Preoperative Controlling Nutritional Status Score on Predicting the Postoperative Complications Following Major Hepatopancreatobiliary Surgery.

Introduction The prognostic significance of the controlling nutritional status (CONUT) score in hepatopancreatobiliary (HPB) surgery has been shown by many studies but the clinical significance of the CONUT score for postoperative short-term outcomes remains controversial. This study aimed to investigate the impact of the CONUT score on early postoperative outcomes in patients following major HPB surgery. Method This was a prospective study of 57 patients who underwent major HPB surgery from November 2019 to January 2021 at the Department of Surgical Gastroenterology, Tribhuvan University Teaching Hospital, Nepal. Result A total of 57 patients, 25 males and 32 females, were operated on. The number of patients assigned to the normal, mild, and moderate malnutrition groups was 13, 41, and 3, respectively. The high CONUT group (CONUT ³ 2) consisted of 44 patients (77%) and the low CONUT group (CONUT <2) consisted of 13 patients (33%). The overall complications (Clavien-Dindo classification ³1) and major complications (Clavien-Dindo classification ³3) were present in 37 patients (64.9%) and 14 patients (24.6%), respectively. Increased operative time and intraoperative blood loss were associated with an increased incidence of major (OR: 1.01, p: 0.018) and overall (OR: 1.006, p: 0.039) postoperative complications, respectively, in univariate analysis. A high CONUT score was not associated with a higher incidence of overall and major postoperative complications. Conclusion In our study, the preoperative CONUT score did not predict the postoperative morbidity following hepatopancreatobiliary surgery.

Assessment of medication discrepancy, medication appropriateness, and cost analysis among patients with pediatric nephrotic syndrome: An ambispective cohort observational study.

BACKGROUND: Nephrotic syndrome (NS) is a commonly encountered chronic kidney disease in pediatric populations, with South Asian children being at high risk and requiring long-term pharmacological management. Thus, identifying medication discrepancies and evaluating the appropriateness of therapy and its economic burden are vital for inpatient management. The aim of the study was to assess medication reconciliation, medication appropriateness, and cost analysis in NS cases. METHODS: An ambispective cohort observational study was carried out with 150 NS patients where medication discrepancies were identified retrospectively and prospectively using the best possible medication history and following up patients correspondingly. Further, the Medication Appropriateness Index and cost variation analysis were used to assess the prescribed therapy and cost analysis, respectively. RESULTS: Out of 150 patients with NS included, 67.3% were male and the mean age was 7.2 years. In total, 36.7% medication discrepancies were found at baseline and 6% discrepancies at follow-up. The majority of discrepancies were unintentional and due to dosing error both at baseline and follow-up. Further, in only 2% of the patients was there inappropriately prescribed medication, and the majority of patients spent between INR (Indian Rupees) 500 and 1000. CONCLUSION: Chronic conditions like NS require continuous monitoring by the specialist pediatric clinical pharmacist, who can contribute significantly by minimizing the medication discrepancies, by assessing the appropriateness of therapy, and lessening the economic burden.

Predicting asthma using imbalanced data modeling techniques: Evidence from 2019 Michigan BRFSS data.

