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Key Clinical Message: Kawasaki disease (KD), a self-limiting vasculitis, can present with a broader spectrum of vascular involvements, necessitating early recognition and prompt management. This case exemplifies the importance of involving multiple teams on board in managing complex presentations of KD. It also highlights the importance of close monitoring for the progression of the disease spectrum as well as family education to ensure favorable outcomes. The case also emphasizes the importance of long-term follow-up and further research to understand the prognosis, early screening tools, and possible complications due to multi-organ involvement in KD along with their management strategies. Abstract: Kawasaki disease (KD) is a multisystem vascular inflammatory syndrome, which predominantly affects the small and medium vessels in children within the age group of less than 5 years. The most threatened complication is the development of coronary artery aneurysms (CAAs). We present an extremely rare case of KD in a 2-month, 21-day-old male infant with extensive vascular involvement, expanding the disease spectrum beyond the involvement of coronary arteries. These included aneurysmal dilatations of both internal carotid arteries, the descending aorta, bilateral multilevel intercostal arteries, coeliac artery, superior mesenteric artery, and both renal arteries. Implementing a multidisciplinary approach with early treatment via intravenous immunoglobulin (IVIG) and dexamethasone proved to be most effective in the patient's management. Despite unique challenges such as severe coronary dilation and pseudomonas sepsis during the special care, the patient was stabilized and discharged after 11 days of hospital stay, highlighting the importance of early prompt management and a centered approach to evaluate in a broader spectrum. This case emphasizes the importance of long-term follow-up and further research to understand the prognosis, early screening tools, and possible complications due to multi-organ involvement in KD along with their management strategies.
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Introduction Non-alcoholic fatty liver disease (NAFLD) is the most prevalent liver condition worldwide. NAFLD has been associated with metabolic syndrome and its symptoms, such as type 2 diabetes, hypertension, dyslipidemia, and obesity. Ultrasound is widely used to grade hepatic steatosis, being the most cost-effective, non-invasive, and readily available modality without radiation exposure. The study aimed to assess the correlation of NAFLD grade as seen on ultrasound with blood parameters in a Pakistani population. Materials and methods The included patients were those who were diagnosed with fatty liver disease on ultrasound and whose laboratory tests were available within two weeks of the ultrasound. Two seasoned radiologists rated the severity of NAFLD after looking over ultrasound scans. Consecutive sampling technique was used to minimize selection bias. The degree and direction of the linear relationship between the NAFLD grade and each biochemical parameter were measured using the Pearson correlation coefficient. Results There were 207 patients in all who had been identified with NAFLD on ultrasound, the majority of whom had grade II NAFLD and were in their sixth decade of life. According to Pearson's analysis, the grade of NAFLD had larger positive associations with triglycerides, total cholesterol, low-density lipoprotein, and fasting blood sugar. High density lipoprotein and C-reactive protein were found to have a negative correlation with the grade of NAFLD. Conclusion The findings of the study highlight the correlation between NAFLD grade on ultrasonography and specific blood parameters, implying that managing these biochemical indicators may help to improve hepatic steatosis.
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Background Radiology reports are important medico-legal documents facilitating communication between radiologists and referring doctors. Language clarity and precision are crucial for effective communication in these reports. Radiology reporting has changed with the evolution of imaging technology, prompting the adoption of precise terminology. Diagnostic certainty phrases (DCPs) play an important role in communicating diagnostic confidence in radiology reports. Objective The aim of this study was to evaluate the use of DCPs in radiology reports, before and after targeted educational interventions. Materials and methods The study was approved by the Aga Khan University Hospital's Ethical Review Committee and includes cross-sectional radiology reports. It involved three cycles of retrospective evaluation, with educational interventions in between to improve the use of DCPs. Results The study found a dynamic shift in the use of DCPs during the three cycles. Initially, intermediate-certainty phrases prevailed, followed by an increase in high-certainty phrases and a drop in low-certainty phrases. Later cycles showed a significant decline in DCPs and an increase in the use of definitive language. Across all subspecialties, there was a consistent decrease in intermediate- and low-certainty DCPs. Conclusion The study validates the transformative impact of educational interventions on the use of DCPs in radiology reports. The radiology reports frequently used DCPs with intermediate to low diagnostic certainty with improvement in the subsequent cycles of the study after educational interventions. It emphasizes the significance of continuing education to ensure the use of precise nomenclature.
