Rashida Ahmed

Distribution of Helicobacter pylori virulence markers in patients with gastroduodenal diseases in Pakistan

BackgroundHelicobacter pylori (H. pylori) infection is known to be associated with a spectrum of gastroduodenal diseases. We studied the association of H. pylori virulence markers cytotoxin-associated gene (cagA) and vacuolating associated cytotoxin gene (vacA) alleles in patients with non ulcer dyspepsia (NUD), gastric ulcer (GU), gastric carcinoma (GC) and duodenal ulcer (DU).MethodsH. pylori infection established by both rapid urease test and histology were studied. The cagA and vacA allelic status was determined by polymerase chain reaction (PCR). Sequencing of vacA i1 and i2 PCR product was carried out.ResultsTwo hundred and twenty-four patients were included, 141 (63%) were males with a mean age of 45 ± 16, range 16-83 years. The virulence marker cagA was associated with GU in 20(63%) (p = 0.04), DU in 23(72%) (p = 0.003) and GC in 29(73%) (p = 0.001) compared to NUD in 51(42%). VacA s1am1 was associated with GU in 23(72%) (p = 0.001), DU in 17(53%) (p < 0.001) and GC in 23(58%) (p = 0.003) compared to NUD in 38(32%) while vacA s1bm1 was also associated with GU in 9(28%) (p = 0.001), DU in 12(37%) (p < 0.001) and GC 11(28%) (p < 0.001) compared to NUD in 13(11%), respectively. The diagnoses of GU in 21(66%), DU in 16(50%), GC in 20(50%) and NUD in 50(42%) were associated with moderately active chronic inflammation. CagA in 55(45%) (p = 0.037), vacA s1am1 in 51(51%) (P < 0.001), s1bm1 in 25(56%) (p = 0.002), s1am2 32(30%) (p < 0.001) and s1bm2 29(69%) (p = 0.004) were also associated with moderately active chronic inflammation.ConclusionCagA was negative in majority of NUD patients with H. pylori infection. However, cagA was associated with peptic ulcer and GC. VacA alleles s1am1 and s1bm1 were associated with H. pylori associated diseases and inflammation.

Intricacies in the surgical management of appendiceal mucinous cystadenoma: a case report and review of the literature

IntroductionMucinous cystadenoma is a type of mucocele of the appendix that is rarely encountered in clinical practice. Dogmatic consensus on the optimal surgical modus operandi of appendicular mucocele is lacking in the literature and this remains a subject of controversy. There is little agreement with regard to the best procedure (right hemicolectomy versus appendectomy) or the best surgical approach (laparoscopic versus laparotomy).Case presentationWe report the case of a 70-year-old Asian woman from Karachi who presented with pain in the right iliac fossa for 15 days. On physical examination, a mobile and firm mass was palpable in the right iliac fossa. A colonoscopy was performed which showed external compression of the cecum. A biopsy of the mucosa was normal. Computed tomography scan showed a mucocele of the appendix with minimal periappendiceal fat stranding. She underwent an initial diagnostic laparoscopy to evaluate any mucin spillage in the peritoneal cavity. Once no spillage was identified, an open appendectomy was then performed. Intra-operatively, a frozen section of the appendiceal sample was sent to ascertain the need for an extension of surgery to a right hemicolectomy. Absence of any malignancy on the frozen section obviated the need for a surgical extension. The final histopathological examination showed a mucinous cystadenoma of the appendix. The patient was symptom-free at one year after surgery.ConclusionIt is important to distinguish between mucinous cystadenomas and mucinous cystadenocarcinomas. However, this distinction remains elusive in the pre-operative setting. A simple appendectomy using an intra-operative frozen section appears to be a reasonable surgical approach for selected cases with an intact mucocele of the appendix. However, long-term follow-up is warranted in such patients to evaluate the risks of using this approach.

Gastrointestinal, liver and biliary tract pathology: a histopathological and epidemiological perspective from Pakistan with a review of the literature.