Studies in the past have examined asthma prevalence and the associated risk factors in the United States using data from national surveys. However, the findings of these studies may not be relevant to specific states because of the different environmental and socioeconomic factors that vary across regions. The 2019 Behavioral Risk Factor Surveillance System (BRFSS) showed that Michigan had higher asthma prevalence rates than the national average. In this regard, we employ various modern machine learning techniques to predict asthma and identify risk factors associated with asthma among Michigan adults using the 2019 BRFSS data. After data cleaning, a sample of 10,337 individuals was selected for analysis, out of which 1,118 individuals (10.8%) reported having asthma during the survey period. Typical machine learning techniques often perform poorly due to imbalanced data issues. To address this challenge, we employed two synthetic data generation techniques, namely the Random Over-Sampling Examples (ROSE) and Synthetic Minority Over-Sampling Technique (SMOTE) and compared their performances. The overall performance of machine learning algorithms was improved using both methods, with ROSE performing better than SMOTE. Among the ROSE-adjusted models, we found that logistic regression, partial least squares, gradient boosting, LASSO, and elastic net had comparable performance, with sensitivity at around 50% and area under the curve (AUC) at around 63%. Due to ease of interpretability, logistic regression is chosen for further exploration of risk factors. Presence of chronic obstructive pulmonary disease, lower income, female sex, financial barrier to see a doctor due to cost, taken flu shot/spray in the past 12 months, 18-24 age group, Black, non-Hispanic group, and presence of diabetes are identified as asthma risk factors. This study demonstrates the potentiality of machine learning coupled with imbalanced data modeling approaches for predicting asthma from a large survey dataset. We conclude that the findings could guide early screening of at-risk asthma patients and designing appropriate interventions to improve care practices.

Perceptions and challenges among health care providers about HIV-TB co-infected children- A qualitative study.

BACKGROUND: Human immunodeficiency virus - Tuberculosis (HIV-TB) co-infected patients have a greater risk of mortality, treatment failure, and recurrence. The significant morbidity and mortality rates associated with tuberculosis and human immunodeficiency virus infection in children cause concern. India aims to enhance the detection and treatment of HIV-TB cases in children and coordinate TB & HIV care. OBJECTIVE: To explore the perceptions and challenges of health care providers regarding the diagnosis and treatment of Tuberculosis in HIV-TB co-infected children. MATERIALS AND METHOD: In-depth interviews among 14 health care providers were conducted in ART centers of 5 talukas of Belagavi district to identify health care providers' perceptions and challenges regarding pediatric HIV-TB diagnosis and treatment. Interviews were conducted after receiving informed consent. RESULTS: Challenges during HIV-TB diagnosis and treatment in children: difficult to get sputum sample for CBNAAT and child was unable to complain about symptoms, caregivers were not able to mention the signs/symptoms correctly, unavailability of a pediatrician in few Taluka ART centers, delay in receiving TB lab report, challenging to feed drugs to an infant, higher loss to follow-up, financial problem, distance from centers, low community awareness, poverty and illiteracy, stigma and death due to TB treatment default. CONCLUSION: Efforts such as expanded health care providers, community education, and a constant supply of HIV rapid test kits are required to ensure successful diagnosis and treatment of HIV-TB co-infected children.

A case report on enormous haemangioma of liver.

Introduction: Hemangiomas are the most common benign liver tumour. These tumours arise from the proliferation of vascular endothelial cells and increase in size owing to dilation. If their diameter exceeds 5 cm, they are classified as giant hemangiomas, while those surpassing 15 cm are considered enormous hemangiomas. Case presentation: A 38-year-old female patient presented with complaints of abdominal fullness for 18 months. Contrast-enhanced computed tomography was performed and two hemangiomas were diagnosed; the , larger one was an enormous hemangioma of size 20 × 16 cm. Non-anatomical hepatic resection was performed to remove the hemangiomas. The patient recovered well, without any complications. Clinical discussion: Hepatic hemangiomas are common, but hemangiomas greater than 15 cm in size are rare. They usually require no treatment unless the patient is symptomatic. Hepatectomy and enucleation of hemangioma are the most common surgical procedure for such hemangioma. Conclusions: Rarely, large hepatic hemangioma can be the cause of abdominal fullness lasting for months. Often, surgical intervention is required.

Pharmacists' medication reconciliation interventions during admission and transfer from an emergency department at a tertiary care hospital: a randomized pilot study and evaluation of physician and patient perceptions.

