JMS SKIMS

Bear Maul Injuries: When the Face Takes the Hit, and the Textbook Fails

Peerzada Umar Farooq Baba — 2026-09-28

Human-animal conflict is not a new phenomenon. It has existed for centuries, almost as long as human civilization itself. However, with expanding human populations, deforestation, and increasing encroachment into forest areas, the boundary between human habitation and wildlife habitats is becoming increasingly blurred. As a result, encounters between humans and wild animals are becoming more frequent, sometimes with devastating consequences. In regions where human settlements and agricultural activities are closely interwoven with forest habitats, such encounters are especially common. Among the various forms of human-wildlife conflict, injuries caused by bears are a particularly serious concern in our Valley.

One Health in the Genomic Era: Connecting Human, Animal and Environmental Genomics

Sonaullah Shah — 2026-09-30

Pathogens do not read borders. They do not distinguish between a bat roost, a livestock market, an irrigation channel, and a hospital ward. For much of modern medicine we drew those lines anyway—one set of institutions for human health, another for animal health, and a third for the environment. The COVID-19 pandemic made the cost of that fragmentation impossible to ignore, and the genomic era now offers the tools to dismantle it. In this editorial, we argue that the hospital in the low- and middle-income country (LMIC) must be recognized as the connective node of a One Health surveillance architecture and that this architecture must now extend beyond pathogens to the chemical and plastic pollutants that increasingly shape infectious disease risk.

Preventive Oncology: A Public Health Priority

Rohul Jabeen — 2026-09-17

Cancer remains one of the foremost causes of morbidity and mortality worldwide, with an estimated 20.6 million new cases diagnosed in 2024 and projections indicating a rise to nearly 35 million cases annually by 2050. Approximately 37% of new cancer cases globally are attributable to modifiable or preventable risk factors, underscoring the substantial potential of evidence-based prevention strategies to reduce the future cancer burden. This review synthesizes current evidence on the global burden of cancer, the modifiable and non-modifiable determinants of cancer risk, and the structured framework of primary, secondary, and tertiary preventive oncology. It further examines systemic barriers to implementation and presents population-level evidence from England, Finland, Australia, and the Indian states of Sikkim and Tamil Nadu, demonstrating that organized, evidence-based preventive interventions can produce measurable reductions in cancer incidence and mortality. The review concludes that strengthening preventive oncology, supported by political commitment, health-system capacity, and equitable financing, is essential to complement advances in cancer diagnosis and treatment.

Perioperative Fluid Therapy: From Restrictive/Liberal Labels to Physiology-Guided Individualization

Aaqib Suhail Mir — 2026-09-25

Perioperative fluid therapy has evolved from fixed replacement of fasting and presumed third-space losses toward restrictive, zero-balance, and increasingly individualized strategies. The therapeutic window is narrow: inadequate circulating volume may impair organ perfusion and contribute to acute kidney injury (AKI), whereas excessive fluid can cause interstitial oedema, pulmonary complications, gastrointestinal dysfunction, and delayed recovery. Enhanced Recovery After Surgery (ERAS) pathways have reduced unnecessary intravenous fluid administration, but the optimal balance remains uncertain. The RELIEF randomized trial found no disability-free survival benefit from a restrictive strategy and reported more postoperative AKI than with liberal therapy. [1] Contemporary PeriOperative Quality Initiative (POQI) recommendations emphasize individualized management according to surgical factors, intravascular volume status, arterial pressure, and comorbidities. [2,3] This narrative review synthesizes evidence on restrictive versus liberal strategies, goal-directed haemodynamic therapy (GDHT), fluid responsiveness, AKI, fluid accumulation, fluid composition, vasopressors, and ERAS integration. The emerging paradigm is not simply restrictive or liberal therapy, but dynamic physiology-guided treatment that seeks adequate organ perfusion while avoiding unnecessary fluid accumulation.

