A Recurrent Nonsense Mutation in NECTIN4 Underlying Ectodermal Dysplasia-Syndactyly Syndrome with a Novel Phenotype in a Consanguineous Kashmiri Family

EDSS1, a syndrome characterized by ectodermal dysplasia-syndactyly, is inherited in an autosomal recessive manner due to mutations in the NECTIN4/PVRL4 gene. Clinical manifestations of the syndrome include defective nail plate, sparse to absent scalp and body hair, spaced teeth with enamel hypoplasia, and bilateral cutaneous syndactyly in the fingers and toes. Here, we report a consanguineous family of Kashmiri origin presenting features of EDSS1. Using whole exome sequencing, we found a recurrent nonsense mutation (NM_030916: c.181C > T, p.(Gln61 ∗)) in the NECTIN4 gene. The variant segregated perfectly with the disorder within the family. The candidate variant was absent in 50 in-house exomes pertaining to other disorders from the same population. In addition to the previously reported clinical phenotype, an upper lip cleft was found in one of the affected members as a novel phenotype that is not reported by previous studies in EDSS1 patients. Therefore, the study presented here, which was conducted on the Kashmiri population, is the first to document a NECTIN4 mutation associated with the upper lip cleft as a novel phenotype. This finding broadens the molecular and phenotypic spectrum of EDSS1.

A Novel Method for Intracavitary Cervical HDR Brachytherapy: Express Finger-Guided Implant Insertion at Simulation Table without Speculum, Cervical Dilatation, Sleeve, Anesthesia, or Sedation

PURPOSE/OBJECTIVE(S)

Our purpose is to develop a fast, effective, and independent intracavitary brachytherapy implant insertion method that does not need sleeve insertion, anesthesia or conscious sedation, and that can be performed at the front edge of the simulation table (CT or MRI), using finger guidance without a need for speculum or cervical dilatation.

MATERIALS/METHODS

From February 2022 to January 2023, we treated 27 locally advanced cervical cancer patients. In the last week of EBRT, we assessed patients with MRI and pelvic exam to determine their eligibility: 89% (24 patients) met the two inclusion criteria for the express insertion which are: the ability to cover any residual disease with intracavitary brachytherapy, and the accessibility of cervix external os. Each patient had 3 HDR express insertions (8Gy x3). A total of 72 consecutive express implant insertions were performed. Each insertion is evaluated for the success of procedure, number of attempts, and time taken. Patients started on laxative 3 days prior to the procedure, and paracetamol & Ibuprofen taken at home 2 hours before the procedure. On arrival, patients used the bathroom, and IM/SC morphine given. Patients were prepared at the front edge of the simulation table and topical lidocaine applied to the cervix. The external os identified with the index finger of one hand which also guided the tandem insertion using the other hand. No cervical dilatation was used. CT simulation was performed to confirm adequate implant placement and to contour and plan CTV-HR and OARs as per GEC-ESTRO/ABS guidelines.

RESULTS

The success rate was 100% in all the 72 express insertions. >90% (66 insertions) were smooth and fast, i.e., completed in 1 attempt that took <20 minutes. <10% (6 insertions) were challenging but successful, in 2 patients: one patient had an acute anteverted uterus for which suprapubic abdominal pressure facilitated the procedure that took <3 attempts and completed in <40 minutes, the other patient had an acute retroverted uterus which was associated with the most challenging procedure that took >3 attempts and completed in >40 minutes. The success rate was not affected by the type of applicator used. 85% of our applications used multichannel tandem and cylinder, 10% used tandem and ovoids, and 5% used tandem and ring applicators.

CONCLUSION

Express finger-guided intracavitary brachytherapy implant insertion at the simulation table without speculum, cervical dilatation, sleeve, anesthesia, or sedation is fast, effective, and an independent method that can be used in most cervical cancer patients to complete their planned brachytherapy treatment regardless of limited resources. Practice and dissemination of this innovative method is important especially when operative rooms and anesthesia support are limited (e.g., epidemics and closures) and in centers lacking such support. Further studies are warranted to optimize the procedure and to highlight its significant medical and socioeconomic benefits.

BRCA 1/BRCA 2 Pathogenic/Likely Pathogenic Variant Patients with Breast, Ovarian, and Other Cancers

The demographic and clinical characteristics of patients who have BRCA 1/BRCA 2 pathogenic/likely pathogenic variants may differ from their relatives who had BRCA-related cancer. In this study, we aimed to demonstrate the clinical and demographic findings of patients who had BRCA-related cancer and to assess the differences comparing their relatives who had BRCA-related cancer with breast, genital tract, prostate, and pancreas cancers as well. The results of sequencing analysis of 200 cancer patients (190 women, 10 men) who have been directed to genetic counseling with an indication of BRCA1/BRCA2 testing from different regions across 9 medical oncology centers were retrospectively analyzed. A total of 200 consecutive cancer patients who harbored the BRCA1/BRCA2 pathogenic/likely pathogenic variant (130 (65%) patients harbored BRCA 1 pathogenic/likely pathogenic variant, and 70 harbored BRCA 2 pathogenic/likely pathogenic variant) were included. Of these, 64.0% had breast cancer (43.8% of them had the triple-negative disease, and about 2.3% had only the HER-2 mutant), 31.5% had genital cancers (92.1% of them had ovarian cancer, 3.2% had endometrium, and 1.6% had peritoneum cancer as the primary site and mostly serous adenocarcinoma was the most common histopathology and 14.3% of the patients had endometrioid adenocarcinoma), 3.5% had prostate (median time from metastasis to castration-resistant status was 28 months) and 1.0% had pancreas cancer. Newly diagnosed cancer (breast and ovary) patients who had BRCA 1/BRCA 2 pathogenic/ likely pathogenic variant were younger than their previous cancer diagnosed (breast, ovary, and pancreas) parents who harbored BRCA pathogenic/likely pathogenic variant. We suggest that the genetic screening of BRCA 1/ BRCA 2 pathogenic/likely pathogenic variant is needed as a routine screening for those with a personal or family history of breast, ovarian, tubal, or peritoneal cancer. In addition, once BRCA 1 or BRCA 2 germline pathogenic variant has been identified in a family, testing of at-risk next-generation relatives earlier can identify those family members who also have the familial pathogenic variant, and thus need increased surveillance.

