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In the myriad of clinical presentations of acute appendicitis, appendicular gastralgia remains a poorly researched entity. In this article, authors present a series of three cases of acute appendicitis that initially presented as appendicular gastralgia. A 35-year-old gentleman initially presented with complaints of epigastric pain of six hours’ duration with an Alvarado score of 3/10 and was managed medically. Re-examination after six hours of unresolved pain revealed Right Iliac Fossa (RIF) tenderness. Similarly, a 13-year-old boy presented with epigastric pain of 12 hours’ duration with a normal clinical examination and an Alvarado score of 5/10. The pain radiated to RIF after 12 hours with RIF tenderness. A 58-year-old lady presented with pain in the epigastrium of six hours’ duration and had a normal clinical examination, haematological and radiological parameters. She was initially managed medically. However, due to the non resolution of symptoms despite treatment, she underwent Contrast Enhanced Computed Tomography (CECT) Abdomen, which revealed a localised appendicular perforation with appendicoliths. All three patients underwent emergency laparoscopic appendectomy and had an uneventful postoperative recovery with no recurrence of epigastric pain. Low Alvarado scores, non specific clinical findings and equivocal imaging delay diagnosis in these cases. Through this article, attempt was made to enhance awareness of this entity amongst clinicians.

Non-clinical approaches such as meditation, yoga, and mindfulness are popular traditional therapeutical interventions adopted by many educational institutions to improve the physical and mental well-being of learners. This study aimed to evaluate the effectiveness of yoga intervention in improving cardiopulmonary parameters such as blood pressure, heart rate, pulmonary function tests and psychosomatic symptoms such as depression, anxiety and stress in medical and dental students. Using the PRISMA protocol, a search from databases such as PubMed, Scopus, and Embase resulted in 304 relevant articles. After screening the title and abstracts, 47 papers were analyzed thoroughly and included in the qualitative analysis. 18 articles with homogenous statistical data on physiology and psychological parameters were included for meta-analysis. In comparison to the control group, the study showed a significant reduction of systolic blood pressure (SBP: 6.82 mmHg, z = -3.06, p = 0.002), diastolic blood pressure (DBP: 2.92 mmHg, z = -2.22, p = 0.03), and heart rate (HR: 2.55 beats/min, z = -2.77, p = 0.006). Additionally, data from 4 studies yielded a significant overall effect of a stress reduction of 0.77 on standardized assessments due to the yoga intervention (z = 5.29, p

Ellis-van Creveld syndrome (EVC), also known as chondroectodermal dysplasia, is a rare entity. It most commonly affects the tubular bones leading to dwarfism and a long trunk with ossification defects. Other presentations are wide hands and feet, dysplastic nails, thin hair, and cardiac malformations. An eight-year-old female patient presented to our tertiary care centre with complaints of short stature, abnormal dentition, and fatigue. The child’s parents were first-degree relatives. On radiological imaging, it was revealed that the patient had postaxial polydactyly, short stature, and genu valgum deformity along with mild cardiomegaly. All these features were indicative of Ellis-van Creveld syndrome. EVC is a rare clinical syndrome with a distinctive clinical presentation. It requires comprehensive radiological investigations and the management is best done with a multidisciplinary approach. Keywords: Cardiomegaly, Polydactyly, Ellis-van Creveld Syndrome.

Carcinoid syndrome consists of the classic symptom triad of flushing, diarrhoea, and valvular heart disease. It occurs in the majority of patients with liver metastases. This report presents a 68-year-old female who suffered from chronic diarrhoea with a history of multiple admissions for the same. On evaluation, a Computed Tomography (CT) scan showed a terminal ileal lesion and bulky ovaries. Suspecting Neuroendocrine Tumour (NET) with carcinoid syndrome, a Gallium 68 DOTANOC (DOTA-1-Nal3-octreotide) scan was done which revealed somatostatin receptor expression in enhancing soft tissue lesion in terminal ileum as well as in bilateral adnexa. This confirmed the diagnosis of NET of the ileum and bilateral ovarian metastases. The patient underwent laparoscopic curative resection of the primary tumour along with bilateral oophorectomy. The patient was diagnosed with ileal NET and presented with clinical symptoms of carcinoid syndrome, yet did not have evidence of hepatic metastasis, but instead had bilateral ovarian metastasis which itself is a rare entity.