AIM: The study aimed to assess the impact of pharmacist interventions during the transition of care. BACKGROUND: Medication discrepancies can occur at various levels of transition, such as during admission, the transition from emergency to special wards or from special to general wards, and during discharge. Discrepancies can be detected through the process of medication reconciliation. OBJECTIVE: The objective of the study was to compare discrepancies among patients exposed to pharmacist intervention groups and those who were not and assess the perception of healthcare professionals and patients towards integrating pharmacists in the transition care process. METHODS: A pharmacist-led interventional study was conducted for six months on patients above 18 years of age and either sex who were admitted to the emergency department, had chronic diseases, and subsequently transferred to another department (any). The patients were randomized into intervention and control groups. The pharmacist performed a medication reconciliation and medication review to identify discrepancies in every transition in both the groups, and then reported to the treating physician to resolve in the intervention group. RESULTS: Among the 73 patients recruited in the study, 152 discrepancies were identified. The total discrepancies observed in the control and intervention groups were 78 (51.3%) and 74 (48.6%), respectively. The majority, 35.53%, were found during the transition from emergency to special wards. The physician, upon pharmacist recommendations, accepted and resolved 48 discrepancies in the intervention group. The healthcare professional acceptance rate of pharmacist interventions was 64.86%. CONCLUSION: The transitions of care are at risk for errors due to medication discrepancies, and pharmacists could potentially identify and resolve discrepancies. Healthcare professionals and patients reported to be satisfied by the involvement of clinical pharmacists in the healthcare team.

Post-operative Pancreatitis as a Predictor of Postoperative Pancreatic Fistula in Patients Following Pancreaticoduodenectomy.

BACKGROUND: Postoperative pancreatic fistula remains the single most important determinant of morbidity and mortality following pancreaticoduodenectomy. A new entity was proposed by Saxon Connor "Post-Operative pancreatitis", which is defined by raised serum amylase more than the upper limit of institutional serum amylase value on Post-Operative day 0 or 1. There has been shown to be an association between postoperative pancreatitis and postoperative pancreatic fistula. We have conducted this study to see the incidence of postoperative pancreatitis and its association with postoperative pancreatic fistula. METHODS: This was a prospective observational study. All patients undergoing pancreaticoduodenectomy at a tertiary care center for one and a half years were included. A cut-off value of serum amylase 80U/L was used to make a diagnosis of postoperative pancreatitis. The patients were followed up for one month. Pancreas specific complications were defined according to the definition given by the International Study Group of Pancreatic Surgery. RESULTS: A total of 49 pancreaticoduodenectomies were done in the given period. The incidence of postoperative pancreatitis was 31(63.3%) and postoperative pancreatic fistula was 19(38.8%). Postoperative pancreatic fistula was seen in 19(61.2%) of patients having postoperative pancreatitis (P<0.001). Post-operative pancreatitis was also significantly associated with post pancreatectomy hemorrhage, increased hospital stay, and mortality. In multivariate analysis, preoperative endoscopic biliary drainage and increased serum amylase on the first postoperative day came out to be an independent predictor of postoperative pancreatic fistula. CONCLUSIONS: Post-operative Pancreatitis was associated with an increased incidence of Post-operative pancreatic fistula and other postoperative complications like Post pancreatectomy hemorrhage and mortality.

Castleman disease of the pancreas mimicking pancreatic neuroendocrine tumor: A rare case report.

INTRODUCTION: Castleman's disease (CD) of the pancreas is a rare benign disease which can sometime resemble a pancreatic neuroendocrine tumor. PRESENTATION OF THE CASE: We report a case of a 46-years-old lady with an incidental pancreatic lesion. Preoperative diagnosis was a neuroendocrine tumor of the pancreas, for which anterior Radical Antegrade Modular Pancreatosplenectomy surgery (RAMPs) was performed. The postoperative histopathology showed features consistent with hyaline vascular type Castleman's disease. She had an uneventful surgical procedure and no serious postoperative complications. DISCUSSION: Pancreatic Castleman's disease is usually difficult to diagnose and there is no specific clinical manifestation to distinguish it from a neuroendocrine tumor. Even with radiological imaging it is very difficult to distinguish Castleman's disease from neuroendocrine tumors, and the preoperative imaging diagnosis may not match with the postoperative histopathological diagnosis. Treatment of CD is surgical resection and has a good prognosis. Partial resection and radiation therapy or observation alone is an alternative to complete surgical resection. CONCLUSION: Castleman disease of the pancreas sometimes mimics neuroendocrine tumors of the pancreas. Clinicians should consider Castleman's disease of the pancreas as a differential diagnosis for neuroendocrine like lesions of the pancreas.

