Anaesthetic Management in a Child with Goldenhar Syndrome

Goldenhar syndrome is a congenital disorder involving deformities of the face. It usually affects one side of the face only and poses significant challenges in the airway management. We herein, report an 8-year boy, known case of Goldenhar syndrome, who presented to our radiology suite for a magnetic resonance imaging (MRI) brain, followed by a computed tomography (CT) scan brain. The boy had various features of Goldenhar syndrome, e.g. cleft palate, absent right eye and ear, right mandibular hypoplasia, micrognathia, and preauricular tags. His developmental milestones were delayed. Airway evaluation showed Mallampati class II with limited movements of head and neck, which suggested possibility of difficult laryngoscopy and intubation. He had no vertebral anomalies or cardiac disease. A difficult airway continues to be a major cause of anaesthesia-related morbidity and mortality; and maintaining spontaneous breathing remains a vital technique in its management. Lack of anaesthesia-related complications with supraglottic devices encouraged us to present the advantage of utilising a laryngeal mask airway (LMA) under anaesthesia for successful management of predicted difficult airway

Numerical Study on The Out-of-Plane Behaviour of Brick Masonry Walls Strengthened with Cement Sand Mortar

Masonry, as a building material, has a long history of usage in construction. The utilization of brick masonry in conjunction with mortar has been widely adopted due to its ease of implementation and structural durability. However, it has been observed that masonry structures exhibit significant vulnerabilities in the face of lateral loads, particularly regarding bending and shear. As seismic activity continues to pose a growing threat, the need for effective methods of strengthening masonry structures against earthquakes is becoming increasingly imperative. In this research, the Finite Element method is employed to assess the influence of the thickness of cement-sand (CS) mortar on the flexural capacity of cement-clay interlocking brick (CCIB) masonry walls through numerical modeling. In this study, three models of CCIB masonry walls with varying thicknesses of cement-sand (CS) mortar are analyzed. The models comprised of CCIB masonry walls with a one-sided application of CS mortar layers of 10mm and 20mm thickness. The findings indicate that the flexural capacity of the CCIB masonry walls can be improved by increasing the thickness of the CS mortar layer

Cognitive disposition to respond in postgraduate trainees of general surgery at Rawalpindi Medical University

Introduction: Cognitive biases leading to diagnostic errors are associate with adverse outcomes and compromise patient safety and contribute to morbidity and mortality. Exploration and identification of cognitive biases have been a difficult task for the clinicians and medical educators. The literature is deficient in the identification of cognitive biases in surgical trainees. The objective of the study was to identify various cognitive biases that may negatively impact clinical reasoning skills and lead to diagnostic errors in trainees of general surgery. Materials and Methods: A quantitative study was conducted involving 48 trainees of general surgery to explore the various cognitive biases. The questionnaire was devised and consisted of ten items devised to explore five biases. .Descriptive statistical analysis was done on SPSS 20 and the respondents with score >25 were categorized as predisposed to error scores of 20-25 were taken as a borderline and overall score of <25 was insignificant for the presence of cognitive bias. Results: Premature closure was the most frequent cognitive bias found significant in 34 (70 %) of trainees followed by anchoring bias in 14 (58, 3 %) trainees. The relative frequencies of different biases are shown in Table 2. The mean score of the questionnaire was 22.7 (range 10 to 38) SD 7.2. Ten out of forty-eight (21%) trainees with a mean score of >25 showed a clear inclination toward cognitive errors whereas 11 (22%) with a score in the range of 21 to 25 were categorized as having an equivocal tendency towards committing an error, Whereas 27 (56%) with a score of less than 20 were less prone to cognitive errors. Conclusion: The two most common errors seen in the study were anchoring bias and premature closure and both are related to information gathering. A larger study is required to explore the association of cognitive bias with different specialties and experience of clinicians

Post-Transplantation Management Strategies

Relapse is an overwhelmingly difficult and tragic event for patients suffering from hematologic malignancies that have been treated with bone marrow transplantation. More often than not, treatment options are fairly limited in each disease. Selecting the appropriate maintenance therapy gives a chance to delay or avoid these recurrences entirely. Although no perfect combination of drugs has yet been established as a mainstay maintenance therapy post-transplant, the authors here discuss the most effective and safest drugs available for different diseases

Type 1 diabetes mellitus presenting with diabetic ketoacidosis (DKA) in a neonate

