Aims: Infections due to metallo-β-lactamase (MBL) producing Gram negative rods are a cause of high mortality and morbidity. Early detection by an economical and accurate method may improve patient outcome. This study was aimed to evaluate the diagnostic accuracy of combined disc method for MBL detection by comparing it with MBL-Etest. Methodology and Results: This cross-sectional, validation study was carried out in the Department of Microbiology, Army Medical College, National University of Sciences and Technology, Rawalpindi, over a period of six months. A total of 52 non-duplicate Gram-negative rods isolated from the routine clinical specimens and found resistant to meropenem/imipenem on Kirby Bauer Disc Diffusion method were subjected to two tests for metallo-β-lactamase detection. One was combined Disc test using imipenem with Ethylene Diamine Tetraacetic Acid (EDTA), where a strain showing an increase in zone of inhibition of combined disc of ≥ 7 mm as compared to imipenem alone, was considered as MBL producer and the other one was MBL-Etest for which results were interpreted as per manufacturer’s guidelines. Combined disc method for MBL detection was found to have a sensitivity, specificity, positive predictive value, negative predictive value and accuracy of 97.5%, 100%, 100%, 92% and 98%. Conclusion, Significance and Impact of study: Combined disc method is an economical and reliable method for metallo-β-lactamase detection which can be used routinely in any laboratory.

Microorganisms adhere to non-living material or living tissue, and form biofilms made up of extracellular polymers/slime. Biofilm-associated microorganisms behave differently from free-floating bacteria with respect to growth rates and ability to resist antimicrobial treatments and therefore pose a public health problem. The objective of this study is to detect the prevalence of biofilm producers among Gram positive and Gram negative bacteria isolated from clinical specimens, and to study their antimicrobial susceptibility pattern. The study was carried out from October 2009 to March 2010, at the Department of Microbiology, Army Medical College/ National University of Sciences and Technology (NUST), Rawalpindi, Pakistan. Clinical specimens were received from various wards of a tertiary care hospital. These were dealt by standard microbiological procedures. Gram positive and Gram negative bacteria isolated were subjected to biofilm detection by congo red agar method (CRA). Antimicrobial susceptibility testing of those isolates, which showed positive results (slime production), was done according to the Kirby-Bauer disc diffusion technique. A total of 150 isolates were tested for the production of biofilm/slime. Among them, 81 isolates showed positive results. From these 81, 51 were Gram positive and 30 were Gram negative. All the 81(54%) slime producers showed reduced susceptibility to majority of antibiotics. Bacterial biofilms are an important virulence factor associated with chronic nosocomial infection. Detection of biofilm forming organisms can help in appropriate antibiotic choice.

Breast cancer is the second leading cause of death among women in North America. Glioblastoma is the most common primary malignant central nervous system tumor in adults. The majority of hereditary breast cancers are associated with deleterious mutations in the BRCA1 and BRCA2 genes. Although few case reports have described the incidence of glioblastoma in patients previously diagnosed with breast cancer, any association between BRCA2 mutations and glioblastoma has not been demonstrated to date. Herein, we report a woman who is a carrier of a familial BRCA2 mutation, and was previously diagnosed with triple-negative breast cancer (TNBC) and subsequently with a second primary TNBC and glioblastoma. Further investigation is required to define the possible relationship between these two aggressive malignances and the BRCA2 mutation, which might be critical for the proper management and treatment of this disease.
Adult ; Breast Neoplasms* ; Breast* ; Cause of Death ; Central Nervous System ; Female ; Genes, BRCA2 ; Glioblastoma* ; Humans ; Incidence ; North America ; Triple Negative Breast Neoplasms

