Gastroparesis, Thymoma, and Asymptomatic Myasthenia: A Rare Clinical Scenario

Background: Paraneoplastic gastroparesis is a gastrointestinal syndrome that rarely precedes a tumor diagnosis. To increase awareness of this rare clinical entity, we present a case of severe gastroparesis, which was later proven to be associated with a thymoma. Case report: A 55-year old man had the sudden onset of severe abdominal cramps and abdominal distension, early satiety with postprandial nausea, acid regurgitation, belching, and flatulence. He lost about 20 pounds. The physical and imaging examination revealed stomach distension, gastroparesis, and the presence of a solid mass in the anterior mediastinum. Radical surgery was performed to remove the thymoma and, given the high value of Mib-1, the patient was submitted to postoperative chest radiation therapy. After thymectomy, a diagnosis of paraneoplastic myasthenia gravis with subacute autonomic failure was made. Conclusion: Autoimmune gastroparesis should be considered as a potential paraneoplastic syndrome in patients with thymoma, myasthenia gravis, and delayed gastric emptying in the absence of mechanical obstruction.

Chikungunya Neurological Manifestations: A Systematic Literature Review

Although the most common Chikungunya (do not capitalize the disease unless it is named after a proper noun such as Zika, Ebola or Carrion’s Disease) manifestations are osteoarticular, those which bring the most morbidity and mortality are neurological, where thorough mapping through studies with a methodological outline have not yet been well structured. Therefore, the objective was to review the literature to identify neurological manifestations of CHIKV. We used the Virtual Health Library (VHL) and PubMed with the following descriptors: #1 “Chikungunya” [MeSH]; #2 “neurological manifestations” [MeSH] and their equivalents in the Portuguese language, selecting literature published between July 2007 to January 2018. From the 180 studies that were found, 30 were selected. Findings were divided into two subcategories: “Chikungunya: Typical Neurological Manifestations” and “Chikungunya: Severe Neurological Manifestations”. The studies show that headaches were characterized as the most common symptom in adult patients affected by CHIKV, followed by meningeal involvement. Meningeal involvement is also a more serious clinical scenario associated with encephalitis, convulsions, polyneuropathies such as Guillain-Barré syndrome and death. CHIKV is a public health problem for many reasons including its chronic potential complications. Given the neurological symptoms, this disease is concerning in age extremes, for patients with comorbidities and for patients with more than one viral infection by arboviruses, in whom the most severe neurological manifestations are more common.

Evaluation of Pharmacology MCQ Papers of MBBS Professional Examinations

This cross sectional descriptive study was conducted to observe the quality of Pharmacology professional MCQ papers of different Universities of Bangladesh. For this purpose, total 80 MCQ papers of five universities dated from January 2007 to July 2015 were reviewed against a checklist to find out the coverage of recall, understanding and problem solving type questions, content coverage and construction of each question. The mean of recall, understanding and problem based type questions of all the universities were 92.1, 7.8 and 0.1 respectively and all of them statistically significantly differed from curriculum standard. All of the MCQ papers contained more than 75% recall type questions and 27.5% MCQ papers had only recall questions, Only 1(1.2%) MCQ papers contained 100 % topics (all the 11 groups). Eighteen (22.5%) contained 10 groups and 26.3% contained 9 groups out of 11. Forty percent MCQ papers contained less than 80% topics. Most of the stems of the MCQ were in the form of incomplete sentence (53.5%), 28.4% were in the form of complete statement and 16.8% were in the form of single word. Only 0.4% stem were in the form of clinical scenario. Fifty (62.5%) MCQ papers had defective stems and 68.75% had defective options. Total 14 (17.5%) MCQ papers were without any flaw but the rest 88.5% MCQ papers were with flaws either defective stem or faulty options or both. Findings of this study may be used to redefine the distribution of different type of questions in SAQ papers and to improve the quality of question papers by ensuring their coverage. Bangladesh Journal of Medical Education Vol.13(1) January 2022: 49-57

A Multimodality Review of Male Urethral Imaging: Pearls and Pitfalls with an Update on Urethral Stricture Treatment

Optimum radiological assessment of the male urethra requires knowledge of the normal urethral anatomy and ideal imaging techniques based on the specific clinical scenario. Retrograde urethrography is the workhorse examination for male urethral imaging, usually utilized as the initial, and often solitary, modality of choice not only in the setting of trauma, but also in the pre- and post-operative evaluation of urethral strictures. There is, however, growing interest in utilization of ultrasound and magnetic resonance for evaluation of the male urethra owing to lack of ionizing radiation and improved delineation of the adjacent tissue. We review the various modalities utilized for imaging of the male urethra for a variety of known or suspected disorders, and provide an update on current treatments of urethral strictures. Additionally, we detail the key information needed by urologists to guide management of urethral strictures. We conclude with a brief discussion of neophallus urethral diseases following female-to-male sexual confirmation surgery.

