A Rectal Sunflower Seed Bezoar Causing Fecal Impaction in a Healthy Young Woman.

Bezoars, characterized by undigested or partially digested foreign bodies in the gastrointestinal (GI) tract, are a rare condition associated with significant complications. We present a case of a 31-year-old woman who sought medical attention due to weight loss, diarrhea, and anorectal pain. Upon investigation, she was diagnosed with fecal impaction caused by a rectal sunflower seed bezoar. The patient had a history of regular sunflower seed consumption, suggesting a potential association with the development of the bezoar. Fecal impaction resulting from the bezoar led to chronic constipation, contributing to the patient's weight loss and anorectal discomfort. Imaging studies, including abdominal X-rays or computed tomography (CT) scans, played a crucial role in confirming the diagnosis by identifying the presence of the bezoar within the rectum. Management involved a multidisciplinary approach, with gastroenterologists and colorectal surgeons. A flexible endoscope was utilized to visualize and remove the sunflower seed bezoar under direct vision, providing immediate relief from the symptoms. This case emphasizes the importance of considering bezoars as a potential cause of GI symptoms, even in young and otherwise healthy individuals. Although rectal bezoars are relatively rare, they can lead to significant morbidity. Therefore, it is essential to include them in the differential diagnosis of patients presenting with fecal impaction, anorectal pain, and associated symptoms. Prompt diagnosis, appropriate imaging, and early intervention are crucial for the successful management and prevention of potential complications and the improvement of patient outcomes.

Trapped in the Bowel.

Intussusception in adults is a rare condition and is usually associated with organic disease. It has been implicated for 1% of all bowel obstructions. Clinical presentation can be non-specific and the rarity of the classic triad of abdominal pain, vomiting, and currant jelly stools contributes to late diagnosis and treatment. A 95-year-old lady presented to the emergency department for evaluation of nausea, vomiting, and a two-month history of intermittent diarrhea, which had been worsening for a few days prior to admission. On examination, the abdomen was soft but tender on deep palpation, with audible bowel sounds. No organomegaly or costovertebral angle (CVA) tenderness was appreciated. CT abdomen revealed a long segment of the colon with a loop within loop appearance from the proximal transverse colon to the distal descending colon, consistent with intussusception. The patient was taken to the operating room where local exploration using laparoscopy revealed complete telescoping and intussusception of terminal ileum into the distended ascending and transverse colon and the patient underwent right hemicolectomy. The signs and symptoms of intussusception among the elderly are very non-specific and include nausea, vomiting, change in bowel habits, and gastrointestinal bleeding. Since the classic triad of symptoms (abdominal pain, vomiting, and currant jelly stools) is rarely observed, timely diagnosis and management become a challenge for clinicians. Literature suggests that up to 90% of adults with intussusception present with ongoing abdominal pain. Especially in outpatient settings, patients presenting with intermittent abdominal pain that resolves quickly with simple analgesia should be promptly evaluated. This case illustrates that the rarity of incidence and non-specific clinical presentation are potential barriers towards timely diagnosis and treatment of intussusception among adults, especially the elderly population. Keeping a low threshold for prompt evaluation using appropriate imaging modalities can help overcome this challenge and help reduce the surgical burden.

Recent updates in the management of Merkel Cell Carcinoma.

Merkel cell carcinoma is an aggressive non-melanomatous cutaneous tumour of neuroendocrine origin with an increasing incidence in the recent years. It is a tumour of the elderly and immunosuppressed, which most often appears on sun-exposed areas of the body. The clinical features of the cutaneous or subcutaneous lesions hardly contribute to the diagnosis, and, hence, histopathology and immunohistochemistry play a vital role in diagnosis. The latest staging system by the American Joint Committee on Cancer includes non-nodal invasion to adjacent structures i.e. bone, muscle, fascia, or cartilage into the criteria, in additionto size and depth of invasion. The management reliesheavily on a multidisciplinary approach due to rarity of incidence of this disease. According to the international guidelines, surgical management is still the preferred choice. The beneficial role of adjuvant radiotherapy has now been more clearly documented. Data is insufficient to assess whether chemotherapy improves disease-free or overall survival.

Hidradenocarcinoma: Five Years of Local and Systemic Control of a Rare Sweat Gland Neoplasm with Nodal Metastasis.

Hidradenocarcinoma is a rare and locally aggressive tumor rendering a poor prognosis. Furthermore, very few cases present with nodal metastasis. Diagnosing such an entity, and then differentiating it from a benign counterpart, poses a great challenge to the clinicians. There are no established treatment guidelines for the management of this disease, particularly in patients with nodal involvement. We present a case of a young male who was diagnosed with hidradenocarcinoma of the scalp, along with a neck swelling. A thorough diagnostic evaluation was done with endoscopy, pathological, and radiological investigations. He was successfully treated with resection of the scalp lesion and right-sided neck dissection followed by adjuvant concurrent chemoradiation. He remains free of any local and distant disease after five years of regular follow-up.

