Pituitary stalk interruption syndrome presenting as short stature: a case report

Introduction: Pituitary stalk interruption syndrome is a rare congenital abnormality of the pituitary that is responsible for anterior pituitary deficiency. It is characterized by a classic triad of interrupted pituitary stalk, absent or ectopic posterior pituitary, and anterior pituitary hypoplasia or aplasia. Clinical presentation varies according to age. In adults it presents as short stature and anterior pituitary deficiency. Without early diagnosis and treatment, mortality and morbidity in these patients is high. Early diagnosis and treatment of this rare disease can prevent permanent short statue of the patient. We report the first case of pituitary stalk interruption syndrome from Pakistan. CASE PRESENTATION: A 17-year-old Pakistani young man presented with short stature and underdeveloped secondary sexual characters. His siblings and parents were healthy, with normal height. An examination showed his blood pressure was 90/60 mmHg, and his height, weight, and body mass index were 142 cm, 34.5 kg, and 17.10 kg/m2, respectively. He had no hair growth on his face, axilla, or pubis. His testes were between 1 and 2 mL in size, with a 4 cm-at-stretch micropenis. His lab investigations showed that his thyroid stimulating hormone (TSH) was 8.58 uIU/mL (0.4 to 4.2), his free thyroid hormone level FT4 was 0.46 ng/dL (0.89 to 1.76), his prolactin was 21.1 ng/mL (3.0 to 14.7), and his baseline cortisol was 0.30 ug/dL (4.3 to 22.4). His cortisol level after 60 minutes of cosyntropin injection was 3.5 ug/dL (4.3 to 22.4), his insulin like growth factor IGF-1 was 31.56 ng/mL (247.3 to 481.7), his testosterone level was under 2.5 ng/dL (2 to 800), his follicle stimulating hormone FSH was 0.41 uIU/mL (0.0 to 10.0), and his leutinizing hormone LH was under 0.1 uIU/mL (1.2 to 7.8). His bone age was 10 years according to the Greulich and Pyle method, as shown by X-rays. The results from his pituitary magnetic resonance imaging scan were consistent with pituitary stalk interruption syndrome. CONCLUSIONS: We describe a young man who presented with short stature and was found to have pituitary stalk interruption syndrome. Despite the fact that this is a rare disorder, it should always be kept in the differential diagnosis of a patient presenting with short stature. Patients with this disease have an excellent opportunity to reach normal height if they present before the joining of epiphyses

Development of skin hypopigmentation in a patient with metastatic papillary carcinoma thyroid treated with Sorafenib.

Background: Sorafenib can be considered as the effective option of treatment in patients with metastatic radioiodine refractory differentiated thyroid cancers. The cutaneous manifestations of Sorafenib include rash, desquamation, hand foot skin reactions, pruritus, alopecia and erythema. We report the first case of hypopigmentation related to sorafenib therapy. Case presentation: We report the case of a middle aged gentleman with metastatic papillary carcinoma of thyroid diagnosed in 2005. He was managed with total thyroidectomy, radioactive iodine and TSH suppressive therapy. Despite receiving radioactive iodine 530 mci cumulative dose, patient had persistant disease with lung metastasis. Therefore a TKI, sorafenib, was started. He developed hypopigmentation of the skin more prominent on face six weeks after starting sorafenib treatment.He also developed diarrhea, desquamation of hands and feet, hair loss over scalp, eye brows and moustache. Sorafenib treatment was discontinued. His diarrhea stopped in one week and after four weeks his skin became normalized whereas he regained his hairs in six weeks. Conclusion: To our knowledge, hypopigmentation in our patient appears to be the first reported of its kind in the literature to date. Sorafenib is used in Renal cell carcinoma, Hepatcellular carcinoma and radioactive iodine refractory thyroid carcinoma therefore it is very important to be aware of hypopigmentation as a potential side effect for both physicians and patients