Early Outcomes of Extended Hepatectomy: An Experience from the University Hospital of Nepal.

Background Extended hepatectomy (≥ 5 liver segments resection) may be required to have a complete surgical resection and provide the best chance of cure of hepatobiliary tumors. It is associated with high morbidity and mortality but with good perioperative care, its outcomes can be improved. This study was conducted to evaluate the early outcomes of extended hepatectomy at a university hospital in Nepal. Methods For this study, prospectively collected data from all patients who underwent extended hepatectomy from October 2012 to April 2022 were reviewed and analyzed retrospectively. Demographic data, liver volume augmentation methods used, intraoperative variables, and postoperative complications were analyzed. Results Seventeen patients underwent extended hepatectomy from October 2012 to April 2022. Among them 11 (64.7%) were female and the mean age was 53.9 ±16.3 years (18-72 years). Right extended hepatectomy was the most commonly performed procedure (n = 15, 88.2%), and left extended hepatectomy was performed in the remaining (n = 2, 11.8%). Six patients underwent liver volume augmentation procedures (35.3%) with portal vein embolization (PVE) in three, portal vein ligation (PVL) in one, and partial associating liver partition and portal vein ligation for staged hepatectomy (ALPPS) in two patients. Overall complications were 70% with major complications (Clavien Dindo ≥ IIIa) constituting 35.3%. The most common hepatectomy-specific complication was post-hepatectomy liver failure (PHLF) in six cases. The 30-day mortality was 17.6% (three patients). Conclusion Extended hepatectomy can be performed with acceptable major complications and mortality rates in selected patients.

LINC01023 Promotes the Hepatoblastoma Tumorigenesis via miR-378a-5p/WNT3 Axis.

Hepatoblastoma is the most common type of hepatic tumors occurring in children between 0 and 5 years. And the exact pathophysiology of the disease is still mysterious. Accumulating studies on LncRNA have shown its pivotal role in the development and progression of distinct human cancers. However, the role of LINC01023 in hepatoblastoma is unknown. The relative expression of LINC01023, miR-378a-5p, and Wnt3 on hepatoblastoma tissue and cell lines was determined by quantitative polymerase chain reaction (qRT-PCR). The effect of LINC01023 downregulation and upregulation on cell proliferation, colony formation and apoptosis activities in HUH6 and HepG2 Cells was assessed by CKK8, clonogenic and flow cytometry analysis, respectively. Dual luciferase, RNA immunoprecipitation (RIP), and RNA pull-down were performed to confirm the interaction between LINC01023 and miR-378a-5p. Similarly, Dual luciferase assay was performed to confirmed the interaction between Wnt3 and miR-378a-5p. The xenograft tumorgenicity test was performed to elucidate the tumorgenicity potential of LINC01023. LINC01023 was significantly upregulated in hepatoblastoma tissue and cell lines rather than in adjacent normal hepatic tissue and QSG7701 cell lines. LINC01023 silencing attenuated cell proliferation, colony formation and increased cell apoptosis. Conversely, LINC01023 upregulation results in significant increase in cell proliferation, and colony formation activities however, a significant reduction in apoptosis activity was reported. Interaction between the LINC01023 and WNT3 was confirmed by dual luciferase assay. Xenograft animal tumorgenicity test confirmed the in-vivo tumorigenesis potential of LINC01203. To the best of our knowledge, this study is the first study demonstrating the role of LINC01023 in hepatoblastoma tumorigenesis through the LINC01023/miR-378a-5p/Wnt3 axis. It could be a potential therapeutic target and a prognostic biomarker in hepatoblastoma.

