Rare renaissance: Quadruple synchronous renal cell tumors in one kidney - A case report.

Multifocality in renal tumors is a rare occurrence, but not unheard of. Commonly the different foci correspond to the same histological pathology, however co-existence with other renal lesions, including both malignant and benign tumors, have also been reported. Here we present a 57-year-old male, ex-smoker who exhibited four distinct histological tumors in an ipsilateral kidney; multilocular cystic clear cell renal cell carcinoma (RCC) of low malignant potential, clear cell papillary RCC, renal oncocytoma, and renomedullary interstitial cell tumor. To our knowledge this is the first time these four tumors were found in the same patient, let alone the same kidney.

The evolving role of digital media in medical education.

Within the last decade, social media has progressed from a form of mere entertainment to a medium for solution of complex issues in our daily lives. During the last few years, social media has gained value in medical education and the diversity in the use of digital media has given new dimensions to medical education while facing the Covid pandemic. Digital media helps in creating virtual communities which not only bring more harmony between teachers and students but has also shown to have reduced anxiety and stress among students. Common social media platforms such as Facebook and WhatsApp have recently gained popularity as platforms which are being actively used in various ways to enhance learning. Social media in medical education is also utilised to enhance communication skills, professionalism and better patient care, but this should be addressed with caution as violation of patient's privacy and confidentiality remains a threat.

Clinicians as Leaders: Impact and Challenges.

Healthcare has always been a complex system phenomenon which needs accountability from the leading clinical and management roles. Adequate and competent leadership is recognized as a driving point for a successful healthcare division. Medical professionals taking charge for quality improvement are well placed yet the style to deliver their leadership qualities bears a massive significance. While exceptional clinical prowess is of tremendous importance, harmonious teamwork, inefficiency reduction and patient communication and safety lead to noteworthy health management outcomes. Explores not explains the importance of leadership, qualities and styles of a leader, various leadership theories, the impact of leadership in medical education and the current issues related to medical leadership.

Barriers in surgical research: A perspective from the developing world.

Research in surgery has led to significant advances over the last century in terms of how medicine is practised in and outside the operating rooms today. Surgical research in the developed countries is responsible for most of this advancement, but it is often inapplicable in resource-limited settings in the developing world. Lower- and middle-income countries are in a unique position to take this work further, but they are limited by certain barriers. These barriers could broadly be classified under social and cultural, infrastructure, financial, ethical, and personal categories. These barriers are often not fully realised, but can potentially be addressed with concerted efforts to continue the advancement of medicine for everyone.

Primary synchronous malignancies of the breast and the kidney.

Synchronous primary malignancies are most frequently seen with cancers of the stomach and oesophagus, mainly attributed to the similar genetic mutations. Most of these multiple malignancies turn out to be metastatic or metachronous lesions. Multiple synchronous malignancies are rarer than metachronous ones. Primary synchronous breast and renal cancer is even rare. These patients require extensive workup to exclude all possible metastases. The nature of the primary tumours must also be confirmed, prior to any treatment strategy. We report the case of a healthy, middle-aged woman who initially presented with a lesion suspicious for breast carcinoma, and further workup revealed the presence of an asymptomatic, synchronous primary renal cell cancer, which is a very rare presentation.

Workplace Based Assessment: Tools to assess competencies in a clinical setting.

The apprenticeship model has been used for long in surgical training. It initially provides opportunity to the trainee to observe the attending surgeon, followed by gradual introduction to surgical technique under direct supervision and later with detached supervision. The attending provides informal feedback at different intervals to the trainee. Several changes have been made in postgraduate programmes with a shift towards using workplace-based assessment tools for formative and summative evaluation of the trainee's clinical skills.

Non-operative treatment of hepatic trauma: A changing paradigm. A Six year review of liver trauma patient in a single institute.