OBJECTIVE: To determine the factors associated with suicidal ideation among college students in Pakistan. METHODOLOGY: This was a cross sectional study, sample was selected randomly from public and private colleges located in different areas of Karachi, Pakistan. Data was collected from Sep 2014 to Feb 2015. 545 adolescents, aged 16 years to 19 years were selected by random sampling. Positive and negative suicide ideation Inventory, Personal Information Form, Beck hopelessness Scale, and Aga Khan Anxiety and Depression Scale were administered. Adolescents with any physical disability, chronic physical illness and any diagnosed psychiatric disease were excluded. Statistical analysis was done by using SPSS 14. RESULTS: Descriptive statistics and Binary Logistic Regression analysis were used to analyse the collected data. The analysis revealed that gender, living in nuclear family setup, suicide attempt in past, a suicide attempt by family members, suicide attempt by friends, illness in family members, and the severity of hopelessness and symptoms of anxiety were found significantly correlated with the suicidal Ideation. CONCLUSION: Findings of the study evidenced that certain socio-demographic and psychological associated risk factors should be consider to design and implement strategies for intervention and prevention of suicidal behaviours. Limitations and implications of the present study have also been recommended.

Objective: This study is designed to assess the diagnostic accuracy of Low-dose unenhanced multi detector computed tomography (MDCT) in patients with suspected urinary tract calculi taking Standard-dose unenhanced MDCT as gold standard. Methods: The cross-sectional study was conducted from July to December 2016 among patients with suspected urinary tract calculi. The patients underwent unenhanced low-dose MDCT scan with reconstruction slice thickness, 7.0 mm; pitch= 1.00; tube potential 120kV; and tube charge per gantry rotation, 25-50 m As, followed by standard-dose computed tomography (CT) scan. Diagnostic accuracy of unenhanced low dose multi-detector computed tomography was calculated taking standard dose MDCT as gold standard. Results: Out of total 50 adult patients, 32 (64%) were males and 18 (36%) were females. The mean age of the patients was 50 ± 11 years. The diagnostic accuracy of Low dose CT showed 100% sensitivity when compared with Unenhanced Standard dose CT in diagnosing urinary tract calculi, indirect signs of obstruction and adjacent organs. However, a difference was observed in blood vessels within the renal sinus which were seen in 48 kidneys in low dose CT and 49 in standard dose CT (True positive 96%, true negative 100%). Conclusion: Low dose MDCT can be effectively used for the evaluation of urinary tract calculi with significantly decrease radiation dose to the patients compared with standard dose CT. This is due to the improvements in CT technology which allow isotropic resolution with faster scan coverage in a single, short breath-hold, and high diagnostic performance.

The study examines the role of economic news surprises on the volatility of the returns of the Indian Index futures market. Theoretical literature posits that news arrivals influence price discovery. In similar lines, we investigated the relationship between economic news releases, trading activity variables, and returns volatility. We find that economic news surprises and trading activity variables significantly affect returns volatility. However, among volume and news surprises, economic news surprises are much stronger informational signals, and the news surprises effects are found seemingly asymmetric in the index futures contract.

Piriformis syndrome is a rare syndrome which is one of the main causes of nondiscogenic sciatica causing severe low back pain due to entrapment of sciatic nerve either by the hypertrophy or by inflammation of the piriformis muscle. We have carried out dissection in 20 Nepalese cadavers. Out of 40 dissected gluteal regions, 37 exhibited typical appearance of sciatic nerve, piriformis muscle, and their relations resembling type-a, whereas 3 gluteal regions showed composite structural variations resembling type-b and type-c based on Beaton and Anson’s classification. Knowledge pertaining to such variations will be helpful during a surgical intervention in the gluteal region and in turn reduces the risk of injuring these nerves which are more susceptible to damage. Our study reports such variations in Nepalese population which will be helpful during evaluation of the pain induction in various test positions and also useful for analysis of the range of the neurological deficiency in sciatic nerve neuropathies. The present study also explains the basis of the unsuccessful attempt of the sciatic nerve block during popliteal block anaesthesia.

Primary leiomyosarcoma is rare tumor approximately 1/100000 people. It is reported that only 2% of leiomyosarcoma is vascular in origin arising from inferior venacava (IVC). Considering its incidence, it is more common in females and middle segment of IVC is most commonly involved. We report here, case of 37-year-old female presented with right lank pain for one year then after radiological imaging neoplastic mass noted arising from infrahepatic and juxtarenal IVC and ultrasound guidance biopsy was taken that proved leiomyosarcoma of IVC. Surgery was performed with clear resection margins and regular follow-up was performed in our oncology OPD with the necessary imaging and laboratory work.

