Addressing the Crimean-Congo Hemorrhagic Fever Crisis in Pakistan's Healthcare System: An Urgent Call for Holistic Action.

The recent resurgence of the Crimean-Congo hemorrhagic fever (CCHF) in Pakistan's Balochistan province has significantly impacted both the medical community and the general population. Initially perceived as a concerning development, the situation has deteriorated, culminating in the infection and mortality of healthcare workers directly engaged in managing this virulent outbreak. This critical situation necessitates an urgent and collective response, transcending national boundaries to involve the international healthcare community.

Gender Bias in Leadership Roles in General Surgery: A South Asian Perspective.

This article addresses the significant issue of gender bias in leadership roles within the realm of general surgery, with a particular focus on the South Asian context. The persistence of cultural norms, entrenched gender stereotypes, and discriminatory practices in this region significantly limits the opportunities available to female surgeons. It calls on all stakeholders, including medical institutions, governing bodies, and surgeons, to take an active role in eliminating gender bias and fervently supporting diversity and inclusivity in leadership positions. By doing so, it argues, we can create a more equitable and promising future for the field of general surgery in South Asia.

Multifocal Desmoplastic Small Round Cell Tumor: A Case Report of a Rare Neoplasm.

Desmoplastic small round cell tumor (DSRCT) is a rare, highly aggressive malignancy predominantly affecting adolescents and young adults. We report a case of multifocal DSRCT in an 11-year-old male who presented with complaints of unilateral forehead swelling, proptosis, and ophthalmoplegia for four months along with abdominal pain and dysphagia for six months. A whole-body computed tomography revealed widespread lesions in the skull, orbit, thorax, and abdomen with local infiltration. Ultrasound-guided biopsy of the forehead lump was performed. Based on histopathological and immunohistochemical investigations, it was diagnosed to be a DSRCT with multifocal presentation. The patient underwent chemo-radiation but unfortunately succumbed to neutropenic sepsis and renal failure. DSRCT is a very rare, highly aggressive malignancy with an extremely poor prognosis. Orbital presentations are even rarer, with less than 10 such cases currently described in English medical literature.

Intraductal papillary neoplasm of the bile duct: A case report of a rare tumor with a brief review of literature.

INTRODUCTION AND IMPORTANCE: Intraductal papillary neoplasm of the bile duct (IPNB) is a rare neoplasm, mostly found in patients from far Eastern areas where hepatolithiasis and clonorchiasis are endemic. Very few cases are reported from India. CASE PRESENTATION: We present a case of recurrent cholangitis in a 59-year-old male, initially suspected to have IPNB based on preoperative imaging. Confirmation occurred intraoperatively, with mucin-filled bile ducts and papillary lesions in the resected hepatic duct. Treatment included left hepatectomy, extrahepatic bile duct excision, and Roux-en-Y hepaticojejunostomy. Histopathology indicated invasive pancreatobiliary-type IPNB with clear margins. The patient experienced post-hepatectomy hepatic insufficiency and superficial incisional surgical site wound infection, managed conservatively. Discharge occurred on postoperative day 21, with satisfactory recovery at the 16-month follow-up. CLINICAL DISCUSSION: IPNB is recognized as the biliary equivalent of intraductal papillary mucinous neoplasm, as these two conditions exhibit multiple commonalities in terms of clinical and histopathological characteristics. The unique aspect of our case lies in the intricacies associated with its diagnosis. Initially, imaging modalities did not yield a definitive characterization of the lesion. Notably, the endoscopist misinterpreted mucin expression emanating from the papilla as purulent material, primarily due to the patient's concurrent cholangitis. Subsequent repetitions of both CT scan and MRI provided some valuable insights that contributed to the diagnostic clarity of the IPNB. CONCLUSION: In cases of symptoms like biliary obstruction with bile duct dilation, wall nodules, papillary/solid-cystic masses, and upstream-downstream dilation, IPNB should be considered. Striving for R0 resection is crucial for enhanced long-term patient survival.

Psychological Stress Experienced by First-Year Medical Undergraduates: A Cross-Sectional Study From Eastern India.

