Subcutaneous fibroblastoma resembling hemangioma: A case of benign tumor of the chest wall.

Key Clinical Message: Desmoplastic fibroma presents similar to other soft tissue tumors to such an extent that even a gold standard investigation can miss. Abstract: This is to report a mass in a 47-year-old male arising from the chest wall, which was first thought to be a hemangioma but was later diagnosed as a case of desmoplastic fibroblastoma with the help of a biopsy.

Fournier's gangrene in a female: A case report.

Fournier's gangrene is characterized by an acute necrotic infection. The infection can occur in all parts of the body including the scrotum, penis, or perineum, and is a rare condition that is primarily reported in men and seldom in women. Existing literature suggests that it might be underreported, possibly leading to overlooked cases. Risk factors include diabetes, chronic illness, and trauma. This case involves a 52-year-old female with a 10-year medical history of diabetes mellitus, multiple healed skin lesions all over the body, and dermatitis. The presentation was a perianal swelling, which progressed into an extensive necrotizing soft tissue infection of the perineum, making a diagnosis of Fournier's gangrene. She underwent wide local debridement and was managed with antibiotics in a timely manner. The patient's clinical course and subsequent follow-up were uneventful. Uncontrolled diabetes and dermatitis significantly increase the risk of Fournier's gangrene; therefore, it should be suspected in women with such comorbid conditions. This case highlights the need for increased awareness and vigilance regarding this condition among women.

Introducing the Muzzammil classification for spoke wheel injuries in children to enhance injury assessment and treatment in developing countries.

Motorbike spoke wheel injuries (SWIs) among children are a notable public health concern, especially in low and middle-income regions. The primary objective of this study is to comprehensively examine the patterns of motorbike spoke wheel injuries (SWIs) in children. Additionally, the study introduces a novel classification system for these injuries. The implementation of this classification system aims to streamline the management of SWIs, making it more efficient and facilitating the development of standardized treatment protocols. This prospective observational study was conducted in the Accident and Emergency Department from January 2019 to 2021. Children < 14 years of age of either gender with foot and ankle injury due to motorbike spoke wheels as passengers and presenting within 3 days were included. The motorbike SWI was assessed for its location and classified by a new classification as Class I, Soft tissue injury without skin loss; Class II, Skin loss of more than 1 cm without underlying tissue involvement; Class III, Skin loss with underlying tissue involvement, this class is further divided on basis of underlying soft-tissue involvement; Class IV: mangled foot/toe. Management plan and outcome were noted. In our study158 children suffering from SWI were registered with a mean age of 6.2 ± 5.4 years, 127 (80.37%) males and 31 (19.62%) females. Class I injury was seen in 18 (11.39%) patients, class II in 69 (43.67%), and class III in 68 (43.03%) patients. Class III injuries were further subcategorized as follows: IIIT (Tendon) injuries, which accounted for 32 cases (20.25%); IIIB (Bone) injuries, with 29 cases (18.35%); and IIINV (Neurovascular) injuries, identified in 7 cases (4.43%). Class IV injuries were observed in 3 (1.8%) children. The flap was needed in 33 (20.88%) patients. There were no complications like flap necrosis or graft rejection. In this current study, a new classification system specific for a motorbike SWI has been introduced along with its application on children presenting at tertiary care hospital's emergency department. The application of the proposed classification will enable universal management guidelines for SWIs, especially in the Ino-Pak region where SWIs are common.

Aseptic meningitis after 20 years of endoscopic transsphenoidal pituitary surgery: a rare complication.

A transsphenoidal surgical (TSS) approach is used for pituitary gland surgery involving pituitary adenomas, as well as for the biopsy of various neurosurgical tumors. TSS, although a relatively safe procedure, can lead to complications like hypopituitarism, visual impairment, nasal septal perforation, diabetes insipidus, carotid artery injury, and cerebrospinal fluid (CSF) leaks. Aseptic meningitis is also one of the complications of this procedure with an incidence of 1-2%, presenting with symptoms similar to bacterial meningitis, but with a low-grade fever of <102 F or even apyrexia. Here, we present a rare case of aseptic meningitis due to CSF leakage, presenting after 20 years of endoscopic surgery. A ventriculoperitoneal shunt was placed to stem the leak after two unsuccessful attempts of endonasal repair.

Global burden of the COVID-19 associated patient-related delay in emergency healthcare: a panel of systematic review and meta-analyses.

