Patella fractures account for 1% of all fractures but there is little in the contemporary literature regarding either an optimal standardized post-operative rehabilitation regimen or the long-term outcomes following these fractures. Tension band wire fixation for displaced patella fractures is a well-recognised and accepted method of operative treatment for these fractures. In this case the authors report a new complication, yet to be documented in the literature that was directly attributable to a well-recognised complication resulting from this method of fixation.An atypical osteochondral defect, from the lateral femoral condyle, was generated as a direct result of bony spur at the site of the previous patella fracture malunion. As the patient fell on to her knee the bony spur was driven into the femoral condyle in a similar fashion to an osteotome, generating the atypical osteochondral defect.This patient had chronic anterior knee pain following the tension band fixation of her patella. An inadequate standardised follow-up regimen failed to identify her fracture malunion that was responsible for her ongoing persistent symptoms. Only as a result of this previously unreported complication, we were able to identify and surgically address the underlying primary pathology responsible for her persistent symptoms. This case highlights the importance for the identification and establishment of a more robust imaging follow-up regimen post patella fracture fixation.

Metastatic carcinoma to the sinonasal tract is rare, by papillary thyroid cancer even rarer. We describe a 44-year old Hispanic woman with follicular variant papillary thyroid carcinoma treated with total thyroidectomy and post-surgery I 131 ablation. Post therapy, two consecutive body scans were negative and thyroglobulin level was less than 5 ng/ml. A year later, she presented with history of urinary retention and lower extremity weakness. A myelogram revealed block at T1-T2. Patient underwent laminectomy followed by external radiation. Pathology revealed metastatic follicular variant of papillary thyroid carcinoma. Total body scan post-surgery was negative, and the thyroglobulin level was 5 ng/ml. Patient was maintained on thyroxine suppression therapy. Two years later, patient started complaining of headaches and double vision. Magnetic resonance imaging (MRI) was done and revealed a soft tissue mass in the sphenoid sinus, eroding the basi-sphenoid and extending into the nasopharynx. Biopsy was positive for metastatic papillary thyroid cancer, follicular variant. Pituitary function testing revealed TSH 0.1 mIU/ml, free T4 level 1.2 mIU/ml. AM cortisol 5.3 mcg/dl, prolactin 182 ng/ml, ACTH 12 pg/ml, FSH 11.5 mIU/ml, LH 4.0 mIU/ml, and Estradiol 20 pg/ml.Metastasis to the sphenoid sinus is rare from any tumour, and from papillary thyroid cancer is extremely rare. An extensive world literature review revealed only 4 cases of papillary thyroid carcinoma with spread to sphenoid sinus region. Of 12 case reports of thyroid carcinoma with spread to the sphenoid sinus, 6 were follicular thyroid carcinoma. Generally, total body scan negative with low stimulated thyroglobulin is an excellent prognostic sign. Our patient demonstrates that we need to remain vigilant for the unusual tumour especially when the initial presentation showed a large lesion.

We report a rare case of hallucinations in a patient with bipolar affective disorder BAD without any history of psychosis or epilepsy following the introduction of lamotrigine as an add-on medication to her current treatment with lithium carbonate. The patient has been on two previous medications (quetiapine and sodium valproate) without significant improvement and only showed partial response to lithium. Lamotrigine was introduced as an adjunctive medication with her lithium carbonate. Her dose of lithium was 800 mg once daily with satisfactory lithium levels.She started to report complex auditory and visual hallucinations which started two days after starting lamotrigine (25 mg once daily) and increased with its dose increase to 50 mg once daily two weeks later and resolved completely with stopping it. Hallucinations following lamotrigine treatment in non- epileptic patients are an extremely rare reaction and only few similar case reports are reported in literature.Awareness of this rare but serious side effect is important to avoid confusion with other psychotic symptoms related to mental illness and avoid unnecessary treatment.

We report three cases of diabetic patients with peripheral neuropathy who sustained severe burn injuries to the foot due to use of thermal footbath with the intention to “improve circulation” and “relieve numbness”. Use of thermal footbath is common among Asian diabetic patients with peripheral neuropathy. This has resulted in accidental burn injuries. Due to high susceptibility to secondary infection, delayed presentation further complicates and prolongs hospital stay. There is a need for greater public awareness. Education regarding avoidance and consequences of this highly preventable injury should be incorporated into standard diabetic foot care education in clinical practice.

