Wulfenioidins D-N, Structurally Diverse Diterpenoids with Anti-Zika Virus Activity Isolated from Orthosiphon wulfenioides.

Eleven diterpenoids, wulfenioidins D-N (1-11), classified into five distinct carbon skeletons with one unreported framework, and four modified abietane diterpenoids were isolated from the whole plant of Orthosiphon wulfenioides. The structures and absolute configurations were characterized by spectroscopic methods, single-crystal X-ray diffraction, and electronic circular dichroism analyses. Compounds 3 and 5 exhibited activity against Zika virus (ZIKV) with EC50 values of 8.07 and 8.50 µM, respectively, and showed no significant cytotoxicity toward Vero cells at 100 µM. Western blot and immunofluorescence experiments showed that compounds 3 and 5 interfered with the replication of the ZIKV by inhibiting the expression of the ZIKV envelope (E) protein.

Detection of A2A2 genotype of beta casein protein (CSN2) gene in local, exotic and cross bred cattle in Pakistan.

Genetic variants of bovine Beta-casein protein (CSN2) gene especially A1 and A2 are the most important variants in dairy cattle. A1 milk protein is considered as risk factor for different disease and milk intolerance which release Beta-Casomorphin-7 during digestion which is a bioactive opioid but not released from A2 milk protein. This opioid is responsible for several human health problems like Coronary Heart disease, type 1 diabetics, milk intolerance and other neurological disorders. In present study, 360 blood sample were collected from Lohani, Achai, jersey, Holstein Friesian, Achai x jersey, Friesian x Sahiwal and Sahiwal x Friesian from different region of Khyber Pakhtunkhwa (KP) province. The polymerase chain reaction (PCR) amplicons were sequenced for the identification of polymorphism in exon 7 of Beta-casein protein (CSN2) gene. Sequencing analysis explored CSN2 genotype in exon 7 using the Genomic sequence from GenBank (X.71104) g.8101 C > A at codon 67. The allelic and genotypic frequencies of CSN2 gene were analyzed and observed that Holstein Friesian cattle exhibited A1A2 33%, A1A1 50% and A2A2 17%, Jersey cattle show 68% A1A1, 18% A1A2 and 14% A2A2, Sahiwal x Friesian 56% A1A1, 26% A1A2 and 18% A2A2, Jersey × Achai 78% A2A2, 15% A1A2 and 7% A1A1, Achai 100% A2A2 Lohani 100% A2A2. This is a preliminary study, conducted with meager resources, therefore, it is very difficult to make conclusion that which particular breed possess harmful alleles and which breed possess useful alleles of beta-casein gene. Therefore, a comprehensive molecular work is needed to be performed with greater number of samples sequencing.

Two New Prostaglandin-Like Compounds from Callicarpa arborea Roxb and Their NLRP3 Inflammasome Activation Inhibitory Activity.

Two new prostaglandin-like compounds callicarboric acids A-B (1-2), along with six known compounds (3-8) were isolated from the stems of Callicarpa arborea Roxb. Their structures were determined with the help of modern spectroscopic techniques such as NMR, UV, IR, HR-ESI-MS, ECD, and ORD with the assistance of quantum chemical calculations. Compound 1 exhibited remarkable anti-NLRP3 inflammasome activation potential, demonstrating an IC50 value of 0.74 µM. Additionally, by reducing GSDMD-NT production, inhibiting caspase-1 activation, and suppressing IL-1ß secretion, it effectively mitigated NLRP3 inflammasome-induced pyroptosis in J774A.1 cells. These findings indicate that compound 1 possesses the capability to be a valuable candidate for further research and development as an NLRP3 inflammasome inhibitor.

Three New Clerodane Diterpenoids and Their NLRP3 Inflammasome Activation Inhibitory Activity from Callicarpa arborea Roxb.