Inguinal Hernia Repair on Day Care Basis During Global COVID-19 Pandemic

  Abstract Background: COVID-19 has effected General Surgical Elective list and most of the surgical procedures are postpone. Inguinal hernia surgery can be performed under local anesthesia on day care basis in selected group of patients taking all necessary precautions for COVID-19. Patients & Methods: This prospective study was conducted at department of General Surgery Federal Hospital, Islamabad for a period of three months from 15th March 2020 to 15th June 2020. All patients were included in the study through purposive sampling and preference was given to patients elder than 50 years of age. This study included 59 adult patients with inguinal hernia who under mesh repair under local anaesthesia on day care basis. Results: A total of 59 patients were included in the study. All patients were male. The age range was from 37 to 82 years (SD=± 10.23).  30 (50.84%) patient had inguinal hernia on left side while 26 (44.06%) had hernia on right side. Mean Operative time was 35 min. Pain was chief complaint postoperatively 30 (50.8%) patients had moderate pain while 6 (10.1%) patients had severe pain in first 24 hours after surgery. Fever was present in 15 (25.42%) patients in first 24 hours. All patients were negative for COVID -19 preoperatively and after 2 weeks none of the patients develop any symptoms of COVID-19. 3 (5.08%) patients needed readmission within 24 hours for pain and some haemorrhage. There was no mortality in our study Conclusions: Inguinal Hernia Surgery under local anaesthesia on day care basis in a very good practice at this time of global pandemic of COVID-19. This is a safe and reliable strategy. Key words: Inguinal Hernia, COVID-19, Local Anaesthesia &nbsp

Frequency of Capillary leak syndrome in Dengue fever Patients

Abstract Background: Dengue fever is the world’s fastest spreading mosquito borne viral infection. It is prevalent throughout both subtropical and tropical region if the world. The severe form of dengue fever with bleeding manifestations called as dengue hemorrhagic fever. Some of the Dengue fever patients developed capillary leak during critical period of illness. This study aims at determining the frequency of capillary leak syndrome in hospitalized dengue fever patients of tertiary care hospital. Patients and Methods: The study was conducted over a period of one month from 1st October to 30th October 2019 at department of Medicine Federal Government Polyclinic Post Graduate Medical Institute, Islamabad. This cross sectional study comprising 200 consecutive hospitalized (≥14 years of both gender) dengue fever patients. Results: Capillary leak syndrome found in 75 patients of Dengue fever. All of them were Primary Dengue Patients. Both ascites and effusion was present in 31 patients. Ascites only found in 25 patients, Pleural effusion bilateral in 7, Right sided pleural effusion in 11 and Left sided in 1 patient. None of the patient had pericardial effusion. Conclusion: It is concluded that capillary leak syndrome is common in primary dengue fever patients and its early diagnosis helps us in better management during critical phase of illness with better outcome. Key Words: Dengue Fever, Capillary Leak Syndrome, Dengue Shoc

In vitro shoot regeneration of fenugreek (Trigonella foenum-graecum L.) using different cytokinins

Fenugreek (Trigonella foenum-graecum L.) is an important vegetable, spice and medicinal legume plantused as fresh and dried leaves and seeds in many parts of the world. Fenugreek seeds contain polysaccharide galactomannan and different saponins and have anti-microbial activity. The study presents an efficient shoot regeneration protocols from 8 - 10 days old in vitro grown cotyledon node explants cultured on Murashige and Skoog (MS) medium supplemented with 0.05 - 0.80 mg/l kinetin, 0.25 - 1.0 mg/l 6 benzyladenine (BA) with 0 and 0.20 mg/l α naphtalene acetic acid (NAA) and 0.05 - 0.80 mg/l thidiazuran (TDZ) with 0 and 0.10 mg/l indole 3 butyric acid (IBA). All culture mediums were solidified with 0.22% gelrite. Maximum shoot regeneration and number of shoots per explant were recorded on MS medium supplemented with TDZ with or without IBA. Maximum of 22.21 shoots per explant were recorded on MS medium containing 0.40 mg/l TDZ. Presence of auxins in the culture medium positively increased the mean shoot length. Regenerated shoots were transferred to rooting media containing 0.1 - 1.0 mg/l IBA or NAA.Key words: Fenugreek , cotyledon node, hypocotyl, shoot regeneration

