Structured Reporting of Superficial Soft Tissue Masses on Ultrasonography: A Closed-Loop Clinical Audit From a Tertiary Care Hospital in Pakistan.

Background Among all the modalities of diagnostic radiology, ultrasonography is considered the least invasive one. However, this benefit usually comes at the cost of its subjective evaluation since it is purely a dynamic diagnostic modality. Thus, instead of ultrasonography, most clinicians usually rely on the report written by the radiologist. Objective The objective of this study is to evaluate the clinical practices of ultrasound reporting of superficial soft tissue masses. Materials and methods A closed-loop retrospective and prospective study was conducted at the Department of Radiology and Medical Imaging, Jinnah Hospital, Lahore between December 2023 and March 2024. In the pre-intervention phase, a randomly collected sample of 100 ultrasound reports documenting superficial soft tissue masses were included in the study and judged against standard criteria set by the Royal College of Radiologists (RCR). The intervention phase included regular presentations, identification of problems, and designing of preformed reporting forms. Post-intervention assessments were based on the judgment of 100 ultrasound reports in each cycle twice. Intervention and post-intervention assessments were done twice to correct the ongoing practices. Results During the pre-intervention phase, the ultrasound reports issued by the department of study showed only 41.5% compliance with the RCR structured reporting guidelines. However, after the first and second post-intervention phases, this percentage increased up to 98.3%. Overall, we observed a compliance difference of 56.5% between the pre-intervention and second post-intervention phases. Conclusion Integration of methods, such as briefing the residents on RCR guidelines, displaying parameters, and making structured report templates available, can greatly increase adherence to RCR guidelines for structured ultrasonography reporting. It also greatly enhances the comprehensiveness and reliability of ultrasonography reports for clinicians. Clinical audits should be routinely practiced in the settings of radiology.

Circulating FK506 binding protein 51 mRNA expression in patients with pituitary adenomas.

Background: FK506 binding protein 51 (FKBP5) is a co-chaperone regulator of the glucocorticoid receptor (GR). Recent studies have reported increased FKBP5 mRNA in the circulation from patients with Cushing disease (CD) which returned to comparable levels seen in healthy controls following successful trans-nasal trans-sphenoidal (TNTS) surgical corticotroph tumor removal. However, the expression of circulating FKBP5 mRNA levels in other pituitary tumor subtypes and its specificity to corticotroph tumors is unknown. Methods: Pre-operative blood was collected from consecutive patients undergoing TNTS for pituitary tumors (n = 57) at our center between 2015 and 2019. Total RNA was isolated from whole blood using RiboPure blood RNA isolation kit and real-time qPCR was used to quantitate circulating FKBP5 mRNA expression. Results: Consistent with the prior report, higher circulating FKBP5 mRNA levels were observed in 20 patients with CD prior to surgical tumor removal, compared to 21 healthy controls (p < 0.0005) and compared to 8 patients harboring gonadotroph pituitary tumors (p < 0.05) and 6 patients with silent corticotroph pituitary tumors (p < 0.05). However, circulating FKBP5 mRNA levels were higher in 10 patients with prolactin (PRL)-secreting pituitary tumors compared to healthy controls (p < 0.05), and did not differ between patients with CD and patients with growth hormone secreting tumors (GH-omas). Conclusions: Although we confirm that circulating FKBP5 mRNA is higher in patients with corticotroph tumors compared to healthy subjects, measurement of circulating FKBP5 does not appear to be helpful to distinguish corticotroph tumors from other pituitary tumor sub-types.

Gastrointestinal Dysbiosis in Neuro-Critically Ill Patients: A Systematic Review of Case-Control Studies.

The human gastrointestinal tract (GIT) has a rich and pre-programmed microbiome. This microbiome is essential for physiological functions such as digestion, immunity, metabolism, and structural integrity, and of prime concern to us in conducting this study is the nervous system communication. This two-way communication between the GIT and central nervous system (CNS) is known as the gut-brain axis (GBA) and has implications for neurocritical disease. A change in any factor relating to this microbiome is known as gut dysbiosis; this can lead to aberrant communication through the GBA and in turn, can contribute to disease states. The primary objective of this study is to determine the cause-specific dysbiotic organisms in neuro-critically ill patients and their effects. We performed this study by searching published literature as per Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies that defined gastrointestinal dysbiosis in neuro-critically ill patients were retrieved using Boolean search from 2000 to 2023 via PubMed and Google Scholar and narrowed the results down to five prospective case-control studies. We performed their quality assessment. The results concluded that in neurocritical illnesses such as encephalitis, brain tumors, intracerebral hemorrhage, and ischemic stroke, fluctuations in specific microbiota correlated with disease severity and prognosis. Moreover, the inhabiting population of dysbiotic organisms in neuro-critically ill patients were different in different diseases and there were no similarities in the composition of gut microbiota in these diseases. Taking stroke patients as an example; increased Enterobacteriaceae and lower Lachnospiraceae microbiome levels were found in patients with a higher stroke dysbiosis index (SDI). Those patients who developed stroke-associated pneumonia (SAP) displayed higher levels of Enterococcus species. In conclusion, dysbiosis has a major effect on neuro-critically ill patients' disease states and dysbiotic organisms can be used as a biomarker for disease. Further prospective studies on this topic are warranted for potential neurological and prognostic correlations.