Three new compounds callicarpenoids A-C (1-3), were isolated from the stems of Callicarpa arborea Roxb together with fifteen known compounds (4-18). The structures of these compounds were elucidated using advanced spectroscopic techniques, including 1D and 2D NMR, UV, IR, HR-ESI-MS, ECD, ORD, and quantum chemical calculations. Compound 3, a rare rearranged diterpenoid with a fused 5/6-ring system demonstrated strong potential as an inhibitor of the NLRP3 inflammasome activation with an IC50 value of 3.153 µM. It effectively reduced GSDMD-NT production, inhibited caspase-1 activation, and suppressed IL-1ß secretion, thereby mitigating NLRP3 inflammasome-induced pyroptosis in J774A.1 cells. These findings suggest that compound 3 warrants further research and development as a promising NLRP3 inflammasome inhibitor.

Callicarpanes A-L, Twelve New Clerodane Diterpenoids with NLRP3 Inflammasome Inhibitory Activity from Callicarpa integerrima.

Twelve new clerodane diterpenoids named callicarpanes A-L (1-12), together with eight known compounds (13-20), were isolated from Callicarpa integerrima. Their structures were determined by comprehensive spectroscopic data. The calculated chemical shifts were used to identify relative configurations using DP4+ analysis. The absolute configurations (AC) were assigned based on quantum chemical calculations and X-ray single-crystal diffraction methods. Compounds 1, 3, 5, 9, 10, 12, 15, 16, and 19 showed significant inhibitory activity for NLRP3 inflammasome activation, with the IC50 against lactate dehydrogenase (LDH) release ranging from 0.08 to 4.78 µM. Further study revealed that compound 10 repressed IL-1ß secretion and caspase-1 maturation in J774A.1 cell as well as blocked macrophage pyroptosis.

The Imposter Syndrome In Surgical Residents.

Imposter syndrome (IS) is an internal sensation of intellectual phoniness in persons who feel fraudulence and worthlessness. The purpose of this study was to assess the prevalence of imposter syndrome among surgical residents. A web-based survey was conducted among all surgical residents of PGMI, Khyber Pakhtunkhwa, Pakistan, from May 1, 2022 to May 30, 2022. Of the 156 respondents, 104 (66.7%) were males and 52 (33.3%) were females. Moderate imposterism was seen in 81(51.9%) of the respondents and 57 (36.5%) respondents reported severe or intense imposterism. Among postgraduate residents, no significant differences in Clance Imposter Phenomenon Scale score by year was noted (p = 0.291). Imposter syndrome was highly prevalent among surgical residents, i.e. 138(88.5%) falling in the range of either moderate, severe, or intense imposterism. Prevalence was more among female residents as compared to male residents. Year of training didn't have any impact on the grades of imposterism.

Callintegers A and B, Unusual Tricyclo[4.4.0.09,10]tetradecane Clerodane Diterpenoids from Callicarpa integerrima with Inhibitory Effects on NLRP3 Inflammasome Activation.

Callintegers A (1) and B (2), unprecedented clerodane norditerpenoids based on a novel carbon skeleton, were isolated from Callicarpa integerrima. Compounds 1 and 2 possess a novel 6/6/6-fused tricyclic ring system. Their structures and absolute configurations were determined by quantum chemical calculations, spectroscopic analysis, and single-crystal X-ray diffraction methods. Biological evaluation showed that compound 2 inhibited IL-1ß secretion in a dose-dependent manner with an IC50 value of 5.5 ± 3.2 µM. Caspase-1 maturation and IL-1ß secretion were also reduced, indicating that compound 2 impaired NLRP3 inflammasome activation.

Effect of team-based learning on critical thinking: A quasi-experimental study.