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OBJECTIVE: To assess communication and interpersonal skills (CIS) of radiology residents through faculty and standardised patients (SP). METHODS: In this day-long objective structured clinical examination (OSCE) in January 2009, 42 radiology residents took part at six stations in Karachi, each with a standardised patient and a faculty evaluator. Each encounter lasted 15 minutes followed by independent assessments of the residents by both the evaluators. RESULTS: Based on rating-scale evaluations, all cases had satisfactory internal consistency (Cronbach's alpha 0.6 to 0.9). The alpha values were comparatively diminutive against the checklist scores. Correlation among faculty was 0.6 (p<0.001) with the use of both the checklist and the rating scale. Among standardised patient, intra-class correlation was 0.6 (p<0.001) for checklists and 0.7 (p=0.001) for rating scales. Moderate to strong correlations (r=0.6 to 0.9) existed between checklist and rating scores by the same type of evaluator. Correlations among the faculty and standardised patient using the same assessment tool were unimpressive. CONCLUSION: Both checklists and rating scales can serve as satisfactory assessment tools for communication and interpersonal skills using objective structured and clinical examination with the assistance of faculty and standardised patients.
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Competência Clínica/normas , Docentes de Medicina/normas , Internato e Residência/normas , Relações Interpessoais , Radiologia , Estudantes/psicologia , Adulto , Avaliação Educacional/métodos , Inteligência Emocional , Feminino , Humanos , Masculino , Avaliação das Necessidades , Paquistão , Seleção de Pacientes , Qualidade da Assistência à Saúde , Radiologia/educação , Radiologia/normasRESUMO
The aim of this retrospective observational study was to describe the neuroimaging manifestations of patients with COVID-19. This study was conducted at Aga Khan University Hospital, Karachi, Pakistan from March to July 2020. COVID-19 patients with neurological symptoms and positive neuroimaging were included after confirmation of COVID-19 by polymerase chain reaction test (PCR). In the 12 included patients, seizures and altered mentation were predominant neurological manifestations. Three cases had acute watershed infarcts (25%), two cases had posterior cerebral artery territorial infarcts (16.7%), two cases had periventricular corona radiata infarcts (16.7%), three cases had hypoxic ischemic encephalopathy (25%), two cases had posterior reversible encephalopathy syndrome (16.7%), and there was one case each of cerebral venous sinus thrombosis, pontine infarct, and bithalamic lesions (8.3%). This study highlights the diagnostic approaches in COVID-19-associated encephalopathy and the variable imaging features that clinicians and neuroradiologists should be aware of, as the pandemic progresses. Key Words: COVID-19, Neuroimaging, Encephalopathy, Magnetic resonance imaging, Coronavirus.
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Encefalopatias/diagnóstico , COVID-19/epidemiologia , Neuroimagem/métodos , Pandemias , Encefalopatias/epidemiologia , Comorbidade , Humanos , SARS-CoV-2RESUMO
The aim of this retrospective observational study was to describe the neuroimaging manifestations of patients with COVID-19. This study was conducted at Aga Khan University Hospital, Karachi, Pakistan from March to July 2020. COVID-19 patients with neurological symptoms and positive neuroimaging were included after confirmation of COVID-19 by polymerase chain reaction test (PCR). In the 12 included patients, seizures and altered mentation were predominant neurological manifestations. Three cases had acute watershed infarcts (25%), two cases had posterior cerebral artery territorial infarcts (16.7%), two cases had periventricular corona radiata infarcts (16.7%), three cases had hypoxic ischemic encephalopathy (25%), two cases had posterior reversible encephalopathy syndrome (16.7%), and there was one case each of cerebral venous sinus thrombosis, pontine infarct, and bithalamic lesions (8.3%). This study highlights the diagnostic approaches in COVID-19-associated encephalopathy and the variable imaging features that clinicians and neuroradiologists should be aware of, as the pandemic progresses. Key Words: COVID-19, Neuroimaging, Encephalopathy, Magnetic resonance imaging, Coronavirus.
