Assessment of Shortcomings of Candidates in the Fellowship of College of Physicians and Surgeons (FCPS)-II (Board/Exit) Examination: A Qualitative Analysis of Dermatology Candidates' Short and Long Cases With Suggestions for Improvement.

Background Clinical examination is the final step for the assessment of a candidate in the Fellowship of College of Physicians and Surgeons-II exam and several stressors are associated with it. After a certain level, the stressors and myths related to this exam increase the chances of poor performance. This study aimed to identify the shortcomings of candidates' short and long cases with suggestions for improvement. Methodology This qualitative research with a thematic analysis approach was conducted at the College of Physicians and Surgeons of Pakistan, Regional Center, Lahore. The data were collected from 20 examiners who assessed 88 candidates' short and long cases of dermatology through observation and cross-questioning. Results The major themes that emerged with more subcategories were poor history taking, poor examination, and poor time management while updated knowledge, rationalization, and enhancement of presentation skills were also highlighted in long cases. The major suggestions to improve the short and long cases were to focus on the command given, maintain the privacy of the patient, and improve training. Conclusions This study highlighted many major shortcomings the candidates showed while performing the long and short cases which may facilitate the forthcoming candidates to avoid these weaknesses by following the suggestions for improvements.

A numerical modelling approach to investigate the fate of brine reject of farm scale desalination plants on groundwater aquifers in arid environments.

Farm-scale desalination units are gaining popularity for agricultural irrigation in arid countries, such as Kuwait to meet freshwater demands. However, less attention has been given to the management of environmentally hazardous brine reject water they produce. In this study we investigated the fate of brine water produced by the inland desalination units on the underlying aquifers using numerical modelling and field investigations. The methodology involved developing groundwater flow and solute transport models using Flex VMF-SEAWAT to simulate the movement of reject brine. The field investigations included collecting 150 water samples and conducting pumping tests on newly drilled wells. This numerical simulation considered advection, dispersion, and adsorption processes with variable groundwater density following rigorous validation and calibration of the developed numerical models. The results show that the RO reject brine will significantly increase groundwater salinity, exceeding 10,000 mg/L when accounting for advection, dispersion, and adsorption processes. The sustainable yield of the aquifer, with a salinity of <10,000 mg/L, averages 500 Mm3 but is expected to be depleted within 16 years with the current extraction rate. The resulting hydraulic properties are favourable with K about 100 m/d, T > 1000 m2/day, and Sy just >0.1. The adopted values for dispersivity and adsorption coefficients for chloride and sulphate salts in the aquifer were 10 m and 1 × 10-7 [mg/L]-1 respectively. Chemical and numerical analyses indicate a mixing ratio between the reject brine and groundwater in the study area of approximately 10 %. Uncontrolled groundwater extraction, combined with the surface disposal of RO reject brine, has led to a significant decline in groundwater levels and an increase in the salinity. The adsorption ratio of simulated brine plume was 13 %. The authors recommend to dispose the RO reject water in a safe location or transfer it to the nearest wastewater treatment plant for proper treatment and reuse.

Sensing the dependable surficial signatures of temporal groundwater variations in arid coastal regions through geospatial techniques with respect to microclimate changes.

Reports on Groundwater level variations and quality changes have been a critical issue, especially in arid regions. An attempt has been made in this study to determine the surface manifestations of groundwater variations through processing imageries for determining the changes in land use, Normalized Differential Building Index (NDBI), Normalized Difference Vegetation Index (NDVI), Land Surface Temperature (LST), along with Groundwater level (GWL) and Electrical conductivity (EC). Decadal variation between these parameters for 2013 and 2023 shows that the average water level had increased by 1.03amsl, while the EC values of groundwater decreased by 418 µS/cm. The decrease in EC values indicates freshwater recharge, promoting natural vegetation, thus reducing the LST values by 3.28 °C. In addition, urban landscaping and relatively lesser emissivity from built-up surfaces than the sandy desert have further reduced the LST. The interrelationship of the parameters indicates that an increase in LST correlates with an increase in NDBI and with less significant changes in NDVI. The lowering of the LST along the coastal regions was inferred to be due to the influence of Sea breeze, adjacent moisture from the ocean, shallow water level, and the shadow effect of the buildings. Further, the increase in water level was mainly attributed to the recent increase in rainfall and the extreme event in 2018. The higher EC in the lesser NDBI regions is attributed to the anthropogenic contamination from agriculture and landfill leachates. Though there was an increase in NDBI, the LST of the region was inferred to be reduced mainly due to the increase in water level and reduction of emission from desert sand by recent urban developments.

Breast imaging of infectious disease.

Infectious diseases of the breast can demonstrate a wide variety of clinical presentations and imaging appearances. Breast abscesses are often a complication of infectious mastitis of the breast. Puerperal mastitis is the most common cause of breast abscess, typically affecting postpartum females. Often diagnosed clinically, it is usually treated with antibiotics without need for imaging. Non-puerperal mastitis is relatively uncommon and typically subareolar in location. Patients can present with asymmetric breast thickening, a palpable lump, nipple discharge, or axillary adenopathy. These presentations can mimic malignancy. Herein, this pictorial review demonstrates imaging findings of common and uncommon infectious processes of the breast and clinically important mimickers of breast infection.