Objectives: To determine the effect of Team-based learning (TBL) on the critical thinking of health professions students. Methods: This quasi-experimental study, was done in paramedical and nursing sciences institutes using the convenience sampling technique. Students included were enrolled in the haematology course of paramedic institute from January to December 2020 and adult health course of the nursing institute of Khyber Medical University. Six dimensions of critical thinking (CT) of the students before and after TBL were determined using the critical thinking disposition inventory. Results: The study participants included 89 students, comprising 58 students from the paramedic's institute and 31 from the nursing institute; 67 (75.28%) males and 22 (24.71%) females. The overall pre-test score of CT was 257.46 ± 21.73, and the post-test score was 274.55 ± 19.36, which was statistically significant (p-value = 0.000). The pre-test score of six dimensions, namely, analyticity, inquisitiveness, systematicity, truth-seeking, self-confidence, and open-mindedness was 41.35 ± 5.15, 44.73 ± 4.77, 41.12±6.87, 43.17± 5.19, 44.94±6.03, 42.38 ± 5.32 respectively, whereas the post-test scores were 44.57± 5.28, 47.11 ± 4.69, 46.12± 5.54, 45.77 ± 5.05, 47.58 ± 5.65, 43.56 ± 4.56 correspondingly. Analyticity (p=.000), inquisitiveness (p=.000), systematicity (p=.000), truth-seeking (p=.000) and self-confidence (p=.000) were statistically significant. However, open-mindedness was statistically insignificant (p=.074). Conclusion: TBL improves five out of six dimensions of students' critical thinking. Besides its established evidence to increase knowledge, TBL can also be used as a teaching methodology for enhancing students' critical thinking.

SARS-CoV-2 nucleocapsid and Nsp3 binding: an in silico study.

Severe acute respiratory syndrome virus 2 (SARS-CoV-2) belongs to the single-stranded positive-sense RNA family. The virus contains a large genome that encodes four structural proteins, small envelope (E), matrix (M), nucleocapsid phosphoprotein (N), spike (S), and 16 nonstructural proteins (nsp1-16) that together, ensure replication of the virus in the host cell. Among these proteins, the interactions of N and Nsp3 are essential that links the viral genome for processing. The N proteins reside at CoV RNA synthesis sites known as the replication-transcription complexes (RTCs). The N-terminal of N has RNA-binding domain (N-NTD), capturing the RNA genome while the C-terminal domain (N-CTD) anchors the viral Nsp3, a component of RTCs. Although the structural information has been recently released, the residues involved in contacts between N-CTD with Nsp3 are still unknown. To find the residues involved in interactions between two proteins, three-dimensional structures of both proteins were retrieved and docked using HADDOCK. Residues at N-CTD were detected in interaction with L499, R500, K501, V502, P503, T504, D505, N506, Y507, I508, T509, K529, K530K532, S533 of Nsp3 and N-NTD to synthesize SARS-CoV-2 RNA. The interaction between Nsp3 and CTD of N protein may be a potential drug target. The current study provides information for better understanding the interaction between N protein and Nsp3 that could be a possible target for future inhibitors.

Mitochondrial phylogenetic and diversity analysis in Azi-Kheli buffalo.

NOVELTY STATEMENT: The present study was conducted for the first time in Pakistan to investigate Cytochrome C Oxidase Subunit 1 (CO1) gene and full-length Displacement Loop (D-loop) region of mitochondrial DNA in Azi-Kheli buffalo breed native to northern hilly areas of Khyber Pakhtunkhwa Province of Pakistan. The present study was designed to investigate phylogeny and diversity in Azi-Kheli buffalo, through two mitochondrial DNA regions, i.e., Cytochrome C Oxidase Subunit-I (CO1) and Displacement Loop (D-loop) region. Thirty (30) blood samples were taken from Azi-Kheli pure breed animals from original breeding tract, i.e., Khwazakhela, Swat. Polymerase chain reactions using gene-specific primers were carried out for amplifying 709-bp region of CO1 gene and 1159-bp region of D-Loop for identification, phylogeny, and diversity in Azi-Kheli buffalo, respectively. The sequences of CO1 gene revealed four (04) haplotypes, whereas D-loop sequences revealed five (05) haplotypes. Mean interspecific diversity with related species was 2.56%, and mean intraspecific diversity within Azi-Kheli buffalo was 0.25%, estimated via Kimura-2 parameter. Phylogenetic tree (maximum likelihood) revealed clustering of Azi-Kheli haplotypes with river buffalo and is distinct from swamp buffalo and other related species of genus Bubalus. Mean haplotype and nucleotide diversity of D-loop were Hd = 0.9601 ± SD = 0.096 and π = 0.01208 ± SD = 0.00182, respectively. Phylogenetic tree (neighbor-joining) revealed two main clades, i.e., river buffalo and swamp buffalo clade. The haplotypes of Azi-Kheli clustered with haplotypes of different river buffalo breeds at different positions. The current study suggests that Azi-Kheli has common origin with other river buffalo breeds; hence, it is river buffalo which harbors high genetic diversity.