BACKGROUND: Simulation training is becoming an increasingly important component of skills acquisition in surgical specialties, including Plastic Surgery. Non-living simulation models have an established place in Plastic Surgical microsurgery training, and support the principles of replacement, reduction and refinement of animal use. A more sophisticated version of the basic chicken thigh microsurgery model has been developed to include dissection of a type 1-muscle flap and is described and validated here. METHODS: A step-by-step dissection guide on how to perform the chicken thigh adductor profundus free muscle flap is demonstrated. Forty trainees performed the novel simulation muscle flap on the last day of a 5-day microsurgery course. Pre- and post-course microvascular anastomosis assessment, along with micro dissection and end product (anastomosis lapse index) assessment, demonstrated skills acquisition. RESULTS: The average time to dissect the flap by novice trainees was 82±24 minutes, by core trainees 90±24 minutes, and by higher trainees 64±21 minutes (P=0.013). There was a statistically significant difference in the time to complete the anastomosis between the three levels of training (P=0.001) and there was a significant decrease in the time taken to perform the anastomosis following course completion (P<0.001). Anastomosis lapse index scores improved for all cohorts with post-test average anastomosis lapse index score of 3±1.4 (P<0.001). CONCLUSIONS: The novel chicken thigh adductor profundus free muscle flap model demonstrates face and construct validity for the introduction of the principles of free tissue transfer. The low cost, constant, and reproducible anatomy makes this simulation model a recommended addition to any microsurgical training curriculum.
Animals ; Chickens* ; Cohort Studies ; Curriculum ; Education ; Microsurgery* ; Plastics ; Simulation Training* ; Specialties, Surgical ; Surgery, Plastic ; Thigh*

Background: Collision tumors are defined by the co-existence of two or more tumors in the same or adjacent organs which are topographically and histologically distinct with minimal or no histological admixture. Collision tumors are rare but some have been reported in other organs, as well as the female genital tract. Objectives: To define and explain the pathogenesis, histogenesis and management; as well as present previously reported collision tumors in different countries as well as in our local setting. Clinical case: This is a rare case of a 68-year-old nulligravid who complained of postmenopausal bleeding. Imaging studies revealed a uterine mass. Differential diagnosis non-neoplastic conditions and benign and malignant neoplasms. Radical Modified hysterectomy with bilateral salpingo-oophorectomy with frozen section and complete staging was performed. Histopathology revealed a coexistence of a colloid carcinoma of the cervix and endometrial adenocarcinoma. Conclusion Collision Tumors are infrequent neoplasias, there are few reports about them in medical literature. Colloid carcinoma of the cervix is a rare subtype and few studies are reported in literature. Their prognosis is unknown since there are no previous similar cases. Colloid carcinomas present a histologic as well as clinical dilemma. Their histogenetic origin remains controversial and their rarity precludes determination of the best treatment options to improve survival outcomes.
Adenocarcinoma, Mucinous ; Mucins ; Neoplasms

Background: Rare inherited coagulation factor deficiencies constitute an important group of bleeding disorders. A higher frequency of these disorders is seen in areas of high consanguinity.Our aim was to study the prevalence and spectrum of rare inherited bleeding disorders, characterize the severity of the deficiencies, identify different clinical manifestations, and evaluate different treatments provided. Methods: This cross-sectional study was conducted in the Department of Haematology, Armed Forces Institute of Pathology Rawalpindi, between January 2014 and December 2018.A detailed history was taken, and an examination was performed. The signs and symptoms were noted, and the patients were diagnosed on the basis of a coagulation profile. The disease severity was assessed using factor assays. Results: Among 2,516 patients with suspected coagulation disorders, 774 (30.8%) had an inherited bleeding disorder. Of the 774 patients, 165 (21.3%) had a rare bleeding disorder;91 (55.2%) of them were males, and 74 (44.9%) were females, with a male-to-female ratio of 1.2:1. The median patient age was 9 years 3 months. The most common disorder was factor VII deficiency (46 patients, 27.9%). The most common clinical presentation was bruising in 102 (61.8%) and gum bleeding in 91 (55.2%) patients. Conclusion The most common rare bleeding disorder in our population is factor VII deficiency. The prevalence of these bleeding disorders is high in our population due to a high number of consanguineous marriages.