AIM To present an epidemiological and histological perspective of diseases of the gastrointestinal tract (including liver and biliary tract) at the Section of Histopathology, Department of Pathology, AKUH, Karachi, Pakistan. MATERIALS AND METHODS All consecutive endoscopic biopsies and resections between October 1 and December 31, 2012 were included. RESULTS A total of 2,323 cases were included. Carcinoma was overwhelmingly the commonest diagnosis on esophageal biopsies (69.1%); chronic helicobacter gastritis (45.6%) followed by adenocarcinoma (23.5%) were the commonest diagnoses on gastric biopsies; adenocarcinoma (27.3%) followed by ulcerative colitis (13.1%) were the commonest diagnoses on colonic biopsies; acute appendicitis (59.1%) was the commonest diagnosis on appendicectomy specimens; chronic viral hepatitis (44.8%) followed by hepatocellular carcinoma (23.4%) were the commonest diagnoses on liver biopsies; chronic cholecystitis was the commonest diagnosis (over 89%) on cholecystectomy specimens. CONCLUSIONS Squamous cell carcinoma comprised 88.8% of esophageal cancers. About 67% were in the lower third and 56.5% were moderately differentiated; mean ages 49.8 years for females and 55.8 years for males; 66% cases were from South West Pakistan. Over 67% patients with gastric adenocarcinoma were males; mean ages 59 and 44 years in males and females respectively, about 74% gastric carcinomas were poorly differentiated; and 62.2% were located in the antropyloric region. About 63% patients with colorectal adenocarcinoma were males; mean ages 46.1 and 50.5 years for males and females respectively; tumor grade was moderately differentiated in 54%; over 80% were located in the left colon. In 21.2% appendicectomies, no acute inflammation was found. Acute appendicitis was most common in young people. Hepatitis C (66.3%) was more common than hepatitis B (33.7%); about 78% cases of hepatocellular carcinoma occurred in males; females comprised 76.7% patients with chronic cholecystitis; and 77.8% patients with gall bladder carcinoma. All resection specimens showed advanced cancers. Most cancers occurred after the age of 50 years.

Oligodendroglioma arising in the glial component of ovarian teratomas: a series of six cases and review of literature.

Aims To report the exceedingly rare occurrence of oligodendroglioma in the glial component of ovarian teratomas. Methods Six cases of oligodendrogliomas arising in the glial component of ovarian teratomas were studied and the literature was reviewed. Immunohistochemistry was performed by the Flex technique. Results The ages of the patients ranged from 12 to 28 years (mean 21 years). Four tumours were located in the right and one in the left ovary. The size of the ovarian cysts ranged from 7 cm to 29 cm (mean 19.6 cm). Four cases arose in immature and two cases in mature teratomas. In all cases, oligodendroglioma was WHO grade II. On immunohistochemistry, glial fibrillary acidic protein stain was positive in all cases. The Mib 1 (Ki 67) proliferative index was low and the tumour cells were negative for synaptophysin. Follow-up was available in five patients and ranged from 1 to 42 months. Two patients died of disease after 1 and 36 months of diagnosis, respectively. In both these cases oligodendroglioma arose in an immature teratoma. The remaining three patients are alive with a follow-up of 4–42 months. Conclusions Oligodendroglioma arising in the glial component of ovarian teratomas is exceedingly rare. Ovarian teratomas should be extensively sampled and carefully evaluated to rule out the possibility of a glial tumour. This is the single and largest series of oligodendrogliomas arising in ovarian teratomas. The prognosis is good for oligodendrogliomas arising in mature teratomas compared with those arising in immature teratomas, although long-term follow-up is needed to determine the exact behaviour.

Osseous metaplasia in a juvenile retention polyp: a case report.

We report a unique case of juvenile rectal polyp occurring in a 15-year-old male which showed osseous (bony) metaplasia on histological examination. The phenomenon is striking on histological examination but it appears to have no clinical significance.

Video or paper for delivery of problem‐based learning cases?