Genetic engineering for enhanced biological nitrogen fixation in cereal crops

Enhancing biological nitrogen (N) fixation in cereal crops has been a long-sought objective. Recently, Yan et al. identified plant compounds that induce biofilm production of diazotrophic bacteria and then performed genetic engineering in order to improve nitrogen fixation in rice plants. These findings hold promise for sustainable agriculture.

Comparison of Post-Operative Analgesic Efficacy of Caudal Epidural Block versus Penile Block in Children Undergoing Hypospadias

Objective: To compare the post-operative analgesic efficacy of penile block vs caudal block following hypospadias repair. Study Design: Quasi-experimental study. Place and Duration of Study: Pediatric and Plastic Surgery Departments, Combined Military Hospital, Multan Pakistan, from Jul 2019 to Jul 2021. Methodology: The total of 34 patients undergoing hypospadias operation was booked for this study after approval of the ethical committee. All patients were operated on under General anaesthesia. The booked patients were randomly divided into Groups 1 and 2. For post-operative analgesia, the first group got penile block while the latter was given caudal epidural block. Results: The mean age of the patients was 3.99±2.68 years. These patients were split into two groups. Group-1 (n=17)underwent a Penile block, and Group-2 (n=17) underwent a Caudal block. There were no serious complications after a penile block or caudal block. A substantial decline in pain scores was noted, more in the penile block group. Conclusion: For patients being treated for Hypospadias, the penile block is a more effective and simple method of pain control post-operatively. This can be performed by the surgeon.

Synthesis and characterization of silver-indium and antimony selenide: role in photocatalytic degradation of dyes

These days, water contamination poses a severe threat to the ecosystem and demands immediate care. This study examined the need to reduce water pollution using clean, renewable energy (solar light irradiations) for the degradation of Congo red by Silver-indium and antimony selenide with chemical composition AgInSbSe₃. The sample was fabricated through a hydrothermal technique. The synthesized sample was characterized through X-ray diffraction (XRD), Fourier-transform infrared spectroscopy (FTIR), Scanning electron microscopy (SEM) and Ultraviolet-Visible spectroscopy. The X-ray diffraction confirms crystalline structure of the synthesized sample. The SEM analysis reveals irregular grains and exhibits a very small inter-particle distance. SEM provides the morphology of the synthesized sample, the grain size of the synthesized sample was 0.58 μm. FTIR results revealed specific absorption bands in the range of 400-4000 cm^-1; optical properties are studied through UV-Vis-spectroscopy. The synthesized sample has 1.97 eV bandgap which is suitable for degradation of organic pollutants. The photocatalytic activity of the material is checked by degrading the Congo red dye under direct sunlight irradiation and for the 75 min illumination 77.8% degradation efficiency is attained.

The role of unsustainable HR practices as illegitimate tasks in escalating the sense of workplace ostracism

Unsustainable HR practices impose illegitimate tasks on employees due to a shortage of resources. These illegitimate tasks bring counterproductive work behavior in terms of workplace incivility that creates a sense of ostracism in employees. To address these issues, the study examined the relationship among unsustainable HR practices in terms of illegitimate tasks and workplace ostracism. Whereas workplace incivility is defined as an underlying reason through which this association exists. Adopting a theoretical framework from earlier research, the study used cross-sectional data and subsequently a method of quantitative research, and the sample comprised permanent faculty members of private universities in Pakistan working in different departments with different role titles. Smart PLS was applied to run multiple statistics analyzed on the obtained data. The results from the study supported the hypothesis by depicting a positive and significant association between illegitimate tasks and workplace ostracism. Further, workplace incivility was playing the mediating role between illegitimate tasks and workplace ostracism. The results from the study carry significant implications for managers and researchers. Recommendations and future research directions are also discussed in the paper.

Ewing Sarcoma of Chest Wall: Analysis of 19 Patients

Objective: To share the short and long term outcomes of the patients having Ewing Sarcoma of the chest wall. Study Design: Prospective longitudinal study. Place and Duration of Study: Thoracic Departments of Combined Military Hospital Rawalpindi, Combined Military Hospital Lahore and Combined Military Hospital Multan from Jan 2010 to Jun 2020. Methodology: In total, 19 patients were enrolled. Inclusion criteria were physiologically fit patients for one-lung ventilation with proven true-cut histopathology. Exclusion criteria were poor performance status and non-compliance to chemotherapy. Results: Out of 19 cases, 13 males (68.42%) and six females (31.58%) patients. The age range was from 8 to 29 years, with a mean age of 17.6 + 4.16 years. The most common symptom was palpable mass 19, followed by chest pain 8 and one patient presented with fungating mass. All patients showed partial response to neo-adjuvant chemotherapy as per RECIST criteria. Following resection and confirmation of negative margins, primary reconstruction was done. The soft tissue coverage was provided using Latissimus Dorsi Muscle Flap in 16 Cases (84.21%) and in 03 patients (15.79%) Rectus Abdominis muscle was used. Post operatively, less than 02 blood transfusions were needed in six patients. There was no post-operative ventilatory support required, and mortality was zero. Conclusion: Ewing Sarcoma of the chest wall is a rare tumour in the adult population. An excellent outcome can be achieved through early diagnosis, meticulous surgical technique and good teamwork in a multi-disciplinary setting.

