Last Rituals and handling of deceased in corona pandemic? 91-93. Effectiveness and safety of endoscopic vs open carpal tunnel release: Single center experience from Maldives. 113-117. Bezoar as a cause of gastric perforation in young female patient: A Case Report

and well being of all the handlers ought to be ensured by providing all, necessary resources for keeping them out of harm’s way, which includes both structural equipment like PPEs (i.e. gloves, gowns, face shields, N95 masks, goggles, shoe covers, etc.), sanitizers, clean autopsy tables, and working environment. Also, comprehensive instructions to follow, allowing minimum fanning out of the infection to healthy individuals including themselves, which may include providing training in hand hygiene and how to put on / remove PPEs. Lonely death and no relation at last rights, this may seem like the ending of an incredibly sad film, but unfortunately, it has become the reality of people infected by the presently-pandemic microbe, the Coronavirus; specifically a novel strain of it, the COVID-19 virus.[1] COVID-19 is one strain that wasn’t previously identified in humans. It first showed signs of its existence in late 2019 in Wuhan, China, where the reported case of the individual developed a mysterious illness, that proceeded to show worsening signs of the acute respiratory disease started.[2] From there, in just a matter of months, it has caused a large and ongoing outbreak. Since then, there have been thousands of confirmed cases and alarmingly increasing deaths worldwide. Recent evidence suggests that it is transmitted between people through droplets, fomites, and close contact, with possible spread also through secretions and feces.[3] This is a new virus whose source and disease progression are not yet entirely clear, hence more precautionary measures are a necessity until more and definite evidence is available about its mode of progression. Ever since the first person passed away from this utterly infectious malady, it became quite clear that the proper last rituals of the suspected or confirmed case of COVID-19 were an urgent necessity, with each situation to be managed on a case-by-case basis, balancing the rights of the family, the need to investigate the cause of death, and the risks of exposure to infection. Hence, an efficient protocol of dealing with the infected corpses has to be devised as a national action plan to combat the risks involved during the transportation, handling and if needed, postmortem examination of the dead body. A separate set of guidelines for the systemic burial of the departed soul should also be set forth to assure the maximum limitation of the spread of the disease while maintaining the dignity of the deceased. Editorial

May -July 2020 | Vol 1 No 2 | V Acquisition of funding, collection of data, or general supervision of the research group, alone does not justify authorship. All persons designated as authors should qualify for authorship & all those who qualify should be listed. A maximum number of four tables or illustrations are allowed. If their number is more, the manuscript may not be accepted for further processing. All persons designated as authors should qualify for authorship and all those who qualify should be listed. Each author should have participated sufficiently in the work to take public responsibility for appropriate portions of the content. In the case of more than one author in a manuscript, the contributions of each person listed as an author in the study should be mentioned. When a large, multi-center group has conducted the work, the group should identify the individuals who accept direct responsibility for the manuscript. These individuals should fully meet the criteria for authorship defined above and editors will ask these individuals to complete journal-specific author and conflict of interest disclosure forms. When submitting a group author manuscript, the corresponding author should clearly indicate the preferred citation and should clearly identify all individual authors as well as the group name. Other members of the group should be listed in the acknowledgments. The addition and deletion of authors may not be permitted after submission with LOU signed by authors. myocardial infarction. Results of the TIMI Phase-II trial. N Eng J Med. 1989;320:618-627. Newspaper articles: Malik Mahmood A, autonomous hospitals, "Pulse" International, Karachi, Pakistan, 2000. January 15-31, Page 1 & 2. Citation of personal communications and unpublished observations should be strictly limited and given in brackets in the text. These should not appear in the list of references. A paper may not be cited as "Under Publication or in Press" unless it has been accepted for publication & the name of the Journal is given. 15. Authorship: Authorship credit should be based on: 1) substantial contributions to conception and design, or acquisition of data, or analysis and interpretation of data; 2) drafting the article or revising it critically for important intellectual content; and 3) final approval of the version to be published. 4) Agreement to be accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved. Authors should meet conditions 1, 2, 3 and 4. (For details of ICMJE Authorship Criteria see Letter of Undertaking). 16. Acknowledgment: All contributors who do not meet the criteria for authorship should be covered in the acknowledgment section. It should include persons who provided technical help, writing assistance and departmental head who only provided general support. Financial and material support should also be acknowledged. Persons who have contributed materially but do not justify authorship can be listed as "clinical investigators" or "participating investigators" or "Scientific advisors" or "critically reviewed the study proposal or collected data." 17. Length of Text: The maximum length of the original manuscript should not exceed 3000 words including title page, table, and references. In exceptional cases, up-to 3500 words may be accommodated. For Review article 4000 words. Any term which is mentioned in the text quite frequently must be abbreviated but only if this does not detract from readers' comprehension. Such as Acute Myocardial Infarction (AMI).The maximum number of tables & illustrations should not exceed four. Case Report: Short report of cases, clinical experience, drug trials and adverse effects can be submitted. Maximum length should not exceed 1500 words, the maximum number of ten references, one table or two illustrations. It must contain genuinely new information. Its format should be Title, Abstract, Introduction, Case Report, Discussion and References. Do mention the contribution of each author as per the authorship criteria. Case reports should not include a review of the literature. Letters: Maximum words 350 with 2 to 3 references. Extra charges will be applicable for lengthy manuscripts. 18. Tables: Do not submit tables as photographs. Give each column an abbreviated heading. Identify statistical measures such as standard deviation and standard error of the mean. Make sure that each figure and table are cited in the text.