Practices of Informed Consent for Emergency Procedures at a Tertiary Care Hospital in Lahore, Pakistan.

Background The purpose of obtaining informed consent is to ensure that patients undergoing any medical or surgical intervention are neither deceived nor coerced. Accurately estimating surgical risks is critical for shared decision-making and informed consent. Probable complications and alternative procedures should be presented to the patient so that they can freely choose an operative option. However, this factor is difficult to carry on in emergencies where an urgent decision is required. Objective This study aimed to assess the ongoing clinical practices of informed consent in emergency surgeries at a tertiary care facility. Materials and methods A cross-sectional survey was carried out from March 2022 to June 2022 at the Department of General Surgery, Lahore General Hospital, Lahore, Pakistan, with patients who had undergone surgical procedures under local, spinal, or general anesthesia within 24 hours of presentation. A Google Form (Google Inc., Mountainview, CA) was designed, containing a predefined set of 32 standard questions, and patients were interviewed in their native language to assess their satisfaction regarding the pattern and components of emergency informed consent. Categorical data were assessed using measures of central tendency, frequencies, and percentages. Results A total of 169 patients were selected for the study. Only 1.6% of them signed the consent form themselves, while 93.5% of the forms were signed by their first-degree relatives. Verbal consent was taken in 4.8% of cases. In 88% of cases, informed consent was obtained by the house surgeons. The majority of patients, i.e., 78.2%, were not able to read the written consent form; however, 83.1% understood the verbal information. About 66.3% of patients agreed that they were informed about the nature of their disease, while 67.5%, 14.8%, and 13.7% affirmed that they were explained the nature of surgical intervention, associated risks, and type of anesthesia, respectively. Overall, 59.5% of patients felt satisfied with the process of informed consent. About 91.1% of the patients believed that their decisions were unaffected by the procurement of informed consent. Conclusion The existing practices of informed consent and comprehension by the population were found to be substandard. Physicians seem to ignore bioethics, and patients appear to be unaware of their basic rights. Although practiced at our center, not all components of informed consent were communicated to the patients. The risks of the procedures and the mode of anesthesia used were not well addressed by doctors. There is a grave need to educate the medical community about the legal and ethical aspects of informed consent, as well as the public masses regarding their rights.

Insight into the photocatalytic mechanism of the optimal x value in the BiOBrxI1-x, BiOClxI1-x and BiOClxBr1-x series varying with pollutant type.

It is known that bismuth oxyhalides (BiOX, X = Cl, Br, I) can easily form solid solutions like BiOBrxI1-x, BiOClxI1-x and BiOClxBr1-x (0 ≤ x ≤ 1) and exhibit composition-dependent photocatalytic performance. However, the reported results indicate that the optimal composition changes with pollutant type. That is to say, the specific x value with the best photocatalytic activity towards the degradation of a certain pollutant does not imply that it is an optimum x value for another pollutant. In order to explore the reason behind this, herein, three types of solid solutions with various x values were prepared in ethylene glycol/H2O (VEG : VH2O = 1) solution at room temperature, and their photocatalytic activity towards the degradation of bisphenol A (BPA), tetracycline (TC), malachite green (MG), methyl violet (MV) and rhodamine B (RhB) was assessed under visible-light illumination. Taking BiOBrxI1-x as an example, BiOBr0.5I0.5 exhibited the best degradation efficiency for BPA, MV and MG, whereas BiOBr0.95I0.05 possessed the best photocatalytic activity towards TC and RhB degradation. Detailed characterization suggests that light absorption and charge separation efficiency are not the main factors behind this difference. Given that direct oxidation of the holes was dominant in the degradation process, the oxidation ability of the solid solutions was correlated with the oxidation behavior of the pollutant. The prerequisite condition for degrading a certain pollutant is that the valence band potential of the solid solution should be more positive than the oxidation potential of the pollutant, and yet, too big a difference between these two potentials does not benefit rapid degradation.