Triterpenoids from Ganoderma gibbosum: A Class of Sensitizers of FLC-Resistant Candida albicans to Fluconazole.

Fungal drug resistance is a major health threat, and reports of clinical resistance worldwide are becoming increasingly common. In a research program to discover new molecules to help overcome this problem, 14 new lanostane-type triterpenoids, gibbosicolids A-G (2-8) and gibbosic acids I-O (9-15), were isolated from the fruiting bodies of Ganoderma gibbosum, along with seven known triterpenoid derivatives. These compounds featured high levels of oxidation, epimerization, and γ-lactonization. Structures were elucidated by comprehensive spectroscopic analyses and HRMS data. Absolute configurations were assigned based on quantum chemical calculations, including calculated chemical shift with DP4+ analysis, coupling constants, and electronic circular dichroism (ECD) methods. Results show that the calculated NMR with DP4+ analysis could not reliably establish the overall spatial configuration of molecules possessing independent and free-rotational stereoclusters. All these compounds significantly increased the sensitivity of fluconazole (FLC)-resistant C. albicans to FLC. Compounds 2, 5, 9, 12, 16, 17, and 21 exhibited strong antifungal activity against FLC-resistant C. albicans when combined with FLC, with MIC50 values ranging from 3.8 to 8.8 µg/mL.

Efficacy of Over-the-Scope Clips in Management of High-Risk Gastrointestinal Bleeding.

BACKGROUND & AIMS: Standard endoscopic therapies do not control bleeding or produce complications in as many as 20% of patients with nonvariceal gastrointestinal bleeding. Most bleeding comes from ulcers with characteristics such as high-risk vascular territories and/or large vessels. We evaluated the efficacy of using over-the-scope clips (OTSCs) as primary or rescue therapy for patients with bleeding from lesions that have a high risk for adverse outcomes. METHODS: We performed a retrospective analysis of data from 67 patients with gastrointestinal bleeding from high-risk lesions who were treated with OTSCs as primary (n = 49) or rescue therapy (n = 18) at a quaternary center, from December 2011 through February 2015. The definition of high-risk lesions was lesions that were situated in the area of a major artery and larger than 2 mm in diameter and/or a deep penetrating, excavated, fibrotic ulcer with high-risk stigmata, in which a perforation could not be ruled out or thermal therapy would cause perforation, or lesions that could not be treated by standard endoscopy. Clinical severity was determined based on the Rockall score and a modified Blatchford score. Our primary outcome was the incidence of rebleeding within 30 days after OTSC placement. We assessed risk factors for rebleeding using univariate hazard models followed by multivariable analysis. RESULTS: Of the 67 patients, 47 (70.1%) remained free of rebleeding at 30 days after OTSC placement. We found no difference in the proportion of patients with rebleeding who received primary or rescue therapy (hazard ratio, 0.639; 95% confidence interval, 0.084-4.860; P = .6653). Only 9 rebleeding events were linked clearly to OTSCs and required intervention, indicating an OTSC success rate of 81.3%. We found no significant associations between rebleeding and clinical scores. However, on multivariable analysis, patients with coronary artery disease had a higher risk of rebleeding after OTSC independent of international normalized ratio and antiplatelet use (hazard ratio, 7.30; P = .0002). CONCLUSIONS: In a retrospective analysis of 67 patients with bleeding from high-risk gastrointestinal lesions, we found OTSCs to prevent rebleeding in more than 80% of cases. In the past, these lesions were treated with surgical or radiologic interventions. Patients with coronary artery disease have an increased risk of rebleeding after OTSCs, suggesting the need for escalated therapies.