Evolution of hydrogeochemistry in groundwater production fields of Kuwait - Inferences from long-term data.

Kuwait Group aquifers and Dammam Formation are the two prominent aquifers, the wells tapping Dammam Formation and Dual completion wells are used for groundwater production. The current study investigates the spatiotemporal evolution of hydrochemical characteristics of the Shagaya water field utilizing long-term (1975-2019) hydrochemical data from 116 water wells. The Shagaya water well field has been differentiated into A to F sub-Fields. Mann-Kendall and Sen's Slope method along with spatial interpolation of change in TDS with time identified a significant decrease in TDS with time in the major portions of the Shagaya B, C, D, and E Fields. The study infers that 82% of wells extracting water from the Dammam Formation and 42% of Dual completion wells show a decrease in TDS concentration. The most plausible explanation for this phenomenon was the inflow of better-quality water from the up gradient parts of the Kuwait Group and the Dammam Formation aquifers due to the fall in the potentiometric head with high volume production in the well field. The results of ionic ratios (Na/Cl, Ca/Mg, Ca/SO4, Ca + Mg/SO4+HCO3), isotopes (34S, 87Sr/86Sr), relationships between 2H and 18O, and Ne/He and 3He/4He ratios identified that salinization was due to the result of rock-water interaction, ion exchange, mixing between groundwater of Kuwait Group and Dammam Formation and with groundwater from deeper parts of the aquifer. The long-term analysis of the data shows a notable variation of chemistry in a few locations and thus the study helps to manage, sustain groundwater resources, and protection of host aquifers.

Trauma on the high seas: an overview of recreational water use injuries.

Recreational water use (RWU) injuries span from superficial lacerations to even death. Given the global popularity of RWU, radiologists should be aware of the common mechanisms and key imaging findings related to injuries in this setting. The goal of this article is to depict common RWU injuries and their emergent radiographic findings, which may have both important surgical and management implications. We present a broad review with case illustrations of these injuries seen at our level 1 trauma center showing the breadth of injury that can occur, general mechanisms and sample imaging findings.

Rapid Nuclear Medicine Blood Volume Analysis for Emergency Assessment.

Assessment of fluid status can play a critical role in the diagnosis and management of emergent conditions such as trauma, shock, decompensated heart failure, syncope, and hypertension. Unfortunately, common methods are all qualitative and/or indirect, and often inaccurate. With the recent introduction of a modernized method of nuclear medicine blood volume analysis (NM-BVA), offering results in 90 min or less as well as improved precision and ease of performance, this decade-old technique is for the first time a viable tool in the emergent setting. In this review, we discuss the history of NM-BVA, the modern method, and our institution's experience implementing this method.

The correlation between sarcopaenia and post-transjugular intrahepatic portosystemic shunt hepatic encephalopathy: a single-institution review.

INTRODUCTION: Sarcopaenia, or muscle wasting, can be used to objectively quantify malnutrition in cirrhotic patients. MATERIAL AND METHODS: In this retrospective study, a list of all patients who underwent transjugular intrahepatic portosystemic shunt (TIPS) procedure at Westchester Medical Centre from September 2009 to July 2018 was obtained, and individual chart reviews were performed. RESULTS: In total, 90 charts were reviewed. Fifty-six patients satisfied our inclusion criteria. Using PMA cut-off values determined in prior studies, we found that 50 of the 56 patients in our study were sarcopaenic. The majority of the patients were male (n = 45). The most common aetiology of cirrhosis was alcoholic cirrhosis (n = 27), followed by viral hepatitis (n = 10), and the most common indication for TIPS was refractory ascites (n = 34). The mean age in the sarcopaenic group was 60.1 years compared to 57.4 years in the non-sarcopaenic group. Mean MELD-Na scores and albumin levels were comparable in both groups. Only one patient was deceased at 6 months post-TIPS. Of the 56 patients included, 18 developed clinically significant hepatic encephalopathy within 6 months of their TIPS procedure. All 18 patients belonged to the sarcopaenic group; 6 patients were not sarcopaenic, and none of them were noted to develop HE within 6 months of their TIPS (p = 0.074). CONCLUSIONS: Based on our results, we concluded that sarcopaenia correlates with the development of hepatic encephalopathy within 6 months of a TIPS procedure; however, the results did not reach statistical significance.

Chemically reprogrammable metal organic frameworks (MOFs) based on Diels-Alder chemistry.

We present the reversible Diels-Alder functionalization of metal organic frameworks (MOFs). Cyclopentadiene (Cp) functional MOFs are ligated with dienophiles to fabricate functional MOFs with a reprogrammable chemical nature. Our strategy thus constitutes an unprecedented concept for chemically dynamic MOFs able to be recoded.

CD8, FoxP3, and CD45RO+ Lymphocytic Infiltrates in Type I and Type II Endometrial Cancers in African American and European American Females.