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Encefalopatias , COVID-19 , Síndrome da Leucoencefalopatia Posterior , Encefalopatias/diagnóstico por imagem , Encefalopatias/etiologia , Humanos , Imageamento por Ressonância Magnética , Pandemias , SARS-CoV-2RESUMO
OBJECTIVE: To assess accurate skeletal age (SA) in clinical and medico-legal decisions using the Greulich-Pyle (GP) atlas and to see its applicability across diverse populations in Karachi. METHODS: Hand-Wrist radiographs obtained at our institution from January 2005 to March 2008, for an indication of trauma, in subjects with chronological age (CA) up to 216 months, were reviewed by two radiologists blinded to CA. Subjects ever investigated for metabolic, growth or nutritional disorders were excluded. SA was assessed according to GP atlas. To establish inter-observer reliability, 100 random radiographs were dually evaluated. Both sexes were divided into four subgroups. For each subgroup, difference between skeletal and chronological age was calculated. (paired t-test, alpha < 0.05). RESULTS: Total 889 radiographs were analyzed. Inter-observer correlation coefficient was 0.992 (p < 0.001). Mean differences of up to 13 months between SA and CA were documented. The differences were statistically significant in all groups except adolescent males. CONCLUSION: Our findings suggest against the applicability of GP atlas for accurate SA assessment in Pakistani children.
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Determinação da Idade pelo Esqueleto , Atlas como Assunto , Adolescente , Criança , Estudos Transversais , Feminino , Mãos/diagnóstico por imagem , Humanos , Masculino , Paquistão , Punho/diagnóstico por imagemRESUMO
The purpose of this research was to investigate the cryoprotective role of EWP-XO in the prevention of oxidative and structural changes in the myofibrillar proteins (MPs). Different concentrations of egg white protein and xylooligosaccharide (EWP-XO) mixture (0, 2, 4 and 6%) were added to the MPs of Culter alburnus fish during frozen storage (-18 °C) of 60 days. During the study, it was observed that EWP-XO significantly (P < .05) reduced the Ca-ATPase activity, which is greatly related with tertiary structural changes. Meanwhile, carbonyl contents of MPs increased in line with frozen storage (control samples). Meanwhile, samples treated with 6% EWP-XO showed less increase in carbonyl content indicating the decreased protein oxidation. The addition of EWP-XO efficiently inhibited the decline in the sulfhydryl contents. Furthermore, through circular dichroism analysis it was confirmed that the addition of EWP-XO increased the secondary structural stability by preventing the reduction in α-helix content. Microstructural analysis confirmed the preservation of a well-structured protein network that reduced the porosity and protein aggregation of MPs gel. It was concluded that 6% EWP-XO was an effective cryoprotectant mixture, which preserved the functional and structural properties of Culter alburnus during 60 days of frozen storage period.
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Utilization of radiology as an educational resource carries great potential. Accreditation bodies, physicians and medical students deem it important for a well rounded medical curriculum. Unfortunately this resource is yet to be developed and implemented to an optimal extent. We share the experiences from the first radiology core clerkship in Pakistan at the undergraduate level. An overview of clerkship objectives and structure is followed by discussion on lessons learnt during the initial three years of institution. Development of assessable objectives, integration of radiology with other specialties, and supervised andragogical learning tailored for undergraduate students are emphasized.
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Estágio Clínico/organização & administração , Radiologia/educação , Estágio Clínico/métodos , Educação de Graduação em Medicina , Humanos , Paquistão , Competência ProfissionalRESUMO
Introduction Magnetic resonance imaging (MRI) is widely used in the evaluation of cervical canal stenosis and spinal cord compression. Kang et al. formulated a new MRI grading system for assessing canal stenosis which takes cord signal change into account. The purpose of the study was to determine the agreement between Kang's grading system and neurological symptoms. Methods A cross-sectional study was conducted at Aga Khan University Hospital between April 2014 and December 2015. Patients meeting inclusion criteria were enrolled. T2 sagittal and T2 axial MRI images were acquired and reported by a consultant neuroradiologist, in accordance with the MRI grading system suggested by Kang et al. Neurologic clinical symptoms were acquired by the history taken by the principal investigator. More than one neurologic symptoms and Kang MRI grade 2 or 3 were taken as positive evidence of cord compression resulting from canal stenosis. Results Amongst 126 subjects, 54% were females. Mean age of patients was 50.3 ± 14.3 years (range 19-83 years). Average disease duration was 4.61 ± 3.73 (range 1-24 months). In the majority of the patients, the findings were found at the C5-C6 level. 65.1% of patients were identified positive for cervical canal stenosis by Kang grading system. Most common neurological symptoms were pain (99%) and numbness (56%). Cohen's Kappa was run to evaluate the agreement between neurological symptoms and Kang grading system. There was a strong agreement between the two methods, K = 0.81 (95% CI 0.70-0.92), p < 0.001. Conclusion There was a substantial agreement between Kang's grading system and the presence of clinical symptoms. The agreement was greatest in females, older patients, and those with longer duration of symptoms.
