Germ Cell Tumor and Takotsubo Cardiomyopathy: A Treatment Dilemma

Germ cell tumors (GCT) are uncommon malignancies in adult males and comprise less than 1% of male cancers. Due to highly curative nature and productive life years gained after treatment; reduction of chemotherapy related toxicities becomes vital. Cisplatin is the backbone of GCT chemotherapy, & is related to myocardial injury, thromboembolism & vasculitis. Though it should not be replaced with Carboplatin, however in certain circumstances, its use maybe unsafe; especially in cases when patient have prior myocardial infarction. We report a case of Takotsubo cardiomyopathy (TCM)secondary to GCT diagnosis in a young male. This patient presented withsymptoms of myocardial infarction however, coronary angiography was normal and a diagnosis of TCM was made. Though, it is rare but a unique challenge, as whether Cisplatin use would be safe in this particular scenario? On one hand patient had stress related myocardial injurywhile he was also at risk of further Cisplatin induced complications.There are no clear cut guidelines, so after informed consent his treatment regimen was modified to EC (Etoposide/Carboplatin) instead of EP (Etoposide/Cisplatin). Patient has completed 4.6 years of follow-up without any evidence of relapse. We suggest informed decisions and to weigh the pros and cons of using an inferior regimen, in order to achieve same long term prognosis while preventing any acute complications,in younger patients with curable cancers

Effects of Exposure Time to Sun on Hair Fall During Lockdown in Covid Pandemic

OBJECTIVES The study aimed to assess the effects of quarantine on non-scarring hair fall and to determine the relationship between sun exposure and hair fall. METHODOLOGY This cross-sectional study was conducted in Karachi from January to June 2022 . Ethical approval was taken from the institutional ethical review committee. Participants were recruited by non-probability convenience sampling technique after obtaining informed consent. Those with dermatologic diseases of the scalp (cicatricial alopecia, alopecia areata, seborrheic dermatitis, infections), high-stress levels, post-pregnancy, thyroid disorders, hormonal disorders and COVID-19 were excluded from the study. Hair loss was assessed using a self-filled questionnaire regarding the history of comorbidities, demographics, education, institute status during quarantine, hair fall experience and personal habits. RESULTSThe study consisted of 137 participants after exclusion criteria were applied. Among these, 95.6% complained of increased hair fall during quarantine. Most participants were women (63.4%) compared to men (36.6%). The average age of the hair fall group was 20 years. Only 15.3% of participants spent more than 1-2 hours in the sun, and the majority had their hair covered when going out during quarantine. CONCLUSION Hair fall is high during quarantine, particularly among women of young age group. Personal habits and exposure to the sun for a short time at noon can affect hair fall in quarantine, although no direct correlation was found. Hair fall during lockdown is inversely related to certain comorbidities

Primary Prostatic Diffuse Large B-Cell Lymphoma: a Case Report and Literature Review

Introduction: Primary lymphomas of the prostate are globally rare representing less than 0.1% of all prostatic neoplasms. In this paper we present a case of an early stage diffuse large B-cell lymphoma (DLBCL) of the prostate managed with six cycles of rituximab-based chemotherapy, and review the related literature. Case description: A 32-year-old man presented to our clinic with complaints of difficult urination and perineal pain. An enlarged, hard and nodular prostate was palpable on digital rectal examination. Needle biopsy of the prostate was performed, which revealed diffuse large B-cell non-Hodgkin's lymphoma by immunohistochemical studies. CT scan showed large pelvic mass arising from prostate encasing ureters with bilateral hydronephroureter.  No abnormal finding was seen on abdominal CT and bone marrow histology. Therefore, the disease was classified into the clinical stage IAXE according to Ann Arbor's criteria. The patient achieved complete response (CR) to six cycles of rituximab based combination chemotherapy, R-CHOP with CNS prophylaxis. He remained disease free, until now, 36 months after the end of chemotherapy. Practical Implications: According to the literature, the treatment and prognosis of primary lymphoma of the prostate is the same as that of other nodal lymphomas. Rituximab-based regimen should be considered in the management of prostatic diffuse large B-cell lymphoma

