Rare case of mixed epithelial and stromal tumor (MEST) of the kidney and its diagnostic and therapeutic approach: A case report.

INTRODUCTION AND IMPORTANCE: Mix epithelial and stromal tumor (MEST) is a benign biphasic renal lesion composed of solid as well as cystic components lining tubular and cystic spaces of kidney. There are very few cases of such variety have been reported with perspective to renal involvement. Herein we have reported a rare case of MEST involving left renal tissue and sparing surrounding tissues. CASE PRESENTATION: A 20 years old female presented to surgical outpatient department with complaint of amenorrhea and left flank pain as well as heaviness for 1 year. Patient was vitally stable and cooperative. On physical examination left flank mass was palpated and ultrasound and CT scan imaging was also showing left renal mass confined to upper, middle and lower portion of the kidney while renal capsule, adrenal gland and ureter were spared. On histological examination showed multi-cystic structures with variably sized simple cysts lined by hobnailed epithelium with clear cells. Septa show ovarian type fibrous stroma with variable inflammation and immature nephrogenic elements. A final diagnosis of MEST was made. Therefore, radical nephrectomy with trans-peritoneal approach was done. CLINICAL DISCUSSION: MEST is a benign tumor of renal tissue that is confined to the renal parenchyma rather than involvement of surrounding structures as occurred in our case. Due to benign nature of the disease involvement of renal capsule and adrenal gland is less likely. The choice of treatment is radical nephrectomy through transperitoneal approach. CONCLUSION: MEST is a rare diagnosis thought case now start reporting since last decade, however, it's still a rare entity to be reported. USG and CT scan are investigating modalities along with histopathological correlation to reach the diagnosis.

Paradigm shift in medical education due to the COVID-19 pandemic: guidelines for developing a blended learning curriculum in medical education.

Background: The coronavirus disease 2019 (COVID-19) pandemic has transformed the world's economy, health and education in a blink of an eye. Almost 1 billion learners have been affected across the globe. This has resulted in a paradigm shift to blended learning. Therefore, it was felt necessary to provide practical guidelines for the development of blended curriculum in medical education. It would help to overcome the challenges faced due to unprecedented transformation of medical education on account of pandemic. Methods: Guidelines based on personal experience of the authors and literature search were developed using the complex adapted blended learning system (CALBS) framework. Seven experts developed these guidelines using the nominal group technique. The consent form and literature for CABLS framework was shared with experts. The experts developed the guidelines independently during phase one of the technique. After a given time, phase 2 started with moderator mediated discussion about the individual guidelines developed by the experts. After discussion and mutual consensus four types of guideline ideas were developed. During the third phase the experts ranked the guideline ideas on a scale of 1 to 5. The guideline idea that ranked highest was selected as a final guideline for developing a blended learning curriculum. Results: The group consensus resulted in developing seven guidelines for a blended course or curriculum in medical education. These guidelines are based on a conceptual framework supplemented by expert's own personal experience and current evidence from literature. Conclusions: These guidelines would provide a comprehensive and systematic approach to develop a blended learning curriculum in medical education.

Ovary and fallopian tube as contents of indirect inguinal hernia: A case report.

INTRODUCTION AND IMPORTANCE: Ovarian and fallopian tube indirect inguinal hernias are rare hernias encountered on surgical floor. Herein, we are reporting a rare happening of obstructed ovarian and fallopian tube indirect inguinal hernia in an unmarried female. PRESENTATION OF CASE: A 19 years old unmarried female presented to surgical emergency with complain of swelling in left inguinal region that was about 3 × 3 cm on visual inspection from last 4 days that was associated with menstruation. Abdominal ultrasound (USG) was showing left ovarian and fallopian tube indirect inguinal hernia with preserved internal follicles and intact vasculature. The diagnosis of obstructed ovarian and fallopian tube indirect inguinal hernia was made and diagnostic laparoscopy and left sided hernioplasty was performed. Ovary was retrieved back into abdominal cavity and stitched to lateral pelvic wall. DISCUSSION: Inguinal hernia itself is a rare happening in females and the presence of ovary and fallopian tube along with other hernial content can become a topic of discussion due to rarity of this case. It is of paramount significance to diagnose such cases with great expertise in order to avoid long term complications in terms of preserving fertility among females. Early utilization of radiological investigations like USG abdomen and laparoscopic retrieval of adnexal structures are standard approach in management of such cases. CONCLUSION: Presence of ovary and fallopian tube in indirect inguinal hernia is a rare happening that need to be diagnosed and treated at earliest to avoid infertility among females.