Chromosome 8 Polysomy Accounting for MYC Over-Expression in Angiosarcoma Arising as Somatic-Type Malignancy in Metastatic Teratoma. Case Report

MYC over-expression by immunohistochemistry (IHC) is utilised in routine pathology practice as a surrogate marker for MYC amplification, which plays a key oncogenic role in post-irradiation and chronic lymphedema-associated angiosarcoma. We present the case of a 32-year old male, who presented with high-grade angiosarcoma arising in a background of metastatic testicular teratoma. IHC for MYC showed strong nuclear expression in the angiosarcoma cells prompting the consideration of post-irradiation-induced angiosarcoma but our patient did not undergo radiotherapy. Fluorescence in-situ hybridization (FISH) excluded MYC amplification and instead showed Chromosome 8 polysomy, which accounted for the strong MYC IHC expression present, not previously described in the context of germ cell tumours. The occurrence of MYC over-expression due to polysomy illustrates a novel clinical scenario (angiosarcoma arising as somatic malignancy) where strong MYC IHC expression can be found in the absence of underlying amplification or prior radiotherapy exposure.

Value of somatostatin receptor PET/CT in MEN1 patients at various stages of their disease

Context Despite the growing evidence of the clinical value of somatostatin receptor (SSTR) PET in the evaluation of neuroendocrine tumors/NET, its role remains to be clarified at different time points in the MEN1 patient journey. The rareness of the disease is however a significant impediment to prospective clinical trials. Objectives The goals of the study were to assess the indications and value of SSTR PET/CT in MEN1 patients. Methods We retrospectively included patients from 7 French expert centres for whom data on SSTR PET/CT and morphological imaging performed at the same period were available. Detection rates of PET study were analysed. Results One hundred eight patients were included. SSTR PET/CT was performed at screening (n=33), staging (n=34), restaging (n=37) and for PRRT selection (n=4). PET detected positive pancreatic lesions in 91% of cases at screening, with comparable results to MRI but superiority to CT (P=0.049). Metastases (mostly LN) were present at the screening phase in 28% of cases, possibly due to the suboptimal value of screening morphological imaging in the assessement of nodal metastases and/or a long delay between imaging studies. SSTR PET/CT was considered as superior or complementary to the reference standard in the assessment of LN or distant metastases in the vast majority of cases and regardless of the clinical scenario. Conclusion This study shows the potential added value of SSTR PET in the assessment of MEN1-associated NETs and provides a great impetus towards its implementation in the evaluation of MEN1 patients.

Classification of AVNRT: an unresolved entity.

The classification of AVNRT is based on HA and VA interval. Typical AVNRT is diagnosed in presence of HA ≤70 ms OR VA interval ≤60 ms and HA>70ms or VA >60ms is required to diagnose atypical AVNRT. This might be fallacious in some clinical situations. The septal VA and the “shortest” VA may be also different depending on clinical scenario .

Classification of AVNRT: an unresolved entity.

The classification of AVNRT is based on HA and VA interval. Typical AVNRT is diagnosed in presence of HA ≤70 ms OR VA interval ≤60 ms and HA>70ms or VA >60ms is required to diagnose atypical AVNRT. This might be fallacious in some clinical situations. The septal VA and the “shortest” VA may be also different depending on clinical scenario .

Access Route for Endovascular Neurointervention - Transfemoral to Transradial: Is it Worth the Effort and are we Ready for the Change?

Transfemoral access for neurointerventions has been a time-tested technique of entering the vascular network of the body and reaching the intended targets. However, it has its own share of shortcomings in the form of long admission times leading to increased costs, patient inconvenience and local (though infrequent) adverse affects. Transradial route has taken the interventional cardiology domain by storm and is staring now at other vascular domains especially neurointervention. It has shown better outcomes than the transfemoral route in many aspects. The current article discusses the vascular access perspectives with an exhaustive overview of the transradial route concerning its historical perspectives, its requirement in the current clinical scenario, the procedure per se including the adverse effects and whether it has the real world charm to displace the transfemoral route into the backseat. Transradial access in neurointervention is here to stay, however it would require training, certain modifications in the standard catheters that one currently uses for cerebral procedures and constant practice by the operator to cross the learning curve and attain a certain level of competence before he becomes comfortable with the technique.