Plastibel Circumcision: Safest Technique in the Infants with the Experienced Hands: A Single Centre Experience

Objective: To evaluate the safety and efficacy of circumcision done by plastibel technique in infants up till six months of age. Study Design: Cross-sectional study. Place and Duration of Study: Department of Surgery, Combined Military Hospital, Multan, from Aug 2019 to Jul 2020 Methodology: The Department of surgery, Combined Military Hospital, Multan, from 2019 to 2020. A sample size of 140 patients was calculated via the EpiTools epidemiological calculator while keeping the significance level at 5% and a confidence level of 95%. Results: A total of 140 infants were circumcised with the plastibel technique. The age of the infants ranged from 21 days to six months with the mean age of 32.2 ± 10.5 days. Maximum circumcisions were done between 30-90 days of life. The best part of the circumcision was that no complication was observed during the study period. Conclusion: Plastibel circumcision can be done under local anaesthesia with the best possible safety in infants younger than six months of age.

Short and long-term follow-up results of soleus muscle rotation flap for coverage of soft tissue defects of proximal and middle leg

Objective: To observe the short and long-term outcomes of the soleus muscle rotation flap for coverage of soft tissue defects of proximal and middle leg. Study Design: Case series Place and duration of study Departments of Plastic and Reconstructive Surgery of Bahawal Victoria Hospital Bahawalpur, Combined Military Hospital Bahawalpur, and Combined Military Hospital Quetta from December 2014 to February 2020.. Materials and methods In total, 36 patients were enrolled for the study through consecutive sampling. Data was processed using SPSS-17. All patients were reviewed at first and second week (early morbidity), and then at six months (late morbidity) from operation. During early follow up, they were examined for hematoma at donor site, wound infection, sural nerve injury, graft loss, and flap necrosis. In late follow-up, patients were examined for reduced knee mobility, muscle weakness, sensory abnormalities, hypertrophic scarring, hyperkeratosis, and soleus muscle contractures. Results The studied patients consisted of 30 (90.9%) men and 3 (0.9%) women. The mean age was 35 years (range: 16 to 64) years. Hematoma was the commonest complication. It occurred in 6.1%. Wound infection, partial loss of flap, partial loss of skin graft and wound infection occurred in 3.03% patients. Late follow up revealed reduced knee mobility in 9.09% patients (n=3) and bothersome contraction of soleus muscle in same number of patients. Conclusion The soleus flap is reliable, versatile, and very useful for provision of supple soft tissue coverage for defects in upper and middle leg.

Integrative molecular analysis of combined small-cell lung carcinomas identifies major subtypes with different therapeutic opportunities

BACKGROUND

Combined small-cell lung cancer (C-SCLC) is composed of SCLC admixed with a non-small-cell cancer component. They currently receive the same treatment as SCLC. The recent evidence that SCLC may belong to either of two lineages, neuroendocrine (NE) or non-NE, with different vulnerability to specific cell death pathways such as ferroptosis, opens new therapeutic opportunities also for C-SCLC.

MATERIALS AND METHODS

Thirteen C-SCLCs, including five with adenocarcinoma (CoADC), five with large-cell neuroendocrine carcinoma (CoLCNEC) and three with squamous cell carcinoma (CoSQC) components, were assessed for alterations in 409 genes and transcriptomic profiling of 20 815 genes.

RESULTS

All 13 cases harbored TP53 (12 cases) and/or RB1 (7 cases) inactivation, which was accompanied by mutated KRAS in 4 and PTEN in 3 cases. Potentially targetable alterations included two KRAS G12C, two PIK3CA and one EGFR mutations. Comparison of C-SCLC transcriptomes with those of 57 pure histology lung cancers (17 ADCs, 20 SQCs, 11 LCNECs, 9 SCLCs) showed that CoLCNEC and CoADC constituted a standalone group of NE tumors, while CoSQC transcriptional setup was overlapping that of pure SQC. Using transcriptional signatures of NE versus non-NE SCLC as classifier, CoLCNEC was clearly NE while CoSQC was strongly non-NE and CoADC exhibited a heterogeneous phenotype. Similarly, using ferroptosis sensitivity/resistance markers, CoSQC was classified as sensitive (as expected for non-NE), CoLCNEC as resistant (as expected for NE) and CoADC showed a heterogeneous pattern.

CONCLUSIONS

These data support routine molecular profiling of C-SCLC to search for targetable driver alterations and to precisely classify them according to therapeutically relevant subgroups (e.g. NE versus non-NE).

PATIENT AND OBSERVER SCAR ASSESSMENT FOLLOWING BASAL CELL CARCINOMA SURGERY: MULTICENTER QUASI EXPERIMENTAL STUDY

Objective: To assess patient and observer reported scar quality after Basal cell carcinoma surgery of face using the Patient and Observer Scar Assessment Scale (POSAS). Study Design: Quasi experimental study. Place and Duration of Study: Dermatology Department, Tertiary Care Hospitals at Multan and Karachi and Plastic Surgery Department, Tertiary Care Hospital Multan, from Apr to Sep 2020. Methodology: Patients with basal cell carcinoma that full filled inclusion and exclusion criteria were enrolled by consecutive sampling technique at Dermatology and Plastic Surgery Department after informed consent. Surgical excision was followed by reconstruction of defect either by direct closure or by rotation or advancement flap. Surgical scar was assessed independently at 8 weeks by POSAS. Data was analyzed with SPSS-23. Results: A total of 27 patients were enrolled in study. There were 11 (37.9%) males and 16 (59.25%) females between ages of 45-70 years. Basal cell carcinoma was located on cheek in 15 (55.5%), nose in 9 (33.3%), temple 2 (7.4%) and forehead 1 (3.7%) cases. Direct closure was performed in 6 (22.2%), rotation flaps in 10 (40.7%), and advancement flaps in 11 (40.7%) cases. Mean score of observer opinion about surgical scar between different surgical techniques was not statistically significant (p=0.191). How-ever, mean score of patient opinion of scar between different surgical techniques was statistically significant (p=0.032). Conclusion: POSAS is a valid tool for scar evaluation by patient and observer-reported scar qualities after Basal cell carcinoma surgery.

