Spontaneous Left Main Coronary Artery Dissection in a Male.

Spontaneous coronary artery dissection (SCAD) is one of the causes of acute coronary syndrome (ACS) that is increasingly recognized in young to middle-aged women without typical coronary risk factors. This case report describes a 46-year-old male with a rare presentation of SCAD involving the left main (LM) coronary artery. The patient underwent an emergency coronary angiogram for high-risk ACS and had percutaneous coronary intervention (PCI) of LM due to active ischemia and hemodynamic instability. The extension of intramural hematoma after the LM coronary artery stent confirmed the initial suspicion of SCAD. The diagnosis of SCAD is crucial, as its management differs from other causes of ACS. Coronary angiography is the gold standard for diagnosing SCAD, with adjunctive imaging using optical coherence tomography (OCT) and intravascular ultrasound (IVUS). In this patient, his physical examination findings and further imaging raised a suspicion for systemic connective tissue disease. Genetic analysis was executed, but no reportable variants in any of the 29 genes studied were identified. This case highlights the importance of recognizing SCAD as a potential cause of ACS even in men and emphasizes the findings during coronary angiography that can aid in an accurate diagnosis and appropriate management.

The Duodenal Accessory Ampulloma and the Role of Endoscopic Retrograde Cholangiopancreatography (ERCP) in Familial Adenomatous Polyposis Coli Inheritance.

The adenomatous lesions, which could be benign or malignant, have been described in the duodenum and along the duodenal ampulla in individuals with familial adenomatous polyposis (FAP) post-colectomy, along with other extracolonic manifestations. To our best knowledge, we present a unique case of the involvement of the accessory duodenal ampulla in a patient who had undergone colectomy with ileorectal anastomosis with an established diagnosis of FAP. During the endoscopic examination, the patient was found to have adenomatous growth in the accessory duodenal ampulla, which was successfully removed via endoscopic retrograde cholangiopancreatography (ERCP). To prevent pancreatitis, a temporary plastic stent was inserted and successfully removed three weeks later.

Esophageal leiomyoma within an epinephric diverticulum.

Epinephric diverticula are distal esophageal pouches protruding from the epithelial lining of the esophagus while esophageal leiomyomas are benign smooth muscle lesions that constitute a significant percentage of all gastrointestinal leiomyomas. Epinephric diverticula and esophageal leiomyomas are common individually but their co-existence is rare. Moreover, they present asymptomatically but can occasionally present with complains of dysphagia and weight loss. In this paper, we present a 58-year-old Asian man with three months history of indigestion and progressive weight loss. Preoperatively, CT Scan with IV Contrast showed a large soft tissue mass appearing on the right distal esophageal wall, with its lumen communicating with the esophageal lumen, likely representing an epinephric diverticulum. Biopsy and immunohistochemistry stains confirmed the diagnosis of smooth muscle neoplasm, likely a leiomyoma. Later, the patient underwent a two-stage esophagectomy. The postoperative biopsy was consistent with the initial one: therefore, supporting the diagnosis of a leiomyoma. Postoperatively, the recovery remained uneventful.

Self-Practice Program for Beating-Heart Minimally Invasive Coronary Anastomosis Using a Homemade Low-Fidelity Simulator: A Proof of Concept.

OBJECTIVE: We evaluated the effectiveness of a consistent and structured self-practice coronary anastomosis program using a homemade low-fidelity beating-heart simulator. METHODS: An intermediary trainee was subjected to an 8-week structured self-practice program. The program was divided into 2 parts of nonbeating and beating practices with a minimum number of timed anastomoses. Each part was followed by an assessment using an objective skills assessment tool score. The beating-heart simulator was built using motorized toy blocks connected wirelessly to a smartphone application. This was coded to enable rate selection. A junior consultant was compared to the subject at the end of the program. Both were tasked to perform 1 coronary anastomosis for both off-pump coronary artery bypass (OPCAB) and minimally invasive CAB (MICS) setup. The primary outcomes were anastomotic time and score compared with the junior consultant. Secondary outcomes were progression of anastomotic time and score throughout the program. RESULTS: Overall performance of the studied subject approached the performance of the junior consultant in terms of time (OPCAB, 489 vs 605 s; MICS, 712 vs 652 s) and scores (OPCAB, 21 vs 20.7; MICS, 19 vs 20.6). There were inverse correlations between anastomosis time and number of practices for both nonbeating and beating anastomoses. Overall improvement was observed in terms of assessment scoring by 26.6%. CONCLUSIONS: A structured self-practice program using an affordable and accessible simulator was able to help trainees overcome the MICS anastomosis learning curve quicker when introduced earlier. This may encourage earlier adoption of MICS among surgeons.