Neonatal diabetes mellitus (NDM) is a rare manifestation with an incidence of one affected individual among 400000 live births. NDM can be divided into Transient (TNDM) and Permanent (PNDM) types. A significant overlap occurs between both groups, to an extent that TNDM cannot be distinguished from PNDM based solely on clinical features. Diabetic ketoacidosis (DKA) is the leading cause of morbidity and mortality in children with type 1 diabetes mellitus (TIDM). DKA at diagnosis is more common in young children near the age of five years. Neonatal DKA is a rare occurrence causing it to be missed in the differential diagnosis of neonatal illness and results delay in appropriate management and increase in morbidity and mortality rate

Visual Improvement after Endoscopic Endonasal Transsphenoidal Excision of Pituitary Gland Tumor

Objective: To evaluate the frequency of improved visual acuity after Endoscopic Endonasal Transsphenoidal excision of pituitary gland tumor.Study Design: Descriptive case series.Materials and Methods: In our study, Pre-operative visual acuity was noted by using the Snellen’s chart. Then patients underwent pituitary gland excision though Endoscopic Endonasal Transsphenoidal approach under general anesthesia. After surgery, patients were shifted in postsurgical wards and then will be discharged from there and were examinedfor 3 months in OPD. Snellen’s chart was used to evaluate patents for visual acuity after 3 months by an experienced ophthalmologist having at least 4 years residency experience If visual acuity increased ≥ 1 line, then improved visual acuity was labeled.Results: Improved visual acuity after pituitary gland tumor excision was seen in 59(89.39%) patients. Age and gender of patients did not show any statistically significant association for improved visual acuity.Conclusions: Results of this study showed that pituitary gland tumor excision through Endoscopic Endonasal Transsphenoidal approach is effective in terms of visual acuity improvement. Our main objectives in pituitary surgery are protection and reinstatement of vision and this surgical approach give maximum cover to vision restoration

Myasthenia Gravis Mimicking Third Cranial Nerve Palsy: a Case Report

Background: The most common pituitary adenoma presentation is a visual field defect and inappropriate pituitary hormone secretion. The compression of the optic chiasma causes visual impairment. Large pituitary adenomas can rarely cause diplopia and ptosis secondary to adenoma's lateral extension into the cavernous sinus. Myasthenia gravis (MG) is an autoimmune disorder involving neuromuscular junctions. It is characterized by skeletal muscle fatigability, commonly involving extraocular muscles, face, and limbs. It is estimated that 75% of MG patients present with ptosis and diplopia. The association of MG with pituitary adenoma is very rare. Case Description: A 30-year-old lady presented with headache, diplopia, and ptosis of the left eye for two months. She was diagnosed with acromegaly secondary to pituitary adenoma. Ptosis is a rare presenting feature in pituitary adenoma. Her case was discussed in a multidisciplinary meeting, and the consensus was that her ptosis is likely secondary to pituitary adenoma, which was involving the left cavernous sinus. She underwent transsphenoidal resection of pituitary macro adenoma. Three weeks post-surgery, she developed bilateral ptosis, dysarthria, dysphonia, which was diagnosed as myasthenia gravis. Clinical implications: Ptosis is a rare manifestation of pituitary adenoma. Nonetheless, pituitary tumor patients presenting with ptosis should be evaluated for the neuromuscular disorder. A high index of suspicion is required for early diagnosis and prompt treatment of myasthenia gravis

Revisit a realistic intersecting D6-brane with modified soft SUSY terms

Because there are a few typos in the supersymmetry breaking sfermion masses and trilinear soft term, regarding the current Large Hadron Collider (LHC) and dark matter searches, we revisit a three-family Pati-Salam model based on intersecting D6-branes in Type IIA string theory on a $\mathbf{T^6/(\Z_2\times \Z_2)}$ orientifold with a realistic phenomenology. We study the viable parameter space and discuss the spectrum consistent with the current LHC Supersymmetry searches along with the dark matter relic density bounds from the Planck 2018 data. For the gluinos and first two generations of sfermions, we observe that the gluino mass is in the range [2, 14] TeV, the squarks mass range is [2, 13] TeV and the sleptons mass is in the range [1, 5] TeV. We achieve the cold dark matter relic density consistent with 5$\sigma$ Planck 2018 bounds via A-funnel and coannihilation channels such as stop-neutralino, stau-neutralino, and chargino-neutralino. Except for a few chargino-neutralino coannihilation solutions, these solutions also satisfy current nucleon-neutralino spin-independent and spin-dependent scattering cross-sections and may be probed by future dark matter searches.Comment: 18 pages, 6 figure