DEPRESSION AND ANXIETY AMONG PATIENTS SEEKING RHINOPLASTY

Objective: To evaluate the presence and relation of depression and anxiety among patients seeking rhinoplasty Study Design: A cross-sectional study. Place and Duration of Study: Departments of Psychiatry, department of Plastic Surgery and ENT, Combined Military Hospital Multan, from Jan 2019 to Mar 2020. Methodology: A total of 102 patients were recruited that reported to Plastic surgery and ENT unit. Patients were divided equally in two groups of 51 each. One group included patients seeking rhinoplasty while other group included those patients that reported in Plastic surgery and ENT unit for reasons other than rhinoplasty. Symptom were assessed using Beck Depressive Inventory for depression and Beck Anxiety Inventory for anxiety. Results: A total of 102 participants were included in the study, of these 51 were patients seeking rhinoplasty and 51 were controls. Significant correlation exist between anxiety and depression (p<0.00). Conclusion: There is a very high frequency of anxiety and depression among patients seeking Rhinoplasty along with significant positive correlation.

EAR RECONSTRUCTION SURGERY: OUTCOME ANALYSIS OF 108 PATIENTS

Objective: To find out the outcome of the ear Reconstruction and its association with improvement in psychological wellbeing along with physical benefits. Study Design: A cross-sectional study. Place and Duration of Study: Department of Plastic Surgery and ENT, Combined Military Hospital Quetta and Multan in liaison with the department of Psychiatry, from Jan 2017 to Jan 2021. Methodology: A sample size of 108 was estimated while keeping level of significance 5%, confidence level 90%, estimated true proportion 63% based on the observation made in the study by Steffen, and 5% of absolute precision. Specific performas were filled by the patient pre and post operatively and data analysis was performed using SPSS-20. Results: The mean age was 20 ± 8.75 years with a range of 12-29 years. Thirteen (11.11%) were male and ninety-five (87.8%) were females, 14 (12.9%) were married, 94 (86%) were un-married and all (100%) had social support. Fifty-two (48.1%) had primary education. Ninety-four (94%) were un-employed. Fifty-five (50.9%) of participants had congenital ear defect. Ninetyeight (90.7%) of the participants showed confidence in surgical procedure and would go for the same procedure if required, 5 (4.6%) said no to the same procedure while 8 (7.4%) did not know whether to opt for same procedure. Conclusion: Ear Reconstruction is a very rewarding procedure for surgeon and patients. Apart from aesthetic and functional improvement it also enhances the self-esteem of the patients.

AESTHETIC SURGERY: IMPACT ON QUALITY OF LIFE

Objective: To determine the impact of aesthetic surgery on quality of life. Study Design: Cross-sectional study. Place and Duration of Study: The departments of Psychiatry, Plastic Surgery and ENT, Combined Military Hospital Multan, from Jan to Nov 2020. Methodology: Seventy-four patients were enrolled for this study. They underwent aesthetic surgery. A standard questioner was designed for these patients and response was obtained before undertaking the procedure and then after six months postoperatively. The questions were designed keeping in mind the specific type of surgery. Questions on Life Satisfaction, and the Patient Health Questionnaire (PHQ-4) were asked. The data were collected and analyzed by using SSPS-25. Results: There is high satisfaction postoperatively after aesthetic surgery. There are improvements in quality of life (p=0.03), physical well-being (Health) (p=0.03), body image (p=0.02), emotional stability (p<0.01) and emotional distress (Depression) (p=0.04 and anxiety (p=0.01) were noted to be reduced. Conclusion: Aesthetic surgery leads to higher satisfaction in physical appearance, health, emotional stability and reduction of anxiety.

A homozygous missense variant in the MLC1 gene underlies megalencephalic leukoencephalopathy with subcortical cysts in large kindred: Heterozygous carriers show seizure and mild motor function deterioration

Megalencephalic leukoencephalopathy with subcortical cysts (MLC) is a rare type of leukodystrophy characterized by epileptic seizures, macrocephaly, and vacuolization of myelin and astrocyte. The magnetic resonance imaging of the brain of MLC patients shows diffuse white-matter anomalies and the occurrence of subcortical cysts. MLC features have been observed in individuals having mutations in the MLC1 or HEPACAM genes. In this study, we recruited a six generation large kindred with five affected individuals manifesting clinical features of epileptic seizures, macrocephaly, ataxia, and spasticity. In order to identify the underlying genetic cause of the clinical features, we performed whole-genome genotyping using Illumina microarray followed by detection of loss of heterozygosity (LOHs) regions. One affected individual was exome sequenced as well. Homozygosity mapping detected several LOH regions due to extensive consanguinity. An unbiased and hypothesis-free exome data analysis identified a homozygous missense variant (NM_015166.3:c.278C>T) in the exon 4 of the MLC1 gene. The variant is present in the LOH region on chromosome 22q (50 Mb) and segregates perfectly with the disorder within the family in an autosomal recessive manner. The variant is present in a highly conserved first cytoplasmic domain of the MLC1 protein (NM_015166.3:p.(Ser93Leu)). Interestingly, heterozygous individuals show seizure and mild motor function deterioration. We propose that the heterozygous variant in MLC1 might disrupt the functional interaction of MLC1 with GlialCAM resulting in mild clinical features in carriers of the variant.

DEPRESSION AND ANXIETY IN CORRELATION TO BODY AREAS INVOLVED IN PATIENTS OF BURNS

Objective: To evaluate the severity of depression and anxiety among patients of burns and correlate depression and anxiety with areas of body involved in burns. Study Design: A cross-sectional study. Place and Duration of Study: The departments of Psychiatry and department of Plastic Surgery, Combined Military Hospital Multan, from Oct 2019 to Mar 2020. Methodology: Through consecutive sampling, 56 patients of burns reporting to burns unit were assessed for anxiety and/ or depression based on the diagnostic criteria of International Classification of Diseases version 10. Symptom severity was assessed using Beck Depressive Inventory for depression and Beck Anxiety Inventory for anxiety. Descriptive statistics like mean with standard deviation was calculated for age. Frequency along with percentages was calculated for sociodemographic variables, Anxiety and depression. Results: Depression was present among 30 (53%) of participants out of which 16 (53.5%) had mild, 11 (37.9%) had moderate while only 3 (12.5%) had severe depression. Anxiety was seen among 50 (89%) of participants out of which sixteen (32.1%) had mild, 26 (51.7%) had moderate while 8 (16%) had severe anxiety. Significant correlation existed among the major area involved in burn with both anxiety and depression (p<0.01). Conclusion: There is a very high prevalence of anxiety and depression among patients of burn. Significant positive correlation existed between the level of anxiety and the areas involved in burns.

