Laparoscopic Retrieval of a 13-Year-Old Retained Iatrogenic Metallic Foreign Body from the Pelvis: An Uncommon Case Report.

Retained surgical foreign bodies are unanticipated events culminating from inadvertent operating room errors and may cause severe medical and legal problems between the patient and the doctor. Here, we report detecting a surgical instrument fragment 13 years after an open abdominal hysterectomy in a quadragenarian during her evaluation of a month-old complaint of lower abdominal and right thigh pain. A computed tomography scan of the abdomen demonstrated a radio-opaque linear foreign body traversing the right obturator foramen with extension into the pelvis cranially and the adductor compartment of the right thigh caudally. The metallic foreign body, identified as a fragmented handle of a uterine tenaculum forceps with a slender sharp-tip hook, could be removed laparoscopically from the pelvis after a diagnostic laparoscopy, preventing significant complications. The minimally invasive approach enabled a smooth recovery, and the patient could go home on the second postoperative day.

Adult Left Colocolic Intussusception Successfully Managed by Left Hemicolectomy and Primary Anastomosis.

Intussusception, although quite common in children with the classic triad of cramping abdominal pain, bloody diarrhea, and palpable masses, is a rare cause of acute abdomen with myriad presentations in adults. It is defined as the telescoping of a proximal segment of the gastrointestinal (GI) tract, called the intussusceptum, into the lumen of the adjacent distal segment of the GI tract, called intussuscipiens. Due to its different manifestations and time course, adult colonic intussusception often poses a diagnostic challenge for emergency doctors. The treatment of colonic intussusception in adults typically involves surgery, often with bowel resection and anastomosis followed by a defunctioning loop ileostomy. We report a case of left-sided colocolic intussusception secondary to a tubular adenoma as the lead point, which was successfully treated by resection and primary anastomosis. The pathological diagnosis of the lesion was reported as adenocarcinoma and resected bowel margins were found free of the tumor.

Demographic and clinicopathological Profile of Gall Bladder Cancer Patients: Study from a tertiary care center of the Sub-Himalayan region in Indo-Gangetic Belt.

INTRODUCTION: Gall bladder cancer (GBC) accounts for 80%-95% of biliary tract malignancies in the world. There is however striking variability in the global incidence of gallbladder cancer, reaching epidemic levels for some regions and ethnicities. The aim of this study was to evaluate the demographic and clinicopathological profile of the gallbladder cancer patients. MATERIALS AND METHODS: All patients of carcinoma gall bladder presenting to department of surgery in hepatopancreaticobiliary unit from July 2017 to November 2020 were included in this study. A proforma containing all the relevant details including history, examination, blood, radiology, and pathological investigations was filled. RESULTS: A total of 326 patients of GBC were analyzed. The majority (75%) were found to be females with a mean age of 55 years. Pain abdomen was the most common presenting symptom in 81% of patients. The most common stage of presentation was stage IV and only 6 were in stage I. Two hundred and thirty three (71.4%) patients had metastatic disease at presentation. Liver infiltration at the time of diagnosis was present in 89% of patients. The most common site of metastasis was found in the liver (23.3%). GBC was more common in patients with A blood group. Baseline serum albumin levels were found to be significantly associated with the staging of GBC. CONCLUSIONS: Due to the non specific symptoms patients of GBC present at very advanced stages, high index of suspicion and health education seems to play an important role in early detection and improvement of survival.

Cavernous Hemangioma of the Adrenal Gland: A Rare Adrenal Incidentaloma.

Cavernous hemangiomas of the adrenal gland are rare, benign, endocrinologically inactive tumors. They present as adrenal incidentalomas, mostly asymptomatic, but patients may have abdominal pain. Surgery is the mainstay of treatment.

Role of carbohydrate antigen 19-9, carcinoembryonic antigen, and carbohydrate antigen 125 as the predictors of resectability and survival in the patients of Carcinoma Gall Bladder.