Background While medical education is vital for producing competent physicians, its rigorous curriculum can harm students' mental well-being. This study focuses on assessing psychological stress in first-year medical students in Eastern India and aims to identify its primary causes. Methods This cross-sectional study involved 125 first-year MBBS students in a tertiary care medical teaching institution in eastern India. They completed the Medical Student Stressor Questionnaire (MSSQ-40) questionnaire to measure stress and provided academic records to be reviewed.  Results Among the 125 students included in the study, male students demonstrated greater academic and interpersonal stress. The findings revealed that a substantial proportion (79%) of the student population experienced high to severe levels of academic stress, followed by 88% who reported moderate to high levels of social-related stress. Furthermore, it was observed that those students who experienced high to severe stress across all six domains tended to perform poorly during the initial half of their academic year. Conclusion The high levels of stress experienced by medical students can have significant implications for their academic performance. However, the nature of our study limits us to only highlight the existence of a correlation between the two. Future studies on the same should be conducted to assess the causal relation between these factors.

Artificial intelligence assisted endoscopic ultrasound for detection of pancreatic space-occupying lesion: a systematic review and meta-analysis.

BACKGROUND: Diagnosing pancreatic lesions, including chronic pancreatitis, autoimmune pancreatitis, and pancreatic cancer, poses a challenge and, as a result, is time-consuming. To tackle this issue, artificial intelligence (AI) has been increasingly utilized over the years. AI can analyze large data sets with heightened accuracy, reduce interobserver variability, and can standardize the interpretation of radiologic and histopathologic lesions. Therefore, this study aims to review the use of AI in the detection and differentiation of pancreatic space-occupying lesions and to compare AI-assisted endoscopic ultrasound (EUS) with conventional EUS in terms of their detection capabilities. METHODS: Literature searches were conducted through PubMed/Medline, SCOPUS, and Embase to identify studies eligible for inclusion. Original articles, including observational studies, randomized control trials, systematic reviews, meta-analyses, and case series specifically focused on AI-assisted EUS in adults, were included. Data were extracted and pooled, and a meta-analysis was conducted using Meta-xl. For results exhibiting significant heterogeneity, a random-effects model was employed; otherwise, a fixed-effects model was utilized. RESULTS: A total of 21 studies were included in the review with four studies pooled for a meta-analysis. A pooled accuracy of 93.6% (CI 90.4-96.8%) was found using the random-effects model on four studies that showed significant heterogeneity ( P <0.05) in the Cochrane's Q test. Further, a pooled sensitivity of 93.9% (CI 92.4-95.3%) was found using a fixed-effects model on seven studies that showed no significant heterogeneity in the Cochrane's Q test. When it came to pooled specificity, a fixed-effects model was utilized in six studies that showed no significant heterogeneity in the Cochrane's Q test and determined as 93.1% (CI 90.7-95.4%). The pooled positive predictive value which was done using the random-effects model on six studies that showed significant heterogeneity was 91.6% (CI 87.3-95.8%). The pooled negative predictive value which was done using the random-effects model on six studies that showed significant heterogeneity was 93.6% (CI 90.4-96.8%). CONCLUSION: AI-assisted EUS shows a high degree of accuracy in the detection and differentiation of pancreatic space-occupying lesions over conventional EUS. Its application may promote prompt and accurate diagnosis of pancreatic pathologies.

Mesenchymal hamartoma versus hepatoblastoma: A diagnostic dilemma.

INTRODUCTION AND IMPORTANCE: Pediatric hepatic tumors present diagnostic challenges due to diverse clinical presentations and limited patient communication. Elevated serum alpha-fetoprotein (AFP) levels, often associated with hepatoblastoma, can occur in various hepatic conditions, adding complexity to diagnosis. This report emphasizes the importance of comprehensive assessment and integrated interpretation in such cases. CASE PRESENTATION: We present a rare case of a 1-year-old female child with abdominal swelling and hepatomegaly. Imaging revealed a hypodense hepatic lesion with punctate calcifications. Initial biopsy suggested mesenchymal hamartoma, but subsequent biopsy confirmed hepatoblastoma, highlighting the diagnostic complexity. CLINICAL DISCUSSION: Hepatoblastoma is the most common pediatric liver tumor, typically presenting with nonspecific symptoms. Serum AFP levels are elevated, aiding diagnosis. Imaging reveals heterogeneous, hypervascular masses. Treatment includes surgery and chemotherapy. Mesenchymal hamartoma is a rare benign tumor with variable symptoms and imaging features, emphasizing the need for histopathological confirmation. This case underscores the importance of a comprehensive diagnostic approach. CONCLUSION: Diagnosing pediatric hepatic tumors requires an integrated assessment of clinical, laboratory, and imaging findings. Confirmatory biopsies are essential, as demonstrated by this case, where an initial diagnosis of mesenchymal hamartoma was revised to hepatoblastoma. Collaborative, multidisciplinary approaches are crucial for accurate diagnosis and effective therapeutic planning, offering hope for improved outcomes in these complex cases.