Teaching Unilateral Cleft Lip Repair Using a Standardized Geometric Landmark-Based Method: A 10-Year Educational Cohort Study

Razan Albrahim — 2026-09-17

Background: Accurate marking is a fundamental component of unilateral cleft lip repair. The Tennison–Randall technique uses predetermined anatomical landmarks and geometric relationships to design a triangular flap and restore lip height. Although the geometric nature of the technique provides a structured framework for operative planning, there is limited literature describing standardised methods for teaching this technique to plastic surgery residents.

We describe a 10-year educational experience using a standardised, landmark- and measurement-based method to teach unilateral cleft lip marking and repair to plastic surgery residents.

Methods: This retrospective educational cohort study included plastic surgery residents who received direct instruction in the Tennison–Randall technique at King Fahad Medical City Riyadh, Kingdom of Saudi Arabia, and during resident rotations over 10 years. The teaching method used a sequential series of fixed anatomical landmarks, bilateral measurements, measurement transfer, and geometric construction to reproduce the cleft-side Cupid’s bow and construct the Randall–Tennison triangular flap.

Residents were required to perform the marking themselves and subsequently perform unilateral cleft lip repairs under direct faculty supervision. Approximately 40 residents underwent training and collectively participated in approximately 400 unilateral cleft lip repairs involving complete and incomplete unilateral clefts.

Immediately following training, residents completed a three-item assessment addressing ease of cleft lip marking, understanding of the marking and operative procedure, and ability to demonstrate the technique to others. Each item was rated on a 5-point scale.

Results: Forty residents received training during the study period. All residents were able to demonstrate the standardised marking technique under direct faculty supervision and subsequently participated in operative repair under supervision.

Approximately 400 unilateral cleft lip repairs were performed by trained residents during the study period.

Thirty-six of the 40 residents completed the post-training assessment, giving a response rate of 90%. All respondents (36/36, 100%) rated each of the three educational domains 5/5.

Conclusions: A standardised landmark- and measurement-based approach provided a reproducible framework for teaching the geometric principles of the Tennison–Randall unilateral cleft lip repair. In this 10-year educational experience, 40 residents acquired the marking technique sufficiently to demonstrate it under supervision, and all questionnaire respondents reported the highest level of perceived learning across three educational domains. Prospective studies using objective technical-skill assessments are warranted to determine whether this approach reduces the learning curve for unilateral cleft lip repair.

Superior Mesenteric Artery Doppler Ultrasound as a Non-Invasive Tool for Monitoring Disease Activity in Crohn's Disease: Validation Against Quantitative Magnetic Resonance Imaging-Based Reference Standards

Aaqib Javid Itoo — 2026-09-18

Background: Crohn's disease activity monitoring is expensive in low-resource settings. Superior mesenteric artery (SMA) Doppler measuring flow rate, pulsatility index (PI) and resistive index (RI) can detect splanchnic hyperaemia of active intestinal inflammation. We validated SMA Doppler indices against quantitative MR enterography (MRE) indices, the simplified Magnetic Resonance Index of Activity (sMaRIA) and London score.

Methods: Cross-sectional diagnostic accuracy study in 50 Crohn's disease patients. Activity was classified by sMaRIA (active, score of 1 or more; inactive, score of 0) and London score (active, 4.1 or more). Receiver operating characteristic curve analysis assessed diagnostic accuracy; Spearman's correlation examined Doppler-MRE associations.

Results: Fifteen patients (30%) had active and 35 (70%) had inactive disease. Active disease showed higher SMA flow rate (712 vs 322 ml/min), lower PI (1.66 vs 2.68) and lower RI (0.70 vs 0.83; all p<0.001). Flow rate achieved the highest accuracy (area under the curve 0.992; 95% CI 0.971–1.000); at a cut-off of 514 ml/min or more, sensitivity was 100%, specificity 97.1%, positive predictive value 93.8% and negative predictive value 100%. PI of 1.88 or less gave 97.1% specificity. Flow rate correlated strongly with sMaRIA (rho +0.770) and moderately with London score (rho +0.662; both p<0.001).