Improved Functional Assessment of Ischemic Severity Using 3D Printed Models.

Objective: To develop a novel in vitro method for evaluating coronary artery ischemia using a combination of non-invasive coronary CT angiograms (CCTA) and 3D printing (FFR3D). Methods: Twenty eight patients with varying degrees of coronary artery disease who underwent non-invasive CCTA scans and invasive fractional flow reserve (FFR) of their epicardial coronary arteries were included in this study. Coronary arteries were segmented and reconstructed from CCTA scans using Mimics (Materialize). The segmented models were then 3D printed using a Carbon M1 3D printer with urethane methacrylate (UMA) family of rigid resins. Physiological coronary circulation was modeled in vitro as flow-dependent stenosis resistance in series with variable downstream resistance. A range of physiological flow rates (Q) were applied using a peristaltic steady flow pump and titrated with a flow sensor. The pressure drop (ΔP) and the pressure ratio (Pd/Pa) were assessed for patient-specific aortic pressure (Pa) and differing flow rates (Q) to evaluate FFR3D using the 3D printed model. Results: There was a good positive correlation (r = 0.87, p < 0.0001) between FFR3D and invasive FFR. Bland-Altman analysis revealed a good concordance between the FFR3D and invasive FFR values with a mean bias of 0.02 (limits of agreement: -0.14 to 0.18; p = 0.2). Conclusions: 3D printed patient-specific models can be used in a non-invasive in vitro environment to quantify coronary artery ischemia with good correlation and concordance to that of invasive FFR.

A review on the preparation, microstructure, and photocatalytic performance of Bi2O3 in polymorphs.

In recent years, the semiconductor bismuth oxide (Bi2O3) has attracted increasing attention as a potential visible-light-driven photocatalyst due to its simple composition, relatively narrow bandgap (2.2-2.8 eV), and high oxidation ability with deep valence band levels. Owing to the symmetry of its unit cell, Bi2O3 exists in more than one crystal form and exhibits phase-dependent photocatalytic properties. However, the phase-selective synthesis of Bi2O3 is a complex process, and its phase transformation usually occurs in a wide temperature range. Therefore, the development of Bi2O3 phases with a controllable microstructure and good photocatalytic properties is a great challenge. Hundreds of articles have been reported on the phase-selective synthesis and photocatalytic performance of Bi2O3. However, an interacting and critical review has rarely been reported, and thus it is essential to fill the gap in the literature. In this review, the phase-dependent photocatalytic performance of Bi2O3 is presented in detail. The phase-selective synthesis and temperature-dependent phase stability of highly active Bi2O3 are explored. The phase junction in Bi2O3 is reviewed, and the future perspective with an outlook on contemporary challenges is provided finally.

Rare late-presentation congenital diaphragmatic hernia mimicking a tension pneumothorax.

Congenital Diaphragmatic Hernia (CDH) is due to a defect in the diaphragm and is usually detected soon after birth. However, in rare cases, asymptomatic CDHs can be missed and present later in life. Late-presentation CDH can be misdiagnosed as tension pneumothorax leading to iatrogenic complications. We report a case of a 10-year-old boy who presented with non-specific symptoms of vomiting and occasional breathlessness, but was subsequently diagnosed as late-presentation CDH. This case highlights the role of imaging in the diagnosis and management of late-presenting CDH. The role of CT imaging as an invaluable tool to further evaluate equivocal radiographic findings in CDH is discussed.

Residual Tumor Confers a 10-Fold Increased Risk of Regrowth in Clinically Nonfunctioning Pituitary Tumors.

OBJECTIVE: We evaluated tumor recurrence and regrowth rates following endoscopic transnasal transsphenoidal (TNTS) surgical removal in a consecutive series of clinically nonfunctioning pituitary adenomas (CNFTs). DESIGN: Retrospective chart review of clinical, biochemical, and sellar MRI findings in all TNTS surgeries in patients with CNFT, performed by a single surgeon, between 2008 and 2015 (n = 280). PATIENTS: Ninety-three patients met eligibility criteria, with complete clinical, biochemical, and imaging follow-up for a 3-year minimum. RESULTS: Of 85 patients who were not irradiated, 3-month postsurgical MRI demonstrated no residual tumor in 58 of 85 (68.2%), equivocal findings in 12 of 85 (14.1%), and definite residual tumor in 15 of 85 (17.6%) patients. Six of 85 (7.1%) demonstrated tumor regrowth by 3 years, and 2 further patients demonstrated true tumor recurrence at 3 and 6 years after surgery, respectively, for a total recurrence rate of 9.4% (8 of 85). Eight of the 93 patients were irradiated between 3 months and 4 years after pituitary surgery. In 3 patients with tumor regrowth, 2 exhibited residual tumor and 1 had no residual findings at the 3-month postoperative imaging. Overall, Ki-67 labeling index or Knosp grading did not predict recurrence. CONCLUSION: Tumor recurrence at 3 years was low (1 of 58; 1.7%) if the 3-month postoperative MRI showed no residual tumor. The findings support a less frequent imaging schedule for this group. Patients with definite residual tumor visible at 3 months harbor the greatest risk for tumor growth, but regrowth does not occur in all patients (6 of 15; 40%).