A Profile of Colorectal Tumors Presenting as Emergency

OBJECTIVE

 To determine the factors, management and outcome of colorectal tumors presenting at Emergency Department, Mayo Hospital, Lahore.

STUDY DESIGN

Observational study.

PLACE AND DURATION OF STUDY

Accident & Emergency Department, Mayo Hospital, Lahore, from August 2017 to July 2019.

METHODOLOGY

Conducted on 40 consecutive patients who presented in the Accident and Emergency Department, Mayo Hospital, Lahore; determined to have colon or rectal cancer as the cause of intestinal obstruction or perforation, were studied. Data was abstracted from patient charts. Studied variables included patient's demographic data, indication for admission, surgical procedure done, complications, histopathology and mortality rate.

RESULTS

Forty patients underwent operations of colon and rectum during the study period. Mean age at presentation was 37.8 ± 16.7 years. Intestinal obstruction (75%) was the main presenting symptom. Ascending colon was the main site involved (50%), followed by recto-sigmoid mass (15%) and rectal mass (12.5%); 80% patients subjected to the stoma formation. Electrolyte imbalance and wound infection were the most common medical and surgical complications. Adenocarcinoma was the most common tumor on histopathology (92.5%). After surgery 87.5% patients survived and 12.5% patients expired. Factors significantly associated with worse outcome were greater ASA score (p=0.004), absence of screening colonoscopy in the past (p=0.013) and postoperative medical complications (p<0.001).

CONCLUSION

Colorectal tumor cases continue to present in emergency in a high number. Male gender, young age and ascending colon cancers were more frequent among such cases. Most patients had to undergo stoma formation in emergency. Mortality is significantly associated with higher ASA score, absence of screening colonoscopy and postoperative medical complications. Key Words: Colorectal carcinoma, Adenocarcinoma, Ascending colon, Wound infection, Emergency, Young males, Screening colonoscopy, ASA score.

Review of potential risk groups for coronavirus disease 2019 (COVID-19)

The current pandemic of coronavirus disease 19 (COVID-19) is a global issue caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Studies have revealed that this virus results in poorer consequences and a higher rate of mortality in older adults and those with comorbidities such as cardiovascular disease, hypertension, diabetes and prolonged respiratory illness. In this review, we discuss in detail the potential groups at risk of COVID-19 and outline future recommendations to mitigate community transmission of COVID-19. The rate of COVID-19 was high in healthcare workers, smokers, older adults, travellers and pregnant women. Furthermore, patients with severe medical complications such as heart disease, hypertension, respiratory illness, diabetes mellitus and cancer are at higher risk of disease severity and mortality. Therefore, special effort and devotion are needed to diminish the threat of SARS-CoV-2 infection. Proper vaccination, use of sanitizers for handwashing and complete lockdown are recommended to mitigate the chain of COVID-19 transmission.

DONOR SITE MORBIDITY OF FIBULAR FLAP

Objective: To present the early and late outcomes related to donor site morbidity of Free Fibular Flap. Study Design: Prospective observational study. Place and Duration of Study: Plastic surgery department, Combined Military Hospital Rawalpindi, from Jan 2009 to Jan 2020. Methodology: In total 361 patients were enrolled for the study through consecutive purposive sampling. All patients requiring free fibula flap for reconstruction of the defect were included in the study. However, the patients with Diabetes Mellitus, Smoking or peripheral vascular disease were excluded from the study. The patients were asked to visit on second week and then at three months for late outcomes. The results were entered SPSS-24 for analysis and interpretation of data. Results: Out of total 361 patients enrolled for study 293 (81.16%) were male and 68 (18.83%) were female. The men age was 51.43 years SD 14.6 (range 4 year to 68 years). In early outcomes, graft loss 29 (8.03%) and sensory deficit 19 (5.26%), are the commonest adverse outcomes. Results of late follow up revealed chronic pain in 29 (8.03%), ankle instability in 24 (6.64%), gait abnormality in 29 (8.76%) and claw toe in 33 (9.14%) patients. The American Orthopedic Foot and Ankle Society (AOFAS) score was 88.45%. Majority (52.63%) patients were very satisfied. Conclusion: The free Fibula is excellent choice for reconstruction of a wide range of osseous defects with minimum donor site morbidity and high satisfaction rate among the patients.Keywords:

The RECONSTRUCTION OF NASAL ALA DEFECTS USING THREE STAGED FOLDED FOREHEAD FLAP: AESTHETIC AND FUNCTIONAL OUTCOMES

Objective: To assess short and long term aesthetic and functional outcomes of nasal ala reconstruction by three staged folded forehead flap. Study Design: Prospective study. Place and Duration of Study: Plastic and Reconstructive Surgery Department of Combined Military HospitalBahawalpur and Quetta, from Dec 2014 to Dec 2018. Methodology: Total of 29 patients were enrolled through consecutive sampling technique. Nasal ala defects were reconstructed by three staged frontal forehead flap under general anesthesia. Follow up visit at 2 weeks bleeding, wound Infection, partial skin graft loss and partial flap necrosis was documented. Follow up at 24 weeks, functional outcome of nasal reconstruction was assessed by history and clinical examination for nasal obstruction and/or crusting. Patients’ subjective satisfaction about aesthetic outcome of nasal reconstruction was documented on 5 point likert scale. Objective aesthetic assessment of reconstruction was done on 2D photograph by two independent surgeons. Results: Twenty six (89.66%) males and 3 (10.34%) females participated in study. The mean age was 35 yearsrange 16 to 64 years. Follow up at two weeks revealed postoperative bleeding in 2 (6.8%), wound infection in 1(3.4%) and partial flap loss in 1 (3.4%) patient. At 24 weeks follow up all patients had patent nasal ala. Subjectiveand objective assessment of nose shape was documented. Conclusion: Use of three staged folded forehead flapis useful method of reconstruction for full thickness defects of nasal alaewith good functional and aesthetic outcome.