The Evolving Clinical Trajectory From a Sliding Hiatus Hernia to Mixed Sliding and Para-Oesophageal Subtype: A Case Report.

We present a compelling case of a patient initially diagnosed with a simple sliding hiatus hernia (HH), which was managed conservatively through optimised medical therapy. Over the span of a few years, she developed new symptoms which included epigastric discomfort and pain, prompting further clinical review and imaging investigation. These revealed the progression of her HH from a simple form to a more complex rolling or para-oesophageal type. This outcome highlights the importance of recognising a potential for progression during the clinical assessment of patients with a history of reflux symptoms and the onset of new epigastric discomfort or pain. Understanding this continuum of HHs is essential for physicians as management plans may need to switch from a conservative to a more invasive approach.

Female genital schistosomiasis mimicking an ovarian neoplasm: A case report.

OBJECTIVE: A case description of a rare occurrence of female genital schistosomiasis affecting the upper genital tract that presented with features mimicking an ovarian neoplasm. CASE REPORT: Female genital schistosomiasis is a neglected clinical manifestation of the water-born parasitic disease which occurs due to the presence of schistosome eggs in the genitalia of women. A 23-year-old nulliparous woman presented with progressive abdominal distension. An abdominopelvic CT scan revealed a multilobulated right adnexal mass with gross ascites. Diagnosis of schistosomiasis was made by histology of biopsied specimens following laparotomy. Cervical colposcopic findings were consistent with female genital schistosomiasis. She was successfully treated with praziquantel. CONCLUSION: Female genital schistosomiasis of the upper genital tract can mimic an ovarian malignancy. Hence there is a need for its consideration as a differential diagnosis in patients with non-classical presentations of pelvic tumours in schistosomiasis-endemic areas.

Sustainable financing for vaccination towards advancing universal health coverage in the WHO African region: The strategic role of national health insurance.

There is a growing political interest in health reforms in Africa, and many countries are choosing national health insurance as their main financing mechanism for universal health coverage. Although vaccination is an essential health service that can influence progress toward universal health coverage, it is not often prioritized by these national health insurance systems. This paper highlights the potential gains of integrating vaccination into the package of health services that is provided through national health insurance and recommends practical policy actions that can enable countries to harness these benefits at population level.

Risk factors of stone residual after retrograde intrarenal surgery: A prospective cohort study.

BACKGROUND: Complete removal of renal stones is crucial for optimal patient outcomes, but recent studies have reported residual stones after retrograde intrarenal surgery (RIRS). This study aimed to identify the associated risk factors to improve patient management and treatment selection. METHODS: This cohort study was conducted over 18 months at two hospitals and recruited adult patients with renal stones less than 3 cm. Preoperative assessment included medical history, physical examination, laboratory tests, and radiological imaging. Intraoperative and postoperative data collection and follow-up were conducted to evaluate surgical success and potential complications. RESULTS: A total of 100 patients were included, with a mean age of 45.3 ± 10.7 years and a mean BMI of 26.2 ± 1.4 kg/m2. Approximately 19% of the patients had residual stones after the RIRS procedure. The RUSS score showed good diagnostic performance with an AUC of 0.843, and the optimal cut point was ⩾2.0 with a sensitivity of 52.6% and specificity of 95.1%. Independent predictors of residual stones were multiple sites (OR = 24.98; p = 0.002), multiple stones (OR = 13.62, p = 0.002), stone size of 21-30 mm (OR = 4.91, p = 0.038), lower calyx site (OR = 4.85, p = 0.033), and surgeon experience of fewer than 50 cases (OR = 6.82, p = 0.020). CONCLUSIONS: This study identifies several factors associated with residual stones after RIRS for renal stones, including stone size, location, number, and surgeon experience. The study suggests that the RUSS score can be used as a reliable tool for predicting the likelihood of residual stones, which can help clinicians in patient selection and treatment planning.