Pulmonary veins (PVs) are the most proximal source of arterial thromboembolism. Pulmonary vein thrombosis (PVT) is an uncommon clinical condition that can be fatal. Its incidence or prevalence is unclear as existing cases are case reports. It is often seen as a complication of malignancy, lobectomy, atrial fibrillation and less commonly idiopathic. It can be diagnosed using different types of non-invasive imaging studies. We present a 68-year-old woman who was undergoing treatment for recurrent urinary tract infection (UTI) but was incidentally noted to be dyspneic and intermittently hypoxic. She was found to have idiopathic pulmonary vein thrombosis that was successfully managed with systemic anticoagulation. Keywords: Pulmonary vein thrombosis, Warfarin, Idiopathic, Systemic anticoagulation, Spontaneous

Along with advantages, evolving surgical techniques bring unique complications. A young male developed urinary symptoms a few months after undergoing laparoscopic inguinal hernia repair. On evaluation, mesh erosion into the urinary bladder was found. Removal of mesh with repair of bladder was done. A vesico-cutaneous fistula resulted which was managed with repeat surgery. We review all such cases reported in literature; discuss the etiopathogenesis, presentation, management and possible preventive measures. To the best of our knowledge, this is only the 12th case being reported.

This study has examined the impact of external debt and the volatility of exchange rate on domestic consumption in Pakistan by using the yearly data (1980–2014). We apply the bounds testing approach to cointegration and error-correction modeling to check their short run and long-run impact on the domestic consumption. The findings of this study has contributed to the existing literature in two ways: bound test results show that income, interest rate, exchange rate, volatility of exchange rate, and external debt have long-term relationship with domestic consumption and income, interest rate and exchange rate have positive impact whereas exchange rate volatility and external debt have negative impact on domestic consumption in the short run as well as in long run. Moreover, the coefficient of ECMt-1 is significantly negative and it shows that adjustment toward equilibrium from short run to long run takes more than half a year. Consumption is the major component of GDP so policymakers use its determinants to fine-tune the economy. This study proposes that policymakers should consider external debt and exchange rate volatility in devising the monetary policy of Pakistan.

Spontaneous rupture of the rectum is a rare occurrence. A total laparoscopic approach to rectal perforation has only occasionally been reported. We report an unusual case of a young boy who developed a spontaneous rupture of the rectum following a trivial fall. A magnetic resonance imaging revealed a tear in the rectum at the peritoneal reflection with the omentum plugging it. He denied any history of rectal instrumentation or abnormal sexual activity. He had no history of constipation or rectal prolapse. The tear was repaired laparoscopically and a covering loop sigmoid colostomy was added. He made an uneventful post-operative recovery. Spontaneous rupture of the rectum can occur in younger age groups and even in the absence of significant trauma. One needs to diligently bring out a history of rectal trauma. Equally important is to rule out any underlying pathological condition. A laparoscopic approach is feasible, especially in early cases.

Pseudoaneurysm arising from the Superior mesenteric artery is very rarely seen as a complication of trauma to abdomen. It has a very low incidence and because of this reason it is less likely to be suspected in patients with traumatic injury to abdomen. If a pseudoaneurysm is ruptured, it can be a life threatening condition and this is the reason, it should always be in mind during management of patients with abdominal trauma. We have reported a case of a young female who was brought in emergency department after blunt traumatic injury to abdomen. She was having the complaints of enlarging lump in epigastric region and pain. She underwent ultrasound followed by CT angiogram and was found to have a pseudoaneurysm arising from superior mesenteric artery.

Introduction: Trauma is a modern day epidemic. Abdominal trauma is the most common cause of trauma-related death that is preventable. Non operative Management (NOM) is increasingly being done in Blunt Abdominal Trauma (BAT). However, for high grade injuries, the risk of failure of NOM has been shown to be higher. Aim: To assess the feasibility and success rate of NOM in abdominal trauma with high grade solid organ injury. Materials and Methods: The present study was a retrospective review of a prospectively maintained database at a Tertiary Care Centre. 17 blunt trauma abdomen cases with high grade solid organ Injuries over a period of four and a half years without peritoneal signs or persistent haemodynamic instability after initial resuscitation were included. Data was analysed using online statistical software (graphpad). Results: Of the 17 cases with high grade injuries, two had contrast extravasation on imaging. Predominant organ involved was spleen in 11 (64.8%), liver in 10 (58.8%) and pancreas in one patient, respectively. NOM was successful in 100% of patients. Three patients had rebleeding and all were successfully managed non-operatively. There was no mortality. Conclusion: The NOM is feasible and safe even in high grade injuries in BAT. This decision is based on a sound clinical judgment and should be attempted at centers with facilities for critical care, interventional radiology and adequate blood bank facilities. The patient condition and not the grade of injury on imaging should dictate the line of management.