INTRODUCTION: Carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) have been reported in previous studies to assess the prognosis of gall bladder cancer (GBC) individually and in combination. However, the evidence of utility of preoperative CA 19-9, CEA and carbohydrate antigen 125 (CA 125) in determining the resectability and prognosis of GBC is still lacking. In the present study we correlated the serum levels of tumor markers CA 19-9, CEA and CA 125 individually and combined to determine the resectability and prognosis of the GBC. MATERIALS AND METHODS: Seventy one diagnosed patients of GBC between January 2018 and September 2019 were included in the present study. Serum CA 19-9, CEA and CA 125 were determined by chemiluminescence. Receiver operating characteristic (ROC) curve was used to evaluate the role of tumor markers in determining the resectability of GBC. The Kaplan Meier survival curves were made and log rank analysis was performed to assess the prognostic role of tumor markers in terms of overall median survival. RESULTS: All the three tumor markers CA19-9, CEA and CA 125 showed high discriminatory power in determining the resectability with respective area under curve of 0.76, 0.68 and 0.78 as determined by ROC. Median survival in patients with high serum CA 19-9, CA 125 was significantly lower than patients with normal serum CA 19-9, CA 125 whereas no significant difference was observed in case of CEA. CONCLUSION: The present study suggested that CA 19-9, CEA and CA 125 can predict resectability in GBC and raised levels of CA 19-9 and CA 125 can predict poor prognosis in patients with elevated levels.

Evaluation of platelet distribution width as novel biomarker in gall bladder cancer.

INTRODUCTION: Gall bladder cancer (GBC) tends to present in advanced stages, therefore, early diagnosis of GBC is necessary. There is no ideal single tumor marker available presently for the diagnosis and prognosis of GBC. Platelet distribution width (PDW) is an early marker for activated platelets and has been used in a variety of tumors to assess prognosis. This study was designed to evaluate the utility of PDW in identifying GBC patients and its association with tumor markers, staging and resectability of GBC. MATERIALS AND METHODS: This cross sectional study was done on 100 patients of GBC and 100 age- and sex- matched healthy controls. PDW was evaluated and compared between GBC and healthy controls. Receiver-operating characteristics was plotted to determine optimal cut-off for identifying GBC patients and to determine sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of PDW. Correlation between serum tumor markers (carbohydrate antigen 19-9, carcinoembryonic antigen, and carbohydrate antigen 125) and PDW were evaluated. Association of PDW with hyperbilirubinemia, staging and resectability of GBC was also studied. RESULTS: A significantly higher PDW with a median of 18.1 was observed in GBC as compared to healthy controls with median value of 13. PDW was found to have a very high sensitivity (90%), specificity (95%), PPV (94%) and NPV (90%) in identifying GBC at cut-off of 16 with area under the curve (AUC) of 0.97. An increase of PDW was observed with increasing stage and unresectable GBC. However, it was not statistically significant. Significant positive correlation was observed between PDW and all three serum tumor markers and good positive correlation with r = 0.61 was observed with CA 19-9. CONCLUSION: PDW was associated with GBC and may be considered as a cost- effective marker in adjunct to other investigations for the diagnosis of GBC.

Pemphigus in Sarcomatoid Renal Cell Carcinoma: A Rare Paraneoplastic Manifestation.

Renal cell carcinoma with sarcomatoid features is a rare presentation with a 5% incidence. Sarcomatoid renal cell carcinoma is usually associated with poor prognosis. It commonly metastasizes to the lungs, bones, and liver. Dermatological manifestation with paraneoplastic syndrome is extremely rare. Pathogenesis of PNP in renal cell carcinoma is not cleat; till date, however, few literature suggest antibodies against a group plakin family which plays a key role in intermediate filament attachment in RCC. We present PNP in a 64-year-old female associated with renal cell carcinoma.

Functional connectivity analysis using whole brain and regional network metrics in MS patients.