Impact of hypercortisolism on skeletal muscle mass and adipose tissue mass in patients with adrenal adenomas.

CONTEXT: Abdominal visceral adiposity and central sarcopenia are markers of increased cardiovascular risk and mortality. OBJECTIVE: To assess whether central sarcopenia and adiposity can serve as a marker of disease severity in patients with adrenal adenomas and glucocorticoid secretory autonomy. DESIGN: Retrospective cohort study. PATIENTS: Twenty-five patients with overt Cushing's syndrome (CS), 48 patients with mild autonomous cortisol excess (MACE) and 32 patients with a nonfunctioning adrenal tumour (NFAT) were included. METHODS: Medical records were reviewed, and body composition measurements (visceral fat [VAT], subcutaneous fat [SAT], visceral/total fat [V/T], visceral/subcutaneous [V/S] and total abdominal muscle mass) were calculated based on abdominal computed tomography (CT). RESULTS: In patients with overt CS, when compared to patients with NFAT, the V/T fat and the V/S ratio were increased by 0.08 (P < .001) and by 0.3 (P < .001); however, these measurements were decreased by 0.04 (P = .007) and 0.2 (P = .01), respectively, in patients with MACE. Total muscle mass was decreased by -10 cm2 (P = .02) in patients with overt CS compared to patients with NFAT. Correlation with morning serum cortisol concentrations after dexamethasone suppression testing revealed that for every 28 nmol/L cortisol increase there was a 0.008 increase in V/T (P < .001), 0.02 increase in the V/S fat ratio (P < .001) and a 1.2 cm2 decrease in mean total muscle mass (P = .002). CONCLUSIONS: The severity of hypercortisolism was correlated with lower muscle mass and higher visceral adiposity. These CT-based markers may allow for a more reliable and objective assessment of glucocorticoid-related disease severity in patients with adrenal adenomas.

Tube Thoracostomy Complications Increase Cost.

BACKGROUND: Tube thoracostomy (TT) can be an effective therapy for thoracic pathologies. Ineffective placement of TT is common and associated with significant complications. Complications require additional interventions to repair damaged tissues or replace dysfunctional TT. We hypothesize that complicated TT insertion increases cost to the hospital system. METHODS: Adult trauma patients requiring TT at a level 1 trauma center (2012-2013) were reviewed. Intraoperative or image-guided TT placements were excluded. Baseline demographics and TT insertion cost (normalized and assigned by hospital billing records) were recorded. Costs included initial TT equipment, radiographs, and subsequent operative or radiologic intervention to correct TT complications. Complications were categorized using previously validated method. Secondary outcomes included: number of TT inserted, number of chest radiographs performed, and TT dwell time utilizing a standardized TT discontinuation protocol. RESULTS: A total of 154 patients with 246 TT were included. Ninety TT (37%) had complication. Complication categories are postremoval (n = 15, 16.7%), insertional (n = 13, 14.4%), positional (n = 62, 68.9%). Overall median complicated TT cost was 9 times greater than uncomplicated TT insertion, p = 0.001. Insertional complications median cost 21 times greater than an uncomplicated, due to operative and radiologic interventions (p = 0.0001). Positional and postremoval complication rates increased median cost by 3 times compared to uncomplicated TT (p = 0.03). Operative or radiologic interventions (n = 10) were performed for organ injury or uncontrolled hemo-/pneumothorax. Increased dwell time median [IQR] was associated with complicated TT compared to uncomplicated 3 [1-5] versus 2 [1-3], p = 0.01. CONCLUSION: TT is a common procedure. TT complications are often considered benign. However, patients with a complicated TT insertion, especially related to insertional subtypes, have markedly increased hospitalization costs due to need for operative or radiologic repair. LEVEL OF EVIDENCE: Level V-retrospective study. STUDY TYPE: This is a retrospective single-institution study.