Predictive Factors Associated With Survival in Periampullary Cancers Following Pancreaticoduodenectomy: A Retrospective Analysis.

Background Periampullary cancers arise from four different anatomical sites and are in close proximity. But they have different survival outcomes. There are various clinicopathological factors associated with survival after pancreaticoduodenectomy done for periampullary cancers. So, we aimed to identify the predictive factors associated with poor survival in periampullary cancers at Tribhuvan University Teaching Hospital, Kathmandu, Nepal. Methods We analyzed the medical records of patients who underwent pancreaticoduodenectomy (PD) at Tribhuvan University Teaching Hospital, Kathmandu, from April 2004 to May 2014. Demography, clinicopathological features, and survival outcomes were analyzed retrospectively. Results This study included 61 patients. The mean age of patients was 56.2 ± 14.2 years, and there was a male preponderance (M:F = 1.4). The median survival of all patients was 24 months. Non-pancreatic periampullary cancer patients had better median survival as compared to pancreatic cancer patients (24 vs. 8 months, p = 0.03). The presence of lymphovascular invasion (LVI), peripheral invasion (PNI), nodal involvement, and a higher lymph node ratio (LNR) were associated with poor median survival. However, perineural invasion was the only factor associated with poor survival in multivariate analysis. Conclusion The presence of perineural invasion is associated with poor survival outcomes in patients with periampullary cancer following pancreaticoduodenectomy. Also, carcinoma of the head of the pancreas has poor survival as compared to other periampullary cancers.

Hepatic mass caused by Fasciola hepatica: A case report.

INTRODUCTION: Fascioliasis is a zoonotic infestation which presents with a wide spectrum of clinical pictures. However, it may often be overlooked, especially in the acute phase, because of uncertain symptoms. Fasciola hepatica can have an initial presentation similar to malignant liver mass or complex hepatic cyst. Here, we report a case of a hepatic mass caused by fasciola hepatica. CASE PRESENTATION: A 48-year-old woman came with chief complaints of epigastric and right hypochondrial discomfort associated with nausea and vomiting. Ultrasonography (USG) showed a heterochronic lesion in the segment VIII of the liver with few cystic lesions. CECT abdomen and pelvic gave impression of ill-defined irregular hypodense lesions in the right lobe of the liver with progressive enhancing peripheral and central cystic areas suggestive parasitic liver infestation likely echinococcus alveolaris. Right hepatectomy was done and the patient was discharged without any complications. DISCUSSION: Fascioliasis is uncommon in developed countries but more commonly seen in developing countries. The identification of fasciola hepatica eggs in the stool is a standard method for the diagnosis of fascioliasis. Fascioliasis may cause a wide variety of clinical signs ranging from asymptomatic infection to severe liver cirrhosis. Surgery for complex hydatid cysts of the liver is potentially burdened by serious complications. Technique of choice for surgical management remains inconclusive. CONCLUSION: Fasciola hepatica infection can mimic a malignant liver mass or a complex hepatic cyst because of its uncertain presentation. The disease can be prevented with public education and environmental precautions.

Huge retroperitoneal liposarcoma encasing right kidney: A case report from Nepal.