In the present study we investigated brain network connectivity differences between patients with relapsing-remitting multiple sclerosis (RRMS) and healthy controls (HC) as derived from functional resonance magnetic imaging (fMRI) using graph theory. Resting state fMRI data of 18 RRMS patients (12 female, mean age ± SD: 42 ± 12.06 years) and 25 HC (8 female, 29.2 ± 5.38 years) were analyzed. In order to obtain information of differences in entire brain network, we focused on both, local and global network connectivity parameters. And the regional connectivity differences were assessed using regional network parameters. RRMS patients presented a significant increase of modularity in comparison to HC, pointing towards a network structure with densely interconnected nodes within one module, while the number of connections with other modules outside decreases. This higher decomposable network favours cost-efficient local information processing and promotes long-range disconnection. In addition, at the regional anatomical level, the network parameters clustering coefficient and local efficiency were increased in the insula, the superior parietal gyrus and the temporal pole. Our study indicates that modularity as derived from fMRI can be seen as a characteristic connectivity feature that is increased in MS patients compared to HC. Furthermore, specific anatomical regions linked to perception, motor function and cognition were mainly involved in the enhanced local information processing.

Testing different ICA algorithms and connectivity analyses on MS patients.

Multiple sclerosis (MS) is a progressive neurological disorder that affects the central nervous system. Functional magnetic resonance imaging (fMRI) has been employed to track the course and disease progression in patients with MS. The two main aims of this study were to apply in a data-driven approach the independent component analysis (ICA) in the spatial domain to depict the active sources and to look at the effective connectivity between the identified spatial sources. Several ICA algorithms have been proposed for fMRI data analysis. In this study, we aimed to test two well characterized algorithms, namely, the fast ICA and the complex infomax algorithms, followed by two effective connectivity algorithms, namely, Granger causality (GC) and generalized partial directed coherence (GPDC), to illustrate the connections between the spatial sources in patients with MS. The results obtained from the ICA analyses showed the involvement of the default mode network sources. The connectivity analyses depicted significant changes between the two applied algorithms. The significance of this study was to demonstrate the robustness of the analyzed algorithms in patients with MS and to validate them before applying them on larger datasets of patients with MS.

Differentiating tremor patients using spiral analyses.

Essential tremor follows an autosomal dominant type of inheritance in the majority of patients, yet its genetic basis has not been identified. The age of onset in this tremor is bimodal, one in young age and another when they are old. The old onset is referred to as senile tremor in this study. The precise pathology is still not completely understood for both these tremors. We wanted to develop an easy diagnostic tool to differentiate these two tremors clinically. In this study, the spirals were asked to be drawn by 30 patients, 15 from each group. The spirals were recorded digitally from each hand, with and without the spiral template, using a Wacom intuos version 4 tablets. The aim of the study was to look at the easy diagnostic measures from these spirals to distinguish the two cohorts of patients. The first measure was to use the well-known clinical scores like the number of complete circles without the template, width, height, axis, and degree of severity. The second measure was to estimate the peak frequency and the peak amplitude for the position, velocity, and acceleration data, in the frequency domain. The well-known clinical scores, most of them, did not show any significant difference between the two patient cohorts except the degree of severity which showed significant difference. The peak frequency and the peak amplitude in most of the data were not significantly different between the two cohorts of patients, only the peak amplitude from the acceleration data showed significant difference. Thus, we could use these two parameters to differentiate between the two tremors patient groups, which would be an easy clinical diagnostic tool without the need for any complicated analyses.

First Record of Acremonium Wilt in Tomato from Pakistan.