Borderline Tumors of the Ovary: A Clinicopathological Study

Objective: To report experience with borderline ovarian tumors (BOTs) in a developing country like Pakistan with limited resources and weak database of health system. Methods: Patients with BOTs managed at Shaukat Khanum Cancer hospital, Lahore, Pakistan from 2004 to 2014 were included and reviewed retrospectively. Data was recorded on histopathological types, age, CA-125, stage of disease, treatment modalities and outcomes. Results: Eighty-six patients with BOT were included with a median age of 35 years. Forty-two (49%) patients had serous BOTs and 43 (50%) had mucinous BOTs, while one (1%) had mixed type. Using FIGO staging, 80 patients had stage I; two patients had IIA, IIB and stage III each. Median follow-up time was 31.5 months. All patients had primary surgery. Seventy (81%) patients underwent complete surgical resection of tumor. Forty-three (50%) patients had fertility preserving surgery. Seventy-three (85%) patients remained in remission. Recurrent disease was observed in 13 (15%) patients. Median time to recurrence was 22 months. On further analysis, age above forty years, late stage at diagnosis and incomplete surgery were significantly associated with invasive recurrence. Conclusion: Despite a low malignant potential, relapses may occur in patients above forty years of age, incomplete surgery and staging information and advanced stage at presentation. Fertility sparing surgery should be considered in young patients. Complete excision of tumor and prolonged follow-up are advised because recurrence and transformation to invasive carcinoma may occur

Efficacy of Chemotherapy for Locally Advanced and Metastatic Pancreatic Cancer: A real life experience and outcome from a tertiary referral centre.

Introduction: To report response rate, progression-free survival and overall survival in patients with advanced pancreatic cancer treated with different available chemotherapeutic regimens over ten years. Materials and Methods: This is a retrospective observational study. All patients with locally advanced and metastatic pancreatic cancer at Shaukat Khanum Memorial Cancer Hospital and Research Centre, Lahore, Pakistan, from January 2008 to December 2017 were studied. Data were collected from the hospital information system. The characteristics and outcomes of all the patients were analyzed. Progression-free survival and overall survival were also estimated. Kaplan Meier curves and Log-rank test were applied, and SPSS version 20 was used for data analysis. Results: Eighty-seven (87) subjects with a median age of 56 years (range 21-76) were included. Sixty-two (71%) subjects were male. The most common tumor location was the head of the pancreas in 46(53%) of all the subjects. Sixty-three (72%) subjects had elevated CA-19.9 values. About 47(54%) subjects had locally advanced pancreatic cancer (LAPC), and 40(46%) subjects had metastatic pancreatic cancer (MPC). Chemotherapy regimens used were FOLFIRINOX in 23(26%), gemcitabine-based 66(65%) and capecitabine-based in 8 (9%) of the subjects.  One (1%) subject had a complete response (CR), 12(14%) had a partial response (PR), 10 (11%) had stable disease, and 59(68%) of the subjects had progressive disease (PD). The objective response rate (ORR) was 15%, and the disease control rate (DCR) was 26%. In MPC, the ORR was 10%, DCR was 18%, and tumor progression was seen in 72% of the patients, while in LAPC, the ORR was 19.1, DCR 34% and tumor progression was documented in 64% of the patients, respectively. The FOLFIRNOX chemotherapy regimen had better ORR, DCR and lesser number of progressions as compared to Gemcitabine and Capecitabine based chemotherapy regimens. The Median PFS of the whole group was 32-weeks, and the median OS was 54-weeks. The PFS was significantly higher for LAPC (39 weeks) as compared to the MPC group (25 weeks) (p=0.028). There was no statistically significant difference between the OS of these 2 groups (p=0.451). In addition, PFS was significantly higher with FOLFIRINOX chemotherapy as compared to the other chemotherapy regimens. Regarding OS, there was no statistically significant difference among all chemotherapy regimen groups (p=0.267). Conclusion: Based on our results, FOLFIRINOX remained the most effective chemotherapy regimen despite the dose modifications and toxicities in all groups, indicating that modified FOLFIRINOX could be considered as a first-line regimen in south East Asian population

Impact of opioid-free analgesia on pain severity and patient satisfaction after discharge from surgery: multispecialty, prospective cohort study in 25 countries