Challenges for implementing WFME standards for accreditation in health professions education in low and middle-income countries: A scoping review.

OBJECTIVE: The accreditation standards developed by the World Federation of Medical Education (WFME) are acknowledged as regulatory mechanism for quality assurance of medical education programmes. The scoping review was planned to collect all the literature for identification of the barriers affecting the implementation of quality curriculum defined by WFME. METHODS: The literature was searched in electronic databases for relevant peer-reviewed studies over the last ten years. The search terms used were, `challenges of WFME accreditation', `barriers to accreditation', `challenges to accreditation in healthcare system', `hindrances to WFME accreditation standards', and `barriers to WFME standards', in PubMed, ERIC, PsycINFO databases, and in Google Scholar for grey literature. After screening and assessing for eligibility, 922 publications were retrieved and only 19 articles were included in study. The QualSyst appraisal tool was used to appraise the quality of studies. Data was synthsized to present the findings. RESULTS: The themes identified after data synthesis broadly described the barriers to implementation in various domains of WFME standards. The themes were social and political support, process of curriculum development, involvement of students in curricular planning, organizational setup, infrastructure, technical issues/ management of curriculum. The social and political support referred to leadership and governance, a prime barrier to address. Similarly, organizational setup, infrastructure and technical issues should also be looked for apart from students and curriculum. CONCLUSIONS: The scoping review will inform and lay the foundation for more empirical studies on quality improvement in health professional education, particularly in low and middle-income countries.

Cranial CT scan evaluation of morphological variations and location of pterion in Pakistani male population for lateral neurosurgical approach.

OBJECTIVE: To determine the morphological variations and location of pterion in Pakistani male population. METHODS: This retrospective observational study was carried out in the Department of Radiology, Shifa International Hospital from December 2018 to June 2019. The sample size was calculated by Open Epi web-based calculator. Fifty-three cranial CT scans with slice thickness of 0.5mm; consecutive scans of males were randomly selected. The patients with no craniofacial fracture and ages from 25 to 45 years were included. The dataset was obtained from Toshiba Aquilion One, 360-slice MDCT. The images were imported into the imaging software PACS (WFM), and analyzed in maximum intensity projection mode with three dimensional multiplanar reconstruction viewers. Measurements were taken in lateral projections of skull in Frankfurt plane, as horizontal and vertical distance from the posterolateral margin of frontozygomatic suture to center of pterion. Vertical distance from the superior border of zygomaticotemporal arch to the center of pterion. The morphological types were also recognized. RESULTS: The type of pterion on right side was 94.3% sphenoparietal 5.6% epipteric whereas left side was (90.5%) sphenoparietal (3.7%) epipteric, (3.7%) stellate type, (1.8%) frontotemporal type. The mean horizontal and vertical frontozygomatic measurements on right side were 2.23 ± 0.22cm and 1.25±0.219 cm respectively. The same measurements on the left side were 2.27-±0.25 cm and 1.226-±0.22 cm respectively. The mean zygomaticotemporal measurements on the right and left sides were 3.45 ±0.29cm and 3.44 ±0.25 cm respectively. The mean distance on right and left side of skull was statistically insignificant. CONCLUSION: The study provides useful data for position and location of pterion for safe neurosurgical procedures via pterion. Moreover, the knowledge about different morphological types of pterion help the radiologist to differentiate between a fracture line and normal morphological variety.