Risk factors for postoperative hematoma after inguinal hernia repair: an update.

BACKGROUND: We recently sensed an increase in the frequency of groin hematoma after inguinal hernia repair (IHR) at our institution. The aim of this study was to provide a more updated assessment of the risk factors inherent to this complication. METHODS: We performed a case-control study of all adult patients (age ≥ 18 y) who developed a groin hematoma after IHR at our institution between 2003 and 2015. Univariate and multivariable analyses were performed to assess for independent predictors for groin hematoma. RESULTS: A total of 96 patients (among 6608 IHR) developed a groin hematoma, (60 were observed, 36 required intervention). The hematoma frequency increased from our previous study (1.4 % versus 0.9%, P < 0.01). Mean age was 64.6 y (range: 18-92), and 84.3% were men. There was no significant difference in the laterality, type, or technique of IHR between cases and controls. Univariate analysis (odds ratio [95% confidence interval], P) identified warfarin usage (3.5, [1.6-6.4], P < 0.01), valvular heart disease (11.6, [2.6-51.3], P < 0.01), atrial fibrillation (2.6, [1.2-5.5], P = 0.01), hypertension (2.03, [1.1-3.6], P = 0.02), recurrent hernia (3.7, [1.4-9.7], P < 0.01), and coronary artery disease (2.1, [1.0-4.4 ], P = 0.05) as significant preoperative factors. The proportion of patients on warfarin decreased since our prior report (31% versus 42%, P = 0.20). On multivariable regression, warfarin and recurrent hernia were independent predictors of hematoma development. CONCLUSIONS: Independent risk factors for the development of groin hematoma after IHR included warfarin use and recurrent hernia. Careful consideration for anticoagulation and surgical hypervigilance remains prudent in all patients undergoing IHR and especially those with recurrence.

Peutz-Jeghers syndrome with polyps in the stomach, duodenum, and small and large intestine: a case report.

BACKGROUND: Peutz-Jeghers syndrome is a rare hereditary condition characterized by gastrointestinal polyps and pigmented oral lesions. The case contributes to a deeper understanding of Peutz-Jeghers syndrome and underscores the significance of interdisciplinary collaboration for accurate diagnosis and tailored therapeutic strategies. CASE DESCRIPTION: We present a case of a 15-year-old Afghan female patient with multiple polyps throughout the gastrointestinal tract and mucocutaneous pigmentation. Despite previous medical visits and colonoscopies, her symptoms persisted. A multidisciplinary team discussed the case and recommended further investigations and interventions. A polypectomy was performed, confirming the presence of hamartomatous polyps. The patient was diagnosed with Peutz-Jeghers syndrome, but during the course of treatment she went through complications and was managed surgically as well. CONCLUSION: Timely polyp removal and lifelong surveillance are crucial in managing Peutz-Jeghers syndrome. Further research and genetic analysis are needed to improve understanding and management of this rare disorder.

Six new quassinoids from Picrasma chinese P·Y. Chen and their cytotoxicity activity.

In the present study, six new compounds namely, picralactones CH (1-6) along with nine known compounds (7-15) were isolated from the branches and leaves of Picrasma chinese P.Y. Chen. Their structures were determined with the help of spectroscopic techniques such as NMR, HR-ESI-MS, UV, IR and CD. Cytotoxicity of all compounds was evaluated against MDA-MB-231, SW-620 and HepG2 human cancer cell lines. Compound 4 showed cytotoxic activities.

Alginate magnetic graphene oxide biocomposite synthesis for removal of aromatic amines from aqueous samples.