Conclusion: SMA Doppler reliably tracks Crohn's disease activity against quantitative MRE reference standards. A two-step strategy, flow rate 514 ml/min or more confirmed by PI 1.88 or less, identifies active disease without radiation, supporting SMA Doppler as a low-cost surrogate for serial monitoring in resource-limited settings.

Role of Transrectal Ultrasonography in Male Infertility

Fahad Bin Showkat — 2026-09-18

Background: Male infertility accounts for nearly 50% of all infertility cases. The evaluation of male infertility is complex, with anatomical abnormalities playing a significant role. This study aimed to assess the role of TRUS in diagnosing anatomical abnormalities contributing to infertility in north Indian region.

Methods: This descriptive observational study was conducted over two years in the Department of Radiodiagnosis & Imaging, Sher-i-Kashmir Institute of Medical Sciences (SKIMS), and its associated hospitals. Sixty male patients aged ≥23 years with complaints of infertility and two samples showing oligospermia/azoospermia underwent TRUS examination. TRUS was performed using a 5.5-7.5 Hz transrectal probe, evaluating the prostate, seminal vesicles, ejaculatory ducts, and vas deferens.

Results: The mean age of patients was 32.5 years, with a mean infertility duration of 6.2 years. TRUS detected abnormalities in 93% of patients, including correctable causes such as ejaculatory duct obstruction (25%), seminal vesicle cysts (40%), and prostatic cysts (30%). Irreversible conditions included congenital bilateral absence of the vas deferens (5%) and seminal vesicle hypoplasia (3%). Life-threatening conditions as prostatic abscesses were identified in 3% of cases.

Conclusions: TRUS is a valuable tool for evaluating male infertility, capable of detecting both correctable and irreversible abnormalities, as well as potentially life-threatening conditions. Its routine use in infertility workup is recommended.

Outcome of Induction Therapy with Various Regimens in Lupus Nephritis: An Observational Study

Mushtaq Ahmad — 2026-09-26

Aim: To evaluate the outcome of induction therapy in biopsy-proven lupus nephritis and to compare the response achieved with intravenous cyclophosphamide and mycophenolate mofetil (MMF).

Materials and Methods: Fifty patients of systemic lupus erythematosus with renal involvement who underwent renal biopsy were studied over five years. Patients with Class III and Class IV nephritis received either intravenous cyclophosphamide 15 mg/kg monthly or MMF 2 g daily for six months, the choice being individualised by reproductive plans and affordability; Class V disease was treated with tacrolimus. Patients were assessed monthly with urine examination, 24-hour urinary protein and serum creatinine. Complete remission at six months was the primary end point, partial remission the secondary. Fisher's exact test was used for comparison in view of the small group sizes.

Results: Forty-six patients (92%) were female and Class IV was the commonest histological class (58%). Twenty-two patients received cyclophosphamide, 22 received MMF and six received tacrolimus. Complete and partial remission were achieved in 5 (22.7%) and 9 (40.9%) patients on cyclophosphamide and in 6 (27.3%) and 8 (36.4%) patients on MMF, an overall response of 63.6% in each group. Treatment failure occurred in 7 (31.8%) and 8 (36.4%) patients respectively. All six patients on tacrolimus responded. No statistically significant difference in six-month renal response was observed between the two treatment groups (p = 1.000).

Conclusion: No statistically significant difference in six-month renal response was observed between the cyclophosphamide and MMF groups. As treatment was not randomly allocated and the sample was small, this does not establish equivalence.

Clinical Significance: Induction therapy in this cohort was selected by reproductive plans and affordability rather than by randomisation. The outcomes describe what was achieved under those constraints.