Figures:
The figures should be sent in JPEG format with at least 300 dpi or resolution as a separate file. The desired position of any figure or table should be marked in the manuscript. 20. Never start a new sentence or paragraph with figures. For example, "9 patients were admitted" should be written as "Nine patients were admitted". Single-digit figures should be written in words i.e. 2 should be written as two. 21. The manuscript should be accompanied by a cover letter signed by all authors stating that the manuscript has been read and approved by all the authors, the requirements as stated earlier have been fully met and each author believes that manuscript contains honest work. Mention the name, address, phone, cell phone, email and Fax Number of the corresponding author who will be responsible for communicating and final approval of the proofs. Only the correspondence author should communicate with the editor. 22. Clinical Trials: Clinical Trials submitted for publication must be registered in the public registry, provide registration proof & all RCTs must be based on CONSORT statement. Unregistered trials will not be published. 23. Procedure: PAKISTAN JOURNAL OF SURGERY AND MEDICINE is a peer REVIEWED international medical journal. All articles on receipt for publication are immediately acknowledged but this does not mean that it has been accepted for publication. After initial screening, the manuscripts with major deficiencies, or of no interest to our readers will not be accepted for further processing and external peer-reviewed and the submitter will get an email within two weeks of submission. 24. Proof Reading: The final version of the manuscript is sent to the corresponding author for proofreading before publication to avoid any mistakes. Corrections should be conveyed clearly & Editor informed by e-mail. 25. Processing Charges: No Article Processing Charges. 26.Publication charges: No Publication Charges. All Articles are Printed Open Access Platinum. 27.Drug Trials: Drug trials of preparations by pharmaceutical firms who are regular advertisers of Quarterly Pakistan Journal of Surgery & Medicine will be published without any additional charges after their approval by the Review Committee. Others will be required to pay a fee of Rs.50,000/= only payable in advance after the manuscript has been approved by the Review Committee and is accepted for publication. 28 given utmost priority. The safety and well being of all the handlers ought to be ensured by providing all, necessary resources for keeping them out of harm's way, which includes both structural equipment like PPEs (i.e. gloves, gowns, face shields, N95 masks, goggles, shoe covers, etc.), sanitizers, clean autopsy tables, and working environment. Also, comprehensive instructions to follow, allowing minimum fanning out of the infection to healthy individuals including themselves, which may include providing training in hand hygiene and how to put on / remove PPEs.
Lonely death and no relation at last rights, this may seem like the ending of an incredibly sad film, but unfortunately, it has become the reality of people infected by the presently-pandemic microbe, the Coronavirus; specifically a novel strain of it, the COVID-19 virus.
[1] COVID-19 is one strain that wasn't previously identified in humans. It first showed signs of its existence in late 2019 in Wuhan, China, where the reported case of the individual developed a mysterious illness, that proceeded to show worsening signs of the acute respiratory disease started.
[2] From there, in just a matter of months, it has caused a large and ongoing outbreak. Since then, there have been thousands of confirmed cases and alarmingly increasing deaths worldwide. Recent evidence suggests that it is transmitted between people through droplets, fomites, and close contact, with possible spread also through secretions and feces. [3] This is a new virus whose source and disease progression are not yet entirely clear, hence more precautionary measures are a necessity until more and definite evidence is available about its mode of progression. Ever since the first person passed away from this utterly infectious malady, it became quite clear that the proper last rituals of the suspected or confirmed case of COVID-19 were an urgent necessity, with each situation to be managed on a case-by-case basis, balancing the rights of the family, the need to investigate the cause of death, and the risks of exposure to infection. Hence, an efficient protocol of dealing with the infected corpses has to be devised as a national action plan to combat the risks involved during the transportation, handling and if needed, postmortem examination of the dead body. A separate set of guidelines for the systemic burial of the departed soul should also be set forth to assure the maximum limitation of the spread of the disease while maintaining the dignity of the deceased.

