe of the left lung. After the diagnosis and ascertaining disease extent, localized radiotherapy to whole skull and retina was given, followed by conventional chemotherapy (Gemcitabine, Carboplatin). The results of radiation and chemotherapy were not satisfactory, therefore, patient was placed on a new agent (tyrosine kinase inhibitor) Erlotinib (150 mg per day orally in a single dose). The response was evaluated using clinical and radiological parameters and was found to be satisfactory.

Correlation of perfusion and contractility of left ventricle myocardium on gated myocardial perfusion scintigraphy.

BACKGROUND: Gated Single Photon Emission Computerized Tomography (SPECT) is a modality which is helpful in the detection of wall motion, thickening and ejection fraction of left ventricle. The purpose of this study was to correlate the ungated and gated SPECT in evaluation of left ventricle dysfunction. METHOD: It was a prospective study done at Institute of Radiotherapy and Nuclear Medicine (IRNUM), Peshawar, in 2001/02. 76 patients (47 male and 29 female) with an average age of 52+/-11 years were inducted in this study. All patients underwent two days stress-rest Tc-99m MIBI (Methoxy Isobutyl Isonitrile) gated SPECT scan where 1110 MBq (30 mCi) was injected intravenously. Eight frames gating technique (variable fixed temporal resolution) of ECG was used to gate the cardiac cycle and whole acquisition was completed in 30 minutes. RESULTS: This technique very well evaluated the perfusion as well as wall motion/thickening (W/M/T) status of left ventricle. Out of 76 scans, 30% were normal, 22% transmural infarct, 25% partial thickness infarct, and 22% reversible ischemia. By doing the 20 segmental analyses, total 1520 segments were analyzed that revealed good concordance of perfusion with W/M/T in 78% of segments while 22% segments showed poor concordance. Out of these 22%, 12% were having more wall motion abnormalities than that of perfusion, while in 10%, it was vise versa. CONCLUSION: Results of this study shows good correlation between gated and ungated SPECT for evaluation of left ventricle dysfunction (r = 0.73, p< or =0.01).

Quantitative evaluation of salivary gland dysfunction after radioiodine therapy using salivary gland scintigraphy.

AIM: The most frequent non-thyroidal complication of high-dose (131)I therapy for thyroid carcinoma is salivary gland dysfunction, which may be transient or permanent. In this study, we assessed radioiodine-induced permanent salivary gland dysfunction using quantitative salivary gland scintigraphy. METHODS: Salivary scintigraphy was performed with (99m)Tc-pertechnetate on 50 thyroid carcinoma patients who had been given radioiodine for thyroid ablation; 20 normal subjects were imaged as the control population. Dynamic scintigraphy was performed and time-activity curves for four major salivary glands were generated. The glandular functional parameters maximum secretion, time at maximum count and uptake ratio of the parotid and submandibular glands were calculated. Correlation of the administered dose and subjective symptoms with findings of salivary gland scintigraphy was evaluated. RESULTS: The maximum secretion and uptake ratio were decreased in 46% and 42% of patients who received radioiodine therapy, respectively. Salivary gland dysfunction correlated well with the administered dose. The parotid glands were more affected than the submandibular glands. Fifty-two per cent of patients were symptomatic, 69.23% of whom showed salivary gland dysfunction. CONCLUSION: Parenchymal damage to the salivary glands induced by radioactive iodine treatment can be evaluated by salivary gland scintigraphy. The impairment was worse in parotid glands and increased with the total dose. The maximum secretion and uptake ratio were found to be sufficiently sensitive to distinguish the severity of the damage.

High dose rate intraluminal brachytherapy in combination with external beam radiotherapy for palliative treatment of cancer rectum.

OBJECTIVE: To evaluate the feasibility, efficacy and toxicity of High Dose Rate Intraluminal Brachytherapy (HDRILB) in combination with External Beam Radiotherapy (EBR) used in the palliative treatment of selected patients of adenocarcinoma rectum. DESIGN: A prospective pilot study. PLACE AND DURATION OF STUDY: The study was conducted at the Institute of Radiotherapy and Nuclear Medicine (IRNUM), Peshawar. The study started in April 1996 and the patients accrual was completed in June 1997. PATIENTS AND METHODS: The patients with adenocarcinoma rectum, who refused surgery, had contraindications for surgery or had advanced and/or metastatic disease were treated with HDRILB in combination with external beam radiotherapy (EBR). The apparatus used for HDRILB was Ralstron 20B remote afterloading unit with 60Co stepping source. Indigenously designed rectal applicators were used. The EBR was delivered through Pheonix 60Co teletherapy machine (Theratron AECL). The data for symptom burden and symptomatic relief was analyzed by applying Likert's method of summated scales. RESULTS: Data was analyzed after one week and at the end of the treatment. After one week of treatment, the relief in pain and bleeding per rectum (P/R) was 97%. Excellent palliation was achieved at the end of the treatment when perineal pain and bleeding P/R were relieved in 100%, discharge P/R in 87% and tenesmus in 93% of the cases. CONCLUSION: The use of HDRILB in combination with EBR can provide quick relief of symptoms in selected patients of adenocarcinoma rectum. This combination has an excellent palliative value because of its effectiveness, acceptable toxicity and overall short treatment duration.