Peutz-Jeghers Syndrome presenting as Intussusception in a young female: A Case Report

Peutz-jeghers syndrome is rare condition with autosomal dominant inheritance. It is due to the mutation in a tumor suppressor gene SK 11 at chromosome no 9. It has a very characteristic presentation. Patient usually presents at a young age with intestinal obstruction due to polyps leading to intussusception. Also there is melanosis at perioral, digits and perineal regions. There is very strong association of cervical and breast carcinoma in females and testicular tumors in males. GIT, pancreatic and lung malignancies occur in both sexes. Regular follow up and screening are necessary for early detection of malignancies. We present a case of young girl who presented with intestinal obstruction along with other signs and symptoms of peutz-jeghers syndrome. Exploratory laparotomy revealed jejunoileal intussusception and hamartomatous polyps. Patient and other family members were advised screening studies of associated malignancies and regular follow up

794 Evaluating disability in adult burn injury patients treated at a tertiary-care burn unit in Karachi, Pakistan: a longitudinal study using who disability assessment schedule II

Abstract Background Disability after burn injury is not assessed in the context of Pakistan. This study assesses disability among adult burn injury patients presenting to a burn unit in Karachi, Pakistan. Methods This longitudinal study was conducted at a burn centre is Karachi, Pakistan. Adult patients(\u3e18 years) who were discharge after 24-hour admission were enrolled from August 2014–March 2015. Baseline assessment before discharge and follow-up at 2,6 and 12 weeks after discharge via telephone was done using 12-item WHODAS 2.0 (5 -point likert-scale; 1 = none; 2 = mild; 3 = moderate; 4 = severe; and 5 = extreme) related to cognition, mobility, self-care, getting along, life activities and participation. The score range was 12–60 with higher score being worse. Ethical approval was taken from collaborating and participating sites. Results Of the 59 eligible patients, 53 completed all follow-ups. There were 69.8% males. Mean age of all patients was 36.8 ± 14.0 years, 71.7% were married and 17.0% had no/informal education. About half the patients were breadwinners. More than half of burn incidents occurred at home. Flame burns (50.9%) and scalds (17%) were the most common type of burns. The average surface area burnt was 43.0 ± 14.2%. The mean-scores for all patients at baseline, 2-week, 6-week and 12-week were 13.9 ± 4.9, 35.3 ± 13.8, 26.8 ± 11.9 and 20.1 ± 9.1, respectively. The mean-scores for males were lower than that of females for the four assessments (Males: 13.5 ± 1.8, 34.2 ± 14.1, 25.3 ± 10.7, 19.2 ± 8.4 and females: 16.1 ± 8.5, 37.3 ± 13.3, 30.5 ± 14.4, 22.1 ± 10.6). The two-week score was higher for those with \u3e15% burn(36.7 ± 13.9) compared to those with ≤15% burn(34.6 ± 14.2) while the score were similar at 12-week follow-up. Conclusions This analysis shows that the burn injury patients tend to recover from their injury over a period of 12 weeks after discharge. Future work should focus on larger group of patients and long term follow-up at one and two years after burn injury

Intestinal Malrotation with Midgut Volvulus leading to Small Bowel Obstruction in a Young Adult: A Case Report

The developing intestine rotates around the superior mesenteric vessels during physiological herniation from 6th to 10th weeks of embryogenesis. Intestinal malrotation leading to midgut volvulus and small bowel obstruction is a rare condition. Patients who develop this condition usually present in the first year of their life. Intestinal malrotation is characterized by right sided duodenojejunal junction, caecum in left iliac fossa and a narrow mesentery. Ladd’s procedure is the treatment of choice which is done to restore the normal anatomy. We report the case of an 18-year-old male patient, who presented with intestinal malrotation in emergency department of Nishtar Hospital, Multan. It is an uncommon age for presentation of this anomaly. The patient had fecal peritonitis due to caecal perforation. He underwent Ladd’s procedure in which ileocolostomy was made after right hemicolectomy. The patient had an uneventful recovery after the surgery and had no complaints on follow up visit one week after the discharge

Clinicopathological features of craniopharyngioma: A 15-year study from a tertiary care center in Pakistan

