BackgroundEarly detection of lung cancer using low-dose computed tomography (LDCT) can potentially reduce morbidity and mortality. However, LDCT for lung cancer screening, especially in low income countries, has been underutilized. The objective of this study was to evaluate the prevalence and the potential personal, social, and economic barriers of lung cancer screening using LDCT.MethodsA total sample of 156 smokers and 200 general physicians was collected during December 2016-February 2017 from community settings in Karachi, Pakistan. Two separate questionnaires were constructed to characterize participants’ knowledge, attitudes, and practices regarding lung cancer screening. Screening-eligible smokers and physicians were asked to identify patient barriers to screening and were asked their opinion regarding most effective approach for increasing awareness of screening guidelines.ResultsThe majority of smokers' (n=91, 58.3%) and physicians' (n=131, 65.7%) beliefs about the US Preventive Services Task Force (USPSTF) eligibility criteria were inconsistent with the actual recommendations. Major barriers to screening included financial cost, lack of patient counseling and health anxiety related to screening. Over two-thirds (n=105, 67.3%) of smokers were receptive to further information about LDCT screening, and half (n=78, 50.0%) favored one-on-one counseling by their physician, compared to other media. Only one-third (n=65, 33.3%) of physicians reported use of LDCT screening, although 54.5% (n=108) felt that screening implementation would be very effective in their practice.ConclusionLDCT screening is currently an uncommon practice in Pakistan. Financial cost, inadequate doctor-patient communication, and lack of awareness of guidelines among both patients and physicians are the major barriers in the utilization of LDCT screening.

We present a case of a 58-year-old man with delayed diagnosed moyamoya disease who underwent encephaloduroarteriosynangiosis (EDAS) procedure. This patient with a history of three strokes presented to our facility with new left facial droop. Neurological examination revealed left facial droop and hemiparesis. Brain magnetic resonance imaging (MRI) described right frontal lobe acute ischemia. Head computed tomography (CT) angiography revealed bilateral supraclinoid internal carotid artery (ICA) occlusions. Cerebral angiography demonstrated diffuse intracranial vascular irregularity with stenosis, more above the bilateral supraclinoid ICAs and the right middle cerebral artery (MCA) suggestive of moyamoya disease. Due to the lack of MCA patency, he underwent EDAS. Superficial temporal artery (STA) was dissected inferiorly and the posterior branch was bipolared, then STA was movable. A bur hole made at the superior and inferior portion along the STA. Dura was opened, and STA was brought on top of the pia. His facial droop gradually improved after that. Nine months later, no new strokes reported.

Liver abscesses have a low incidence and can be caused by multiple etiologies. We present an interesting case of a 74-year-old woman who presented with abdominal pain and leukocytosis. Imaging revealed a foreign body in the antrum of the stomach extending to an area of hypodensity in the liver. She was taken for an exploratory laparotomy and was found to have a gastric perforation due to a sewing needle. The needle had embedded in the liver causing the formation of an abscess. The patient was successfully treated with surgical management and a course of antibiotics.

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Wernicke’s Encephalopathy (WE) is a neurological condition characterized by ophthalmoplegia, ataxic gait, and altered mental status. It is an underdiagnosed yet severely limiting disease process precipitated by thiamine deficiency. Often times, it can occur in conjunction with other disease states like refeeding syndrome in which the underlying etiology is prolonged periods of malnutrition. We present a unique case of non-alcoholic WE in a middle-aged male who initially presented with gallstone pancreatitis complicated with severe metabolic derangements. This ultimately resulted in the development of non-alcoholic WE. Prevention of this condition is a clinical challenge for most physicians as the classic features associated with thiamine deficiency lack diagnostic sensitivity and specificity in critically ill patients. As a result, early recognition and prompt management of this can dramatically decrease morbidity and mortality. Our case highlights and emphasizes the importance of maintaining a high index of suspicion for WE and refeeding syndrome in the setting of altered sensorium and metabolic derangements.