During a survey in May 2011, tomato (Lycopersicon esculentum Mill.) plants were observed exhibiting wilt symptoms on the vegetable farm of the University of the Punjab Lahore (31°32'59″ N, 74°20'37″ E), Pakistan. Plants were pale yellow and stunted. Diseased plants were scattered in the field either singly or in groups of two or three. Lower leaves turned yellow following necrosis and shedding from the plants. Roots of diseased plants were dark brown in comparison to the healthy ones. Vascular browning was observed when infected stems were split longitudinally and sectioned transversely. Necrotic vascular strands were also observed in infected stems. With a stereoscope, white hyphae were noticed in the vascular region of infected plants. Stained cross sections of stems of wilted plants showed fungal hypha. A diseased plant sample was taken to the First Fungal Culture Bank of Pakistan (FCBP) for identification of the pathogen. Conidia appeared on potato dextrose agar after incubation in diurnal light, and were unicellular, smooth, thin-walled, and oval in shape (3 to 6 × 1 to 3 µm), forming aggregations on the tip of conidiophores. With the help of diagnostic keys and available literature, the isolated fungus was identified as Acremonium strictum W. Gams. The fungus formed whitish flat colonies with deposition of gum granules on its surface. Hyphae and phialides were hyaline and non-pigmented. Phialides with expanded bottoms were elongated measuring 25 to 40 µm and solitary in position at right angles to the filament. To further confirm identification, amplification of the ITS1 and ITS2 regions was performed with universal primers ITS1 and ITS4 (4). The ITS sequence obtained was submitted to NCBI as accession JQ916901. The culture was deposited in FCBP (1099), Institute of Agricultural Sciences, University of the Punjab, Pakistan. A pathogenicity test of the isolated fungus was performed by inoculating 15 healthy tomato plants cv. Rio Grande in three replicates. The spore suspension (2 × 105 conidia/ml of sterile distilled water) was prepared from 12-day-old cultures of the fungus grown from a single spore on PDA in continuous light. Control plants were treated with sterile distilled water. Tomato plants inoculated with the fungus started showing wilting symptoms within 2 weeks, while the control remained healthy. A. strictum was re-isolated from inoculated wilted plants, thus satisfying Koch's postulates. Previously, A. strictum was a reported cause of wilt in many plants including Chrysanthemum maximum (2), watermelon (1), and Gladiolous grandiflorus (3). To our knowledge, wilt in tomatoes has been reported only from Fusarium oxysporum and Pseudomonas solanacearum from Pakistan. To our knowledge, this is the first record of Acremonium wilt in this economically important crop. References: (1) B. D. Bruton et al. Plant Dis. 79:754, 1995. (2) A. R. Chase. Calif. Agric. 32(10):21, 1978. (3) E. Gonzalez-Perez. J. Plant Pathol. 90:586, 2008. (4) T. J. White et al. Pages 315-322 in: PCR Protocols: A Guide to Methods and Applications. Academic Press, San Diego, CA, 1990.

First Report of Curvularia lunata Causing Leaf Spots on Sorghum bicolor from Pakistan.