Objective: The purpose of this research is to evaluate common and uncommon variant of hepatic arterial anatomy that usually come across during Hepatic Angiographies. Study Design: Cross sectional study. Methods: This study included 50 patients having history of Hepatocellular Carcinoma from May to October 2015. Hepatic Angiography (Transarterial chemoembolization for management of Hepatoma and identification of classical and variant anatomy of hepatic artery) was evaluated in angiography unit. All procedures were performed on Digital Subtraction Angiography (DSA) machine (Toshiba KXO100 G). Selective DSA of the superior mesenteric artery and celiac trunk is performed initially to evaluate the frequency of normal and variant arterial anatomy and secondly to determine origin and course of tumor-feeding vessels. Evaluation of common and uncommon variants of hepatic arteries was done by using Michel’s classification as reference standard.

Altered bowels habits along with rectal mass in an elderly would point toward a rectal cancer. We report an unusual case of a post-menopausal lady who presented with these complaints. We had difficulties in establishing a pre-operative diagnosis. With a tentative diagnosis of a rectal cancer/gastrointestinal stromal tumor, she underwent a laparoscopic anterior resection. On histopathology, this turned out to be endometriosis. Bowel endometriosis is an uncommon occurrence. That it occurred in a post-menopausal lady was a very unusual finding. We discuss the case, its management, and the relevant literature.

Necrotizing pancreatitis occurs in 10 to 25% of patients requiring hospital admission for acute pancreatitis and carries a high mortality rate. Necrotizing pancreatitis can cause a spectrum of complications. However, we report an extremely rare complication of necrotizing pancreatitis: necrotizing fasciitis of the abdominal wall. A 56-year-old male patient presented to our center with discoloration of skin over left flank of 15 days duration and pus discharge from it since three days. Two months back he was managed at a private hospital as a case of acute necrotizing pancreatitis and was discharged after one week of inpatient treatment. After discharge patient continued to have malaise and weakness but was able to do his routine day to day activity. On presentation at our hospital, patient was in septic shock and was taken emergently to operating theatre for debridement. However, later, the patient succumbed to his illness. Necrotizing fasciitis is an extremely uncommon complication of necrotizing pancreatitis and has a fulminant course. Timely detection and debridement can avert a potential mortality.

Background: Congenital inguinal hernias are a common paediatric surgical problem and herniotomy through a groin incision is the gold standard. Over the last 2 decades minimally invasive surgery (MIS) has challenged this conventional surgery. Over a period, MIS techniques have evolved to making it more minimally invasive - from 3 to 2 and now single port technique. All studies using single port technique are from tertiary care centres. We used a modification of the technique described by Ozgediz et al. and reviewed the clinical outcome of this novel procedure and put forth our experience at a secondary level hospital. Materials and Methods: Prospective review of 37 hernias in 31 children (29 male and 2 female) (8 months - 13 years) performed laparoscopically by a single surgeon at a single centre between September 2007 and June 2010. Under laparoscopic guidance, the internal ring was encircled extraperitoneally using a 2-0 non-absorbable suture and knotted extraperitoneally. Data analyzed included operating time, ease of procedure, occult patent processus vaginalis (PPV), complications, and cosmesis. Results: Sixteen right (52%), 14 left (45%) and 1 bilateral hernia (3%) were repaired. Five unilateral hernias (16.66%), all left, had a contralateral PPV that was repaired (P = 0.033). Mean operative time for a unilateral and bilateral repair were 13.20 (8-25) and 20.66 min (17 -27 min) respectively. Only one of the repairs (2.7%) recurred and another had a post operative hydrocoele (2.7%). One case (2.7%) needed an additional port placement due to inability to reduce the contents of hernia completely. There were no stitch abscess/granulomas, obvious spermatic cord injuries, testicular atrophy, or nerve injuries. Conclusion: Single port laparoscopic inguinal hernia repair can be safely done in the paediatric population. It permits extension of benefits of minimal access surgery to patients being managed at secondary level hospitals with limited resources. The advantage of minimal instrumentation and avoidance of intracorporeal knotting makes it a feasible technique for a secondary care centre.

Given the promising growth of digital payments in India, this study aims to identify motivational factors influencing digital payment acceptance among Indian consumers and how consumers perceive these services when segregated by demographic profiles of gender, age, education and income levels. An online survey targeting 386 respondents was targeted to study the key determinants of digital payments adoption. The study reveals that trust, subjective norm, perceived risk, ease of use, and usefulness are key predictors of digital payment adoption. In addition, invariance analysis provides empirical evidence of scale non-invariance when consumers are segregated by gender and education. The study is pioneering in digital payments as useful insights are gained, which can help policymakers and service providers design future strategies for wider acceptance of digital payments. [ABSTRACT FROM AUTHOR]