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Objective To investigate which bone age assessment techniques are utilized by radiologists in Pakistan to determine skeletal age in three defined age groups: less than one year, one to three years and three to 18 years. We also assessed the perceived confidence in skeletal age assessments made by respondents using their chosen bone age assessment technique, within each defined age group. Materials and methods A cross-sectional survey was conducted among 147 practicing radiologists in Pakistan. A pre-validated survey form was adopted from a similar study conducted amongst members of the Society for Pediatric Radiology. The survey collected demographic information, choice of bone age assessment technique in each age group and confidence of bone age assessments in each age group. Results The hand-wrist method of Greulich and Pyle was used by 87.5% of respondents when assessing bone age in infants (less than one year), followed by Gilsanz-Ratib hand bone age method (7.3%). In children aged one to three years, Greulich and Pyle method was chosen by 85.7% of respondents, followed by Gilsanz-Ratib hand bone age method (6.1%) and the Hoerr, Pyle, Francis' Radiographic Atlas of Skeletal Development of the Foot and Ankle (3.1%). In children, older than three years, the Greulich and Pyle technique was used by 83.7% of respondents. This was followed by Gilsanz-Ratib hand bone age method (5.8%) and the Hoerr, Pyle, Francis' Radiographic Atlas of Skeletal Development of the Foot and Ankle (3.8%). 26.4% were "very confident" in bone age assessments conducted among infants. In children aged one to three years, 38.1% were "very confident". In children, greater than three years, 48.6% were "very confident" in their chosen technique. Conclusion Greulich and Pyle is the dominant method for bone age assessments in all age groups, however, confidence in its application among infants and young children is low. It is recommended that clear recommendations be developed for bone age assessments in this age group alongside incorporation of indigenous standards of bone age assessments based on a representative sample of healthy native children.
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Diffuse astrocytoma with bilateral thalamic involvement is extremely rare. We present a case of 10 years old female who presented with decreased mentation, dysarthria, decreased performance at school and later on with seizures. MRI scans were performed twice and were reported as Leigh's disease and hemimegalencephaly respectively. Patient presented again with complaint of unconsciousness, vomiting and chest congestion. No further imaging was performed. Biopsy showed grade III Astrocytoma with bilateral thalamic involvement. Patient was admitted to intensive care unit but could not survive and expired.
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Astrocitoma/patologia , Neoplasias Cerebelares/patologia , Doenças Talâmicas/patologia , Astrocitoma/diagnóstico , Neoplasias Cerebelares/diagnóstico , Criança , Feminino , Humanos , Doenças Talâmicas/diagnósticoRESUMO
RATIONALE AND OBJECTIVES: Workplace-based assessments gauge the highest tier of clinical competence. Chart-stimulated recall (CSR) is a workplace-based assessment method that complements chart audit with an interview based on the residents' notes. It allows evaluation of the residents' knowledge and heuristics while providing opportunities for feedback and self-reflection. We evaluated the utility of CSR for improving the radiology residents' reporting skills. MATERIALS AND METHODS: Residents in each year of training were randomly assigned to an intervention group (n = 12) or a control group (n = 13). Five pre-intervention and five post-intervention reports of each resident were independently evaluated by three blinded reviewers using a modified Bristol Radiology Report Assessment Tool. The study intervention comprised a CSR interview tailored to each individual resident's learning needs based on the pre-intervention assessment. The CSR process focused on the clinical relevance of the radiology reports. Student's t test (P < .05) was used to compare pre- and post-intervention scores of each group. RESULTS: A total of 125 pre-intervention and 125 post-intervention reports were evaluated (total 750 assessments). The Cronbach's alpha for the study tool was 0.865. A significant improvement was seen in the cumulative 19-item score (66% versus 73%, P < .001) and the global rating score (59% versus 72%, P < .001) of the intervention group after the CSR. The reports of the control group did not demonstrate any significant improvement. CONCLUSION: CSR is a feasible workplace-based assessment method for improving reporting skills of the radiology residents.