Systemic Lupus Erythematosus Presenting as Longitudinally Extensive Transverse Myelitis and Nephritis: A Case Report.

Systemic lupus erythematosus (SLE) is an autoimmune disorder that can potentially affect any organ. It usually presents between the ages of 15 and 45 with 9:1 ratio of female to male patients. Its clinical manifestations vary among people of different ethnicities. Longitudinally extensive transverse myelitis (LETM) is a rare life-threatening complication of SLE. We, herein, report a case of 26-year-old male diagnosed with LETM along with lupus nephritis. The patient presented with high-grade fever associated with chills and burning micturition followed by progressive bilateral lower limb weakness and urinary retention. His physical examination showed decreased bilateral lower limb power, absent reflexes, and mute plantars. His abdominal reflexes were also found to be absent and sensory level was identified at T10. T2 weighted magnetic resonance imaging (MRI) of the dorsal spine showed hyper-intense signals between T5-L1 suggestive of extensive longitudinal myelitis. Renal biopsy confirmed the presence of lupus nephritis stage III + V. Anti-nuclear antibodies (ANA) were reactive and anti-dsDNA was positive, indicative of SLE as the underlying cause of his clinical manifestations. The treatment strategy proved to be beneficial in our patient. However, there is still a vast gap between understanding the mechanisms of self-reactive diseases such as SLE and the appropriate therapeutic approach. As Pakistan's first documented case of Lupus Myelitis, we hope to delve deeper into this matter.

Potential risk of viral transmission from flying foxes to domestic animals and humans on the southern coast of West Java, Indonesia.

Flying foxes have been considered to be involved in the transmission of serious infectious diseases to humans. Using questionnaires, we aimed to determine the direct and/or indirect contacts of flying foxes in an Indonesian nature conservation area with domestic animals and humans living in the surrounding area. We surveyed 150 residents of 10 villages in West Java. Villages were classified into 3 groups: inside and/or within 1 km from the outer border of the conservation area and 1-5 km or 5-10 km away from the reserve's outer border. Data were collected by direct interview using a structured questionnaire consisting of the respondent characteristics (age, sex and occupation); histories of contacts between flying foxes and humans, dogs and other domestic animals; and knowledge about infectious diseases, mainly rabies, in flying foxes. We found that flying foxes from the nature conservation area often enter residential areas at night to look for food, especially during the fruit season. In these residential areas, flying foxes had direct contacts with humans and a few contacts with domestic animals, especially dogs. People who encounter flying foxes seldom used personal protective equipment, such as leather gloves, goggles and caps. The residents living around the conservation area mostly had poor knowledge about flying foxes and disease transmission. This situation shows that the population in this region is at a quite high risk for contracting infectious diseases from flying foxes.

Studies on the Lewis acid mediated cleavage of alpha-aminoacetals: synthesis of novel 1,2-aminoethers, and evidence for alpha-alkoxy aziridinium ion intermediates.

The nucleophilic cleavage of alpha-amino acetals induced by TMSOTf can be used to prepare a wide range of substituted 1,2-aminoethers. In particular, organometallic reagents, N-heterocycles, and enamines all react efficiently to give products in good yield. In appropriate cases, good levels of stereocontrol are possible, but this is very dependent on the nature of the nucleophile and the substrate, with diethylzinc proving particularly effective across a range of substrates. The degree of stereocontrol can be used to infer the nature of the reactive intermediates involved in the reaction. With diethylzinc, it is most likely that the reaction proceeds by coordination of the nucleophile to the amino group followed by transfer of an ethyl group to an alpha-oxocarbenium ion. With non-coordinating nucleophiles, the stereochemical outcome can be rationalised in terms of addition to the possible alpha-alkoxy aziridinium ion intermediates.