Background: Due to high-risk exposure of surgical residents to coronavirus, surgical residency programs have changed their training methods and working hours drastically. The purpose of this study is to find out the positive and negative impacts of the pandemic on surgical residency programs and on the lives of surgical residents. Materials and methods: A cross-sectional study was conducted on 112 surgical residents of a tertiary care hospital in Pakistan, with a mean age of 30.5 years from all the departments of surgery using a self-made, validated 40point questionnaire comprising three sections. The last section also included modified Maslach Burnout inventory.Results: Of all the residents, 97 (86.6%) stated that their surgical hands-on duration is adversely affected by the pandemic. As for clinical exposure, 92 (82.1%) trainees responded that their clinical exposure is affected too. Among all the subjects, 69 (61%) were concerned about transmitting it to their family members and 43 (38.4%) affirmed on being afraid of dying because of their direct exposure.On the brighter side, the average number of working hours per week for surgical residents were reduced from 81.10 ± 6.21 to 49.16 ± 6.25 (p < 0.001) due to the outbreak. Modified Maslach Burnout inventory score was 8.33 ± 2.34 after the outbreak, showing statistically significant reduction in burnout among the surgical residents (p < 0.001). Conclusion:The changes in the surgical residency programs amidst the pandemic has reduced the working hours, hands-on and clinical exposure of the surgical residents. Moreover, the situation has provided an opportunity to explore efficient methods of learning that can lead to lesser burnout. However, psychological burdens of surgical residents like fear of acquiring the infection should be appropriately addressed.

A pericardial cyst is one of the rare causes of mediastinal masses. Most of the cases are secondary to congenital incomplete fusion of the pericardial sac. More than two-thirds of the cases are present in the right cardiophrenic angle, and the left cardiophrenic angle is the second most common location. In our study, we illustrated an incidental finding of the pericardial cyst in a patient who presented with nonspecific symptoms and was found to have a left-sided cardiophrenic pericardial cyst, which is only found in about 20% of the cases. A CT scan and echocardiogram confirmed the diagnosis of a 4.39-centimeter cyst with no signs of complications like tamponade or pericarditis. As the patient's symptoms resolved, outpatient follow-up with serial echocardiogram was advised. Through this report, we aim to raise awareness of the importance of further investigation for nonspecific symptoms like atypical chest tightness and differentiating simple pericardial cysts from other pericardial lesions. Based on the symptoms, size, and compression effect of the cyst, management may vary from serial echocardiogram to aspiration or surgical resection.

BackgroundDepression is a well-known risk factor that aggravates the chances of having various complications of acute coronary syndrome (ACS) such as cardiovascular collapse, heart failure, arrhythmia, recurrent myocardial infarction, and stroke among patients of ACS. ACS is a broad term which includes unstable angina as well as myocardial infarction (MI). The purpose of this study is to analyze the prevalence of depression among the patients of MI admitted to the tertiary care hospitals of Karachi, Pakistan.Methods and materialsA hospital-based, cross-sectional study was conducted in which 375 admitted and diagnosed patients of MI with a mean age of 58 years were interviewed at the cardiology department of the Civil Hospital and National Institute of Cardio-Vascular Diseases (NICVD) Hospital, Karachi, from June to November 2017 using a self-made validated questionnaire, including patient health questionnaire-9 (PHQ-9).ResultsOverall, about 12.8% of the cases were screened positive for severe depression, 17.1% for moderately severe depression, 17.6% for moderate depression, and 32% for mild depression (total of 79.5%). Of 146 female subjects, 119 (81.5%) were found to be suffering from some degree of depression while 179 (78.2%) of the 229 males screened positive for some degree of depression. Furthermore, 79 (82.3%) of the 96 smokers were suffering from a range of depression while 219 (78.5%) of the 279 non-smokers suffered the same. In addition, the results of the PHQ-9 were cross-tabbed with age (p=0.34), gender (p=0.66), marital status (p=0.07), living status, smoking (p= 0.72), hypertension (p=0.55), and diabetes (p=0.19).ConclusionThis study concludes that many of the patients of MI who were admitted to the tertiary care hospitals in Karachi, Pakistan, are suffering from major depressive behavioral changes following the cardiovascular event, which is known to aggravate the chances of having complications associated with it.

Acute flare of multiple sclerosis usually presents with sensorimotor deficits in limbs or one side of the face, optic neuritis, internuclear ophthalmoplegia, and/or cerebellar signs and symptoms. Isolated aphasia is observed only in a handful of cases. Herein, we present a case of a patient who presented with isolated transcortical motor aphasia. Initial thought was that the patient was having a cerebrovascular accident as he had a history of uncontrolled hypertension. It was only later found on magnetic resonance imaging (MRI) of the brain that the patient had demyelinating lesions compatible with his new symptoms. He exhibited an excellent response to intravenous methylprednisolone therapy and was discharged with outpatient evaluation for immunotherapy.

Achromobacter xylosoxidans is a catalase-positive, oxidase-positive, motile, gram-negative rod. When isolated, it is usually a cause of bacteremia in immunocompromised patients. Here we present a case of liver abscess caused by this rare organism in an immunocompetent host. A 57-year-old Colombian woman came to the emergency department with complaints of subacute onset of back pain, burning in urination, fever, nausea, and vomiting. She was febrile and tachycardic. Urinalysis was positive for leukocyte esterase, nitrite, and bacteria. The patient was started on empiric piperacillin tazobactam 3375 mg as intravenous piggyback every 8 hours. On day 3 of hospitalization, the patient continued to experience flank pain without improvement. Computed tomographic scan of the abdomen and pelvis with contrast revealed 2 thick-walled complex collections in the right hepatic lobe and the caudate lobe of the liver. Purulent aspirate grew A. xylosoxidans. In this report, we explore the characteristics of A. xylosoxidans and the associated infections it is known to cause as well as suggested treatments from previously reported cases.

Cocaine is considered a leading non-opioid cause of drug overdose in the US. It acts as a sympathomimetic and increases the amount of catecholamines, thereby increasing the risk of ventricular irritability and resultant arrhythmias. Its sodium (Na) channel blockage is the principal mechanism behind the Brugada pattern on an electrocardiogram (ECG), which is often transient but is indistinguishable from that of Brugada syndrome, the autosomal dominant channelopathy.We are presenting a case of a 32-year-old male with a history of cocaine and nicotine abuse, who sought medical attention for sudden-onset palpitations and pressure-like chest pain after having snorted an impressive amount of cocaine. His ECG depicted a classical Brugada pattern with ST-elevation with T inversion in V1; however, previous ECGs were normal without ST changes, signifying the Brugada pattern unmasked by cocaine use. Other investigations including stress tests and nuclear imaging were equivocal. His symptoms as well as the ECG pattern reverted to baseline signifying the presence of Brugada phenotype in the absence of channelopathy.Hence, as a sodium channel blocker, cocaine may unmask latent Brugada syndrome in asymptomatic patients without a family history. Recognizing Brugada syndrome on ECG is vital to avoid misdiagnosis and mistreatment of the patient with and without a genetic predisposition.

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Figure 1. (A-B) Non-contrast CT abdomen and pelvis done upon initial presentation showing findings suggestive of bowel wall thickening in the ascending colon and cecum concerning for colitis in axial (A) and coronal (B) planes. (C-E) Repeat non-contrast CT abdomen/pelvis in axial (C) and sagittal (D, E) planes which showed increase in colonic distention within the transverse colon measuring up to 7cm (C, E) and increased distention within the cecum and ascending colon (D) concerning for toxic megacolon.