Peri-Intubation Haemodynamic Response in Critically Injured Trauma Patients: Delayed Sequence versus Rapid Sequence Induction

Aaqib Suhail Mir — 2026-09-26

Background: Peri-intubation haemodynamic instability — hypotension, bradycardia and abrupt pressor surges — is a recognised hazard of emergency airway management in critically injured trauma patients. Ketamine-facilitated delayed sequence induction (DSI) has been proposed as an alternative to rapid sequence induction (RSI) in agitated patients, but its haemodynamic profile relative to RSI is not well characterised. This study compared peri-intubation systolic blood pressure (SBP), diastolic blood pressure (DBP) and heart rate (HR) response, together with the incidence of hypotension and bradycardia, between DSI and RSI in critically injured trauma patients.

Methods: This prospective observational study was conducted in the trauma triage unit of a tertiary-care centre from June 2025 to April 2026. Critically injured patients with a low Glasgow Coma Scale score requiring emergency tracheal intubation were allocated to RSI (n=60) or DSI (n=60) according to the treating physician's chosen airway strategy. SBP, DBP and HR were recorded at baseline and at 1, 2 and 3 minutes after induction and immediately post-intubation. Hypotension was defined as SBP <90 mmHg and bradycardia as HR <60 beats/min.

Results: Of 138 patients screened, 120 were enrolled (60 RSI, 60 DSI); baseline demographic, mechanism-of-injury and agitation-severity characteristics were comparable between groups. Baseline SBP was 109.46±12.62 mmHg (RSI) versus 107.4±13.72 mmHg (DSI; p=0.394), and did not differ significantly at 1 minute (109.89±11.77 vs. 109.2±11.12; p=0.742), 2 minutes (110.97±12.05 vs. 109.4±10.45; p=0.447), 3 minutes (112.49±11.42 vs. 112.0±10.05; p=0.803) or post-intubation (121.49±5.94 vs. 119.83±6.08; p=0.133). DBP and HR followed similarly comparable trajectories at every time point (all p>0.05). Hypotension occurred in 7 (11.7%) RSI patients versus 3 (5.0%) DSI patients (p=0.322), and bradycardia in 2 (3.3%) versus 1 (1.7%) patient (p=1.000); any adverse event occurred in 11 (18.3%) versus 4 (6.7%) patients (p=0.095). First-pass intubation success was identical between groups (96.7% each).

Conclusion: Peri-intubation SBP, DBP and HR response were statistically comparable between ketamine-facilitated DSI and RSI in critically injured trauma patients, and hypotension, bradycardia and composite adverse events were numerically — though not significantly — less frequent with DSI. These findings support the haemodynamic safety of both airway strategies and suggest DSI does not compromise cardiovascular stability while facilitating oxygenation in agitated trauma patients.

Flexible Bronchoscopy in Young Children with Treatment-Refractory Wheeze

Javeed Iqbal — 2026-09-26

Aim: To evaluate the clinical utility of flexible bronchoscopy (FB) in young children with persistent or treatment-refractory wheeze.

Materials and Methods: This retrospective audit was conducted at the pediatric bronchoscopy service of a tertiary care center and included children aged ≤5 years who underwent flexible bronchoscopy (FB) for persistent or poorly responsive wheeze between January 2020 and December 2024. Clinical, demographic, bronchoscopic, and procedural data were retrieved from medical records. Structural and dynamic airway abnormalities were recorded. Tracheomalacia and bronchomalacia were defined as >50% reduction in airway lumen during expiration.

Results: Of 623 bronchoscopies performed during the study period, 65 were undertaken for treatment-refractory wheeze. After exclusion of 23 children because of inadequate data, 42 were analyzed. Mean age was 27.6±12.6 months and mean symptom duration was 10.1±6.5 months. Generalized wheeze was present in 33 (78.6%) children and localized wheeze in 7 (16.7%); 2 had inspiratory stridor with expiratory wheeze. Dynamic airway abnormalities were identified in 16 (38.1%). Tracheomalacia was found in 7 (16.7%), three children in this subgroup had double aortic arch. Bronchomalacia was present in 3 (7.1%), all with congenital heart disease. Laryngeal abnormalities were associated with tracheomalacia in 4 children. No major procedural complications occurred. Minor events included transient hypoxia in 8 (19.0%) and epistaxis in 4 (9.5%).