In October 2012, reddish brown, oblong lesions with chlorotic centers were observed on the leaves of Sorghum bicolor in Punjab Province, Pakistan. Early symptoms appeared as reddish brown circular spots on the leaves. These spots increased in size and coalesced to form oblong lesions. Entire fields were severely affected by the disease. Pathogen isolations were made on malt extract agar (MEA) media. Symptomatic leaf samples were cut into 4 to 6 mm2 pieces, surface sterilized (10% bleach for 1 min, 90% ethanol for 30 sec) and rinsed in sterilized water several times, followed by air drying. These samples were plated onto 2% MEA media, supplemented with 10 mg/liter chloramphenicol, and incubated at 25°C for 6 days in the dark. A mitosporic fungus of dark brown colony, bearing large stroma, appeared on the media. Conidiophores were brown, septate, geniculate, simple or unbranched, with dark brown scar. Conidia were brown, straight to pyriform, with 3 to 4 cells, with large and curved central cells, smooth walled, ranging in size from 7.3 to 21.26 µm, and produced apically in a sympodial manner. Based on morphological characteristics, the pathogen was identified as Curvularia lunata (Wakk.) Boedijn. (1,2). Morphological identification was also confirmed by the First Fungal Culture Bank of Pakistan (FCBP), Institute of Agricultural Sciences, University of the Punjab, Lahore, Pakistan, and samples were submitted to FCBP (Accession No. 1201). The fungus was further identified by amplifying internal transcribed spacer region sequences (ITS1, rDNA, ITS2) by using ITS4 and ITS5 primers (4). The resulting 584-bp sequence was submitted to GenBank with Accession No. HG326308. This sequence showed 99% homology with C. lunata strain pingxiang (GenBank Accession No. JQ701897), causing leaf spots of lotus in China. Pathogenicity assay was conducted on 20-day-old seedlings of S. bicolor variety Indian Gold, grown from surface sterilized seeds. Fifteen replicate plants were sprayed with a spore suspension of 1 × 106 spore/ml in distilled sterilized water, prepared from 1-week-old fungal culture, grown in the dark on 2% MEA media. Five replicate plants were sprayed with distilled sterilized water as control. Plants were covered with transparent polyethylene bags to retain moisture and enhance disease development, and kept in a greenhouse at ~30°C. Bags were removed after 5 days of incubation. Inoculated plants developed lesions similar to those observed on naturally infected plants. No symptoms were observed on control plants. The pathogen was re-isolated from infected leaves, and the morphology features were again studied, matching those of the pathogen isolated from field samples. Curvularia leaf spot diseases, caused by different Curvularia species, have been previously found on many grass species worldwide (3). To our knowledge, this is the first report of C. lunata leaf spots on S. bicolor in Pakistan. References: (1) M. B. Ellis. Dematiaceous Hyphomycetes. Commonwealth Mycological Institute, Kew, Surrey, England, 1971. (2) F. B. Rocha et al. Austral. Plant Pathol. 33:601, 2004. (3) J. D. Smith et al. Fungal diseases of amenity turf grasses. E & F.N. Spon., New York, 1989. (4) T. J. White et al. Page 315 in: PCR Protocols: A Guide to Methods and Applications. Academic Press, San Diego, CA, 1990.

A comparative study based on gender and age dependence of selected metals in scalp hair.

Levels of 10 metals (Ca, Mg, Fe, Zn, Cu, Mn, Cd, Co, Cr and Ni) in the scalp hair of male and female donors, with age groups between 3 and 100 years, were determined by ICP-AES. In total, 58 male and 30 female hair samples were analyzed in triplicate. The donors belonged to the rural area of district Chakwal, a well-known typical non-urban site in Pakistan. Calcium showed the highest concentration of 462 microg/g in the hair of males and 870 microg/g in those of females followed by Zn, at 208 and 251 microg/g for the two sexes. For male donors, Cd showed the lowest concentration (1.15 microg/g) while for female donors Co remained at minimum level (0.92 microg/g). The order of decreasing metal concentration in the hair of male donors was: Ca > Zn > Mg > Fe > Cu > Mn > Ni > Cr > Co > Cd while that for female donors it was: Ca > Zn > Mg > Fe > Cu > Mn > Cr > Ni > Cd > Co. The female group exhibited enhanced levels of all selected metals except Fe and Co in their hair as compared with the male counterparts. A strong bivariate positive correlation was found between Fe and Zn (r = 0.841) for the hair samples from male category while for the female category, strong positive correlations were observed between Ca-Mg (r = 0.617), Ca-Zn (r = 0.569), Ca-Mn (r = 0.565), Mg-Mn (r = 0.655), Cr-Cu (r = 0.655) and Cr-Ni (r = 0.685). The distribution of metals in the hair of donors with respect to different age groups was also investigated for both genders. The study showed that in case of males, the concentration of all selected metals decreased with increasing age except for Cu, Co and Cr. However, for females the hair metal levels increased with age, except for Co for which the concentration decreased with age. No appreciable change in the metal concentration was observed as a function of age for the combined sexes.