Clinicopathologic Spectrum of Nephrotic Syndrome in the Elderly

The elderly population is affected by a wide range of kidney diseases like young adult patients. However, their clinical course and morphological manifestations are affected by aging. Recognition, diagnosis, and management of glomerular disease in elderly persons have several unique challenges. We aimed to study the clinicopathologic spectrum of elderly patients with nephrotic syndrome (NS). In this retrospective study, we looked at 234 patients of adult NS who were biopsied during the last 5 years. Among them, 31 patients were above the age of 60 years (Elderly). Mean age in elderly patients was 67.48 ± 6.11 years, with age range from 60 to 86 years. Elderly NS patients constituted 13.2% of total adult NS patients. Nineteen patients (61.2%) were males and 12 (38.7%) were females. Hematuria was observed in 19% and hypertension in 48% patients. Mean serum albumin was 2.79 ± 0.39 g/dl and mean 24 h urinary protein was 3.77 ± 0.8 grams. Membranous nephropathy (MN) followed by minimal change disease (MCD) was the most common diagnosis. No major complication with biopsy was reported in our study as has been the case with most studies

Geo-spatial reporting for monitoring of household immunization coverage through mobile phones: Findings from a feasibility study

Background: The addition of Global Positioning System (GPS) to a mobile phone makes it a very powerful tool for surveillance and monitoring coverage of health programs. This technology enables transfer of data directly into computer applications and cross-references to Geographic Information Systems (GIS) maps, which enhances assessment of coverage and trends.Objective: Utilization of these systems in low and middle income countries is currently limited, particularly for immunization coverageassessments and polio vaccination campaigns. We piloted the use of this system and discussed its potential to improve the efficiency of field-based health providers and health managers for monitoring of the immunization program.Methods: Using 30×7 WHO sampling technique, a survey of children less than five years of age was conducted in random clusters of Karachi, Pakistan in three high risk towns where a polio case was detected in 2011. Center point of the cluster was calculated by the application on the mobile. Data and location coordinates were collected through a mobile phone. This data was linked with an automated mHealth based monitoring system for monitoring of Supplementary Immunization Activities (SIAs) in Karachi. After each SIA, a visual report was generated according to the coordinates collected from the survey.Result: A total of 3535 participants consented to answer to a baseline survey. We found that the mobile phones incorporated with GIS maps can improve efficiency of health providers through real-time reporting and replacing paper based questionnaire for collection of data at household level. Visual maps generated from the data and geospatial analysis can also give a better assessment of the immunizationcoverage and polio vaccination campaigns.Conclusion: The study supports a model system in resource constrained settings that allows routine capture of individual level data through GPS enabled mobile phone providing actionable information and geospatial maps to local public health managers, policy makers and study staff monitoring immunization coverage

Preablation Stimulated Thyroglobulin/TSH Ratio as a Predictor of Successful I(131)Remnant Ablation in Patients with Differentiated Thyroid Cancer following Total Thyroidectomy

Background. About 90% of thyroid cancers are differentiated thyroid cancers. Standard treatment is total thyroidectomy followed by radioactive I(131)remnant ablation and TSH suppression with thyroxine. Unsuccessful ablation drastically affects the prognosis of patients with DTC particularly high risk individuals; therefore, identifying the factors that affect the success of ablation is important in the management of patients with DTC. sTg is a good predictor of successful ablation in DTC. Its levels can be influenced by tumor staging and TSH values, as well as other factors. Therefore, we did this study using TSH to correct the predictive value of sTg in success of RRA. Methods. We retrospectively reviewed the records of 75 patients with DTC, who underwent total thyroidectomy followed by RRA and TSH suppression. Results. Preablation sTg and sTg/TSH ratio are significantly associated with ablation outcome. Cutoff value for sTg to predict successful and unsuccessful ablation was 18ng/mL with 76.7% sensitivity and 79.1% specificity, while for sTg/TSH cutoff was 0.35 with 81.4% sensitivity and 81.5% specificity (P \u3c 0.001). Association was stronger for sTg/TSH ratio with adjusted odds ratio (AOR) 11.64 (2.43-55.61) than for sTg with AOR 5.42 (1.18-24.88). Conclusions. Preablation sTg/TSH ratio can be considered as better predictor of ablation outcome than sTg, tumor size, and capsular invasion