Introduction: Craniopharyngiomas (CPs) are benign neoplasms and most common suprasellar tumors. They are more frequent in children, contributing to a significant number of intracranial tumors in the pediatric population and are thought to be arising either from the epithelial remnant cells of the craniopharyngeal duct or from the adenohypophysis epithelium. Two subtypes of CPs exist, namely, adamantinomatous craniopharyngioma (ACP) and papillary craniopharyngioma (PCP). ACP is more common in children with a relatively aggressive clinical course and more frequent relapses than PCP. The study objective was to evaluate the clinicopathological features of CP in our population.Methods: We conducted a retrospective observational study in the Department of Histopathology at Aga Khan Hospital, Karachi, Pakistan, over a period of 15 years, from January 2001 to December 2015. All CP cases were included in the study. A total of 207 cases were diagnosed during this period by histopathologists based on histologic features. All slides were retrieved, and diagnosis was confirmed after a reexamination of slides.Results: We found that the mean age of diagnosis was 25.59±14.71 years, and the median follow-up time was 7 (3-19) years. The number of male patients was 136 (65.7%) and the number of female patients was 71 (34.3%). The most common tumor site was suprasellar (71.5%) followed by the sellar and temporal lobe (12.1% and 6.8%, respectively). The most common complaints were headache (21.7%), followed by loss of vision/decreased vision (16.4%) and vomiting (5.3%). The overall survival rate was 95.2% with a recurrence rate of 5.8%. A significant association of survival was noted with tumor recurrence.Conclusion: CP is a rare brain tumor with good overall survival. We found a low recurrence rate of CP in our study. However, recurrence was found to be the most important factor determining survival in patients with CP

Applying quality improvement methods to neglected conditions: Development of the South Asia Burn Registry (SABR)

Objective: South Asia has the highest mortality rate from burns in the world. Application of quality improvement methods to burn care can help identify health system gaps. Our overall aim is to introduce a sustainable hospital-based burn registry for resource-constrained settings to assess health outcomes of burn injury patients presenting to dedicated burn injury centers in South Asia.Results: The South Asia Burn Registry (SABR) is implemented through collaborative approach in selected burn centers in Bangladesh and Pakistan. Th registry collects data on burn injury events, the care provided, and the functional status of patients at discharge from burn centers. It covers the entire spectrum of care provision for burn injury patients from the actual event through their discharge from the healthcare system. SABR investigates locally relevant contextual factors associated with burn injury and health-system requirements for burn patients receiving emergency and inpatient care in resource-constrained settings. It also explores factors associated with burn injury and care provision. SABR will inform better prevention and management efforts in South Asia and help to address healthcare needs of burn injury patients

Mapping Snowmelt Progression in the Upper Indus Basin with Synthetic Aperture Radar

The Indus River is a vital resource for food security, ecosystem services, hydropower, and economy for millions of people living in Pakistan, India, China, and Afghanistan. Glacier and snowmelt from the high altitude Himalaya, Karakoram, and Hindu Kush mountain ranges are the largest drivers of discharge in the upper Indus Basin (UIB), and contribute significantly to Indus flows. Complex climatology and topography, coupled with the challenges of field study and meteorological measurement in these rugged ranges, elicit notable uncertainties in predicting seasonal runoff as well as cryospheric response to changes in climate. Here we utilize Sentinel-1 synthetic aperture radar (SAR) imagery to track ablation season development of wet snow in the Shigar Watershed of the Karakoram Mountains in Pakistan from 2015 to 2018. We exploit opportune local image acquisition times to highlight diurnal differences in radar indications of wet snow, and examine the spatial and temporal contexts of radar diurnal differences for 2015, 2017, and 2018 ablation seasons. Radar classifications for each ablation season show spatial and temporal patterns that indicate a dry winter snowpack undergoing diurnal surface melt-refreeze cycles, transitioning to surface snow that remains wet both day and night, and finally snow free conditions following melt out. Diurnally differing SAR signals may offer insights into important snowpack energy balance processes that precede melt out, which could provide useful constraints for both glacier mass balance modeling and runoff forecasting in remote alpine watersheds

Metaplastic breast carcinoma: Clinicopathological parameters and prognostic profile

Introduction: Metaplastic breast carcinoma (MBC) is defined as breast cancer with a heterologous non-glandular component. MBC is considered a special type of breast cancer with a prognosis that is worse than invasive ductal carcinoma (IDC) of the breast. MBC is the most common breast cancer with a triple-negative profile. Therefore, in this study, we evaluated the clinicopathological parameters, recurrence and survival of MBC in our population.Methods: We conducted a retrospective observational study in the Department of Histopathology at Prince Faisal Oncology Centre, Buraidah, Saudi Arabia, over a period of five years. All cases diagnosed as MBC were included in the study. Estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2/neu) immunohistochemistry (IHC) was performed on representative tissue blocks.Results: Total 183 cases of MBCs were included in the study, out of which 120 cases were excision specimens. The mean age of the patients was 48.84±12.99 years, and the most common age group was between 36 and 50 years of age. Most of the cases were tumor (T) stage T3 (50%), and nodal metastasis was present in 40% of cases. Most cases were grade III (78.7%). ER, PR and HER2/neu positivity was noted in 15.8%, 13.1%, and 9.8% cases, respectively. Follow-up data were available for 70 cases, with a median follow-up period of 4 (1-7) years. Tumor recurrence was noted in 31.4% cases, with a survival rate of 71.4%. Squamous, chondroid, spindle cell differentiation, and matrix production were noted in 70.5%, 7.1%, 13.7%, and 2.2% cases, respectively. A significant association of squamous differentiation was noted with HER2/neu positivity. An inverse association of spindle cell differentiation was seen with axillary metastasis. Survival analysis by Kaplan-Meier revealed a significant association of survival with tumor recurrence.Conclusion: MBC is an important subtype of breast cancer, histopathological identification of which is challenging, owing to varied histological differentiation. We found squamous differentiation to be the most common in MBC, which was associated with HER2/neu positivity. A high recurrence rate of MBC was also observed in our study that was significantly associated with survival