Exploring soil radon (Rn) concentrations and their connection to geological and meteorological factors.

The relationship between soil radon and meteorological parameters in a region can provide insight into natural processes occurring between the lithosphere and the atmosphere. Understanding this relationship can help models establish more realistic results, rather than depending on theoretical consequences. Radon variation can be complicated to model due to the various physical variables which can affect it, posing a limitation in atmospheric studies. To predict Rn variation from meteorological parameters, a hybrid mod el called multiANN, which is a combination of multi-regression and artificial neural network (ANN) models, is established. The model was trained with 70% of the data and tested on the remaining 30%, and its robustness was tested using the Monte-Carlo method. The regions with low performance are identified and possibly related to seismic events. This model can be a good candidate for predicting Rn concentrations from meteorological parameters and establishing the lower boundary conditions in seismo-ionospheric coupling models.

COVID-19 associated mucormycosis (CAM) in Kashan, Iran: clinical presentations, risk factors, management, and outcomes.

BACKGROUND: This study aimed to estimate the disease burden and describe the clinical presentation, risk factors, and outcome of CAM in a single centre in Iran. METHODS: A case of mucormycosis was defined as one that had clinical and radiological features consistent with mucormycosis along with demonstration of the fungus in tissue via KOH mount/culture/histopathological and molecular examination. RESULTS: We report 30 cases of COVID-19 associated mucormycosis (CAM). The results of this study showed the affected age group in the range of 40-79 years (median = 65.5; IQR = 5) with women (16/30, 53%) affected more than men (14/30, 47%). Among the fungi recovered, Rhizopus oryzae had the highest frequency (79%). Out of the 30 patients, 28 (93%) patients were diabetic with 24 (80%) patients having other co-morbidities. Headache followed by retro-orbital pain, proptosis/ptosis and rapid diminution of vision was a common sequence of symptoms reported by the majority of cases. Use of mechanical ventilation (58% vs. 6%, p = 0.003), O2 required (92% vs. 50%, p = 0.024), and development of renal dysfunction during hospital stay (17% vs. 0%, p = 0.041) was significantly higher in non-survivors than survivors. Temperature (C°), PR (pulse rate), mean levels of serum creatinine, BUN, troponin, and neutrophils were significantly higher in non-survivors (p < 0.05). Besides, Albumin and PO2 were also significantly higher in survivors than non-survivors. CONCLUSION: Despite medical and surgical treatment, the mortality rate among CAM patients is still high. Thus, concerted efforts of revamping surveillance, diagnosis and management, along with public awareness and patient education, are the requisites for managing COVID-19 and mucormycosis.

Decoding the Genetic and Structural Features of HPV16 E5 Oncogene in Cervical Cancer Isolates from Pakistan: A Pilot Study.

Background: Many anogenital cancers are caused by high-risk HPV. The most common subtype is HPV16, which is prevalent in the world, including Pakistan. Various amino acid residues in HPV16 E5 are associated with high cell cycle progression and proliferation. Lack of studies on HPV16E5 in Pakistan prompted the current study. This is the first report on the occurrence of pathogenic E5 variant of HPV16 in tissue sections obtained from invasive cervical cancerous patients in Pakistan. Methods: A subset of 11 samples from HPV-positive biopsies were subjected to E5 gene amplification using PCR and analyzed using bioinformatics programs. The bioinformatics analysis detected mutations causing structural variations, which potentially contribute to the oncogenic properties of proteins. Results: The two-point mutations, C3979A and G4042A, observed in isolate 11 caused the substitution of isoleucine for leucine and valine at positions 44 and 65 in E5 protein. The rest of the isolates had Leu44Val65 amino acids. Intratypic variations and phylogenetic analysis revealed that the majority of the isolates were closely clustered with European-Asian lineage. Moreover, C3979A and G4042A contributed to higher degree of interactions with host receptors, i.e. EGFR. Conclusion: This is the first study reporting HPV16 variants in a Pakistani population based on variations in the E5 region. Our findings indicate that isolate 11 has a strong interaction with the intracellular domain of EGFR, which may enhance the generation of downstream signals. Since this was a pilot study to explore E5 gene mutation, future studies with large samples are absolutely needed.