BACKGROUND: Apart from infecting a large number of people around the world and causing the death of many people, the COVID-19 pandemic seems to have changed the healthcare processes of other diseases by changing the allocation of health resources and changing people's access or intention to healthcare systems. OBJECTIVE: To compare the incidence of endpoints marking delayed healthcare seeking in medical emergencies, before and during the pandemic. METHODS: Based on a PICO model, medical emergency conditions that need timely intervention was selected to be evaluated as separate panels. In a systematic literature review, PubMed was quarried for each panel for studies comparing the incidence of various medical emergencies before and during the COVID-19 pandemic. Markers of failure/disruption of treatment due to delayed referral were included in the meta-analysis for each panel. RESULT: There was a statistically significant increased pooled median time of symptom onset to admission of the acute coronary syndrome (ACS) patients; an increased rate of vasospasm of aneurismal subarachnoid hemorrhage; and perforation rate in acute appendicitis; diabetic ketoacidosis presentation rate among Type 1 Diabetes Mellitus patients; and rate of orchiectomy among testicular torsion patients in comparison of pre-COVID-19 with COVID-19 cohorts; while there were no significant changes in the event rate of ruptured ectopic pregnancy and median time of symptom onset to admission in the cerebrovascular accident (CVA) patients. CONCLUSIONS: COVID-19 has largely disrupted the referral of patients for emergency medical care and patient-related delayed care should be addressed as a major health threat.

Frequency of Subclinical Hypothyroidism in Old-age Population.

This study was conducted to determine the frequency of subclinical hypothyroidism (SCH) in the old age population (>60 years). A cross-sectional study was conducted from July 2019 to January 2020 at Jinnah Postgraduate Medical Centre, Karachi, Pakistan. Healthy subjects (having no active complaint) of either sex aged 60-80 years were included. Those already on thyroid replacement, preexisting thyroid diseases, prior radiation therapy, or having chronic kidney disease were excluded. A total of 133 participants, 79 males and 54 females, were selected with a mean age of 69.5 ± 6.4 years. There were 29 diabetics, 30 hypertensives, and 10 smokers. A total of 17 (12.8%) were found to have SCH. On stratification, gender, diabetes mellitus, and hypertension had a significant association with the presence of SCH. SCH is a modifiable risk factor, more in females, diabetics, hypertensives, and the old age population. These results highlight the need for screening for SCH in primary care settings, especially in old age. Key Words: Subclinical hypothyroidism, Old age, Gender, Diabetes, Hypertension.

Treatment of high-energy intra-articular fractures of tibia with Ilizarov external fixator in adults: A tertiary centre experience.

OBJECTIVE: To evaluate the clinical and radiological outcomes of the Ilizarov fixator in the proximal and distal fractures of the tibia. MATERIALS AND METHODOLOGY: This retrospective study reviewed 59 patients having high-energy intra-articular proximal and distal tibia fractures associated with severe soft-tissue injury, who were managed surgically with an Ilizarov fixator. The functional outcome was evaluated by using the American Orthopaedic Foot and Ankle Society scoring system (AOFAS) and the Association for the Study and Application of the Method of Ilizarov (ASAMI) Italy scoring system for tibial plateau and plafond fractures respectively. RESULTS: The most common mode of injury was road traffic accidents. According to the Gustilo open fracture classification, there were 16 patients with grade-I and nine with grade II open fractures. The remaining had closed fractures. According to the Schatzker classification of plateau fractures, 20 were graded as type V and 15 as type VI. According to the AO classification of plafond fractures, 12 fractures were graded as Type-43C1, 5 as Type-43C2, and 7 as Type-43C3. There was delayed union in 11 proximal and four distal fractures, all of which achieved union without additional bone grafting. In proximal fractures, according to AOFAS, out of 35, 26 had an acceptable while nine had a fair result. In distal fractures, according to ASAMI, out of 24, 16 had an acceptable while five had fair results. There were 192/448 wires in 58 patients with pin site infection; all were superficial and settled. Posttraumatic joint arthrosis was noted in nineteen. CONCLUSIONS: The postoperative clinical and radiological outcome indicated that primary Ilizarov external fixator is a reliable minimal invasive surgery and definitive fixation method for high-energy intra-articular proximal and distal tibial fractures with compromised soft-tissue. It also offers early stabilisation and painless joint motion without a high rate of complications.

The height as an independent risk factor of atrial fibrillation: A review.