Stealth invaders: unraveling the mystery of neurotropic viruses and their elusive presence in cerebrospinal fluid - a comprehensive review.

Neurotropic viruses are a threat to human populations due to ongoing zoonosis. A wide array of neurological manifestations can occur most often including parkinsonism, encephalitis/encephalopathy, flaccid myelitis, and Guillain-Barré syndrome. Neuroinvasion occurs through: transneural transmission, blood brain barrier (BBB) dysfunction, and 'trojan horse' mechanism or infected immune cell trafficking into the central nervous system (CNS). Transneural transmission occurs through virus mediated hijacking of intracellular transport proteins allowing retrograde viral transport. BBB dysfunction occurs through cytokine storm increasing membrane permissibility. Increased chemokine expression allows leukocyte trafficking to the BBB. Virally infected leukocytes may successfully pass through the BBB allowing the pathogen to infect microglia and other CNS cell types. We define cerebrospinal fluid (CSF) nondetection as a virus' ability to evade direct CSF detection but still causing significant neurological symptoms and disease. Mechanisms of CSF nondetection include: transneuronal propagation through trans-synaptic transmission, and synaptic microfusion, as well as intrathecal antibody synthesis and virus neutralization. Direct virus detection in CSF is associated with an increased neurological disease burden. However, the lack of CSF detection does not exclude CNS involvement due to possible neuroevasive mechanisms.

Challenges in managing anorectal melanoma, a rare malignancy.

INTRODUCTION AND IMPORTANCE: Anorectal melanoma is a rare and aggressive malignancy that can be difficult to diagnose due to its nonspecific presentation. CASE PRESENTATION: We present a case of a 69-year-old woman who presented with painful defecation, bleeding per rectum, and a mass coming out of her anal opening. The initial differential diagnosis included hemorrhoids, rectal polyp, or a malignant lesion of the rectum. However, histopathological evaluation following transanal excision of the rectal mass revealed mucosal melanoma in the anorectal region. Further investigation showed no evidence of locoregional or distant metastasis. CLINICAL DISCUSSION: Surgery remains the primary treatment option for anorectal melanoma, but complete resection is often not feasible, leading to high rates of local recurrence and distant metastasis. The incidence of metastatic disease at the time of presentation is high, and a multidisciplinary approach is necessary to manage these patients. Currently, standard systemic therapies used for cutaneous melanoma are the mainstay of treatment for metastatic anorectal melanoma, but there is a need for further research to develop tailored treatment strategies. CONCLUSION: Our case report highlights the importance of considering anorectal melanoma in the differential diagnosis of patients presenting with anorectal symptoms. It emphasizes the need for a multidisciplinary approach to managing this rare malignancy. Early diagnosis, a multidisciplinary approach, and ongoing research into more effective treatments are crucial for improving outcomes for patients with anorectal melanoma.

Advanced gastric neuroendocrine tumor with hepatic metastasis - A case report.