In the present work, alginate magnetic graphene oxide biocomposite was synthesized for the removal and extraction of aromatic amines (aniline, p-chloroaniline (PCA), and p-nitroaniline (PNA)) from water samples. The biocomposite was investigated for its physiochemical characteristics such as surface morphology, functional groups, phase determination, and elemental composition. The results revealed that the functional groups of graphene oxide and alginate retained in biocomposite with magnetic properties. The biocomposite was applied to water samples for the removal and extraction of aniline, p-chloroaniline, and p-nitroaniline through adsorption process. The adsorption process was studied under various experimental conditions like time, pH, concentration, dose, and temperature, and all the parameters were optimized. The maximum adsorption capacities at room temperature have an optimum pH = 4 for aniline = 18.39 mg g-1, for PCA = 17.13 mg g-1, and for PNA = 15.24 mg g-1. Kinetic and isotherm models showed that the experimental data is best fitted to pseudo-second-order kinetic model and the Langmuir isotherm model. Thermodynamic study suggested that the adsorption process is exothermic and spontaneous. Ethanol was found to be the best eluent for the extraction of all the three analytes suggested by the extraction study. The maximum percent recoveries from spiked water samples were calculated for aniline = 98.82%, PCA = 96.65%, and PNA = 93.55% which showed that alginate magnetic graphene oxide biocomposite could be a useful and ecofriendly adsorbent for the removal of organic pollutants in water treatment processes.

Acute pancreatitis with chylous ascites mimicking acute appendicitis: A rare case report.

INTRODUCTION AND IMPORTANCE: Chylous ascites, characterized by the accumulation of lymphatic fluid in the peritoneal cavity, presents a significant diagnostic and management challenge, particularly in resource-limited settings. CASE PRESENTATION: We report a case of a 63-year-old female with acute abdominal pain who was initially diagnosed with acute perforated appendicitis. During open surgery, Chylous ascites was found with normal appendix and bulky pancrease with surrounding fluid accumulation. Drain was placed in lesser sac area and appendectomy was performed with drain placed in right iliac fossa. Recovery was uneventful. CLINICAL DISCUSSION: Chylous ascites can be challenging to diagnose, especially in resource-limited settings. Laboratory analysis and imaging studies play a critical role in establishing the diagnosis, while conservative measures and invasive interventions, if necessary, comprise the treatment strategy. CONCLUSION: Our case highlights the importance of considering chylous ascites as a potential differential diagnosis in acute abdomen cases. Accurate diagnosis and management can be particularly challenging in resource-limited settings, and increased awareness among clinicians and further research is necessary to improve outcomes for patients.

Comparison of Alvarado score, appendicitis inflammatory response score (AIR) and Raja Isteri Pengiran Anak Saleha appendicitis (RIPASA) score in predicting acute appendicitis.

Introduction: Acute Appendicitis is the most common surgical emergency encountered in emergency departments. To prevent the rate of negative appendectomies, different systems i.e. Alvarado score and Appendicitis Inflammatory Response Score (AIR) scores were used, but their diagnostic accuracy in Asian population is questionable. Raja Isteri Pengiran Anak Saleha (RIPASA) score has showed promising results in the recent literature. The purpose of this study is to compare the efficacy of Alvarado, AIR and RIPASA scores in the diagnosis of acute appendicitis. Methods: Alvarado, AIR and RIPASA scores were prospectively applied to 132 included patients that were admitted with provisional diagnosis of acute appendicitis and then their surgery was performed in General Surgery Unit, Hayatabad Medical Complex Peshawar, Pakistan from 1st January 2022 to 31st July 2022. Final diagnosis was confirmed by histopathology report and scores were correlated with final report. Cut off value of score >7, >5 and >7.5 were set for Alvarado, AIR and RIPASA score, respectively according to previous literature. Statistics analysis was done for all 3 scoring systems on SPSS version 23. Results: Of 132 patients, there were n = 79(59.8%) males and n = 53(40.2%) females. Mean age was 24 years (SD ± 11.6) with youngest patient of 9 years and oldest one was 70 years old. Negative Appendectomy rate was 8.3%(n = 11). RIPASA score was superior to AIR and Alvarado score in Sensitivity, NLR, Accuracy and Area under the Curve. AIR score performed better in specificity, NPV, PLR compared to RIPASA and Alvarado score. Conclusion: RIPASA score is an overall better scoring system in diagnosing acute appendicitis in compared to Alvarado and AIR score.