SHORT AND LONG TERM FOLLOW UP RESULTS OF (THE VERSATILE) GASTROCNEMIUS MUSCLE FLAP

Objective: To see the long and short term outcome of the Gastrocnemius muscle flap for coverage of soft tissue defects of knee and proximal Tibia. Study Design: Case series. Place and Duration of Study: Surgery Department of Combined Military Hospital Bahawalpur, from Dec 2014 to Oct 2017. Methodology: A total of 33 patients were enrolled for the study through consecutive sampling. Data was processed using SPSS-17. All patients were followed up at first and second week (early morbidity), and then at 06 months (late morbidity) from operation. During early follow up, they were examined for Hematoma at donor site, wound Infection, sural nerve injury, partial skin graft loss and Partial Flap Necrosis. In late follow up patients were examined for reduced Knee mobility and Gastrocnemius muscle contractions. Results: The studied 33 patients consisted of 30 (90.90%) men and 3 (9.09%) women. The mean age was 35 years (range: 16 to 64) years. Hematoma was commonest complication. It occurred in 6.06%. Wound infection, partial loss of flap, partial loss of skin graft and wound infection occurred in 3.03% patients. Late follow up revealed reduced knee mobility in 9.09% patients (n=3) and bothersome contraction of gastrocnemius muscle in same number of patients. Conclusion: The gastrocnemius flap is reliable, versatile, and very useful for provision of supple soft tissue coverage for defects around the knee and the upper leg.

Antibiotic susceptibility and drug prescription pattern in uropathogenic Escherichia coli in district Muzaffarabad, Azad Jammu and Kashmir, Pakistan

The present research study was done to determine the correlation between antibiotic susceptibility and drug prescription patterns in empirical treatment of uropathogenic Escherichia coli (E. coli) in two hospitals of district Muzaffarabad, Azad Kashmir, Pakistan. One hundred uropathogenic E. coli clinical isolates were collected from UTI patients who attended the Combined Military Hospital (CMH) and Abbas Institute of Medical Sciences (AIMS), district Muzaffarabad, AJK. All isolates were subjected to antibiotic susceptibility against seven commonly prescribed antibiotics by Kirby-Bauer disk diffusion method. However, all the E. coli isolates were susceptible to Imipenem. Eight percent and 10% of isolates from CMH and AIMS were found to be resistant against Nitrofurantoin drug respectively. Similarly, 94% and 74% isolates from CMH and 60% and 64% isolates from AIMS were found to be resistant against Co-trimoxazole and Coamoxiclave, respectively. Pipemedic acid resistance was also detected in 76% and 60% isolates from AIMS and CMH, respectively. Ciprofloxacin resistance was also observed in 54% and 36% isolates from AIMS and CMH, respectively. The finding of the study revealed that both hospitals have different drug susceptibility pattern against uropathogenic E. coli, which may be associated with patterns of drug prescription in empirical treatment of urinary tract infections. There is a vital need for appropriate development of hospital-specific antibiograms to determine appropriate empiric therapy of urinary tract infections.

Sequencing and Characterization of Mitochondrial Protein-Coding Genes for Schizothorax niger (Cypriniformes: Cyprinidae) with Phylogenetic Consideration

The present study was conducted to get more information about the genome and locate the taxonomic position of Schizothorax niger in Schizothoracinae through mitochondrial 13 protein-coding genes (PCGs). These PCGs for S. niger were found to be 11409 bps in length ranging from 165 (ATPase 8) to 1824 bps (NADH dehydrogenase subunit 5) and encode 3801 amino acids. In these PCGs, 4 genes overlap on the similar strands, while one shown on the opposite one: ATPase 6+8 and NADH dehydrogenase subunit 4+4L overlap by 7 nucleotides. Similarly, ND5-ND6 overlap by 4 nucleotides, while ATP6 and COIII overlap by 1 nucleotide. Similarly, four commonly used amino acids in S. niger were Leu (15.6 %), Ile (10.12 %), Thr (8.12 %), and Ala (8.7 %). The results presented that COII, COIII, NDI, ND4L, and Cytb had substantial amino acid conservation as compared to the COI gene. Through phylogenetic analysis, it was observed that S. niger is closely linked with S. progastus, S. labiatus, S. plagiostomus, and S. nepalensis with high bootstrap values. The present study provided more genomic data to know the diversity of the mitochondrial genome and its molecular evolution in Schizothoracinae.

Surgical Outcome of Peripheral Vascular Injuries in Adults

OBJECTIVE

To describe the management and outcome of adult patients after peripheral vascular injuries.

STUDY DESIGN

Observational study.

PLACE AND DURATION OF STUDY

Accident & Emergency Department, Mayo Hospital Lahore, Pakistan, from January 2014 to December 2018.

METHODOLOGY

All adult trauma patients (aged ≥13 years), who were admitted following injury to peripheral blood vessels regardless injuries, were included. Variables including patient data, mechanism of injury, vessel involved, injury severity score (ISS), surgical procedure etc. were retrospectively extracted from patient charts. Binary logistic and multinomial regression analyses were performed. The p-value <0.05 was considered significant for mortality and limb outcome.