Microangiopathic hemolytic anemia (MAHA) is a rare subtype of hemolytic anemia characterized by elevated hemolytic markers and red blood cell destruction. Though uncommon, MAHA can occur as a complication of acute pancreatitis because of the associated inflammatory response. Patients with MAHA secondary to pancreatitis show favorable outcomes when treated with plasma exchange.This paper presents the case of a patient diagnosed with acute pancreatitis-induced hemolytic anemia and thrombocytopenia, who was managed successfully with plasma exchange, steroids, and rituximab. Clinicians should maintain a high index of suspicion in patients with acute pancreatitis who present with anemia, thrombocytopenia, and schistocytes on peripheral smears, even in the absence of end-organ injuries and with normal ADAMTS13 activity. The early initiation of plasmapheresis can be lifesaving. The timely introduction of rituximab in cases where plasma exchange and steroids are insufficient, despite the ADAMTS13 activity status, may lead to better outcomes.

Microangiopathic hemolytic anemia (MAHA) is a rare subtype of hemolytic anemia characterized by elevated hemolytic markers and red blood cell destruction. Though uncommon, MAHA can occur as a complication of acute pancreatitis because of the associated inflammatory response. Patients with MAHA secondary to pancreatitis show favorable outcomes when treated with plasma exchange.This paper presents the case of a patient diagnosed with acute pancreatitis-induced hemolytic anemia and thrombocytopenia, who was managed successfully with plasma exchange, steroids, and rituximab. Clinicians should maintain a high index of suspicion in patients with acute pancreatitis who present with anemia, thrombocytopenia, and schistocytes on peripheral smears, even in the absence of end-organ injuries and with normal ADAMTS13 activity. The early initiation of plasmapheresis can be lifesaving. The timely introduction of rituximab in cases where plasma exchange and steroids are insufficient, despite the ADAMTS13 activity status, may lead to better outcomes.

Microangiopathic hemolytic anemia (MAHA) is a rare subtype of hemolytic anemia characterized by elevated hemolytic markers and red blood cell destruction. Though uncommon, MAHA can occur as a complication of acute pancreatitis because of the associated inflammatory response. Patients with MAHA secondary to pancreatitis show favorable outcomes when treated with plasma exchange.This paper presents the case of a patient diagnosed with acute pancreatitis-induced hemolytic anemia and thrombocytopenia, who was managed successfully with plasma exchange, steroids, and rituximab. Clinicians should maintain a high index of suspicion in patients with acute pancreatitis who present with anemia, thrombocytopenia, and schistocytes on peripheral smears, even in the absence of end-organ injuries and with normal ADAMTS13 activity. The early initiation of plasmapheresis can be lifesaving. The timely introduction of rituximab in cases where plasma exchange and steroids are insufficient, despite the ADAMTS13 activity status, may lead to better outcomes.

BACKGROUND/AIMS: Different non-invasive diagnostics strategies have been used to assess patients with gastroesophageal reflux. Gastroesophageal reflux disease (GERD) questionnaire (GerdQ) is a 6-item, easy to use questionnaire that was developed primarily as a diagnostic tool for GERD in primary care. Our aim was to validate and assess diagnostic utility of GerdQ questionnaire in Mexican patients in the primary care setting. METHODS: The study was performed in 3 phases: (1) a questionnaire translation and comprehension study (n = 20), (2) are a reproducibility and validation study (50 patients and 50 controls) and (3) a study to assess the clinical utility in 252 subjects with GERD symptoms. Diagnostic accuracy was calculated using endoscopy and/or pH-metry as the gold standard. RESULTS: Internal consistency measured by the Cronbach's alpha coefficient was 0.81 for patients and 0.90 for healthy controls, with a mixed coefficient of 0.93. Reproducibility for GerdQ was very good and its discriminating validity was 88%. Most of the patients with erosive reflux and non-erosive reflux with abnormal pH-metry had scores > 8, meanwhile most of the patients with functional heartburn and hypersensitive esophagus had < 8. Sensitivity, specificity and positive predictive value of GerdQ compared to the gold standard were 72%, 72% and 87%, respectively. CONCLUSIONS: In Mexico, the GerdQ questionnaire Spanish validated version is useful for GERD diagnosis in the primary care setting.
Comprehension ; Diagnosis ; Endoscopy ; Esophagus ; Gastroesophageal Reflux* ; Heartburn ; Humans ; Mexico* ; Primary Health Care* ; Surveys and Questionnaires* ; Sensitivity and Specificity