An overview of groundwater monitoring through point-to satellite-based techniques

Groundwater supplies approximately half of the total global domestic water demand. It also complements the seasonal and annual variabilities of surface water. Monitoring of groundwater fluctuations is mandatory to envisage the composition of terrestrial water storage. This research provides an overview of traditional techniques and detailed discussion on the modern tools and methods to monitor groundwater fluctuations along with advanced applications. The groundwater monitoring can broadly be classified into three groups. The first one is characterized by the point measurement to measure the groundwater levels using classical instruments and electronic and physical investigation techniques. The second category involves the extensive use of satellite data to ensure robust and cost-effective real-time monitoring to assess the groundwater storage variations. Many satellite data are in use to find groundwater indirectly. However, GRACE satellite data supported with other satellite products, computational tools, GIS techniques, and hydro-climate models have proven the most effective for groundwater resources management. The third category is groundwater numerical modeling, which is a very useful tool to evaluate and project groundwater resources in future. Groundwater numerical modeling also depends upon the point-based groundwater monitoring, so more research to improve point-based detection methods using latest technologies is required, as these still play the baseline role. GRACE and numerical groundwater modeling are suggested to be used conjunctively to assess the groundwater resources more efficiently

Effect of angiotensin-converting enzyme inhibitor and angiotensin receptor blocker initiation on organ support-free days in patients hospitalized with COVID-19

IMPORTANCE Overactivation of the renin-angiotensin system (RAS) may contribute to poor clinical outcomes in patients with COVID-19. Objective To determine whether angiotensin-converting enzyme (ACE) inhibitor or angiotensin receptor blocker (ARB) initiation improves outcomes in patients hospitalized for COVID-19. DESIGN, SETTING, AND PARTICIPANTS In an ongoing, adaptive platform randomized clinical trial, 721 critically ill and 58 non–critically ill hospitalized adults were randomized to receive an RAS inhibitor or control between March 16, 2021, and February 25, 2022, at 69 sites in 7 countries (final follow-up on June 1, 2022). INTERVENTIONS Patients were randomized to receive open-label initiation of an ACE inhibitor (n = 257), ARB (n = 248), ARB in combination with DMX-200 (a chemokine receptor-2 inhibitor; n = 10), or no RAS inhibitor (control; n = 264) for up to 10 days. MAIN OUTCOMES AND MEASURES The primary outcome was organ support–free days, a composite of hospital survival and days alive without cardiovascular or respiratory organ support through 21 days. The primary analysis was a bayesian cumulative logistic model. Odds ratios (ORs) greater than 1 represent improved outcomes. RESULTS On February 25, 2022, enrollment was discontinued due to safety concerns. Among 679 critically ill patients with available primary outcome data, the median age was 56 years and 239 participants (35.2%) were women. Median (IQR) organ support–free days among critically ill patients was 10 (–1 to 16) in the ACE inhibitor group (n = 231), 8 (–1 to 17) in the ARB group (n = 217), and 12 (0 to 17) in the control group (n = 231) (median adjusted odds ratios of 0.77 [95% bayesian credible interval, 0.58-1.06] for improvement for ACE inhibitor and 0.76 [95% credible interval, 0.56-1.05] for ARB compared with control). The posterior probabilities that ACE inhibitors and ARBs worsened organ support–free days compared with control were 94.9% and 95.4%, respectively. Hospital survival occurred in 166 of 231 critically ill participants (71.9%) in the ACE inhibitor group, 152 of 217 (70.0%) in the ARB group, and 182 of 231 (78.8%) in the control group (posterior probabilities that ACE inhibitor and ARB worsened hospital survival compared with control were 95.3% and 98.1%, respectively). CONCLUSIONS AND RELEVANCE In this trial, among critically ill adults with COVID-19, initiation of an ACE inhibitor or ARB did not improve, and likely worsened, clinical outcomes. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT0273570

Testing overconfidence bias in Pakistani stock market

Abstract: Excessive trading phenomenon is contrary to the concept of traditional finance that is based on the rational expectation theorem and efficient market hypothesis. Therefore, this study is aimed at exploring the existence of overconfidence behavior in the stock market. The market-wide panel VAR model is used to investigate the lead-lag relationship between stock returns and turnover. Our results suggest that investors are overconfident in Pakistani stock market because turnover depends directly upon stock returns. The findings have important implications for investors and brokers for developing appropriate trading strategy