Conclusions: FB identified structural or dynamic airway abnormalities in a substantial proportion of young children with treatment-refractory wheeze. It may be useful in selected children, particularly when symptoms persist despite conventional therapy or an airway or vascular abnormality is suspected.

Study of Fragile Histidine Triad (FHIT) gene Promoter DNA Methylation in Acute Lymphoblastic Leukemia (ALL) patients

Arshad Pandith — 2026-09-28

Background: The fragile histidine triad (FHIT) gene has earlier been projected as a tumor suppressor in many disease mechanisms including acute lymphoblastic leukemia (ALL). DNA methylation at in the promoter region of FHIT gene has been linked with gene silencing, and hence its inactivation is responsible in the pathogenesis of many kinds of human malignancies. We first time from the Indian subcontinent evaluated the frequency of FHIT hypermethylation in a cohort of ALL cases from Kashmir region (North India).

Methods: FHIT gene hypermethylation was investigated in a cohort of 66 confirmed ALL patients at diagnosis by methylation specific PCR (MSP-PCR).

Results: Our results significantly showed FHIT promoter methylation was considerably higher in ALL subjects with a frequency of 80% (53 of 66). FHIT gene promoter methylation was seen higher in males 84% as compared to females 75%. Older age group (≥25years) patients showed higher 87% FHIT gene hypermethylation as compared to 78% in lower age group (<25 years. Around 94% of subjects harboring hypermethylated FHIT gene were having higher WBC count as compared to cases with lower WBC count (p>0.05).

Conclusion: We conclude that FHIT gene hypermethylation is highly implicated in ALL cases and seems as an initial event in the ALL pathogenesis

Mitigating the Catecholamine Surges: A Case Series on Intraoperative Anaesthetic Management of Resistant Pheochromocytoma

Aaqib Suhail Mir — 2026-09-25

Background and Aims: Surgical excision of pheochromocytoma is associated with exaggerated catecholamine surges that may lead to life-threatening haemodynamic instability. Resistant pheochromocytoma, characterised by intraoperative hypertension despite adequate preoperative preparation, poses additional anaesthetic challenges. We present our institutional experience in managing such patients.

Methods: We retrospectively analysed 20 patients who underwent adrenalectomy for pheochromocytoma at Sher-i-Kashmir Institute of Medical Sciences, Soura, Srinagar, from October 2023 to March 2025. Among them, 6 patients developed resistant hypertension intraoperatively. Details of anaesthetic technique, drug infusions, haemodynamic events, and postoperative outcomes were reviewed.

Results: All patients were preoperatively optimised with alpha- and beta-blockade. Intraoperatively, all 6 resistant cases required simultaneous infusions of nitroglycerine, esmolol, labetalol, lignocaine, and sodium nitroprusside (0.5–5 µg/kg/min) to control hypertension during tumour manipulation. Two patients developed severe hypotension after tumour ligation requiring aggressive fluid therapy, phenylephrine boluses/infusion, and vasopressin infusion. No patient developed arrhythmias, myocardial ischaemia, or cerebrovascular complications. All were shifted to ICU for elective ventilation and recovered uneventfully.

Conclusion: Resistant pheochromocytoma presents formidable intraoperative challenges. Anticipation, vigilant monitoring, and proactive use of multidrug infusion protocols—including SNP—ensure haemodynamic stability and favourable outcomes.

Primary Splenic Hydatidosis: An Institutional Case Series and Review of the Literature

Imad Banday — 2026-09-29

Background: Primary splenic hydatidosis is an uncommon manifestation of cystic echinococcosis. Because of its rarity, most available evidence consists of small retrospective series, and the optimal extent of surgery remains debated.

Methods: We retrospectively reviewed 15 consecutive patients with primary splenic hydatidosis who underwent surgical treatment at our institution between 2010 and 2026. Demographic, clinical, radiological, operative, postoperative and follow-up data were collected. A focused narrative review of the literature was undertaken to contextualize the institutional experience.