INTRODUCTION AND IMPORTANCE: Gastric neuroendocrine tumors (NETs) are rare neoplasms that originate from enterochromaffin cells in the gastric mucosa and pose a diagnostic dilemma due to their non-specific presentation. CASE PRESENTATION: We present a 79-year-old woman, who came with complaints of abdominal pain associated with loss of pain and appetite. Although on the first look multiple differentials could be listed, upon complete evaluation she was diagnosed to have type III Gastric NET. Histopathology and immunohistochemistry allowed diagnostic confirmation of the disease along with strong clinical suspicion. The patient however succumbed to the illness due to advanced disease and lack of established protocol for its management. CLINICAL DISCUSSION: The treatment of Gastric NETs primarily involves surgical resection of the tumor and is especially helpful in type I and II cases. For advanced metastatic type III NETs, lines of therapy have not been established although surgical resection can be done if the majority (∼90 %) of the tumor is resectable. Patients should be given a choice in decision making and newer drug therapies should always be considered. CONCLUSION: Since gastric NETs are a rarer cause of abdominal pain, it can often be overlooked in favor of other, more common differentials. One should be aware of this disease and the newer diagnostic methods to have any sort of clinical suspicion when presented with such a scenario. The management of the condition although not been established, novel therapies should be considered if the tumor is not resectable.

Budd-Chiari syndrome in myeloproliferative neoplasms: A review of literature.

Myeloproliferative neoplasms (MPNs) are defined as clonal disorders of the hematopoietic stem cell in which an exaggerated production of terminally differentiated myeloid cells occurs. Classical, Philadelphia-negative MPNs, i.e., polycythemia vera, essential thrombocythemia and primary myelofibrosis, exhibit a propensity towards the development of thrombotic complications that can occur in unusual sites, e.g., portal, splanchnic or hepatic veins, the placenta or cerebral sinuses. The pathogenesis of thrombotic events in MPNs is complex and requires an intricate mechanism involving endothelial injury, stasis, elevated leukocyte adhesion, integrins, neutrophil extracellular traps, somatic mutations (e.g., the V617F point mutation in the JAK2 gene), microparticles, circulating endothelial cells, and other factors, to name a few. Herein, we review the available data on Budd-Chiari syndrome in Philadelphia-negative MPNs, with a particular focus on its epidemiology, pathogenesis, histopathology, risk factors, classification, clinical presentation, diagnosis, and management.

Surgical outcomes after re-operation for excision of choledochal cyst with delayed biliary complications: A retrospective study on 40 patients.

PURPOSE: The purpose of this study is to review our experience in patients who underwent re-operation for delayed biliary complications after choledochal cyst (CDC) excision. METHODS: All the patients who underwent re-operation. for delayed biliary complications after CDC excision between August 2007 and July 2020 were included in this retrospective study. The outcomes of these patients were compared with those who underwent primary surgery (CDC excision) at our institution. RESULTS: Of the total 40 patients with delayed biliary complications, 25 (62.5%) were female. Thirty-seven (92.5%) patients had a history of cholangitis. The median interval between CDC excision and the reoperation was 70 (4-216) months. The median duration of symptoms before reoperation was 12 (2.5-84) months. Re-do hepaticojejunostomy and direct hepaticojejunostomy were performed in 34 and in 6 patients respectively. Median operative time and blood losses were 219 min and 150 ml respectively. The median postoperative stay was 9 days. Postoperative complications developed in 10 (25%) patients. There was no operative mortality. Over a median follow-up of 71 months, a satisfactory outcome was achieved in 86% of patients. Restricture and intrahepatic stones developed in three and two patients respectively. Incidence of type IV cyst, cholangitis before operation, and operative blood loss were significantly more in the re-operative group. Clinical outcomes like the incidence of recurrent cholangitis, re-stricture, and postoperative hospital stay were comparable between the two groups. CONCLUSION: Surgery affords excellent results for majority of the patients with delayed biliary complications after CDC excision. Type IV cysts are more commonly associated with the development of delayed biliary complications.

Primary Arterial Hypertension and Drug-Induced Hypertension in Philadelphia-Negative Classical Myeloproliferative Neoplasms: A Systematic Review.