Background: Balancing opioid stewardship and the need for adequate analgesia following discharge after surgery is challenging. This study aimed to compare the outcomes for patients discharged with opioid versus opioid-free analgesia after common surgical procedures.Methods: This international, multicentre, prospective cohort study collected data from patients undergoing common acute and elective general surgical, urological, gynaecological, and orthopaedic procedures. The primary outcomes were patient-reported time in severe pain measured on a numerical analogue scale from 0 to 100% and patient-reported satisfaction with pain relief during the first week following discharge. Data were collected by in-hospital chart review and patient telephone interview 1 week after discharge.Results: The study recruited 4273 patients from 144 centres in 25 countries; 1311 patients (30.7%) were prescribed opioid analgesia at discharge. Patients reported being in severe pain for 10 (i.q.r. 1-30)% of the first week after discharge and rated satisfaction with analgesia as 90 (i.q.r. 80-100) of 100. After adjustment for confounders, opioid analgesia on discharge was independently associated with increased pain severity (risk ratio 1.52, 95% c.i. 1.31 to 1.76; P < 0.001) and re-presentation to healthcare providers owing to side-effects of medication (OR 2.38, 95% c.i. 1.36 to 4.17; P = 0.004), but not with satisfaction with analgesia (beta coefficient 0.92, 95% c.i. -1.52 to 3.36; P = 0.468) compared with opioid-free analgesia. Although opioid prescribing varied greatly between high-income and low- and middle-income countries, patient-reported outcomes did not.Conclusion: Opioid analgesia prescription on surgical discharge is associated with a higher risk of re-presentation owing to side-effects of medication and increased patient-reported pain, but not with changes in patient-reported satisfaction. Opioid-free discharge analgesia should be adopted routinely

Mortality from gastrointestinal congenital anomalies at 264 hospitals in 74 low-income, middle-income, and high-income countries: a multicentre, international, prospective cohort study

Summary Background Congenital anomalies are the fifth leading cause of mortality in children younger than 5 years globally. Many gastrointestinal congenital anomalies are fatal without timely access to neonatal surgical care, but few studies have been done on these conditions in low-income and middle-income countries (LMICs). We compared outcomes of the seven most common gastrointestinal congenital anomalies in low-income, middle-income, and high-income countries globally, and identified factors associated with mortality. Methods We did a multicentre, international prospective cohort study of patients younger than 16 years, presenting to hospital for the first time with oesophageal atresia, congenital diaphragmatic hernia, intestinal atresia, gastroschisis, exomphalos, anorectal malformation, and Hirschsprung’s disease. Recruitment was of consecutive patients for a minimum of 1 month between October, 2018, and April, 2019. We collected data on patient demographics, clinical status, interventions, and outcomes using the REDCap platform. Patients were followed up for 30 days after primary intervention, or 30 days after admission if they did not receive an intervention. The primary outcome was all-cause, in-hospital mortality for all conditions combined and each condition individually, stratified by country income status. We did a complete case analysis. Findings We included 3849 patients with 3975 study conditions (560 with oesophageal atresia, 448 with congenital diaphragmatic hernia, 681 with intestinal atresia, 453 with gastroschisis, 325 with exomphalos, 991 with anorectal malformation, and 517 with Hirschsprung’s disease) from 264 hospitals (89 in high-income countries, 166 in middleincome countries, and nine in low-income countries) in 74 countries. Of the 3849 patients, 2231 (58·0%) were male. Median gestational age at birth was 38 weeks (IQR 36–39) and median bodyweight at presentation was 2·8 kg (2·3–3·3). Mortality among all patients was 37 (39·8%) of 93 in low-income countries, 583 (20·4%) of 2860 in middle-income countries, and 50 (5·6%) of 896 in high-income countries (p<0·0001 between all country income groups). Gastroschisis had the greatest difference in mortality between country income strata (nine [90·0%] of ten in lowincome countries, 97 [31·9%] of 304 in middle-income countries, and two [1·4%] of 139 in high-income countries; p≤0·0001 between all country income groups). Factors significantly associated with higher mortality for all patients combined included country income status (low-income vs high-income countries, risk ratio 2·78 [95% CI 1·88–4·11], p<0·0001; middle-income vs high-income countries, 2·11 [1·59–2·79], p<0·0001), sepsis at presentation (1·20 [1·04–1·40], p=0·016), higher American Society of Anesthesiologists (ASA) score at primary intervention (ASA 4–5 vs ASA 1–2, 1·82 [1·40–2·35], p<0·0001; ASA 3 vs ASA 1–2, 1·58, [1·30–1·92], p<0·0001]), surgical safety checklist not used (1·39 [1·02–1·90], p=0·035), and ventilation or parenteral nutrition unavailable when needed (ventilation 1·96, [1·41–2·71], p=0·0001; parenteral nutrition 1·35, [1·05–1·74], p=0·018). Administration of parenteral nutrition (0·61, [0·47–0·79], p=0·0002) and use of a peripherally inserted central catheter (0·65 [0·50–0·86], p=0·0024) or percutaneous central line (0·69 [0·48–1·00], p=0·049) were associated with lower mortality. Interpretation Unacceptable differences in mortality exist for gastrointestinal congenital anomalies between lowincome, middle-income, and high-income countries. Improving access to quality neonatal surgical care in LMICs will be vital to achieve Sustainable Development Goal 3.2 of ending preventable deaths in neonates and children younger than 5 years by 2030

