Multiple system atrophy - The cerebellar type with “hot cross bun sign” on MRI

Multiple system atrophy (MSA) is an adult onset, progressive, idiopathic neurodegenerative disease that clinically manifest as MSA-C with cerebellar signs predominant, MSA-P with Parkinsonian features predominant and MSA-A with autonomic signs and symptoms. MRI has an important role in its diagnosis with a characteristic finding described as hot cross bun sign seen in MSA of cerebellar type (MSA-C). We have seen two cases of MSA-C referred to Radiology Department, Civil Hospital Karachi in February 2017 and March 2017 who presented with difficulty in walking and speech and foecal and urinary incontinence. The MRI showed atrophy of pons, cerebellum and middle cerebellar peduncles with cruciform hyperintense signals in pons (hot cross bun sign). Multiple system atrophy has no specific treatment so the patients were on supportive therapy. We are reporting these interesting cases along with the clinical and radiological findings as well as literature review

Medical Disorders in Pregnancy Among Inpatients at a Tertiary Level Hospital of Peshawar (Khyber Pakhtunkhwa)

OBJECTIVES This study aimed to determine the prevalence, type, and demographic makeup of pregnancy-related medical conditions among patients receiving treatment in a tertiary care facility. METHODOLOGY The Monocentric retrospective impact study was conducted in the Department of Obstetrics and Gynaecology of MTI, Hayatabad Medical Complex Peshawar, from January to December 2022. Case records of all pregnant women (n=1811) with previous or recently developed medical conditions treated during the study period were collected from the records / medical registers, and all the information was recorded in a pre-structured proforma. All women with previous or recently developed medical conditions treated during the study were included. All pregnant women without any medical conditions were excluded. Data was analyzed using simple statistical measures, and the results were presented as frequency percentages. Prior approval from the institution’s ethical committee was obtained to conduct the study. vRESULTS Among 6327 antenatal admissions, 1811 (28.62%) women had medical disorders. The most common medical disorder was PIH, reported in 384 (21.20%) of the females, followed by RH incompatibility and Gestational Diabetes Mellitus (GDM) seen in 235 (12.98%) and 205 (11.32%) females, respectively. Other notable medical conditions include UTI in 170 (9.39%), Chronic HTN in 134 (7.40%), iron deficiency anemia in 122 (6.74%), and pre-eclampsia in 100 (5.52%) of women. CONCLUSION Pre-existing medical conditions in pregnancy are not uncommon. Early recognition of acute illness and treatment of chronic conditions in pregnancy is of clear benefit and needs to be managed to arrest any adversaries to the mother and fetus

Substantial and sustained reduction in under-5 mortality, diarrhea, and pneumonia in Oshikhandass, Pakistan : Evidence from two longitudinal cohort studies 15 years apart

Funding Information: Study 1 was funded through the Applied Diarrheal Disease Research Program at Harvard Institute for International Development with a grant from USAID (Project 936–5952, Cooperative Agreement # DPE-5952-A-00-5073-00), and the Aga Khan Health Service, Northern Areas and Chitral, Pakistan. Study 2 was funded by the Pakistan US S&T Cooperative Agreement between the Pakistan Higher Education Commission (HEC) (No.4–421/PAK-US/HEC/2010/955, grant to the Karakoram International University) and US National Academies of Science (Grant Number PGA-P211012 from NAS to the Fogarty International Center). The funding bodies had no role in the design of the study, data collection, analysis, interpretation, or writing of the manuscript. Publisher Copyright: © 2020 The Author(s).Peer reviewedPublisher PD

Exploring UK medical school differences: the MedDifs study of selection, teaching, student and F1 perceptions, postgraduate outcomes and fitness to practise.