Editorial
May -July 2020 | Vol 1 No 2 | Pg 91 Pakistan Journal of Surgery & Medicine Last Rituals and handling of deceased in corona pandemic.

2
Considering the contiguity of this virus, it only makes sense that the health care workers and all other associated personnel such as, funeral directors and mortuary staff, in close contact with the corpse be Hence after the death of the patient, the first and foremost thing is the complete protection of the staff, ensuring all protective precautions. After covering yourself up according to the extent of the task at hand, the body is to be wrapped "up in a cloth" and transferred to a mortuary ASAP, while ensuring all orifices are closed and bodily fluids are contained. In accordance to WHO guidelines, cadavers lack the ability to spread infections; however, as reported by an authentic news source, Thailand had allegedly the first fatal case of the infection transmitted from a dead patient to a medical examiner, a finding that added to the safety concerns for morgue and funeral home workers amid the global pandemic.
[4] "It is more resilient in that it sticks around the dead body," says California's Dr. Judy Melinek, bringing forth another warning sign for forensic pathologists dealing with the malady in their laboratories. "  is a respiratory pathogen and can be transmitted via respiratory droplets, but also through the blood of a viremic patient. Even though decedents don't cough, they can expel bodily fluids while they are being moved or transported, "she explained. [5] Hence some additional precautions to be taken into Embalming the dead body is not to be allowed. Round ended scissors should be used. At the end of the procedure, the body should be disinfected with 1% Sodium Hypochlorite and placed in a body bag, the exterior of which will again be Thereafter the body can be handed over to the relatives.
procedures (i.e. must be a well-lit room, with enough ventilation, etc.) decontaminated with the same solution.
The relatives can then perform their burial rituals, as desired. Some families may prefer handing the body over to funeral directors so that the standard precautionary measures can easily be brought to action and proper arrangements are made. It is significant to note in some cultural institutes of specific societies, cremation is preferred over the burial ritual. Some sources believe that the perfect route to disposal of infected vessels is cremation, as it completely rids of the entire body by burning its entirety to ashes. Still, other religions accept a proper burial as the only way of 'resting in peace', their deceased. This decision requires consideration of the religious and cultural perspectives of the family of the deceased, and it is our responsibility to uphold the dignity of both the alive and the dead. In the Islamic Republic of Pakistan, we have put forward the disposal in a plastic well-compacted bag as the best choice of laying down the dead, and perform the Islamic ritual of praying in congregation, funeral prayer, to seek pardon for the expired Muslim; but of course, the standard protocol has to be followed, by limiting the number of persons and maintaining a safe distance of about 2 meters or more between each attending Individuals. The risk from not following protocol is catching the horrible disease, which may be mild like dry cough and fever, to severe COVID dragging the patient down to his deathbed. The physicians can only provide the symptomatic treatment, helpless if souls start leaving their bodies despite providing the highest quality of medical care. Known definite risk factors are old age, underlying illnesses (e.g. diabetes, heart disease, AIDS, etc.) but we have yet to figure out the risk factors for healthy young patients. "One day they're okay, the next day they require intubation. [It's] one of scariest parts of this When the body arrives in a morgue, the decision to perform an autopsy is made. In areas where there is a known pandemic, the autopsy is not required in patients with diagnosed COVID infections, and a mere chest X-ray, extraction of a Nasopharyngeal swab specimen and the patient's complete history is enough to deduce whether the patient has died of corona or not. [6] However, in cases where a John Doe or a Jane Doe is brought over by the police, a postmortem is done to confirm the cause of death and that may turn out to be a neglected case of the virus outbreak.