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Competência Clínica , Comunicação , Internato e Residência/métodos , Radiologia/educação , Ensino , Diagnóstico por Imagem , Humanos , Entrevistas como Assunto , Estudos Prospectivos , Radiologia/métodos , Radiologia/normas , Distribuição Aleatória , Método Simples-CegoRESUMO
OBJECTIVE: To assess the frequency of various MRI findings in patients with lumbar spondylosis and determine their association with symptoms of patients. DESIGN: Cross-sectional analytical study. PLACE AND DURATION OF STUDY: Radiology Department,The Aga Khan University Hospital, Karachi, from January to December, 2002. PATIENTS AND METHODS: The study included 120 patients who presented with low back and leg pain. Segmental classification system was used to classify the pain distribution. All patients underwent lumbar MRI using 1.5 T-scanner. MRI scans was evaluated for magnitude and location of nerve compression, disc extrusion and the nature of nerve and thecal sac deformation in the central canal, lateral recess and intervertebral foramen at each spinal level. Statistical analysis was performed using computer program SPSS (Version; 10). Chi-square test was also used to determine significance of association between degree of compression, duration of symptoms, site of pain and presence of weakness and numbness. Independent samples test (Levenes test) and Chi-square test were used to determine the significance of associations between age, gender, chronicity of symptoms and MRI findings. A p-value of <0.05 was considered to indicate statistically significant association. RESULTS: The study included 120 patients, the age range was 22 to 88 years (mean 47 years). Twenty-three patients had acute pain of less than 2 months, 40 patients had recurrence of previous symptoms within past 2 months and 57 patients had chronic pain. Disc herniation was most frequent finding seen in 107 patients (89%). Eighty-eight patients (73%) had MRI evidence showing some degree of nerve or thecal sac compression. Severe nerve compression was present in 48 patients (40%). Disc extrusion was present in 22 patients (18%). There was no significant association between segmental distribution of symptoms and presence of anatomic impairment. However, severe nerve compression and disc extrusion were significantly associated with pain distal to the knees. CONCLUSION: The presence of disc extrusion or ipsilateral severe nerve compression at one or multiple side is strongly associated with distal leg pain. There should be a correlation between patient symptoms and signs of sciatica and imaging demonstration of nerve root compression before invasive therapy is undertaken.
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Vértebras Lombares , Osteofitose Vertebral/diagnóstico , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos Transversais , Feminino , Humanos , Deslocamento do Disco Intervertebral/diagnóstico , Imageamento por Ressonância Magnética , Masculino , Pessoa de Meia-Idade , Ciática/diagnósticoRESUMO
The case of a 28 years old woman presenting with headache, drowsiness and vomiting of a short duration, is presented. She was diagnosed as deep cerebral venous thrombosis on the basis of MRI findings. Treatment with heparin gave completed recovery.
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Encéfalo/patologia , Trombose Intracraniana/diagnóstico , Trombose Venosa/diagnóstico , Adulto , Encéfalo/diagnóstico por imagem , Feminino , Cefaleia/diagnóstico , Cefaleia/etiologia , Heparina/uso terapêutico , Humanos , Hipertensão/complicações , Trombose Intracraniana/complicações , Trombose Intracraniana/tratamento farmacológico , Imageamento por Ressonância Magnética , Flebografia , Resultado do Tratamento , Trombose Venosa/complicações , Trombose Venosa/tratamento farmacológico , Vômito/diagnóstico , Vômito/etiologiaRESUMO
Technology assessment should touch upon four areas; utility, target population, cost and alternatives. Hybrid Positron Emission Tomography/Computed Tomography (PET/CT) is a promising modality for oncologic imaging. However, reservations about its accessibility and affordability prevail. Magnetic Resonance Imaging (MRI) is an alternative with certain key advantages that can potentially prove equivalent if not better than PET/CT. We have highlighted the value of comparative studies between PET/CT and whole body MRI. Diffusion Weighted sequences may aid in better diagnosis of malignancies on MRI. The 'Eye of Medicine' should not have a restricted vision even where there is no PET/CT.