45 year old male presented with cough, chest pain and dyspnea and was found to have a mediastinal mass extending into the left hemi-thorax. At thoracotomy a 30 x 32 x 10 cm well-circumscribed mass was found consisting of spindle cells. Immuno-histochemical stains were positive for Cluster of Differentiation (CD34), Anti Smooth Muscle Antibody(ASMA) patchy, but were negative for cytokeratin AEl/AEB, desmin, S-100, Cluster of Differentiation (CD31), Epithelial Membrane Antigen (EMA). Thus a diagnosis of solitary fibrous tumor was confirmed. The differential diagnosis of a mediastinal tumor are diverse while the clinical presentations are predominantly similar.

 Hemodialysis through a central venous catheter (CVC) is advised to be used only in acute renal failure setting and as temporary bridging access for patients awaiting arterio-venous fistula. However, it is not uncommon to even patients with end stage renal disease (ESRD), to have their hemodialysis done through temporary CVC for long duration without any attempt to have permanent access. Complications are not uncommon with such lines. Commonly encountered complications are infection, thrombosis, haemorrhage, arterio-venous malformation, and pseudoaneurysm etc. Among the uncommon complications, migration of fractured CVC, migration of guide wire, fracture of the tip of catheter with embolization etc are described. We report an early fracture (on 3rd day) of a femoral venous catheter and embolization leading to an emergency in a 44 year old woman with ESRD which was successfully retrieved by endovascular intervention.

Intrathoracic extension of a goitre is rare and the anaplastic carcinoma in the intrathoracic goitre is extremely rare. Retrosternal or intrathoracic goitre can be operated through cervical incision but in difficult cases sternotomy may be required. We present a case of a 58 year old male who presented with 2-year history of goitre and hoarseness of voice and dysphagia for few months. Ultrasound and CT scan of the neck confirmed marked enlargement and intrathoracic extension of right lobe of thyroid gland. Fine needle aspiration cytology showed atypical cells. Total thyroidectomy was performed through cervical and sternotomy incisions. Intraoperatively, tumour was found to be dumbbell shaped and the thoracic part was larger than the cervical part. Tumour was compressed by the right subclavian vessels anteriorly and by the ribs posteriorly.  Histopathological examination showed spindle cell variant of the anaplastic carcinoma of thyroid. Anaplastic carcinoma can rarely be intrathoracic and still be resect able. Even after sternotomy, removal and delivery of the thoracic part of gland is not  possible and additional manoeuvres have to be performed.

 BACKGROUND: Methylxanthines produce renal effects such as diuresis and natriuresis. Premature neonates have increased urinary calcium excretion following treatment with methylxanthines for apnea. We compared the effect of two commonly used methylxanthines, caffeine and aminophylline, in the development of osteopenia of prematurity and phosphorus and alkaline phosphatase levels.

METHODS: In a randomized clinical trial, 125 preterm infants with gestation age 32 weeks or less and birth weight less than 1500 grams with an indication for methyxanthine therapy were enrolled in the study. Group A (N=60) received aminophylline and group C (N=65) received caffeine. These drugs were started from the second day of birth until neonate was apnea free for 1 week or reached corrected gestation age of 34 weeks.  Serum phosphorus and alkaline phosphatase levels were measured at 45 days of life as surrogate biomarkers for the osteopenia of prematurity.

RESULTS: The mean gestation age and birth weight were 28.7±1.8 weeks and 1090±144 grams in group A and 28.7±2.0 weeks and 1042±170 grams in group C (P>0.05). Osteopenia of prematurity was diagnosed in 65 neonates (52%) of which 29 neonates (48.3%) were in aminophylline group and 36 patients (55.3%) in caffeine group (P=0.27). Bronchopulmonary dysplasia was detected in 53 neonates (42%) of which 21 (35%) were in group A and 32 (49.2%) were in group C (P= 0.07).

CONCLUSION: In our study, aminophylline and caffeine were similar with respect to the risk of osteopenia of prematurity in preterm infants.

BACKGROUND: The aim of this study was to determine the frequency of headache disorders in undergraduate medical students of Karachi, Pakistan and determination of various associating factors.

METHODS: This was a descriptive cross-sectional study including 402 participants. All were medical students from first year to final year enrolled at two medical colleges of Karachi, Pakistan. The ethical approval of study was obtained from Dow University of Health Sciences. The students were inquired about the occurrence of headaches during the past one year and various triggering and risk factors.

RESULTS: Headaches were experienced by 87.8% students (N=353; females= 249). Of these, 17.8% were found to have migraine, 75.3% had tension-type headache (TTH), 4.0% had both migraine and TTH and 2.3% suffered from cluster headaches. A quarter of students suffering from headache were found to have a positive family history, while stress, fatigue, sleep disturbance and nasal congestion were the most commonly reported trigger factors. More than half (60%) students stated that they did not take any medications for headaches.

CONCLUSION: This study found a very high frequency of headache among medical students of Karachi, Pakistan. A number of trigger factors were identified which if curtailed may reduce the occurrence of headache.

BACKGROUND: The changes in amino acid catabolism contribute to the regulation of immune system. The role of indoleamine 2,3-dioxygenase (IDO), and enzyme that mediates the catabolism of tryptophan (trp), remains a controversy. The aim of this study was to determine the relationship between serum level of IDO and the extent of asthma control in patients with allergic bronchial asthma.

METHODS: This was a cross-sectional study enrolling 40 atopic patients with allergic bronchial asthma; 20 patients with controlled asthma and 20 patients with uncontrolled asthma. Asthma diagnosis and the level of asthma severity and control were established according to The Global Initiative for Asthma (GINA) recommendations 2012. Atopy was defined by the presence of at least one positive skin prick test reaction to common environmental allergens.  Total serum immunoglobulin E (IgE) and serum IDO concentration were measured in all patients. Twenty healthy individuals were included in this study to determine the cutoff level of serum IDO. We used unpaired t-test and Fisher’s exact test for determining statistical significance.

RESULTS: Serum IDO levels were significantly different across the three study groups (p<0.001). Uncontrolled asthma and controlled asthma patients had significantly higher median (IQR) level of IDO [1200 (975–1950), 1000 (762.5–1650) respectively] compared to controls [300 (150–300)]. On the other hand, serum IDO level did not differ significantly between uncontrolled and controlled asthma patients.

CONCLUSION: Atopic patients with bronchial asthma have high serum IDO levels. There is no relationship between IDO levels and asthma control.