Pethidine is used in some centres for post operative rescue analgaesia, among other indications. We report an unusual and dramatic side effect from IV pethidine administration and its implications.

The importance of physical activity during and after cancer treatments is now being appreciated, as emerging evidence suggests that it improves several common side-effects of cancer treatments, as well as correlating with improving overall survival and reduced the probability of relapse. The biological mechanisms through which these benefits are achieved may include effects on cell growth regulatory pathways, levels of hormones, gene expression patterns and tumour immunity. Here we review the evidence for the benefits of exercise during and after cancer, discuss the possible underlying biological mechanisms, and suggest ways in which this knowledge may be used to improve mainstream care of cancer patients.

Background: Diagnosis of cancer in one’s child causes not only social but also psychological devastation for the whole family especially mothers. Depressed mothers are less able to help their sick child cope with intensive treatments. This study was done to identify frequency and severity levels of depression in mothers of children with cancer. Methods: Across sectional study was conducted from September 2011-March 2012 at Aga Khan University Hospital, pediatric oncology clinics. Hundred mothers were enrolled according to inclusion and exclusion criteria. A pre-coded validated questionnaire regarding mothers and child’s demographics along with Hamilton-D (HAM-D), a depression screening and severity scale, was used. Data was analyzed using SPSS (19.0), frequencies, and proportions were reported accordingly.Results: Forty-three percent mothers were in the age group of 30-39 years. Seventy-eight percent mothers were found to be depressed. Out of those 69% had mild, 25% moderate, 5% severe, and 1% had very severe depression.Conclusion: Majority of mothers were found to be depressed in this study. This known high level of depression in mothers, it is recommended that early non-therapeutic and/or therapeutic interventions should be done to help them cope with their situation.

Background: Haemoglobin A1c (HbA1c) has been adopted by physicians as a surrogate for monitoring glycemic control. There exists concern that other factors      beyond      serum      glucose      concentration      may      affect      glycation      rates      and      by      extrapolation      HbA1c       levels. Study Objectives: The study attempts to discern clinical differences in HbA1c levels in patients with anaemia compared to patients without anaemia, quantifying and showing the direction of such differences.Study Design: Using a convenient sampling method and a set of inclusion and exclusion criteria, it examined (retrospectively) patterns in [Hb] and HbA1c in non-diabetics with and without anaemia.Results: The study observed a statistically significant 0.4units (8%) difference in the mean HbA1c in anaemia vs. non-anaemic populations. Reference ranges of HbA1c for non-anaemic population and anaemia subtypes was computed. Computed ranges for anaemia group and its subgroups were significantly wider compared to non-anaemia population. Modest but statistically significant correction of anaemia did not result in significant changes in HbA1c.Discussion: i. The linear relationship between [Hb] and HbA1c holds true for anaemic and non-anaemia populations. ii. Non-diabetic, anaemic have a significantly lower mean HbA1c (5.3% vs. 5.7%), but a similar upper limit of reference range due to a higher variance. iii. The variance and proposed reference ranges for anaemia group and its subtypes was greater than in non-anaemia group, perhaps due to homogenization of clinically heterogeneous entities. iv. Modest correction anaemia did not cause significant change in HbAIc, perhaps the increase in [Hb] was too modest or persistence of correction was too short to be impactful.Conclusion: It makes the case for defining HbA1c reference ranges for each anaemia subtype, as well as utilizing other surrogates for monitoring glycemic control in populations with anaemia.

Introduction: Aggression in various forms may be one of the components of emotional/behavioural problems seen in a Child and Adolescent Mental Health Service. Aggressive symptoms may result from a psychiatric condition or a physical illness such as Primary Hyperparathyroidism. Case Presentation: The authors present a case of worsening psychiatric symptoms in a patient who was serendipitously diagnosed with Primary Hyperparathyroidism. His aggressive outbursts, suicidal and homicidal thoughts remitted following parathyroidectomy. Conclusion: Primary Hyperparathyroidism should be considered in the differential diagnosis in young people with worsening neuropsychiatric symptoms which are unresponsive to standard psychiatric treatment. Child Psychiatrists should always take holistic approach when managing patients and should be familiar with medical conditions that present with psychiatric symptoms.