Atrial fibrillation (AF) is characterized by abnormal heart rhythm. Among other well-known associations, recent studies suggest an association of AF with height. Height is related to 50 diseases spanning different body systems, AF is one of them. Since AF, a heterogeneous disease process, is influenced by structural, neural, electrical, and hemodynamic factors, height alters this process through its contribution to increasing atrial and ventricular size, leading to altered conduction patterns, autonomic dysregulation, and development of AF. Multiple underlying mechanisms associate height with AF. Apart from these indirect mechanisms, genome-wide association studies suggest the involvement of the same genes in AF and growth pathways. Tall stature is independently associated with a higher risk of AF development in healthy individuals. Since adult height is achieved much earlier than the onset of AF, protective measures can be taken in individuals with increased height to monitor, manage, and prevent the progression of AF.

Prevalence of vitamin D deficiency in children presenting with supracondylar fractures of humerus.

OBJECTIVE: The purpose of the current analysis is to evaluate the predominance of vitamin D inadequacy in children with supracondylar fracture of the humerus. METHODS: This is a cross-sectional study conducted at Dr Ruth K. M. Pfau Civil, Hospital, Karachi, Pakistan, from December 2019 to July 2020. Patients aged 18 months-18 years presenting with supracondylar fractures were included in the study. Patients were divided into four groups based on their age as toddlers (18 months to 3 years), pre-school age (3-5 years), school-age (6 to 11 years) and adolescents (11-18 years). RESULTS: A total of 227 children presented with upper limb fractures of which 72 (31.7%) were supracondylar. The mean vitamin D level was found to be 32.5 ± 9.1 ng/mL. Of the study subjects, low vitamin D levels were found in 34.7% (n = 25), adequate in 59.7% (n = 43) and ideal in 5.5% (n = 4) of patients. The mean vitamin D levels for toddlers were 33.5 ng/mL, for preschool children was 27.66 ng/mL, for school-age children was 30.4 ng/mL and for adolescents was 37 ng/mL. CONCLUSION: Vitamin D deficiency is not only restricted to Pakistan but also other parts of the world, although the reasons may vary in each of those regions. However, vitamin D supplementation in all parts of the globe can prevent a significant number of fractures. This prevalence study showed vitamin D deficiency in 35% of children with supracondylar fractures, with the lowest mean values in the preschool age group.

A rare case of idiopathic ileocolic intussusception in an adult.

Intussusception is an invagination of one segment of the bowel into its adjoining segment. In children, the cause is usually benign, while in adults it is secondary to a mass lesion. Here we present a case in which the preoperative diagnosis of intussusception secondary to colonic mass was made, but no definitive cause was identified by histopathology. A 30-year-old male presented with abdominal pain, altered bowel habits, weight loss, loose motions, bleeding per rectum, and vomiting. The abdomen was distended, firm, mildly tender, and guarded. A vague mass of 15 × 10 cm was palpated on the left upper quadrant. X-ray and ultrasound showed dilated small bowel. A computed tomography scan suggested ileoileal intussusception. Colonoscopy showed a growth at 15 cm of the anal verge. Exploratory laparotomy was performed, showing the presence of ileocolic intussusception with two large perforations. Subtotal colectomy with ileostomy was done. The histopathological examination showed signs of perforation.

Case Report: Rare comorbidity of celiac disease and Evans syndrome: The rare correlation of Celiac and Evans syndrome.

Background: Celiac disease is an immune-mediated enteropathy due to permanent sensitivity to gluten in genetically predisposed individuals. Evans syndrome is an autoimmune disorder designated with simultaneous or successive development of autoimmune hemolytic anemia and immune thrombocytopenia and/or immune neutropenia in the absence of any cause. Case Report: We report a rare case of Celiac disease and Evans syndrome in a 20-year-old female who presented to us with generalized weakness and shortness of breath. Her examination finding included anemia, jaundice, and raised jugular venous pulse. Her abdominal exam revealed hepatosplenomegaly. Her laboratory values showed microcytic anemia, leukocytosis and thrombocytopenia. To rule out secondary causes of idiopathic thrombocytopenia purpura, we tested viral markers for Human immunodeficiency virus, Epstein bar virus, Cytomegalovirus and performed a Helicobacter pylori test, all of which were negative. We also ruled out idiopathic thrombocytopenia purpura associated with any thyroid disorder.  For celiac disease, we took anti-tissue transgulataminase titers of IgA and IgG which confirmed the diagnosis of celiac disease. For the diagnosis of Evans syndrome, despite a negative serum coombs test initially, her bone marrow sample showed a positive Coombs test along with immune mediated hemolytic anemia and immune mediated thrombocytopenia. The patient was treated with prednisone which was tapered off and counseling was provided regarding a gluten free diet. Conclusion: Although rare, tests for Evans syndrome (and other coexisting autoimmune problems) should be performed in patients with celiac disease.