INTRODUCTION AND IMPORTANCE: Retroperitoneal liposarcoma is a rare entity originating from adipocytes. Before showing any symptoms, it can grow hugely and envelop nearby structures. Surgery is the optimum course of treatment, however, well-differentiated liposarcomas make it challenging to discern between malignant and normal adipocytes during surgery. CASE PRESENTATION: We report a case of a 62-year-old male referred to evaluate his abdominal distention presented for four years. Recently he had developed loin pain for six months. A computerized tomography scan showed extensive tumor encompassing the right kidney and ureter, colon, and duodenum, however, exploratory laparotomy revealed free colon and duodenum. Complete resection of the mass with a right nephrectomy was performed. Subsequently, a histopathological assessment of the resected specimen confirmed the diagnosis of well-differentiated liposarcoma. Adjuvant chemotherapy was initiated as the tumor was a high-risk sarcoma but local recurrence was observed after 2 years despite surgery and chemotherapy. CLINICAL DISCUSSION: Imaging modalities are the mainstay of preoperative diagnosis. Preferably, surgical resection with a tumor-free margin is recommended to avoid tumor recurrence which remains the primary challenge. This, along with the grade of the tumor, multifocal disease, and invasion of adjacent structure dictate the prognosis of the disease. Adjuvant chemotherapy and radiotherapy are not regarded as standard therapies for resectable retroperitoneal liposarcoma, although further research is still needed to determine their value in the case of high-risk sarcoma. CONCLUSION: Retroperitoneal liposarcoma has the potential to present as huge asymptomatic masses which with an added predilection for recurrence poses a huge challenge to any surgeon.

Pectolinarigenin Suppresses LPS-Induced Inflammatory Response in Macrophages and Attenuates DSS-Induced Colitis by Modulating the NF-κB/Nrf2 Signaling Pathway.

Pectolinarigenin (PEC), a natural flavonoid present in cirsium chanroenicum and citrus fruits, has possess the distinct pharmacological activities. However, its molecular mechanisms and pharmacological effects on intestinal illness have not been elucidated. In the present study, we investigated the potential beneficial effects of pectolinarigenin (PEC) on lipopolysaccharide (LPS)-induced macrophage cells and the dextran sulfate sodium (DSS)-induced colitis model. Our findings showed that PEC pretreatment inhibits the LPS-induced nuclear factor-kappa B (NF-κB) activation by interfering with the degradation of IκB-α. Further, increased Nrf2 protein expression was reported on PEC treated RAW 264.7 and THP1 cell lines. In addition, we revealed that PEC mediated the NF-κB/Nrf2 pathway regulation, which in turn inhibits the synthesis of inducible nitric oxide synthase (iNOS), cyclooxygenase-2 (COX-2), interleukin-6 (IL-6), interleukin-1beta (IL-1ß), and tumor necrosis factor-alpha (TNF-α) on RAW 264.7 and THP1 cells. Furthermore, PEC dose-dependently reduced the DSS-induced inflammation in the colon by regulating NF-κB/Nrf2 signaling pathway and enhancing the myeloperoxidase (MPO) activity and redox regulators such as superoxide dismutase (SOD), catalase (CAT), glutathione (GSH), and lipid peroxidation byproduct malondialdehyde (MDA) in DSS-induced inflamed colon. Similarly, we reported the minimal pathological damages in the PEC-treated mice colon, as well as increase goblet cell population and mucin-2 production. In conclusion, our findings demonstrate that PEC reduces the DSS-induced colitis in mice by regulating the NF-κB/Nrf2 pathway. Thus, PEC might be a promising therapeutic agent for the treatment of inflammatory bowel disease.

Duodenal perforation due to migrated biliary stent: Case report.

INTRODUCTION: Biliary stents are frequently associated with various complications; however biliary stent migration causing duodenal perforation is rare and has only been reported in few cases. PRESENTATION OF CASE: We present a case of 33 years old male with pain abdomen and fever for 2 days came to Emergency department. He had undergone open common bile duct exploration (CBD), clearance of stone and placement of CBD stent. In X-ray abdomen, biliary stent migration was suspected. CECT abdomen was done for the confirmation of diagnosis which showed migrated stent with duodenal perforation. Patient underwent exploratory laparotomy and Thal patch repair, pyloric exclusion, retrograde duodenostomy and feeding jejunostomy. Post-operative period was uneventful. DISCUSSION: Biliary stents are used to relieve biliary obstruction. There is increasing use of endoscopic retrograde drainage via plastic endoprosthesis and so the related morbidities. One of the rare but serious complications is intestinal perforation and duodenal perforation is seen in most of the cases, explanation being the relative fixed position of the duodenum. CONCLUSION: Although intestinal perforation is an uncommon complication following CBD stenting, we should suspect it in patients presenting with pain and fever.

