Carcinoid syndrome refers to the array of symptoms that occur secondary to carcinoid tumors. Carcinoid syndrome occurs in approximately 5% of carcinoid tumors. These are diverse group of tumours of neural crest (enterochromaffin cells) origin, by definition capable of producing 5HT (Serotonin). Etiology of carcinoid tumors is not known, but genetic abnormalities are suspected. Reported chromosomal abnormalities include changes in chromosomes, such as numerical imbalances. Manifest when vasoactive substances from the tumors enter the systemic circulation escaping hepatic degradation.

Main  vasoactive substances include:

• Serotonin
• Kallikrein (catalyzes the conversion of kininogen to bradykinin which is a powerful vasodilator and bronchoconstrictor)
• Histamine

If the primary tumor is from the GI tract (hence releasing serotonin into the hepatic portal circulation), carcinoid syndrome generally does not occur until the disease is so advanced that it overwhelms the liver's ability to metabolize the released serotonin.

Signs and symptoms vary greatly and depend on the tumor location and size as well as on the presence of metastases. It may present as

• Incidental Finding
• tumor-related symptoms
• carcinoid syndrome
• GI tumors can cause appendicitis, intussusception, or obstruction.
• Hepatic metastases may cause RUQ pain
• Pellagra

Pellagra is due to niacin deficiency, because tryptophan (which is needed for niacin production) is diverted towards excessive production of serotonin. Leading to Dermatitis, Diarrhea, Dementia.

1. For symptomatic relief of carcinoid syndrome
Octreotide (Sandostatin)

• somatostatin analogue which decreases the secretion of serotonin by the tumor
• Initial Treatment with solution: 100-600 mcg/day SC divided q6-12hr; may titrate up to 1500 mcg/day for 2 weeks
• Maintenance with Suspension (depot injection): 20 mg IM every 4 weeks

2. Surgical resection of tumor
3. Chemotherapy (5-FU and doxorubicin)
4. Endovascular chemoembolization, targeted chemotherapy directly delivered to the liver through special catheters used for patients with liver metastases.

Zika virus is a member of the virus family Flaviviridae and the genus Flavivirus, transmitted by daytime-active Aedes mosquitoes, such as A. aegypti and A. albopictus. Its name comes from the Zika Forest of Uganda, where the virus was first isolated in 1947. Below is the documentary video about this virus.

 - positive Hoffmann’s reflex reflects presence of an upper motor neuron lesion from spinal cord compression;
 - is elicited by flipping either the volar or dorsal surfaces of the middle finger and observing the reflexcontration of the thumb and index finger;
- positioning the neck in extension (sometimes flexion) may worsen the reflex;
- at or above the level of compression, upper extremity should be diminished or absent due to nerve root compression;
- in the report by Sung and Wang (2001), asymptomatic patients with a positive Hoffmann’s reflex were prospectively studied with cervical radiographs and magnetic resonance imaging;
          - to determine a relationship between a positive Hoffmann’s reflex and cervical pathology in asymptomatic patients and to evaluate if further work-up was necessary in this patient population;
          - 16 patients without cervical pain or radiculopathy and a positive Hoffmann’s reflex were prospectively studied with cervical radiographs and magnetic resonance imaging;
          - all 16 patients were asymptomatic;
          - 14 patients (87.5%) demonstrated spondylosis on cervical radiographs;
          - MRI showed pathologic findings in all 16 patients;
          - 15 patients (94%) had cervical involvement with cord compression from a herniated nucleus pulposus;
          - remaining patient had a T5-T6 thoracic disc with resultant compression

Dr Saleem Qureshi Congratulates Dr Musarrat Iqbal and Getz Pharma on Installing the first CGSM & Insulin Pump in Islamabad in a Type 1 Diabetic Patient named Himala at Center for Diabetes and Liver Disease. (CDLD) located at 11 Hill Road F-6/2, Islamabad.

Diabetes, the silent killer, is directly linked with other body malfunctions like renal failure, blindness and cardiovascular diseases. Thus a diabetic patient should be seen as a potential case of other malfunctions and be treated as such.

Dr Saleem Qureshi, Head of the Department of Medicines KRL Hospital said this while addressing a seminar held at the end of a walk commemorating the World Diabetes Day held at the Aiwan-e-Quaid, F-9 Park here on Saturday. Alliance for Diabetes and Liver Diseases had organized the event. A large number of diabetic patients, members of civil society, health professionals and general public had turned up to get awareness about the deadly disease and its prevention.

Former Inspector General of Police and ex-Tax Ombudsperson Dr Shoaib Suddle who is also patron-in-chief of the Alliance, eminent nutritionist Dr Salma Badruddin, noted artist Zeba Bakhtiar and Imran Abbas also attended the seminar and shared with the audience their views regarding how to control the rising incidence of diabetes in Pakistan.

Dr Qureshi said in Pakistan the number of diabetes patients is steadily increasing. At present there are seven million diabetes patients and in next twenty years, the number can reach almost double i.e. 13 million. In the developing countries out of every 4 patients, three are diabetic, deplored Dr Saleem Qureshi calling upon the people to adopt a healthy lifestyle and avoid fats and sweetened dishes.

He attributed bulkiness as the major cause of diabetics. “Unless we start exercise and be mindful of our diet we cannot get rid of this looming threat on our heads,” said he.

Dr Shoaib Suddle drew the audience’s attention towards the grim fact that 10 persons are dying every one hour due to diabetes related complications. Incidence of diabetes is highest in South Asia because of the unregulated eating patterns of the people of this region, said he. However he expressed optimism that diabetes is preventable and total cost for the treatment of diabetic patient is around $55. Regular walk and healthy (not excessive) diet are the two main factors to check diabetes, he said.

He wished Dr Saleem Qureshi and his team good luck and commended their efforts for generating awareness about the disease among people.

Earlier, Dr Salma Burhanuddin gave a detailed presentation of diabetes and its impact on human health. Diabetes not only affects men’s health, women especially pregnant women become an easy target of the disease, she said. Diabetes affects women’s ability to conceive and most of its victims are from average income groups, she said. Like Dr Suddle she said awareness is the first step towards prevention of diabetes. She asked the families that were present in the Aiwan-e-Quaid in large number to discourage their children from excessive intake of potato chips, French Fries, noodles which are generally considered normal healthy food for kids.

Similarly, she said dry fruit in excess can also raise the sugar level in blood. Flour should be used instead of maida and rice should be taken with pulses, she advised. Imran Abbas TV and film star shared with the audience that his mother was a sugar patient and in the beginning she was scared of insulin, but when she came to know how effective it is in sugar control, she is taking it willingly. He asked the youth to promise that they would adopt a healthy life style and avoid late and excessive food. Dr Amir Awan the eye specialist warned the audience about diabetes’ bad effects on eyesight. Zeba Bakhtiar said she supported the noble cause Alliance for Diabetes and Liver Diseases was taking along for awareness about and prevention of diabetes.