Results: Fifteen patients were included, with a median age of 38 years; 9 (60.0%) were women. Three patients (20.0%) were diagnosed incidentally. Thirteen patients (86.7%) had solitary cysts and the median maximum cyst diameter was 7.9 cm. Histopathology confirmed hydatid disease in all 15 patients. Spleen-preserving surgery was performed in 11 patients (73.3%), while 4 (26.7%) underwent total splenectomy. Six patients (40.0%) developed a postoperative complication. Two patients (13.3%) developed recurrence during follow-up; both had initially undergone spleen-preserving cystectomy/enucleation with omentopexy, corresponding to 2/9 (22.2%) within that procedure group. These observations are descriptive and do not establish a causal or comparative effect of operative technique.

Conclusion: In this institutional series, spleen-preserving surgery was feasible in selected patients. Postoperative morbidity occurred in 6 of 15 patients (40.0%), and recurrence occurred in 2 of 15 patients (13.3%). Both recurrences followed cystectomy/enucleation with omentopexy, but the small retrospective and non-comparative design precludes attributing recurrence to the procedure.

Adult Colonic Lymphangioma presenting as Intussuseption

Danish Ashraf — 2026-09-17

Background: Lymphangiomas are rare benign neoplasms of lymphatic origin mostly occurring in the neck and axillary region. Gastrointestinal involvement is uncommon, with colonic localisation representing an exceptionally rare occurrence, particularly in adults.

Case Presentation: We report the case of a 78-year-old female presenting with abdominal pain for two days. Ultrasound (USG) abdomen revealed a large ileocolic intussusception in the infraumbilical region. Contrast-enhanced computed tomography (CECT)-Abdomen revealed an intramural, low-density, multilocular mass with a low-contrast-enhanced wall and internal septations located in the ascending colon. Right hemicolectomy was performed which revealed ileocolic intussusception along with a large grey-brown polypoidal mass in the ascending colon and cecum measuring 5 x 4.5 cm. Cut section through the mass was grey-brown with areas of haemorrhage. Histopathology revealed thin-walled lymphatic channels lined by flattened benign endothelial cells and containing eosinophilic proteinaceous fluid and occasional lymphocytes, consistent with submucosal lymphangioma.

Conclusion: Colonic lymphangiomas are rare benign lesions with nonspecific clinical manifestations. Imaging techniques can assist in identifying the lesions, but microscopic evaluation is necessary for confirmation. Complete surgical excision is curative and associated with excellent prognosis.

Hormonal Mimics: Early Detection of Bilateral Testicular Adrenal Rest Tumors in Congenital Adrenal Hyperplasia. A Case report

Athar Nazir Paddar — 2026-09-19

Testicular adrenal rest tumors (TART) are benign ectopic adrenal tissue proliferations commonly associated with congenital adrenal hyperplasia (CAH). Early recognition is crucial to prevent misdiagnosis as testicular neoplasm and avoid unnecessary surgical intervention. We report a case of 11-year-old male who is a follow up case of CAH with salt wasting and GnRH dependent precocious puberty, in whom scrotal ultrasonography and magnetic resonance imaging demonstrated characteristic features of bilateral TART

Successful Low-Dose Spinal Anaesthesia for Caesarean Section in a Parturient With Myasthenia Gravis: A Case Report

Aaqib Suhail Mir — 2026-09-25

Myasthenia gravis (MG) is an autoimmune neuromuscular disorder characterised by fluctuating skeletal muscle weakness and presents significant challenges during pregnancy and anaesthesia. Both general and regional techniques carry potential risks, including postoperative respiratory failure, prolonged neuromuscular blockade, and myasthenic crisis. We report the successful use of low-dose spinal anaesthesia with intrathecal opioid supplementation for elective caesarean delivery in a parturient with well-controlled MG. Careful dose titration, continuation of anticholinesterase therapy, and multidisciplinary planning enabled safe perioperative management without respiratory compromise. This case supports the use of modified neuraxial techniques in selected patients with stable disease.