Anti-diabetic potential of Corn silk (Stigma maydis): An in-silico approach.

Corn silk is known to possess anti-diabetic activity, the current study is aimed to predict the binding affinity of bio-actives from corn silk against targets involved in diabetes mellitus i.e. Protein Tyrosine Phosphatase 1-B (PTP1B), Glucose Transporter-1 (GLUT1), Dipeptidyl Peptidase-4 (DPP4), α-glucosidase, and α-amylase. The 3D molecular structure of bio-actives was retrieved from the PubChem database and the structure of targets was retrieved from protein data bank. Later, hetero atoms were removed using Discovery studio visualizer 2019. Molecular docking was performed using Autodock4.0. Ten different poses were obtained from which the pose possessing the highest binding affinity was visualized for protein-ligand interaction in Discovery studio visualizer 2019. Twenty-six bio-actives were docked against five different targets i.e. PTPN1B, GLUT1, DPP4, α-glucosidase, and α-amylase from which flavones were found to possess the highest binding affinity towards PTPN1B with a binding energy of -8.5 kcal/mol. Similarly, ß-carotene, gallotannins, 3-O-caffeoylquinic acid, and stigmasterol were predicted to possess the highest binding affinity towards GLUT1, DPP4, α-glucosidase, and α-amylase with binding energy -11.1 kcal/mol, -10.7 kcal/mol, -8.9 kcal/mol, and -9.8 kcal/mol respectively. Our study screened the anti-diabetic potential of 26 bio-actives towards five different diabetic proteins indicating a possibility of bio-actives from corn silk to possess anti-diabetic potential which needs to be further validated via experimental protocols; this serves as a future scope as well as lacuna for the present study. Thus, bio-actives from corn silk have anti-diabetic potential and can be used in the future to investigate and develop novel anti-diabetic molecule.

Gefitinib induced Pemphigus Vulgaris with PRIDE complex.

Introduction: Pemphigus Vulgaris is a rare, noncommunicable, non-hereditary fatal autoimmune dermatological manifestation in which a painful blister initiates from the oral cavity. PRIDE complex stands for Papulopustules or paronychia, regulatory abnormality of hair and nails, itching, and dryness due to inhibition of EGFR. Both of these mucocutaneous manifestations are rare and are often caused by drugs. Case report: Our case reports 53-year-old patient presented with multiple crusted plaques, multiple hyperpigmented macules to patches, Solitary fluid-filled lesions on several parts of the body, and numerous erosions positive over buccal mucosa on initial follow up which was diagnosed as Pemphigus Vulgaris with PRIDE complex induced by Gefitinib. Management and outcome: The patient was treated with almost all possible treatment options, i.e., both steroids plus adjuvant therapy for pemphigus and antihistaminic, antibiotics, moisturizer, and lotions for PRIDE complex. The patient was initially admitted for infusion of the first dose of rituximab and later for management of flare-up condition and infusion of the second dose of rituximab infusion. Discussion: The complexity of the management of Pemphigus Vulgaris and PRIDE complex demands adequate monitoring of the patient's anti-cancerous therapy by clinical pharmacists, which can impact the clinical outcomes by providing pharmaceutical care and minimize the economic burden.

A Randomized, Single Centered, Parallel and Open Labelled Interventional Study on Effectiveness of Clinical Pharmacists on Adverse Event Following Immunization (AEFI) in Pediatric Population.