CONFLICT OF INTEREST
The author declared no conflict of interest

MATERIALS AND METHODS
via an open or endoscopic approach. Other newer techniques also include ultrasound-guided steroid injection combined with mini scalpel-needle release, nerve hydro-dissection, z-elongation of the transverse carpal ligament and radial extracorporeal shock waves. [1][2][3] We conducted this randomized control study to compare the efficacy between 'endoscopic' and 'open' carpal tunnel release surgeries. The study was performed in a single-center, in the department of Neurosurgery in ADK hospital, Maldives. We analyzed a total sample size of

Electronic Opinion
Dear Sir, I have read with interest the article by Kamran M et al.
[1] I would like to highlight that misadventures occur when details are omitted from history. It is essential that a doctor gains the trust of his patient and obtains information regarding taboo topics (sexual relations, drug abuse etc) as well. However, there are instances when the health and safety of another individual is also at risk (Epidemics, STDs, Corona Virus, etc), and then this oath is deliberately broken. It is the onus of doctors to uphold their oath of providing the best medical diagnosis and treatment to the concerned parties. Often times, to do so means to violate the terms of confidentiality, but in good faith.
Thank You.
Sir, The prevalence of drug abuse is rising at an alarming rate with cannabis as the most popular drug used in Pakistan. Per the United Nations Illicit Drug Trends Report on Pakistan, cannabis is a drug of choice and the most commonly abused substance since it is cheaply and easily available for recreational purposes.
[1] Additionally, the findings of the survey conducted by Bajwa et al to determine Cannabis trends in 2013 revealed approximately 4 million cannabis users in Pakistan.
[2] The term Cannabis, also known as marijuana, denotes the variety of psychoactive constituents including d-9 tetrahydrocannabinol derived from the plant Cannabis sativa. It carries a spectrum of psychological and physical manifestations including altered state of consciousness, euphoria, relaxation, and increased appetite.
[3] Cannabis is widely used for medical purposes to improve chemotherapy-associated vomiting and nausea, to increase appetite in AIDS/HIV patients, and to treat body pain and muscle spasms. However, there are a variety of adverse side effects associated with cannabis use including confusion and memory loss, delusions, hallucinations along with anxiety, and agitation. Additionally, Chronic bronchitis leading to excessive coughing with the production of sputum and wheezing is a clinical manifestation observed in chronic heavy cannabis smokers. Moreover, the consistent use of cannabis in young adulthood leads to an increased risk of schizophrenia and psychotic symptoms. Andreasson et al in his study reported that the proportion of sample population that consumed cannabis before an age of 18 years was 2.4 times more likely to suffer from schizophrenia than those who had not.