Spontaneous Endoscopic Esophageal Stent Fracture Post-endoscopic Placement: A Case Report.

Endoscopic esophageal stent (EES) placement is an important tool for the non-operative management of esophageal pathologies. A rare and infrequently reported complication of EES placement is stent fracture and subsequent migration of the broken fragments. We report a rare case of a spontaneous EES fracture from Pakistan four weeks following its placement for esophageal perforation management, and an uneventful endoscopic retrieval of the fractured stent pieces. The recommended guidelines from available, albeit limited, research literature are also discussed as part of this case report.

Gastric Schwannoma: A Rare Subepithelial Lesion of the Stomach.

Gastric schwannomas (GS) are rare, slow-growing, benign subepithelial (SE) lesions of the stomach. These are difficult to differentiate preoperatively from other types of SE lesions, as the gross appearance and clinical presentation are very similar especially the gastrointestinal stromal tumors (GISTs), which are the most common SE lesions of the stomach. We present the case of a 35-year-old Asian man with a one-month history of intermittent, right, upper quadrant pain and hematemesis. Preoperatively, intravenous contrast-enhanced computer tomography scan (CECT) showed a well-circumscribed lesion in the upper abdomen closer to the stomach's lesser curvature. Endoscopic ultrasound revealed an ulcerated subepithelial lesion and subsequent biopsy with a 22-gauge fine-needle biopsy (22G FNB) needle confirmed the diagnosis of GS. The patient underwent distal gastrectomy and a Bilroth 1 procedure. The postoperative biopsy was consistent with the initial one, therefore supporting the diagnosis of gastric schwannoma. Postoperatively, the recovery remained uneventful.

Student satisfaction and academic efficacy during online learning with the mediating effect of student engagement: A multi-country study.

The COVID-19 pandemic caused unprecedented changes to educational institutions, forcing their closure and a subsequent shift to online education to cater to student learning requirements. However, successful online learning depends on several factors and may also vary between countries. As such, this cross-sectional study sought to investigate how engagement of university students, a major driver of online learning, was influenced by course content, online interaction, student acceptance, and satisfaction with online learning, as well as self-efficacy across nine countries (China, India, Iran, Italy, Malaysia, Portugal, Serbia, Turkey, and the United Arab Emirates) during the COVID-19 pandemic. Using a questionnaire-based approach, data collected from 6,489 university students showed that student engagement was strongly linked to perception of the quality of the course content and online interactions (p < .001). The current study also indicated that online interactions are a major determinant of academic efficacy but only if mediated by engagement within the online learning context. A negative correlation between student engagement and satisfaction with online learning was found, demonstrating the importance of students being engaged behaviorally, emotionally, and cognitively to feel satisfied with learning. Academic efficacy and student satisfaction were explained by course content, online interaction, and online learning acceptance, being mediated by student engagement. Student satisfaction and, to a lesser degree academic efficacy, were also associated with online learning acceptance. Overall, the structural equation model was a good fit for the data collected from all nine countries (CFI = .947, TLI = .943; RMSEA = .068; SRMR = .048), despite differences in the percentage variations explained by each factor (no invariance), likely due to differences in levels of technology use, learning management systems, and the preparedness of teachers to migrate to full online instruction. Despite limitations, the results of this study highlight the most important factors affecting online learning, providing insight into potential approaches for improving student experiences in online learning environments.

Inquiring asymmetric effects of oil prices, money supply, and domestic debt on consumer prices: an empirical evidence from Pakistan.

Oil prices (OP) may play a significant role in determining inflation in any oil-importing economy and could have an asymmetrical effect as well. Thus, this paper aims to explore the asymmetric influence of OP, broad money supply (BMS), and domestic debt (DD) on the Consumer Price Index (CPI) in the oil-importing economy of Pakistan using the nonlinear autoregressive distributive lag (NARDL) methodology on an annual sample from 1980 to 2021. The long-run results show that increasing OP and BMS have a positive effect on CPI. Similarly, decreasing OP and BMS have a positive effect on CPI. So, increasing OP and BMS is raising price levels, and decreasing OP and BMS is reducing price levels. OP has a positive and symmetrical effect on CPI. However, the BMS has a positive but asymmetrical effect on CPI. Furthermore, the effect of decreasing BMS is found greater than increasing BMS. Moreover, the effect of DD on CPI is also found asymmetrical. The increasing DD has a positive effect, and decreasing DD has a negative effect on CPI. The most of short-run results follow the long-run results. However, energy usage shows a negative effect on CPI in the short run, which is insignificant in the long-run results. This study recommends controlling the money supply and oil prices to reduce consumer prices.