BACKGROUND: Medical schools differ, particularly in their teaching, but it is unclear whether such differences matter, although influential claims are often made. The Medical School Differences (MedDifs) study brings together a wide range of measures of UK medical schools, including postgraduate performance, fitness to practise issues, specialty choice, preparedness, satisfaction, teaching styles, entry criteria and institutional factors. METHOD: Aggregated data were collected for 50 measures across 29 UK medical schools. Data include institutional history (e.g. rate of production of hospital and GP specialists in the past), curricular influences (e.g. PBL schools, spend per student, staff-student ratio), selection measures (e.g. entry grades), teaching and assessment (e.g. traditional vs PBL, specialty teaching, self-regulated learning), student satisfaction, Foundation selection scores, Foundation satisfaction, postgraduate examination performance and fitness to practise (postgraduate progression, GMC sanctions). Six specialties (General Practice, Psychiatry, Anaesthetics, Obstetrics and Gynaecology, Internal Medicine, Surgery) were examined in more detail. RESULTS: Medical school differences are stable across time (median alpha = 0.835). The 50 measures were highly correlated, 395 (32.2%) of 1225 correlations being significant with p < 0.05, and 201 (16.4%) reached a Tukey-adjusted criterion of p < 0.0025. Problem-based learning (PBL) schools differ on many measures, including lower performance on postgraduate assessments. While these are in part explained by lower entry grades, a surprising finding is that schools such as PBL schools which reported greater student satisfaction with feedback also showed lower performance at postgraduate examinations. More medical school teaching of psychiatry, surgery and anaesthetics did not result in more specialist trainees. Schools that taught more general practice did have more graduates entering GP training, but those graduates performed less well in MRCGP examinations, the negative correlation resulting from numbers of GP trainees and exam outcomes being affected both by non-traditional teaching and by greater historical production of GPs. Postgraduate exam outcomes were also higher in schools with more self-regulated learning, but lower in larger medical schools. A path model for 29 measures found a complex causal nexus, most measures causing or being caused by other measures. Postgraduate exam performance was influenced by earlier attainment, at entry to Foundation and entry to medical school (the so-called academic backbone), and by self-regulated learning. Foundation measures of satisfaction, including preparedness, had no subsequent influence on outcomes. Fitness to practise issues were more frequent in schools producing more male graduates and more GPs. CONCLUSIONS: Medical schools differ in large numbers of ways that are causally interconnected. Differences between schools in postgraduate examination performance, training problems and GMC sanctions have important implications for the quality of patient care and patient safety

The Analysis of Teaching of Medical Schools (AToMS) survey: an analysis of 47,258 timetabled teaching events in 25 UK medical schools relating to timing, duration, teaching formats, teaching content, and problem-based learning.

BACKGROUND: What subjects UK medical schools teach, what ways they teach subjects, and how much they teach those subjects is unclear. Whether teaching differences matter is a separate, important question. This study provides a detailed picture of timetabled undergraduate teaching activity at 25 UK medical schools, particularly in relation to problem-based learning (PBL). METHOD: The Analysis of Teaching of Medical Schools (AToMS) survey used detailed timetables provided by 25 schools with standard 5-year courses. Timetabled teaching events were coded in terms of course year, duration, teaching format, and teaching content. Ten schools used PBL. Teaching times from timetables were validated against two other studies that had assessed GP teaching and lecture, seminar, and tutorial times. RESULTS: A total of 47,258 timetabled teaching events in the academic year 2014/2015 were analysed, including SSCs (student-selected components) and elective studies. A typical UK medical student receives 3960 timetabled hours of teaching during their 5-year course. There was a clear difference between the initial 2 years which mostly contained basic medical science content and the later 3 years which mostly consisted of clinical teaching, although some clinical teaching occurs in the first 2 years. Medical schools differed in duration, format, and content of teaching. Two main factors underlay most of the variation between schools, Traditional vs PBL teaching and Structured vs Unstructured teaching. A curriculum map comparing medical schools was constructed using those factors. PBL schools differed on a number of measures, having more PBL teaching time, fewer lectures, more GP teaching, less surgery, less formal teaching of basic science, and more sessions with unspecified content. DISCUSSION: UK medical schools differ in both format and content of teaching. PBL and non-PBL schools clearly differ, albeit with substantial variation within groups, and overlap in the middle. The important question of whether differences in teaching matter in terms of outcomes is analysed in a companion study (MedDifs) which examines how teaching differences relate to university infrastructure, entry requirements, student perceptions, and outcomes in Foundation Programme and postgraduate training