CONFLICT OF INTERST
The author declared no conflict of interest

MANUSCRIPT PROCESSING
The views and opinion expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any other agency, organization, employer or company.
the spread of the virus on an even bigger scale, and therefore should be discouraged. [10] In light of these events, we urge Health Regulatory Bodies in Pakistan and other developing countries to thoroughly investigate individuals claiming to be doctors especially in areas that have low-income and low-literacy populations and are hence, susceptible to such fraudulent and potentially lethal practices. These events re-iterate the importance of raising public awareness towards proper sanitary practices, especially regarding any local practices which can result in blood-borne infections to be transmitted Furthermore, developing countries continue to bear the load of the most HIV infected individuals with Sub-Saharan Africa alone having almost 25 million individuals from a total of 38.6 million people infected globally until 2007. [5] In light of these devastating numbers, the sudden outbreak of HIV in Sargodha, a city in Pakistan with a population of 1.5 million people, requires immediate attention from the global medical community, especially in developing countries which share the same high-risk status for HIV infections like Pakistan, so that precautions can be taken to prevent this from happening again. [6,7] Dawn News reports that in the past decade, Sargodha has had one of the most HIV infected populations in Pakistan with over 800 people being carriers. [7] In 2017, 37 people were diagnosed as carriers of HIV, and it was found that they had all gone to the same self-proclaimed doctor, practicing without a license, and would re-use syringes, leaving these people infected with HIV. [7] A recent outbreak occurred in June 2019 in Larkana, Sindh in which a tested population of 26041 people, confirmed 751 cases of HIV/AIDS, constituting 2.88% of the total population, however, the precise reason for this is still unknown. A large number of people Letter to Editor tested was done in accordance with WHO guidelines on HIV treatment which recommends a test-and-treat strategy. [8] In a comprehensive review of the literature done in 2011 over the AIDS epidemic in Pakistan, the study stated that the reasons underlying the presence of HIV are due to Pakistan being a developing country. [9] Since 2007, a consistent increase in the usage of drugs and narcotics has been seen in the Pakistani youth.
[10] Additionally, truck drivers constitute a significant population living in the rural areas of Pakistan; hence, during the time away from home, they tend to have sexual intercourse, usually without protection, with young boys who are usually the helpers and other fellow workers. [10] Furthermore, barbers in Pakistan are not aware of the spread of HIV, and the routine of reusing razors has added to this troublesome situation. Such practices lead to 10.

11.
May -July 2020 | Vol 1 No 2 | Pg 99 Pakistan Journal of Surgery & Medicine such as re-using of blades by local barbers in this particular case. [11,12] This also raises the critical issue of public dialogue regarding contraceptive and sexually transmitted infections (STI) prevention practices such as the employment of condoms in countries similar to Pakistan where the majority of the discussions about sexual practices are considered taboo and invite great criticism from the public, along with the illicit use of drugs by needles is making it an even greater issue. [13] A single intervention will not prove to be effective. The need of the hour is a customized, combined intervention plan with a specific focus on the target population, that can prove to be much more effective, including, but not limited to, public awareness campaigns regarding HIV and its transmission combined with sex-education in schools focusing on practicing safe sex, as well as government-endorsed mandatory check-ups for sex workers. [12] REFERENCES 12

CONFLICT OF INTERST
The author declared no conflict of interest

MANUSCRIPT PROCESSING
The views and opinion expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any other agency, organization, employer or company.