Community-Acquired Escherichia coli Sepsis and Meningitis Complicated by Bilateral Subdural Effusion in a Previously Healthy Three-Month-Old Infant: A Case Report

Salib Hamid Mir — 2026-09-29

Background: Escherichia coli is an important cause of bacterial meningitis during the neonatal period but is an uncommon cause of community-acquired meningitis in previously healthy infants beyond the neonatal period. Subdural effusion is a recognized complication of bacterial meningitis in infancy and may mimic subdural empyema, creating an important diagnostic and therapeutic challenge.

Case Description: Reported here is a case of a 3-month-old infant with a bilateral subdural effusion culture positive for E. coli. The child was managed successfully with 6 weeks of meropenem.

Conclusion: Community-acquired E. coli meningitis should be considered in young infants with severe bacterial meningitis even beyond the neonatal period, including those without recognized predisposing conditions. In infants with persistent fever, seizures, irritability, or delayed clinical recovery, neuroimaging is important for identifying intracranial complications and distinguishing subdural effusion from empyema. In the absence of imaging or clinical features suggesting subdural infection or significant mass effect, conservative management with close clinical and radiological follow-up may be appropriate.

Extensive Pneumoperitoneum in a Hemodynamically Stable 62-Year-Old Male Managed Conservatively: A Case Report Emphasizing the Importance of Clinical Judgment Over Radiological Findings

Abrar Hussain Teli — 2026-09-29

Pneumoperitoneum is most commonly caused by gastrointestinal perforation and classically mandates emergency surgical exploration. A distinct subgroup of spontaneous (non-surgical) pneumoperitoneum exists in which free intraperitoneal air is not accompanied by clinical peritonitis, and the source of air cannot be identified even after thorough investigation. We report a 62-year-old male who presented with diffuse abdominal pain, vomiting, and obstipation. Contrast-enhanced computed tomography (CT) of the abdomen revealed extensive pneumoperitoneum with free air under the right hemidiaphragm, multiple extraluminal air foci in the peritoneal cavity, and marked colonic distension. Despite these findings, the patient showed no signs of peritonitis and remained hemodynamically stable. After an exhaustive workup including contrast-enhanced CT, erect abdominal radiography, and sigmoidoscopy failed to identify an ongoing perforation source, a diagnosis of spontaneous pneumoperitoneum — most plausibly representing a self-sealed microscopic gastrointestinal perforation — was established as a diagnosis of exclusion. The patient was managed conservatively with nasogastric decompression, intravenous fluids, intravenous piperacillin–tazobactam for four days followed by a five-day course of oral cefuroxime after discharge, and bowel rest, with complete clinical resolution over a four-day hospitalization. Follow-up colonoscopy and upper gastrointestinal endoscopy performed fifteen days after discharge were entirely normal. This case illustrates that extensive pneumoperitoneum in a carefully selected, hemodynamically stable patient without peritonitis may be managed non-operatively when CT and endoscopy reveal no evidence of ongoing leak or contamination and close observation confirms clinical improvement. Conservative management in this setting must remain highly selective, with a low threshold for urgent laparotomy should deterioration occur.

A case of Chromoblastomycosis

Gulnaz Bashir — 2026-09-17

A 45-year-old Kashmiri flute player presented with a 5-year history of a progressively enlarging lesion on the right thigh. The lesion developed following minor soil-contaminated trauma sustained in Punjab and gradually increased in size, eventually forming a cauliflower-like verrucous growth (a). Direct microscopy of a biopsy specimen following 10% potassium hydroxide (KOH) preparation demonstrated characteristic sclerotic (Medlar) bodies, confirming the diagnosis of chromoblastomycosis (b).

Ruptured Intracranial Dermoid Cyst

Saiyak Habib Ganaie — 2026-09-19

Background: Intracranial dermoid cysts are rare congenital inclusion cysts accounting for less than 1% of all intracranial tumors. Spontaneous rupture releases lipid droplets into the subarachnoid and ventricular spaces, producing chemical meningitis and acute neurological symptoms.
Clinical presentation
A young male in his 30s presented to the Emergency Department of SKIMS with sudden severe headache preceded by nausea. He had a history of chronic intermittent headache and low mood. Neurological examination was otherwise unremarkable.