The impact of primary arterial hypertension (HTN) in myeloproliferative neoplasms (MPNs) remains unclear, with scant literature available, mostly focusing on cardiovascular risk factors as a singular entity or on organ-specific HTN. Furthermore, available studies reporting findings on drug-induced HTN in MPNs report varying and contradictory findings. In consideration of the above, this study set out to systematically review the available literature and shed light on the occurrence of HTN in MPNs, its association with thrombosis, as well as the drugs used in MPN management that could increase blood pressure. The literature search yielded 598 potentially relevant records of which 315 remained after the duplicates (n = 283) were removed. After we screened the titles and the abstracts of these publications, we removed irrelevant papers (n = 228) and evaluated the full texts of 87 papers. Furthermore, 13 records did not meet the inclusion criteria and were excluded from the systematic review. Finally, a total of 74 manuscripts were entered into the qualitative synthesis and included in the present systematic review. Our systematic review highlights that HTN is the most common comorbidity encountered in MPNs, with an impact on both the occurrence of thrombosis and survival. Moreover, drug-induced HTN remains a challenge in the management of MPNs. Further research should investigate the characteristics of patients with MPNs and HTN, as well as clarify the contribution of HTN to the development of thrombotic complications, survival and management in MPNs. In addition, the relationship between clonal hematopoiesis of indeterminate potential, HTN, cardiovascular disease and MPNs requires examination in upcoming assessments.

Giant choledochal cyst: The largest reported!

Choledochal cyst (CC) is an atypical congenital abnormality of the biliary system. CC more than 10 cm is rare and only a few cases are reported. Herein, we reported a 25 × 18 cm CC and highlighted how definitive treatment after a timely diagnosis provides good prognosis irrespective of the size.

Predictors of 90-day morbidity and mortality after Frey procedure for chronic pancreatitis.

BACKGROUND: The literature on predictors for postoperative complications after Frey procedure (FP) is sparse. The aim of this study is to report our experience with 90-day complications of FP and predictors for complications. METHODS: All patients with chronic pancreatitis (CP), who underwent a FP between August 2007 and July 2021, were retrospectively reviewed. Univariate and multivariate analysis were used to identify predictors of 90-day morbidity and mortality. RESULTS: Of the total 270 patients, 84 (31%) patients developed at least one postoperative complication. Major complications occurred in 32 (12%) patients. Most common complication was wound infection and it was significantly more common in stented patients (p = 0.017). Pancreatic fistula and post pancreatectomy hemorrhage (PPH) developed in 7.4% of patients. Thirteen patients (4.8%) required early re-operation and the most common cause of re-exploration was PPH. 90-day mortality was 1% (n = 3) and all 3 patients required re-exploration for PPH. Median postoperative hospital stay was 9 (5-51) days. Perioperative blood transfusions was the only independent predictor of postoperative complications after FP. CONCLUSIONS: Frey procedure is an acceptable treatment modality with low rates of mortality and reasonable perioperative morbidities. Minimizing blood transfusions may further improve 90-day outcomes.

Factors affecting depression and anxiety in diabetic patients: A cross sectional study from a tertiary care hospital in Eastern India.

Background: Diabetes is one of the most common chronic disease in the world and its prevalence in India is rising day by day. Diabetic patients often suffer from depression and anxiety which has a negative impact on patients resulting in non-adherence to medication, rapid disease progression and overall poor prognosis. India is the land of diversity and so are the causes of depression and anxiety in the people from different parts of the country. The study done in the current population has revealed certain indicators of both depression and anxiety that were not significant in previous studies. These new findings point towards the changing scenario and the need for more precise steps for improving the quality of life of diabetics. Aims: The study aims to determine the prevalence of depressive symptoms and anxiety among diabetic patients and the factors associated with them. Methods: A prospective cohort study was conducted with 305 participants among which 152 were diabetic while 153 were non diabetic patients. Depression and anxiety of the patients was measured through PHQ-9 scale and GAD-7 scale respectively. Factors associated with prevalence of depression and anxiety in the diabetic population was analysed. Results: The prevalence of depressive symptoms (39.5% versus 12.4%) and anxiety (36.2% versus 14.4%) were significantly higher in diabetic patients as compared to non-diabetic participants. Low-income, urban residence, unmarried status, insulin therapy, presence of retinopathy, and ischemic heart disease were significantly associated with depression among diabetic group of patients. Similarly the major predictors of anxiety were marital status, literacy and diabetic complications like neuropathy, retinopathy and ischemic heart disease. Conclusion: Our study shows depression and anxiety are highly prevalent among diabetic patients. All diabetic patients while seeking clinical contact should be screened for depression and anxiety especially those patients with predisposing risk factors.

Prognosis of Spontaneous Pneumothorax/Pneumomediastinum in Coronavirus Disease 2019: The CoBiF Score.