Long-term complications following different treatment modalities for mandibular fractures

Background: All the approaches for mandibular fracture treatment have their associated advantages and complications. The complications associated with treated mandibular fractures as listed in literature are found to be approximately in the range of 9% to 36 percent. Various complications seen after treating mandibular fractures can be attributed to the site of the fracture, type of fracture, displacement, peri-operative occlusion, contributing factors, and treatment chosen. Aims: The present trial was aimed at evaluating various long-term complications associated with different treatment procedures for managing mandibular fractures. Materials and Methods: 78 subjects were retrospectively analyzed within the age range of 19 years to 62 years with the mean age range of 42.4 years. The previous records of the patients were obtained from the previous hospital records for analyzing retrospectively. The patients managed either with open reduction and internal fixation or with closed reduction. Weekly follow-up was done for all the subjects for 6 weeks post-operatively to assess the complications. The collected data were subjected to statistical evaluation. Results: Fractures of parasymphysis and ZMC were most commonly seen in the study population which were 30.26% (n=23) and 57.69% (n=45) respectively. This was followed by fractures of the mandibular condyle and mandibular angle with the relative percentage of 29.48% (n=.22) and 21.79% (n=17) respectively. The most common etiological factor associated with the mandibular fracture was road traffic accident with 66.66% (n=52) followed by the fall from some height which was seen in 15.38% of subjects (n=12), assault (n=6), and sports injury in 6.41% (n=5). The most common complaint reported by the study subjects post-operatively was malocclusion in 21.79% of study subjects. Among various malocclusions, open-bite was most commonly seen. The next common complication was paresthesia of the lower lip which was reported as a lack of sensitivity in 8.97% of subjects (n=7). Less commonly mandibular deviation/deflection, pain in TMJ, infection, and malunion was also noticed. Conclusion: As per the present study, a total of 47.43% (n=37) subjects presented with either major or minor complications. The most common malocclusion was open bite which was frequently seen with displaced bilateral condylar fractures. No significant difference in the postoperative complications was seen with either closed treatment or open treatment of fractured mandible. Keywords: Complications, Malocclusion, Mandibular Fracture, Retrospective, Road Traffic Accident

Comparative evaluation of Lycopene-Hyaluronidase combination and Lycopene alone in the treatment of OSMF

Introduction: OSMF is a common potentially malignant disorder found in India caused by chewing gutkha with tobacco. Many studies have proven the beneficial effect of antioxidants in the management of osmf.Aim: The aim of the present study is to compare the efficacy of antioxidant Lycopene alone and in combination with intralesional Hyaluronidase injection in the treatment of OSMF patients.Material and Method: 50 diagnosed OSMF patients (Stage-2) were included in the study and were divided randomly into two groups. Group-A patients received 8 mg capsule of lycopene daily in two equally divided dose while Group-B patients received 8 mg capsule of lycopene daily in two equally divided dose in combination with intralesional injection of hyaluronidase 1500 IU twice weekly for 3 month. The clinical parameters (inter-incisal mouth opening &amp; VAS for burning) were evaluated at baseline &amp; at the completion of treatment on 90th day.Results: By the completion of study, inter-icisal mouth opening increased significantly (p&lt;0.05) from 25.20 ± 3.01 mm to 29.36 ± 3.17 mm&amp; 24.58 ± 3.90 mm to 32.41 ± 3.22 mm for Group-A &amp; Group-B patients respectively. Changes in VAS for burning sensation decreased significantly (p&lt;0.05) from 7.16 ± 0.96 to 0.88 ± 0.72 &amp;6.47 ± 1.10 to0.20 ± 0.12 for Group-A &amp; Group-B patients respectively. Also, Group-B patients witnessed statistically significant changes in clinical parameters at 90th day compared to Group-A patients.Conclusion: Lycopene in combination with intralesional hyaluronidase is more effective in treating the patients with OSMF than lycopene alone