What problem was addressed? Problem-based learning (PBL) is one of the pedagogical approaches utilised in the Aga Khan University Medical College. In Years 1 and 2, students derive learning objectives related to anatomy, biochemistry, community health sciences, ethics, microbiology, pathology, pharmacology and physiology from clinical scenarios presented as text-based paper PBL cases. As informal feedback by students and formal case evaluations revealed a decline in student interest in the paper-based PBL cases, we piloted a change in delivery strategy by introducing video PBL cases, the premise being that the students, as digital natives, may engage more with video cases, which might also enhance the student-centred learning process. What was tried? All first-year undergraduate medical students and their PBL facilitators consented to participate in this Ethical Review Committeeapproved study during the introductory module. One hundred students were randomly divided into groups of 9–10 students each for PBL sessions and each group was facilitated throughout the study by an experienced faculty member. Four PBL cases were used; two were introduced using the traditional paper format and two were presented as video cases, each of 5–10 minutes’ duration using simulated patients or amateur actors. Students and facilitators were asked to complete a brief structured questionnaire after each PBL case using: (i) a 7point Likert scale to query whether the case was engaging, interesting, appropriate, relevant; (ii) open-ended questions asking respondents to comment on their perceptions regarding the effectiveness or ineffectiveness of the PBL delivery method. Data were entered and analysed using SPSS v19.0 (SPSS, Inc. Chicago, IL, USA). Proportions and means were calculated and Student’s t-test was applied to compare the difference in student and facilitator preference of video versus paper cases. Statistical significance was defined as p ≤ 0.05. What lessons were learned? In total, 392 studentcompleted (98% response rate) and 42 facilitatorcompleted (95% response rate) questionnaires on four cases were evaluated. Students found paper cases more effective compared with video cases (p = 0.001). More than 90% of students found paper cases interesting, engaging and helpful in enhancing the group discussion, dynamics and communication skills compared with video (p = 0.0001). Ninety-three per cent found triggers in paper cases more appropriate to derive learning objectives and helpful in improving their thinking process compared with video cases (p = 0.0001). Facilitators found no significant difference between the effectiveness of the two approaches (p = 0.19). Facilitators found video more interesting (p = 0.031) as compared with students as a delivery method in PBL. However, facilitators found no difference between the two delivery methods in enhancing the group discussion, dynamics and communication skills (p = 0.49). In light of student and facilitator responses and the development cost of video cases, we recommend that videos be utilised selectively for problems that provide observable cues for deriving learning objectives. Utilisation otherwise may prove more detrimental and unnecessarily costly than beneficial. Video cases should be introduced once students have become accustomed to the PBL approach using more traditional case delivery methods, such as paper cases, rather than at the point of entry into medical school.

Rhabdomyosarcoma - an Epidemiological and Histopathologic Study of 277 Cases from a Major Tertiary Care Center in Karachi, Pakistan

AIM To present the epidemiologic data (age, gender, size etc) and histopathologic and immunohistochemical features of cases of rhabdomyosarcoma (RMS) reported in our department. SETTINGS Section of Histopathology, Department of Pathology and Microbiology, Aga Khan University Hospital, Karachi, Pakistan. DURATION All cases of RMS diagnosed between January 1, 2003 and December 31, 2012 were included in the study. RESULTS A total of 277 cases were included. Embryonal rhabdomyosarcoma (ERMS) was by far the dominant histologic type (87.4%) followed by alveolar type (ARMS)(9.4%). ERMS was much more common in males (64.0%)and over 65% of cases occurred in the first decade of life (over 90% in the first two decades). Head and neck region was commonest site for ERMS (46.7%), followed by the genitourinary system (16.1%). Over 65% cases of ARMS occurred in the extremities. Over 80% cases of ARMS occurred in the first 3 decades of life. Immunohistochemical staining for Desmin and MyoD1 was positive in 96.7% and 85.4% respectively. CONCLUSIONS The epidemiologic data and microscopic findings in our patients are similar to international published data on rhabdomyosarcoma.