Effect of Migraine Headache on Productivity of Patients According to Migraine Disability Assessment Score: A Cross-Sectional Study.

INTRODUCTION: Migraine, a primary headache disorder, is usually recurrent with moderate to severe intensity. Migraine is the third most common cause of disability under the age of 50. There are various scoring systems for assessing this disability, one of which is MIDAS; the Migraine Disability Assessment Score. The objective of our study was to determine the extent of disability among migraine patients, patterns of prophylaxis, and their healthcare-seeking behaviors. METHODS: This survey was done in 50 migraine patients at Jinnah postgraduate medical Centre from April to May 2018. The questionnaire inquired about the demographic information, management of migraine, and effect of this condition on their sleep, and the last part had assessment to know about their functional disability. RESULTS: The majority of the patients were females with a mean age of 31 ± 10 years. Acetaminophen was the most common medication used during a migraine attack, followed by nonsteroidal anti-inflammatory drugs. Only 54% of subjects admitted using prophylaxis, out of which 94% had stopped taking it after some time, with the most common reason being their side effects. ß-blockers were the most common prophylaxis used. Only 32% had a regular follow-up visit with their doctors. Patients were graded according to the MIDAS score as: little or no disability, 22%; mild disability, 14%; moderate disability, 24%; and severe disability, 40%. CONCLUSIONS: The majority of migraine patients were found to have severe disability, which affected their daily work and social activities. Despite an increase in disability rate due to migraine, people do not seek regular medical care for this type of headache in Pakistan.

Disease Spectrum and Frequency of Illness in Pediatric Emergency: A Retrospective Analysis From Karachi, Pakistan.

Background: The National Institute of Child Health (NICH) is the largest tertiary care pediatric hospital operating in Karachi, Pakistan. Its emergency department (ED) is always occupied. However, the spectrum of illness in patients presenting to this ED has not been investigated in depth to identify the most common presentations and to develop effective management for treating patients. Methods: This retrospective study included all children visiting the pediatric ED of the NICH from January 2017 through December 2017. Newborns to children 14 years of age were included, for a total cohort of 188,803 patients. Sociodemographic data and clinical information were extracted from the medical record. Univariate analysis was performed to determine the frequency and percentage for all the variables. Results: The cohort consisted of 9% (n=16,952) neonates (0 to 1 month) and 91% (n=171,351) older children (>1 month to 14 years). Among the neonates, 36.6% presented as triage level 1. Sepsis was diagnosed in 23.8% of neonates, low birth weight/preterm in 18.4%, and respiratory distress/pneumonia in 15.2%. In infants and older children, diagnoses related to the respiratory system (37.3%), gastrointestinal system (16.4%), and multisystem involvement (15.9%) were the most common. During the evening shifts, 38.1% of patients were seen, and on weekends, 51.6% of patients were seen. Sunday was the busiest day in the ED. Conclusion: The tertiary care pediatric EDs in Pakistan have witnessed an increasing number of critical emergencies over time. Respiratory and gastrointestinal emergencies form the majority of the ED burden. A surge of patients is seen on the weekends and during the evening shifts. The spectrum of illnesses should be investigated via prospective, longitudinal studies in other pediatric EDs in Pakistan to understand the trends and to provide the foundation for developing nationwide recommendations for improving pediatric emergency care.

Burnout Among Orthopedic Surgeons and Residents in Pakistan.

Objective Burnout is exceptionally pervasive among medical professionals, especially surgeons, and is considered the main indicator of surgeons' fulfillment with career choice. Our objectives are to discover the extent of orthopedic specialist burnout in Pakistan and to explore the clinical impact of burnout. The efficacy of surgeons may be enhanced by implementing burnout prevention and treatment plans. Data collection This observational study was conducted from April 2018 to May 2018 in various tertiary care hospitals in Pakistan and includes post-graduate trainees and consultants. Those who agreed to be part of this study were asked to complete a self-structured questionnaire about demographics and burnout. The questionnaire had 28 questions based on a standard questionnaire from the American Public Welfare Association. Results In our study, 15% (n=15) of respondents had advance burnout, 22% (n=22) had early burnout, and 43% (n=49) had a fair chance of burnout. All 15 participants suffering from advance burnout were consultants. Of participants suffering from early burnout, 36.3% (n=8) were consultants, and 63.7% (n=14) were post-graduate trainees. Conclusion Compared to other countries, the burnout rate is higher among Pakistani orthopedic surgeons. Special care and attention should be paid towards the stress and workload of surgeons.