Giant Hyperplastic Polyp at the Gastroesophageal Junction: A Rare Provocateur of Upper Gastrointestinal Bleeding.

Esophageal hyperplastic polyps (HPs) are a rare benign polypoidal growth most commonly resulting from gastroesophageal reflux disease (GERD). The lesion is asymptomatic in most patients unless large enough to cause luminal obstruction or gastrointestinal bleeding. The treatment of choice is endoscopic resection if it becomes symptomatic. Here, we report a case of a 51-year-old woman presenting with dyspeptic symptoms and upper gastrointestinal bleeding. An upper gastrointestinal endoscopy showed a large polyp with active oozing of blood at the gastroesophageal junction (GEJ), which was removed endoscopically after injecting adrenaline at its base. Histopathological analysis was suggestive of HPs.

Rare but critical: Aberrant vascular communication leading to multiorgan ischemia after prophylactic gastroduodenal artery embolization for refractory upper gastrointestinal bleeding.

Upper gastrointestinal bleeding (UGIB) carries a high risk of morbidity and mortality despite recent improvements in diagnosis and management. Many patients failed to respond to initial endoscopic and medical management. Transcatheter arterial embolization (TAE) is now considered the next line of therapy over surgery in refractory UGIB because of its good safety profile and high technical and clinical success rate. We discuss the case of a 66-year-old female patient who presented with massive UGIB and had TAE after endoscopic hemostasis failed. She developed widespread ischemia involving multiple organs following the procedure, including the liver, gallbladder, pancreas, spleen, and small intestine, as a result of an abnormal communication between the gastroduodenal artery (GDA) and superior mesenteric artery (SMA), resulting in PVA particle reflux and widespread ischemic injury. It is important to carefully evaluate the vascular anatomic variations before the procedure to avoid potential complications of ischemia.

A young man with Guillain-Barré syndrome, with a stroke-like presentation and physical findings suggestive of cervical myelopathy.

We describe the case of a 44-year-old gentleman with hypertension and asthma presenting to the emergency department after noticing right upper-extremity weakness upon awakening. Brain imaging did not reveal a stroke. Initial neurological examination pointed to cervical myelopathy with radiculopathy as well as possible underlying length-dependent peripheral neuropathy as there was right arm strength of 4/5 and there were brisker (3+) reflexes all over except at the right biceps reflex and both ankle reflexes. Cervical spine magnetic resonance imaging (MRI) showed myelomalacia at the C2 level and an os odontoideum (OO). Os odontoideum is a chronic condition that occurs due to the failure of the center of ossification of the dens to fuse with the body of C2. By the next day after a few hours of sustaining a fall, weakness progressed to quadriparesis, without a sensory level on examination, followed by urinary retention. This situation was attributed to a possible cervical cord contusion due to the fall in the presence of OO, with other possibilities being spinal cord hemorrhage, infarct and transverse myelitis. However, repeat scanning of the cervical spine (MRI) did not reveal any acute cord changes. The initial examination for common causes of peripheral neuropathy did not reveal any findings. Finally, the diagnosis of Guillain-Barré syndrome (GBS) was considered, and treatment was initiated with intravenous immunoglobulin. Cerebrospinal fluid analysis was normal. The diagnosis was confirmed using electromyography. Our patient's initial presentation of monoparesis and progression in an asymmetric descending manner was unusual for GBS. His initial presentation mimicked a stroke, and the later progression masqueraded as cervical myelopathy secondary to a chronic cervical cord lesion. The presence of a cervical cord lesion (upper motor neuron) concealed the expected areflexia in GBS. The presence of OO on spine imaging, absence of expected areflexia in GBS, and progression to paraparesis after the fall sidetracked the direction of the initial investigation and led to a relative delay in diagnosis. Nonetheless, appraising the diagnostic data in the clinical context led to an appropriate diagnosis. We emphasize the importance of reconciling the available clinical and diagnostic information to reach the correct diagnosis.