Stretching the boundaries of medical education: A case of medical college embracing humanities and social sciences in medical education

Objective: Aga Khan University, a private medical college, had a vision of producing physicians who are not only scientifically competent, but also socially sensitive, the latter by exposure of medical students to a broad-based curriculum. The objective of this study was to identify the genesis of broad-based education and its integration into the undergraduate medical education program as the Humanities and Social Sciences (HASS) course. Methods: A qualitative methodology was used for this study. Sources of data included document review and in-depth key informant interviews. Nvivo software was utilized to extract themes. Results: The study revealed the process of operationalization of the institutional vision to produce competent and culturally sensitive physicians. The delay in the establishment of the Faculty of Arts and Sciences, which was expected to take a lead role in the delivery of a broad-based education, led to the development of an innovative HASS course in the medical curriculum. The study also identified availability of faculty and resistance from students as challenges faced in the implementation and evolution of HASS. Conclusions: The description of the journey and viability of integration of HASS into the medical curriculum offers a model to medical colleges seeking ways to produce socially sensitive physicians.

Commonest Cancers in Pakistan - Findings and Histopathological Perspective from a Premier Surgical Pathology Center in Pakistan.

CONTEXT There are no recent authoritative data about incidence and prevalence of various types of cancers in Pakistan. AIM To determine the frequency of malignant tumors seen in our practice and provide a foundation for building a comprehensive cancer care strategy. MATERIALS AND METHODS 10,000 successive cases of solid malignant tumors reported in 2014 were included. All cases had formalin fixed, paraffin embedded specimens available and diagnosis was based on histological examination of H and E stained slides plus ancillary studies at the Section of Histopathology, Department of Pathology and Laboratory Medicine, Aga Khan University Hospital, Karachi. The latest WHO classifications were used along with the latest CAP protocols for reporting and the most updated TNM staging. RESULTS There were 9,492 (94.9%) primary tumors while 508 (5.1%) were metastatic. Some 5,153 (51.5%) were diagnosed in females and 4,847 (48.5%) in males. The commonest malignant tumors in females were breast (32%), esophagus (7%), lymphomas (6.8%), oral cavity (6.7%) and ovary (4.8%), while in males they were oral cavity (13.9%), lymphomas (12.8%), colorectum (7.9%), stomach (6.9%) and esophagus (6.6%). Malignant tumors were most common in the 5th, 6th and 7th decades. About 8% were seen under 20 years of age. CONCLUSIONS Oral cavity and gastrointestinal cancers continue to be extremely common in both genders. Breast and esophageal cancers are prevalent in females. Lung and prostate cancer are less common than in the west. Ovarian cancer was very common but cervix cancer was less so.

Calcifying/ossifying synovial sarcoma: a clinicopathologic and molecular study of 5 cases.

BACKGROUND Synovial sarcoma (SS) is a soft tissue sarcoma with a generally aggressive behavior. Calcifying/ossifying SS is a rare variant associated with a favorable prognosis. AIM The aim was to report clinicopathological features and molecular analysis of 5 cases of calcifying/ossifying SS. MATERIALS AND METHODS Record of 370 cases of SS reported in the section of Histopathology, of a tertiary care Hospital, between 2002 and 2011 were retrieved. Five cases exhibiting extensive calcification and ossification were identified. Immunohistochemistry was performed using Flex technique. Molecular analysis of these 5 cases was performed later at the collaborative Hospital abroad, by reverse transcription polymerase chain reaction. RESULTS AND CONCLUSIONS The ages of the patients ranged from 13 to 44 years (mean age 27 years; female to male ratio 1.6:1). The duration of symptoms ranged from 5 months to 5 years. Histologically, 4 were monophasic, and 1 was biphasic. Three cases exhibited extensive calcification and two extensive ossification. Immunohistochemical stain (epithelial membrane antigen was positive in all 5 cases, CKAE1/AE3 (3/4), Bcl2 (4/4), S100 (4/4), CK7 (2/2), CD99 (1/3) and vimentin (2/2). Intact RNA was obtained from 3 cases, all of which were positive for the SYT/SSX fusion transcript. Follow-up was available in 4 cases and ranged from 19 months to 85 months (mean 50 months). Local recurrence was seen in 2 cases. In conclusions, we report clinicopathologic features of 5 cases of calcifying/ossifying SS. The duration of symptoms and mean age of patients is similar to the literature. A slight female predominance was seen in contrast to a male predominance described in the literature. The clinical course of our cases validates the favorable prognosis of this rare type of SS.