African American (AA) females with endometrial carcinoma have a significantly worse prognosis with regard to disease-free survival and overall survival than their European American (EA) counterparts and this finding is true across all stages and grades. The presence of tumor-infiltrating lymphocytes (TILs) has been demonstrated to be of prognostic significance in a variety of malignancies, including endometrial cancers. This study aims to determine whether clinically significant differences in levels of CD8+ cytotoxic T lymphocytes, FoxP3+ regulatory T lymphocytes, and CD45RO+ memory T lymphocytes exist between races and to document the clinical impact of TILs. One hundred ten patients with endometrial adenocarcinoma, treated with hysterectomy from 2003 to 2011 were studied. Patients were selected to provide equal representation across type and grade for both EAs and AAs. Immunohistochemical stains were used to highlight CD8-positive, FoxP3-positive, and CD45RO-positive TILs at the endometrial-myometrial interface on slides from paraffin-embedded tissue. Patients with "high" or "low" levels of TILs were compared with respect to the race, tumor type, and survival. High levels of CD45RO+ TILs were associated with improved overall survival in EA women (hazard ratio, 0.32; 95% confidence interval, 0.11-0.92; P=0.034). Comparatively, AA women with high levels of CD45RO+ TILs received no survival benefit (hazard ratio, 0.96; 95% confidence interval, 0.35-2.64; P=0.94). High levels of CD8-positive or FoxP3-positive TILs, alone, had no impact on survival. EA patients with TILs containing high levels of CD45RO cells but low levels of CD8+ cells lost the survival benefit; however, limited numbers preclude significant conclusions from this observation. Neither tumor type nor race were predictive of the levels of TILs of any type. Further study with a larger sample size is required to determine the impact of TIL subtype combinations on survival.

CONVERSION OF LAPAROSCOPIC CHOLECYSTECTOMY INTO OPEN CHOLECYSTECTOMY: AN EXPERIENCE IN 300 CASES.

BACKGROUND: Laparoscopic cholecystectomy is getting popularity in developing countries especially in Pakistan. Conversion from laparoscopic to open cholecystectomy is also common. This study intends to evaluate the causes of conversion from laparoscopic cholecystectomy to open cholecystectomy and to establish the efficacy and safety of the procedure. METHODS: This descriptive case series was conducted in the department of General Surgery at Social Security Teaching Hospital Islamabad from November 2012 to October 2015. Patients of more than 20 years of age presenting in OPD with symptomatic gallstones were included in the study. Patients with dilated CBD (> 8 mm in diameter), jaundice, acute cholecystitis, mass at porta hepatis and positive hepatitis B or C virology were excluded. RESULTS: A total of 300 patients were included in the study; 262 (87.33%) were females and 38 (12.67 %) were males. Twenty-one (7%) patients were converted to open cholecystectomy. Most common cause of conversion was dense adhesions followed by obscure anatomy at Calot's triangle. Other common causes were bleeding, bile leakage, visceral injuries and instrument failure. In the first 100 cases, 10% patients were converted to open cholecystectomy followed by 6% in the next 100 cases. Only 5% patients were converted to open cholecystectomy in the last 100 cases. CONCLUSION: Most common cause of conversion from laparoscopic cholecystectomy to open cholecystectomy was dense adhesions followed by obscure anatomy at Calot's triangle.

COMPLICATIONS OF LAPAROSCOPIC CHOLECYSTECTOMY: AN EXPERIENCE OF 247 CASES.

BACKGROUND: Laparoscopic cholecystectomy needs lot of training and experience in developing countries like Pakistan. After the introduction of laparoscopic cholecystectomy several studies have been conducted to evaluate the complications of laparoscopic cholecystectomy and to establish the efficacy and safety of the procedure. The aim of this study was to determine the complications of laparoscopic-cholecystectomy in a teaching hospital during the learning process. METHODS: This descriptive case series was conducted in the department of General Surgery at Social Security Teaching Hospital, Islamabad, from October 2012 to February 2015. Patients of more than 15 years of age having symptomatic gallstones were included. Patients with dilated common bile duct (>8 mm in diameter), jaundice, acute cholecystitis, mass at porta hepatis and positive hepatitis B or C virology were excluded. RESULTS: A sample of 247 consecutive patients was studied. Of them, 218 (88.26%) were females and 29 (11.74%) were males. Their age ranged from 15 to 73 years (mean 45.37). Six (2.43%) patients developed epigastric port site wound infection. Four patients (1.62%) had bleeding. There was bile leakage in 2 (0.82%) patients postoperatively. Two patients (0.82%) had collection (haematoma) in pouch of Morrison. One patient (0.41%) had duodenal injury. Eighteen (7.29%) laparoscopic procedures were converted to open cholecystectomy. The mean postoperative hospital stay was 1.8 days. CONCLUSION: Complication rate is high in early learning phase of laparoscopic surgery which can be reduced with proper training of surgeons and they should perform these procedures under supervision of experienced laparoscopic surgeons during their learning phase.