Wernicke Encephalopathy Due to Hyperemesis Gravidarum in Pregnancy: A Case Report.

Wernicke's encephalopathy (WE) is a life-threatening acute or sub-acute neurological emergency characterized by ataxia, confusion, nystagmus, and ophthalmoparesis caused by thiamine deficiency. It was first described in 1881 by Carl Wernicke with alcohol being the most common cause. We present a rare case of a 35-year-old pregnant female who presented to our emergency department with a history of vomiting and loose motions for two weeks. She later developed fever, confusion, slurred speech and blurring of vision. Magnetic resonance imaging (MRI) of the brain revealed typical lesions of WE. She was immediately treated with thiamine and her symptoms improved in a few days.

Post-football Gonathrosis: Injuries and Surgeries are A Risk.

Football is one of the most popular sports in the world. Many studies have shown there is a high incidence of gonarthrosis in football players. The reason for this increase is said to be injuries to the meniscus, the anterior cruciate ligament (ACL) and the resulting surgeries. The incidence is significantly increased in players with knee injuries. The knee is also the most commonly injured site in football and the most common cause of surgery in football players. Together these injuries, particularly of the ACL or meniscus and the resulting surgeries, increase the risk of developing gonarthrosis in post-football years.

Pattern of Infecting Microorganisms and Their Susceptibility to Antimicrobial Drugs in Patients with Diabetic Foot Infections in a Tertiary Care Hospital in Karachi, Pakistan.

Diabetes mellitus is a universal health problem, with its prevalence in Pakistan making it among the top 10 countries in the world. Approximately 13.9 million people in Pakistan will have developed diabetes by 2030. Diabetic foot ulcer (DFU) is one of the more serious complications of diabetes. If not treated properly, patients may develop diabetic foot osteomyelitis leading to gangrene and amputation. These infections are usually polymicrobial, with Staphylococcus aureus (S. aureus), Proteus, Pseudomonas, and Escherichia coli (E. coli) being among the more common organisms isolated from DFU. This survey of patients with DFU in a tertiary hospital in Karachi, Pakistan found 68.5% of patients had peripheral neuropathy, 57% had chronic osteomyelitis, and 37% and 49% had Wagner grades 2 and 3, respectively. Infections were polymicrobial in 83% of patients, E. coli was isolated from 63%, and S. aureus from 58%. Of the isolated organisms, 95% were sensitive to meropenem and 81% to linezolid.

The H Syndrome: A Genodermatosis.

H syndrome (histiocytosis lymph adenopathy plus syndrome) is an autosomal recessive disorder caused by mutations in the SLC29A3 gene, encoding the human equilibrative nucleoside transporter (hENT3), characterized by cutaneous hyperpigmentation and hypertrichosis, hepatosplenomegaly, hearing loss, heart anomalies, hypogonadism, low height, hyperglycemia/insulin-dependent diabetes mellitus, and hallux valgus/flexion contractures. Exophthalmos, malabsorption, renal anomalies, flexion contractions of interphalangeal joints and hallux valgus, and lytic bone lesions, as well as osteosclerosis, are also seen. If these are lacking, the constellation of additional findings should raise suspicion for H syndrome. As most of the patients reported to date with H syndrome are from traditional, low-income populations, where consanguinity is common, it is highly important to develop a cheap and affordable technique for a mutation analysis. Two siblings presented to us, diagnosed as having insulin-dependent diabetes mellitus (IDDM) since the age of eight years and progressive flexion contracture of the small joints for seven-eight years. On examination, both had short stature. One also had bilateral cervical lymphadenopathy. The female had the Tanner stage of B3P3A2 M0 and the male had the Tanner stage of prepuberty. Laboratory workup, including antinuclear antibodies, rheumatoid factor, erythrocyte sedimentation rate, thyroid profile, and Celiac serology were negative. Genetic studies confirmed the diagnosis of H syndrome.