PUBLISHER'S NOTE
Background: Medical students are well known to work long hours, have financial difficulties, and face intense competition to succeed which may predispose them to significant psychological stress. Physical Activity may provide relief to stress in this population. Objectives: To evaluate the effect of physical activity on the reduction of stress in medical students in a developing country. Methods: Between April and May 2015, medical students at a private medical college within Karachi, Pakistan participated in a cross-sectional study to evaluate physical activity and stress levels. Questionnaires were distributed to all medical students by convenience sampling. A three-part questionnaire was developed based on the Perceived Stress Score to evaluate for the presence of stress. Patient demographics, Perceived Stress Score, participation, and the total duration of physical activity per week were obtained. Participants were also instructed to answer questions on other activities that they may be performing with the intention to relieve stress. Results: A total of 235 participants were identified for further analysis. Based upon the Perceived Stress Scale (PSS), 30.3% of the medical students were found to have evidence of the stress with a mean PSS score of 16.95 ± 5.72. Participation in physical activity was found to cause a reduction in stress levels with medical students not reporting exercise is twice as likely to be stressed (OR 0.48, p = 0.015). In addition, the total duration of physical activity per week (>4 vs <2) was seen to be independently related to reduced PSS score (16.2 vs 18.2, p=0.028). Conclusion: Both participation and longer duration of physical activity per week are associated with a significant reduction in stress levels within medical students. Keywords: Stress, medical student, exercise, activity, burnout, college in mental health-related symptoms has been attributed to a reduction in distraction and cognitive dissonance while simultaneously improving self-efficacy. [6] A biochemical hypothesis for these changes in anxiety, depression, and other mood disorder may be best explained by the monoamine and endorphin hypothesis. [6] The hippocampal 5HT1A receptor-mediated cAMP/PKA/CREB signaling pathway disturbance results in a depressed mind, it is thought that this signal pathology is improved by chronic exercise which subsequently produces improved mental health outcomes. [7] ABSTRACT INTRODUCTION Psychological stress is a term synonymous with a A cross-sectional survey was distributed to medical students between April and May 2015 in a private medical college associated with a tertiary care hospital within Karachi, Pakistan. Before the initiation of the study, consent was obtained from all participating medical students with written informed consent which was supervised by the ethical review committee. Medical students from all years (1-5) were included for participation in the study regardless of whether they reported regular participation in physical activity or not. Convenience sampling was utilized to select subjects for survey distribution however to reduce selection bias, attempts were made to distribute the survey evenly between all five groups. The initial section of the questionnaire queried the medical students' demographic information which consisted of the participants' age, residence (on-campus residence vs off-campus day scholar), and year of medical school enrollment. Also, the survey inquired about frequency, type, and total time spent on physical activity for 1 week.The second part of the survey evaluated stress levels within the participating medical students, the questionnaire utilized assessment based upon the Perceived Stress Scale. [9] A 5-point scale, from a minimum of 0 (rarely) to 4 (almost always) was used to evaluate responses. The questionnaire was not modified from its original form. Answers to negative questions were summed together followed by subtraction from the sum of positive questions. Participants with a Perceived Stress Scale score of < May -July 2020 | Vol 1 No 2 | Pg 101

Pakistan Journal of Surgery & Medicine
Depression is typically managed with a combination of psychological and pharmaceutical therapy, however, there may be a significant benefit in symptom control by the addition of alternative approaches such as physical activity. [8] In the evaluation of stress, the goldstandard remains the perceived stress scale; this 14item questionnaire contains 7 positive and 7 negative items, each of which is assigned a numerical value between 0-4 based on symptoms, subsequently, the sum of 7 negative stress questions are subtracted from the sum of the 7 positive questions to establish a final score. [9] Although the use of physical exercise to improve symptoms of mental health in the general population, the specific effect of this physical activity on medical students in a developing country is less well known. We hypothesize that a reduction in stress levels may be seen with physical exercise. Subsequently, to evaluate this we evaluated the effect of physical activity and stress based on the perceived stress scale. 20 were identified to not be stressed however participants with a score of ≥20 were acknowledged as being stressed. The third part of the survey comprised of questions regarding alternative stress-relieving practices employed by medical students who were not related to physical activity. Medical students were not given limited choices to answer these questions and were free to report any activity which relieved stress for them such as hobbies or meditation. The appropriate sample size for the study was calculated by a descriptive study open-source calculator with OpenEpi software version 3.0. Precision for the study was maintained at 5% with an anticipated stress percentage frequency of 50% which resulted in a total calculated sample size of 218. The sample size was inflated to 235 given anticipation for refusal of participation and non-responders. EpiData version 3.1 was utilized for data entry and collection. The data was subsequently transferred to a Microsoft Excel Sheet following which analysis was completed by IBM SPSS version 19.0. A total of 4 response questionnaires had incomplete data and were subsequently removed from the final analysis. Tables related to baseline demographics and between physically active medical students was established. A bar chart illustrated the correlation between physical activity per week and Perceived Stress Scale scores. Subsequently, odds ratios were calculated for variables to locate significant factors.