OBJECTIVE: To review the managing strategies of adult patients with liver trauma in a tertiary care hospital during a six years period. METHODS: The medical records of all patients admitted with a diagnosis of liver trauma from January 2012 to December 2017 in the Aga Khan University Hospital were retrospectively reviewed. The details of demographic, clinical, and outcome variables including morbidity and mortality rates were noted. RESULTS: A total of 182 patients were admitted at AKUH with liver trauma between January 2012 and December 2017. Twenty-two patients were excluded according to our study criteria. Of 160 patients, 139 were male and 21 were female. One hundred twenty seven (79.4%) patients were less than 45 years of age. Most patients (89.4%) had no comorbids and 48 (44%) arrived at the hospital within 4 hours of injury. Majority, 101 (63.1%) of the patients had blunt trauma and 142 (89%) met with road accidents. A total of 109 (68.1%) patients were stable at arrival and 77 (48.1%) had abdominal signs present on examination. FAST ultrasound was done on 75 (46.9%) patients and CT scan abdomen on 145 (90.6 %) patients. Liver injuries were associated with other abdominal or systemic injuries in 139 (86.6%) patients. Low grade (Grade I & II) liver injuries were found in only 41 (25.6%) patients, with the remainder being high grade (Grade III- 41 patients, Grade IV-42 patients and Grade V-2 patients). Conservative treatment was offered to 68 (41.9%) patients, of which 57 (85.1%) remained stable and were eventually discharged. Of these, 2 expired and 3 required intervention. There were a total of 92 (57.2%) interventions done of which 60 patients were cured, 14 expired and 18 readmitted. Interventions included perihepatic packing (n=18), hepatorraphy (n=3), angioembolization (n=12) and hepatectomy (n=1). There were 16(10%) deaths in which liver haemorrhage and sepsis were the most common cause of mortality. Mean hospital stay in our study population was 8.9 days. Second admission was observed in 28 (17.5%) patients (n=28). Morbidity rate in our patients was 17.5% (n=28). The most common complication noted was that of a liver abscess, developing in 2 (1.3%) patients. Other significant problems were intra-abdominal collections (n=2) and biliary complications (n=3). Unstable haemodynamic status at arrival and prolonged stay in high dependency unit were noted to be independent risk factors for mortality. CONCLUSIONS: Conservative treatment was found successful in most of our patients with an intervention rate of 57.5% and overall mortality rate of 10%. So, NOMLI can be safely offered to liver trauma patients, even in high grade injuries.

Comparison of position-related changes on uroflowmetric parameters in healthy young men.

OBJECTIVE: To determine the mean difference in maximum urine flow rate and post-void residual urine volume in sitting as well as standing voiding position in healthy males. METHODS: This descriptive, cross-sectional study was conducted at the Department of Urology, Indus Hospital, Karachi, from October 2013 to March 2014, and comprised healthy volunteers enrolled using non-probability, consecutive sampling technique. Each volunteer was asked to perform uroflowmetry in sitting and standing positions on two separate days, and a post-void residual volume was assessed after each test. The values of maximum flow rate, average flow rate, voiding volume, and post-void residue were compared between the different voiding positions. RESULTS: A total of 50 volunteers were inducted. In standing position the maximum flow rate was 32.4±9.6 ml/sec, average flow rate 8.8±16.9 ml/sec, and post-void residue was 8.8±16.9ml. Similarly, in sitting position, the maximum flow rate was 14.8±5.4 ml/sec, average flow rate 14.8±5.4 ml/sec, and post-void residue was 6.6±9.4ml. A significant difference in both voiding positions was observed regarding the maximum flow rate, and average flow rate (p=0.001; p=0.003). However, the difference was not significant for voided volume (p=0.676), or post-void residual volume (p=0.771) in either position. Age-wise stratification of data showed significant difference in both younger and older age groups in terms of maximum flow rate (p=00.19). However, the average flow rate was only significantly different in younger age group (p=0.00). There was no difference in voided volume or post-void residue in either age group (p>0.05). CONCLUSIONS: The standing voiding position in healthy people influenced uroflowmetry findings, and was associated with higher flow rates.