RESULTS

There were 117 patients, with mean age of 28.9±11.6 years. The commonest cause was blunt trauma (55.6%). The popliteal artery was most commonly involved (44.4%). Complete transection of artery was the most common type of injury (58.1%). The mean ISS was 17.2 ± 10. Reverse saphenous vein graft (RSVG) was the most common surgical repair (49.6%) procedure. Wound infection (17.1%) was the main complication. Limb salvage rate was 73.5% and mortality rate was 5.1%. Variables significantly influencing the limb outcome (amputated vs. salvaged) were duration of injury (p <0.001), concomitant body injury (p=0.009), ISS (p <0.001), surgical procedure (p <0.001), hemoglobin on presentation (p<0.001), number of blood transfusion (p=0.05) complications after surgery (p <0.001) and referral or not (p=0.001). Factors significantly associated with mortality were duration of injury (p=0.008), ISS (p = 0.002) and complications after surgery (p=0.011).

CONCLUSION

Low hemoglobin on presentation, postoperative increased requirement of blood transfusions and having reverse saphenous graft as procedure were independent risk factors for amputation. ISS score and postoperative complications led to higher amputation and mortality rates after surgery. Key Words: Injury severity score (ISS), Glasgow coma scale (GCS), Reverse saphenous graft (RSVG), Fasciotomy, Popliteal artery, Mortality.

Identification of a recurrent nonsense mutation in HR gene responsible for atrichia with papular lesions in two Kashmiri families

BACKGROUND

Congenital atrichia (CA) is a rare form of irreversible alopecia with an autosomal recessive mode of inheritance. This form of hair loss is mainly associated with mutations in the human hairless (HR) gene located at chromosome 8p21.3. An additional unique feature atrichia with papular lesions (APL) comprises keratin-filled cysts known as papules. The present study aimed to uncover the underlying genetic causes of APL in two consanguineous Kashmiri families.

METHODS

In the present study, two consanguineous families of Kashmiri origin with APL displaying an autosomal recessive mode of inheritance were investigated. Whole exome and Sanger sequencing followed by bioinformatic studies, variant prioritization, Sanger validation and segregation analysis was performed to find the mutation.

RESULTS

A recurrent nonsense (NM_005144: c.2818C > T:p.Arg940*) mutation was detected in exon 13 of the human HR gene.

CONCLUSIONS

Whole exome sequencing analysis has widely been used in the screening of single gene disorders mutations, both in research and diagnostic laboratories. Sanger sequencing alone for genes such as HR becomes expensive and time consuming. Instead, it is recommended that a patient is to screen by whole exome sequencing and then special attention first focuses on known genes of the APL phenotype. This is helpful for intime diagnosis, being more efficient and economic. The results obtained in the present study may contribute to prenatal diagnosis, carrier secreening and the genetic counseling of families with the APL phenotype in Kashmiri poplution.

Confirmation of the Role of DHX38 in the Etiology of Early-Onset Retinitis Pigmentosa

Purpose

Retinitis pigmentosa (RP) is a genetically heterogeneous trait with autosomal-recessive (ar) inheritance underlying 50% of genetic disease cases. Sixty-one arRP genes have been identified, and recently, DHX38 has been reported as a potential candidate gene for arRP with only a single family reported with a variant of unknown significance. We identified a missense variant in DHX38 that co-segregates with the arRP phenotype in two Pakistani families confirming the involvement of DHX38 in the etiology of early-onset RP.

Methods

Exome sequencing was performed using two DNA samples from affected members of Pakistani families (MA88 and MA157) with early onset arRP. Sanger sequencing of DNA samples from all family members confirmed the segregation of candidate variant within both families.

Results

A novel missense DHX38 variant c.971G>A; p.(Arg324Gln) was identified which segregates with the arRP phenotype and yielded a logarithm of the odds (LOD) score of 5.0 and 4.3 for families MA88 and MA157, respectively. This variant is predicted to be conserved and deleterious by several bioinformatics tools.

Conclusions

We identified a second deleterious DHX38 variant that segregates with arRP in two families, providing additional evidence that DHX38 is involved in RP etiology. DHX38 encodes for pre-mRNA splicing factor PRP16, which is important in catalyzing pre-mRNA splicing.

FAM92A Underlies Nonsyndromic Postaxial Polydactyly in Humans and an Abnormal Limb and Digit Skeletal Phenotype in Mice

Polydactyly is a common congenital anomaly of the hand and foot. Postaxial polydactyly (PAP) is characterized by one or more posterior or postaxial digits. In a Pakistani family with autosomal recessive nonsyndromic postaxial polydactyly type A (PAPA), we performed genomewide genotyping, linkage analysis, and exome and Sanger sequencing. Exome sequencing revealed a homozygous nonsense variant (c.478C>T, p.[Arg160*]) in the FAM92A gene within the mapped region on 8q21.13-q24.12 that segregated with the PAPA phenotype. We found that FAM92A is expressed in the developing mouse limb and E11.5 limb bud including the progress zone and the apical ectodermal ridge, where it strongly localizes at the cilia level, suggesting an important role in limb patterning. The identified variant leads to a loss of the FAM92A/Chibby1 complex that is crucial for ciliogenesis and impairs the recruitment and the colocalization of FAM92A with Chibby1 at the base of the cilia. In addition, we show that Fam92a^-/- homozygous mice also exhibit an abnormal digit morphology, including metatarsal osteomas and polysyndactyly, in addition to distinct abnormalities on the deltoid tuberosity of their humeri. In conclusion, we present a new nonsyndromic PAPA ciliopathy due to a loss-of-function variant in FAM92A. © 2018 American Society for Bone and Mineral Research.

Novel candidate genes and variants underlying autosomal recessive neurodevelopmental disorders with intellectual disability

Identification of Mendelian genes for neurodevelopmental disorders using exome sequencing to study autosomal recessive (AR) consanguineous pedigrees has been highly successful. To identify causal variants for syndromic and non-syndromic intellectual disability (ID), exome sequencing was performed using DNA samples from 22 consanguineous Pakistani families with ARID, of which 21 have additional phenotypes including microcephaly. To aid in variant identification, homozygosity mapping and linkage analysis were performed. DNA samples from affected family member(s) from every pedigree underwent exome sequencing. Identified rare damaging exome variants were tested for co-segregation with ID using Sanger sequencing. For seven ARID families, variants were identified in genes not previously associated with ID, including: EI24, FXR1 and TET3 for which knockout mouse models have brain defects; and CACNG7 and TRAPPC10 where cell studies suggest roles in important neural pathways. For two families, the novel ARID genes CARNMT1 and GARNL3 lie within previously reported ID microdeletion regions. We also observed homozygous variants in two ID candidate genes, GRAMD1B and TBRG1, for which each has been previously reported in a single family. An additional 14 families have homozygous variants in established ID genes, of which 11 variants are novel. All ARID genes have increased expression in specific structures of the developing and adult human brain and 91% of the genes are differentially expressed in utero or during early childhood. The identification of novel ARID candidate genes and variants adds to the knowledge base that is required to further understand human brain function and development.