Mammographic parenchymal patterns in solid breast tumors

Objective: to determine the frequency of various breast parenchymal patterns on mammography and an association of the presence of a solid tumor with any pattern.Study design: analytical descriptive study.Duration and Setting: January 2009 to September 2010, at Radiology Department, Dow University of Health Sciences/Civil Hospital Karachi.Methods: Adult females diagnosed with single solid breast lesion placed in BIRADS category II-VI on mammography and ultrasound, were included. The parenchymal pattern of breast was classified into predominantly fatty (N1), \u3c 25% glandular (P1), \u3e25% glandular (P2) and very dense glandular tissue (DY) according to Wolffe’s classification. Those with multiple lumps, ductal dilatation, chemo or radiation therapy to breast, or recent hormonal or contraceptive use were excluded. The overall data was described as measures of central tendency and dispersion. Significance of association was determined using chi square test at P\u3c0.05.Results: There were a total of 76 patients with mean age of 47.6± 10.45 years; 74 (97.4%) were married with average parity of 4.5 ± 2.8 and 64 (84.2%) had lactated. Lesions included 65 (82.2%) carcinomas, 10 (10.5%) fibro adenomas and 01 (1.3%) lipoma. The distribution of parenchymal patterns was found to be 22.4% N1, 44.7% P1, 26.3% P2 and 6.6% DY patterns. There was a strong association of P1 and P2 patterns with solid breast lesions (p=0.024). The overall association of carcinoma with P1 and DY patterns was also significant (p= 0.041).Conclusion: Scattered fibro glandular and heterogeneously dense mammographic parenchyma had a strong association with presence of solid malignant lesion in breast. These findings are incongruous with the reported patterns from the West and may represent inherent oncogenic characteristic in Pakistani ladies

Solitary rectal ulcer mimicking rectal carcinoma on imaging

A 37-year lady presented with pain, per rectal bleeding and altered bowel habits. She was suspected to have a rectal growth on colonoscopy , contrast enhanced CT scan and MRI. However the CEA levels were normal and histopathology showed a solitary rectal ulcer. The report highlights the importance of this benign condition as confounding for rectal malignancy

Transient elastography of liver fibrosis in chronic hepatitis C patients: Diagnostic importance

Title: Transient Elastography of Liver Fibrosis in Chronic Hepatitis C patients: Diagnostic Importance.Objective: To determine the diagnostic accuracy of Transient Elastography of liver in assessing fibrosis in adult chronic Hepatitis C patients keeping liver biopsy as gold standard.Subjects and Methods: This cross-sectional study was conducted at the Radiology department of Civil Hospital Karachi, Pakistan from May 2014 to January 2015. Consecutive adult patients aged 18 to 60 years with presence of HCV RNA in serum according to polymerase chain reaction, and minimum of 6 months duration of known Hepatitis C were included in the study. All patients underwent transient elastography of liver by a consultant radiologist and the Principal investigator. Ten valid measurements were taken and mean value was classified accordingly (F0-F4). The elastography scores were correlated with METAVIR scores of liver biopsy. Diagnostic accuracy was determined in terms of sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV).Results: Transient elastography correctly identified presence of fibrosis in 190 (95.4%) out of 199 patients with fibrosis and ruled out fibrosis in 63 (88.7%) of 71 patients with normal liver on histopathology. The diagnostic accuracy of transient elastography in determining the presence of fibrosis was: Sensitivity 95.5%, specificity 87.5%, PPV 95.5% and NPV 88.7%. However, for assessing the stage of fibrosis the sensitivity and specificity respectively were 80% and 95.23% for F1, 79.6% and 96.29% for F2, 88% and 96.61% for F3, and 98% and 99.54% for F4.Conclusion: Transient elastography has high diagnostic accuracy in determining the presence of fibrosis as well as in assessing late fibrosis and cirrhosis (F3-F4). However, the sensitivity was comparatively less in identification of early fibrosis (F1-F2) in the studied group of patients