BACKGROUND: Adverse events are a major threat to any immunization programs, which have proven to be a boon for developing nations like India. Hindering factors, such as inadequate knowledge, inappropriate attitude, incorrect practices, etc., of the guardian affect the vaccination rate. AIM: This study aims to assess the effectiveness of clinical pharmacist intervention on an adverse event following immunization in the pediatric population receiving immunization. METHODS: Pediatric subjects <5 yrs of both genders receiving immunization in a tertiary care hospital during the period of 8 months were considered. Subjects were randomized into control and interventional groups. Pharmaceutical intervention was done in interventional group in the form of patient counselling, and a patient information leaflet. Adverse event following immunization was recorded and analysed for both groups along with Knowledge, Attitude, and Practice scores of guardians' pre and post intervention through customized data collection forms. Microsoft excel and statistical software SPSS IBM version 22 was used to analyse the data. RESULTS: The study was conducted on a total of 88 subjects (n) in which 79 were <2 years, 1 and 8 were between 2-4 years and 4-5 years, respectively. Forty-nine subjects (55.69%) were female, while 39 were male (44.31%) with a response and completion rate of 91.66%. 97.7% of subjects received Bacillus Calmette-Guerin vaccination (majority), while 8.88% received pneumococcal special vaccine (minority). Adverse event following immunization was recorded in 31(35.22%) cases. Knowledge, Attitude and Practice scores increased by 42.17%, 52% and 12.67%, respectively in guardians after clinical pharmacist intervention. CONCLUSION: This study demonstrates that educational inputs, awareness programs, and proper medical professional intervention can act as a helping factor to fight against AEFI and towards the success of an immunization program.

Chylous leak following pylorus-preserving gastrectomy with D1 lymphadenectomy for carcinoma stomach: A case report.

INTRODUCTION AND IMPORTANCE: Chyle leak is the leakage of milk-like triglyceride-rich lymphatic fluid from the lymphatic system to the peritoneal cavity. The incidence of chyle leak after radical gastrectomy is very low. CASE PRESENTATION: A 77-year-old female presented with complaints of decreased appetite and weight loss for six months. Upper gastrointestinal endoscopy showed a polypoidal growth along the greater curvature and the histopathological report of the biopsy taken showed high-grade tubular adenoma with high-grade dysplasia. The patient underwent pylorus-preserving gastrectomy with D1 lymphadenectomy. Postoperatively, after initiation of the oral diet, the abdominal drain started draining milky white fluid, which was rich in triglyceride. The patient was managed conservatively with nil per oral, total parenteral nutrition, and somatostatin analogue. CLINICAL DISCUSSION: The appearance of milky, nonpurulent fluid in abdominal drain concurrent with the initiation of oral feeding is characteristic of postoperative chyle leak. In our case, we managed the case successfully over a few days with total parenteral nutrition, nil per oral status, and somatostatin analogue. CONCLUSION: The incidence of chyle leak after gastrectomy is low, if it occurs it prolongs the hospital stay. Higher age, female gender, and early enteral feeding have been seen as the risk factors for chyle leak. Conservative treatment is effective and is the treatment of choice.

Right-sided paraduodenal hernia with malrotation - A case report.

INTRODUCTION: Paraduodenal hernia is a rare cause of internal hernia. It is the herniation of small bowel through a peritoneal sac in the duodenum. It occurs due to incomplete rotation and fixation abnormalities of the primitive midgut during fetal development. We report a case of right sided paraduodenal hernia in an adult male. CASE PRESENTATION: This is a case of 36-year-old gentleman who presented with complaints of abdominal fullness and upper abdominal pain for 1.5 months and 7 to 8 episodes of vomiting. CT scan of abdomen gave an impression of right-sided paraduodenal hernia. Exploratory laparotomy with hernia repair was performed and patient was discharged without complications. DISCUSSION: Right sided paraduodenal hernia is the protrusion of viscera through the fossa of Waldeyer. It is frequently associated with malrotation and strangulation. Its diagnosis is frequently delayed. Symptoms are non-specific and may need laparotomy for diagnosis. Technique of choice for surgical management remains inconclusive. CONCLUSION: Paraduodenal hernias are frequently diagnosed late or incidentally because of vague symptoms. They are rarer and carry higher lifetime risk of strangulation and bowel obstruction. Surgical management is necessary after diagnosis.