Sequence variants in four genes underlying Bardet-Biedl syndrome in consanguineous families

PURPOSE

To investigate the molecular basis of Bardet-Biedl syndrome (BBS) in five consanguineous families of Pakistani origin.

METHODS

Linkage in two families (A and B) was established to BBS7 on chromosome 4q27, in family C to BBS8 on chromosome 14q32.1, and in family D to BBS10 on chromosome 12q21.2. Family E was investigated directly with exome sequence analysis.

RESULTS

Sanger sequencing revealed two novel mutations and three previously reported mutations in the BBS genes. These mutations include two deletions (c.580_582delGCA, c.1592_1597delTTCCAG) in the BBS7 gene, a missense mutation (p.Gln449His) in the BBS8 gene, a frameshift mutation (c.271_272insT) in the BBS10 gene, and a nonsense mutation (p.Ser40*) in the MKKS (BBS6) gene.

CONCLUSIONS

Two novel mutations and three previously reported variants, identified in the present study, further extend the body of evidence implicating BBS6, BBS7, BBS8, and BBS10 in causing BBS.

DNA barcoding of Schizothorax species from the Neelum and Jhelum Rivers of Azad Jammu and Kashmir

The mitochondrial Cytochrome Oxidase 1 gene is used as a standardized, authenticated, and reliable genetic marker for a global species-level bio-identification system. The present study was conducted to determine whether barcoding can help accurate species identification in fishes. The overall base composition of Schizothorax species was 29.6% of T, 25.5% of C, 26.5% of A, and 18.4% of G, A + T content 56.1% and G + C content 43.9%. The Ts/Tv bias (R) was 2.51. Complete COI gene was amplified using PCR and sequenced from 17 samples collected from river Neelum and Jhelum, and identification of species were done by following Mirza (1991), Jhingran (1991) classification and also through BOLD (99.3 to 99.9%) and NCBI (99.6 to 99.9%) reference sequences of those species. Multiple alignments of CO1 mtDNA gene resulted in a range of 1535-1551 base pairs. Out of 1535 consensus sites, 1490 were constant, 61 characters were variable, in which 54 were parsimony informative, and 7 variables were parsimony uninformative. This is the very first study reported from a reservoir of cold water bodies of Azad Kashmir which have a great potential for conservation of cold water fish species. We emphasized that, DNA barcoding is an accurate, reliable and has the great potential for identification of freshwater fish species.

A Novel Locus for Ectodermal Dysplasia of Hair, Nail and Skin Pigmentation Anomalies Maps to Chromosome 18p11.32-p11.31

Ectodermal dysplasias (EDs) are a large heterogeneous group of inherited disorders exhibiting abnormalities in ectodermally derived appendages such as hair, nails, teeth and sweat glands. EDs associated with reticulated pigmentation phenotype are rare entities for which the genetic basis and pathophysiology are not well characterized. The present study describes a five generation consanguineous Pakistani family segregating an autosomal recessive form of a novel type of ectodermal dysplasia. The affected members present with sparse and woolly hair, severe nail dystrophy and reticulate skin pigmentation. After exclusion of known gene loci related with other skin disorders, genome-wide linkage analysis was performed using Illumina HumanOmniExpress beadchip SNP arrays. We linked this form of ED to human chromosome 18p11.32-p11.31 flanked by the SNPs rs9284390 (0.113Mb) and rs4797100 (3.14 Mb). A maximum two-point LOD score of 3.3 was obtained with several markers along the disease interval. The linkage interval of 3.03 Mb encompassed seventeen functional genes. However, sequence analysis of all these genes did not discover any potentially disease causing-variants. The identification of this novel locus provides additional information regarding the mapping of a rare form of ED. Further research, such as the use of whole-genome sequencing, would be expected to reveal any pathogenic mutation within the disease locus.

Novel VPS13B Mutations in Three Large Pakistani Cohen Syndrome Families Suggests a Baloch Variant with Autistic-Like Features

Background

Cohen Syndrome (COH1) is a rare autosomal recessive disorder, principally identified by ocular, neural and muscular deficits. We identified three large consanguineous Pakistani families with intellectual disability and in some cases with autistic traits.

Methods

Clinical assessments were performed in order to allow comparison of clinical features with other VPS13B mutations. Homozygosity mapping followed by whole exome sequencing and Sanger sequencing strategies were used to identify disease-related mutations.

Results

We identified two novel homozygous deletion mutations in VPS13B, firstly a 1 bp deletion, NM_017890.4:c.6879delT; p.Phe2293Leufs*24, and secondly a deletion of exons 37-40, which co-segregate with affected status. In addition to COH1-related traits, autistic features were reported in a number of family members, contrasting with the “friendly” demeanour often associated with COH1. The c.6879delT mutation is present in two families from different regions of the country, but both from the Baloch sub-ethnic group, and with a shared haplotype, indicating a founder effect among the Baloch population.

Conclusion

We suspect that the c.6879delT mutation may be a common cause of COH1 and similar phenotypes among the Baloch population. Additionally, most of the individuals with the c.6879delT mutation in these two families also present with autistic like traits, and suggests that this variant may lead to a distinct autistic-like COH1 subgroup.

Electronic supplementary material

The online version of this article (doi:10.1186/s12881-015-0183-0) contains supplementary material, which is available to authorized users.