A cross-sectional study to investigate pneumococcal vaccination in the elderly in a low income county: patient knowledge, awareness, and attitudes of vaccination and prevalence rates by socioeconomic status.

BACKGROUND: Pneumonia represents the leading cause of infection-related death and the fifth cause of overall mortality, in the elderly. With increasing age, the human immune system undergoes characteristic changes which lead to increased incidence and severity of infectious diseases and to insufficient protection following vaccination as antibody response of elderly vaccines are weaker and decline faster. OBJECTIVE: Knowledge and Attitude toward Pneumonia and its Vaccination in elderly patients. RESULT: Among low SES, 54.9% (549/1000) while from high SES, 91.8% (918) responded that they had heard about pneumonia before (P<0.05). 79.5% (795/1000) patients of high SES had heard about pneumococcal vaccination while only 28.8% (288/1000) patients from low SES had heard about pneumococcal vaccine. Only 2.3% of low SES patients were immunized for pneumococcal vaccine while 16.5% high SES patients were vaccinated. Reported reason for not being immunized were; did not hear, no body advised, vaccine is too expensive, and ignored thinking it is not necessary. METHOD: We conducted a cross-sectional study on 2000 elderly patients who were admitted in medicine and surgery wards of Civil Hospital Karachi and Aga Khan University Hospital Karachi from the period of October to December 2012 to determine their knowledge and attitude toward pneumonia and its vaccination in elderly. Study group was divided into low and high socio-economic status on the basis of patients coming to government Hospital i.e., civil hospital and private hospital i.e., Aga khan hospital. Data was collected through convenient sampling technique. Exclusion criteria were patients below 60 years and those who didn't give consent to be part of study. CONCLUSION: Aside from introducing public awareness program about elderly vaccination at state level, free of cost vaccination of elderly individuals should be done.

Perceived stress and stressors among house officers.

BACKGROUND: House officers training has always been regarded as a highly stressful environment to doctors. The objectives of our study were to assess perceived stress and sources of stress among house officers. MATERIALS AND METHODS: A cross-sectional questionnaire-based survey was carried out among house officers working in Civil Hospital, Karachi, Pakistan, and Jinnah Postgraduate Medical Centre, Karachi, Pakistan, during November and December, 2013. Perceived stress was assessed using perceived stress scale. A 15-item questionnaire was used to assess sources of stress and was graded by Likert scale (1 = very low, 5 = very high). To calculate the difference of mean for stressors by gender of house officers, t-test with 95% confidence interval was used. RESULTS: The overall response rate was 81.5% (269 out of 330). One hundred twenty-nine (47.9%) were found to be under stress of whom 32 (24.8%) were males and 97 (75.2%) were females. Top five stressors reported by house officers were night calls, workload, time pressure, working alone, and coping with diagnostic uncertainty. Significant differences for stressors by gender were found for night calls (P < 0.05), unrealistically high expectation by others (P < 0.05), financial issues (P < 0.05), and lack of senior support (P < 0.05). CONCLUSION: Majority of house officers working in Civil Hospital, Karachi, and Jinnah Postgraduate Medical Centre, Karachi, were under high level of stress. Therefore, immediate steps should be taken for control of stress and its management.

Reasons behind the increase in research activities among medical students of Karachi, Pakistan, a low-income country.

CONTEXT: Previously, in a low-income country with limited resources like Pakistan, biomedical research was conducted mostly by individuals working in private organizations. Recently, there has been an upsurge in the number of medical students conducting research in both private and public medical colleges of Karachi, Pakistan. We investigated student perceptions of the reasons behind the increase in biomedical research among medical students of private and public medical colleges in Karachi, Pakistan. METHODS: This cross-sectional study was conducted at four medical universities of Karachi, using structured data collection tool. Participants included medical students who stated that they were interested in medical research. We assessed how many had been involved in research or stated that they intended to be, and tallied students' stated reasons why they were involved in research. Chi-square analyses were used to assess if year of training, institution, and other factors were associated with the likelihood of past or current actual research involvement. RESULTS: Out of the 398 students with research interest who participated in the study, 349 (88%) stated that they intended to do research projects in their undergraduate years. At the time of the study, only 202 (51%) reported that they had actually conducted research. The reasons given for engaging in research for a minority included personal interest (n = 136; 34%), while majority stated that their motivation was to improve their curriculum vitae (75%) and/or to be more competitive for a residency in the United States (43%). The reasons students gave for involvement in research were related to whether their schools were public versus private and to their year of study. DISCUSSION: According to students' reports, improving one's curriculum vitae to get a strong residency in the USA appeared to be a principal reason for the increase in biomedical research in Karachi. The challenges of research, such as lack of good mentors and increased work-load were reported to affect few students' ability to engage in research.