Arthritis Mutilans: The Devastating Face of Psoriatic Arthritis

Shaariq Mehraj Naqati — 2026-09-26

Psoriatic arthritis is a heterogeneous seronegative spondyloarthropathy that affects up to one-third of patients with cutaneous psoriasis. The rarest and most destructive subtype of arthritis is arthritis mutilans, which results in shortened, flail, telescoping digits as a result of unremitting osteolysis of the phalanges and metacarpals. This results in the classical "opera-glass hand." We present the clinical photograph and corresponding plain radiograph of the hands in a patient with long-standing psoriatic arthritis. The images demonstrate gross digital shortening, nail dystrophy, and cutaneous psoriasis, as well as widespread bone resorption, pencil-in-cup deformities, and acro-osteolysis. The images serve as a reminder that psoriasis is not restricted to the skin and that the deformity depicted here is now largely preventable through the opportune escalation of disease-modifying therapy and early recognition.

Heart Failure: Classification, Diagnosis and Management

Aamir Shafi — 2026-09-22

The 2026 ESC guidelines have reshaped how heart failure is classified and treated. The three ejection fraction phenotypes are reduced to two. HFrEF now covers any LVEF below 50%, and HFpEF begins at 50%, with the mildly reduced band absorbed into HFrEF on the grounds that these patients share its pathophysiology and respond to the same drugs. Treatment is grouped into foundational medical therapy, additional medical therapy, and guideline-directed interventional therapy. Four classes make up the foundational tier, all carrying Class I recommendations: an ACE inhibitor, ARNI or ARB, a beta-blocker, a mineralocorticoid receptor antagonist, and an SGLT2 inhibitor. Two changes matter most in daily practice. Mineralocorticoid receptor antagonists now hold Class I status at any ejection fraction, where previously they stopped at 40%. Semaglutide or tirzepatide reaches Class IIa for preserved ejection fraction with obesity, the first time an anti-obesity agent has entered a heart failure guideline on outcome grounds. This review sets out the revised classification and staging, natriuretic peptide thresholds for diagnosis, the foundational drugs and how fast to titrate them, additional agents for defined subsets, and device and interventional therapy, with class of recommendation stated throughout.

Intravenous Thrombolysis in Acute Ischaemic Stroke: Practice Points from Current Guidelines

Shaariq Mehraj Naqati — 2026-09-28

The 2026 American Heart Association/American Stroke Association guideline on the early management of acute ischaemic stroke replaces the 2018 guideline and its 2019 update and revises several decisions taken at the CT console. Tenecteplase 0.25 mg/kg as a single bolus now carries the same standing as alteplase within 4.5 hours; thrombolysis is recommended for a disabling deficit irrespective of the NIHSS score; imaging-selected treatment is endorsed in extended and unknown-onset windows, including up to 24 hours in large-vessel occlusion where thrombectomy is unavailable; and the approach to contraindications has been restructured. This article distils these changes into six practice points for general physicians, emergency physicians and postgraduate residents, with tables of eligibility windows, weight-band dosing and contraindications.

Adult measles: A possible shift in age pattern

Suhail Mantoo — 2026-09-28

Background: Measles is traditionally considered a childhood disease. However, during January–August 2026, we observed an unexpected increase in adult measles admissions at our tertiary care centre in Kashmir.

Observation: Eighteen adults with clinically and/or serologically confirmed measles were admitted during this period compared with only two adult admissions during the preceding year. Several patients presented with atypical features and required serological confirmation for diagnosis.

Conclusion: This observation parallels the recent global resurgence of measles and raises the possibility of changing age distribution of disease. Further studies evaluating vaccination history, immunity patterns, and age-specific trends are needed to determine whether this represents a true epidemiological shift.