Prevalence of Fascioliasis in Livestock and Humans in Pakistan: A Systematic Review and Meta-Analysis

Fascioliasis is a parasitic infection that affects both livestock and humans. Understanding the distribution of Fasciola spp. can help the development of preventive measures to control fascioliasis. This systematic review and meta-analysis aimed to estimate the status of fascioliasis among livestock and humans in Pakistan between 2000 and 2020. Based on the selection criteria, 25 articles were selected from Google Scholar, PubMed, and Scopus. This review included 76,099 animals, including 13,738 that were positive for fascioliasis. The overall prevalence was 18.1%; it was 0.3% in humans and 20.1% in livestock. Among animal hosts, the prevalence was highest in sheep (53.5%), followed by the goats (44.9%), cows (21.3%), buffaloes (16.8%), cattle (12.7%), and humans (0.3%). Sindh had the highest prevalence at 42.7%, followed by Baluchistan (25.2%), Punjab (17.7%), Khyber Pakhtunkhwa (10.7%), and Islamabad capital territory (1.5%). In the Punjab province, sheep had the highest prevalence (65.7%); in Khyber Pakhtunkhwa, it was buffalo (15.9%); and in Baluchistan, it was cows (28.5%). The prevalence of Fasciola spp. was higher in Sindh and Baluchistan than in the other provinces. The presented results are essential for developing preventive approaches for the management of human health and minimizing economic loss in the livestock industry in Pakistan. Preventive-curative treatments two times a year followed by a prophylactic treatment at the end of the dry season are crucial throughout the areas of Pakistan that serve as hotspots for infection by Fasciola sp. For humans, regular, prioritized surveys must be performed for high-risk populations so that the real situation can be assessed and addressed in a timely manner

Diallyl Sulfide Attenuation of Carcinogenesis in Mammary Epithelial Cells through the Inhibition of ROS Formation, and DNA Strand Breaks

Garlic has long been used medicinally for many diseases, including cancer. One of the active garlic components is diallyl sulfide (DAS), which prevents carcinogenesis and reduces the incidence rate of several cancers. In this study, non-cancerous MCF-10A cells were used as a model to investigate the effect of DAS on Benzo (a)pyrene (BaP)-induced cellular carcinogenesis. The cells were evaluated based on changes in proliferation, cell cycle arrest, the formation of peroxides, 8-hydroxy-2-deoxyguanosine (8-OHdG) levels, the generation of DNA strand breaks, and DNA Polymerase β (Pol β) expression. The results obtained indicate that when co-treated with BaP, DAS inhibited BaP-induced cell proliferation (p &lt; 0.05) to levels similar to the negative control. BaP treatment results in a two-fold increase in the accumulation of cells in the G2/M-phase of the cell cycle, which is restored to baseline levels, similar to untreated cells and vehicle-treated cells, when pretreated with 6 μM and 60 μM DAS, respectively. Co-treatment with DAS (60 μM and 600 μM) inhibited BaP-induced reactive oxygen species (ROS) formation by 132% and 133%, respectively, as determined by the accumulation of H2O2 in the extracellular medium and an increase in 8-OHdG levels of treated cells. All DAS concentrations inhibited BaP-induced DNA strand breaks through co-treatment and pre-treatment methods at all time points evaluated. Co-Treatment with 60 μM DAS increased DNA Pol β expression in response to BaP-induced lipid peroxidation and oxidative DNA damage. These results indicate that DAS effectively inhibited BaP-induced cell proliferation, cell cycle transitions, ROS, and DNA damage in an MCF-10A cell line. These results provide more experimental evidence for garlic’s antitumor abilities and corroborate many epidemiological studies regarding the association between the increased intake of garlic and the reduced risk of several types of cancer