Effect of mobile phone text message reminders on routine immunization uptake in Pakistan: randomized controlled trial

Background: Improved routine immunization (RI) coverage is recommended as the priority public health strategy to decrease vaccine-preventable diseases and eradicate polio in Pakistan and worldwide.Objective: The objective of this study was to ascertain whether customized, automated, one-way text messaging (short message service, SMS) reminders delivered to caregivers via mobile phones when a child is due for an RI visit can improve vaccination uptake and timelines in Pakistan.Methods: This was a randomized controlled trial, conducted in an urban squatter settlement area of Karachi, Pakistan. Infants less than 2 weeks of age with at least one family member who had a valid mobile phone connection and was comfortable receiving and reading SMS text messages were included. Participants were randomized to the intervention (standard care + one-way SMS reminder) or control (standard care) groups. The primary outcome was to compare the proportion of children immunized up to date at 18 weeks of age. Vaccine given at 6, 10, and 14 weeks schedule includes DPT-Hep-B-Hib vaccine (ie, diphtheria, pertussis, and tetanus; hepatitis B; and Haemophilus influenza type b) and oral poliovirus vaccine (OPV). Data were analyzed using chi-square tests of independence and tested for both per protocol (PP) and intention-to-treat (ITT) analyses.Results: Out of those approached, 84.3% (300/356) of the participants were eligible for enrollment and 94.1% (318/338) of the participants had a working mobile phone. Only children in the PP analyses, who received an SMS reminder for vaccine uptake at 6 weeks visit, showed a statistically significant difference (96.0%, 86/90 vs 86.4%, 102/118; P=.03).The immunization coverage was consistently higher in the intervention group according to ITT analyses at the 6 weeks scheduled visit (76.0% vs 71.3%, P=.36). The 10 weeks scheduled visit (58.7% vs 52.7%, P=.30) and the 14 weeks scheduled visit (31.3% vs 26.0%, P=.31), however, were not statistically significant.Conclusions: Automated simple one-way SMS reminders in local languages might be feasible for improving routine vaccination coverage. Whether one-way SMS reminders alone can have a strong impact on parental attitudes and behavior for improvement of RI coverage and timeliness needs to be further evaluated by better-powered studies and by comparing different types and content of text messages in low-and middle-income countries (LMICs)

Prevalence of anemia in pediatric patients of traumatic brain injury and problems associated with management in a developing country: unfolding of an underrated comorbidity

Background: Pediatric anemia has a high prevalence in developing countries such as Pakistan. It is common knowledge among hospital specialties but little is done to manage this condition by hospitalists. The issue is compounded with a poor primary care infrastructure nationally. The aim of this study is to bring to light the high prevalence of anemic children in neurosurgery and to describe the difficulties in managing their anemia in a tertiary hospital setting. A literature review is presented highlighting the socioeconomic difficulties that contribute to this widespread comorbidity and the difficulty in managing it from a hospital specialty point of view. Methods: A prospective descriptive case series was carried out between March 2020 and September 2020. All patients under the age of 13 who presented to our department for traumatic brain injury (TBI) meeting our inclusion and exclusion criteria were enrolled and assessed for the presence and severity of anemia. Demographic data were collected. Following discharge, patients were referred to our hospital’s pediatrics’ anemia clinic which was before their first neurosurgery follow-up 2 weeks following discharge and attendance to follow up was documented. Results: The prevalence of anemia was 78.9%. Over 95% of patients attended their neurosurgery follow-up but only 28% of patients attended their referral to the anemia clinic. Conclusion: Anemia is highly prevalent in children presenting to neurosurgery for TBI and its longitudinal management has difficulties with lost to follow up in a tertiary hospital setting. There is a need for national initiatives to reduce the prevalence of anemia but concurrently better strategies need to be devised to manage anemic children in a hospital setting