Objectives: Pneumothorax and pneumomediastinum are associated with high mortality in invasively ventilated coronavirus disease 2019 (COVID-19) patients; however, the mortality rates among non-intubated patients remain unknown. We aimed to analyze the clinical features of COVID-19-associated pneumothorax/pneumomediastinum in non-intubated patients and identify risk factors for mortality. Methods: We searched PubMed Scopus and Embase from January 2020 to December 2021. We performed a pooled analysis of 151 patients with no invasive mechanical ventilation history from 17 case series and 87 case reports. Subsequently, we developed a novel scoring system to predict in-hospital mortality; the system was further validated in multinational cohorts from ten countries (n = 133). Results: Clinical scenarios included pneumothorax/pneumomediastinum at presentation (n = 68), pneumothorax/pneumomediastinum onset during hospitalization (n = 65), and pneumothorax/pneumomediastinum development after recent COVID-19 treatment (n = 18). Significant differences were not observed in clinical outcomes between patients with pneumomediastinum and pneumothorax (±pneumomediastinum). The overall mortality rate of pneumothorax/pneumomediastinum was 23.2%. Risk factor analysis revealed that comorbidities bilateral pneumothorax and fever at pneumothorax/pneumomediastinum presentation were predictors for mortality. In the new scoring system, i.e., the CoBiF system, the area under the curve which was used to assess the predictability of mortality was 0.887. External validation results were also promising (area under the curve: 0.709). Conclusions: The presence of comorbidity bilateral pneumothorax and fever on presentation are significantly associated with poor prognosis in COVID-19 patients with spontaneous pneumothorax/pneumomediastinum. The CoBiF score can predict mortality in clinical settings as well as simplify the identification and appropriate management of patients at high risk.

Prevalence of the Retro-Renal Colon: A Systematic Review and Meta-Analysis with Implications for Percutaneous Nephrolithotomy.

Background: This systematic review and meta-analysis aims to determine the prevalence of the retrorenal colon (RRC) and its implications in percutaneous nephrolithotomy with the overall objective of promoting the prevention of associated iatrogenic complications. Methods: A systematic search of literature was conducted on the electronic databases PubMed, ScienceDirect, and Hinari to identify studies eligible for inclusion. Search results were screened by title and abstract, and those potentially relevant were evaluated by full text. Studies were deemed eligible for inclusion if they reported clear extractable data regarding the prevalence of the retro-renal colon. A meta-analysis was completed using MetaX1 to calculate the pooled prevalence of the retro-renal colon. Sub-group analysis was performed based on geographical regions from which the studies originated, imaging modality, and patient position. Results: 174 records were screened and a total of 10 records included in the analysis with retrospective cohort studies being the most common study design. A male predominance was seen in most sample sizes that had reported data on gender demographics ranging from 41.5-62%. The most common imaging modality utilized was computerized tomography (CT) scan followed by ultrasound. The range of the unweighted prevalence of retro-renal colon across all studies that had absolute numbers reported was from 3.5-25%. One of the studies reported a colonic perforation rate of 0.3% in patients without CT images. Conclusion: The retro-renal colon is a relatively common finding with observed preponderance to females and left lateralization. The presence of RRC increases the likelihood of colon perforations while gaining percutaneous access to the kidney. Pre-procedural imaging can help detect its presence and choose an appropriate route of entry. USG and CT have both been found useful as a modality to pick up RRC.

Hilar tuberculosis versus Klatskin tumour: a diagnostic challenge.

Hepatobiliary tuberculosis is a rare condition causing obstructive jaundice either by enlarged lymph nodes around the bile ducts or involvement of biliary epithelium by the tuberculous process. Since a tissue diagnosis is not mandatory to proceed with the resection or initiation of a liver transplant protocol, benign lesions are occasionally misdiagnosed as hilar cholangiocarcinoma. Here, we present a case of hepatobiliary tuberculosis which presented as obstructive jaundice due to hilar obstruction. The mass causing the obstruction was then later found to be a pseudotumour, typical of tuberculosis. This diagnosis meant that extensive surgical resection as a protocol for cholangiocarcinoma was avoided. The patient recovered completely after a course of antitubercular therapy.