RESULTS
A total of 235 participants met the inclusion criteria for the study. Table 1 describes the demographic characteristics, participation in physical activity, and stress levels of the medical student subjects. Although both males and females were represented in our study sample, the later were marginally more frequent (52.8%). Third-year medical students were the most represented class (30.2%) whilst a majority of the participants resided in university housing (59.1%). Participants were aged between 17 and 27 years with a mean age of 21.44 ± 1.663 years. A large portion of the study population (72.3%) were physically active and were involved in a minimum of 1 form of exercise. Medical Students most frequently reported running (45.5%) as their preferred form of physical activity although jogging (29.8%), swimming (27.7%), football (23.0%) and floor exercises (23.0%) were also popular. Less frequent but other reported activities included dancing, horse riding, martial arts, and tae-kwon-do. Study participants who reported physical activity most Table 1: Demographics, participation in physical activity, and stress levels of the subjects. Table 2: Relation between stress with physical activity and other stress relieving factors commonly stated that they were involved in the chosen activity for an average of 2-4 hours per week (22.6%). A minority of medical students reported involvement in physical activity for > 5 hours per week (15.0%). A total of 70 participants (30.3%) were classified to be stressed based on the Perceived Stress Scale. The number of participants with each calculated Perceived Stress Scale score (PSS) is shown in the bar graph in Figure 1. Medical students had PSS scores which were between 2 and 30 points. The mean PSS score was 16.95 ± 5.72 whereas the median PSS score was 17. A large portion of the participants had a borderline PSS Females were slightly more populous within the study population (52.8%), this is in-line with prior reported literature on higher female prevalence within medical schools, and given this, it may be presumed that our reported findings may be generalized to other medical students. [10][11][12][13] A drawback of convenience sampling is an unequivocal number of participants from each medical school year with first (17.9%), second (7.7%), third (30.2%), fourth (29.8%), and fifth (14.5%) year students. Prior literature has suggested that disparities exist between prevalence and management techniques of stress within different years of medical school enrollment with a recent study, which utilized the Perceived Stress Scale reported that 59.7% of students suffered from stress. [12][13] Our study reported that second and fifth medical students were most frequently stressed (71.6% and 71.1%), whereas fourth (53.3%), first (50.0%), and third (50.0%) year students were less likely to experience stress. This is in contrast to prior data which suggested that first-and third-year medical students had higher stress levels however without statistical significance. [14] The difference in stress levels between different May -July 2020 | Vol 1 No 2 | Pg 103 Pakistan Journal of Surgery & Medicine score of 20 which was associated with a diagnosis of stress. Population distribution was negatively skewed. A significant co-relation was witnessed between physical activity and stress levels within medical students (p=0.015). Evaluation of secondary factors and stress levels in medical students is compared in Table 2. Medical students who took part in their hobbies were found to be significantly less stressed (p=0.044), however other secondary factors including meditation, breathing exercises, mental imagery, and extracurricular activities were not associated with a reduction in stress. The participation of medical students in consistent physical activity was likely to result in stress reduction, however, statistical significance could not be attained. Perceived Stress Scale scores and physical activity were compared utilizing one-way ANOVA with stratification based on several hours per week, (< 2 hours, 2-4 hours, > 4 hours). The duration of physical activity was associated with a reduction in stress level (F=2.475; p=0.008). Post-hoc statistical analysis was completed with Fisher's test. Medical students with >4 hours of exercise per week had a significantly lower PSS score (-2.94, p=0.028) when compared to participants with a total duration of the exercise of < 2 hours per week.

DISCUSSION
academic years is likely multifactorial; given schedule differences, workload, and variations in types of education-related activity. Despite this, our reported prevalence of stress was much lower than prior studies which may be attributed to differences in medical school curriculum and emphasis on student well-being. [15] These confounding factors can result in lower participation in physical activity and lead to the discrepancies seen in the literature.Participants were characterized as stressed (≥ 20) or non-stressed (<20) based on the Perceived Stress Scale questionnaire. [9] A minority of medical students demonstrated significant stress (30.3%) which was found to be lower than both national (41.7%) and international (49.0%) data. [14,16] Results may have been confounded with medical students participating in the study within 1 week of their exams. Despite this, other cross-sectional studies have shown similar results with a questionnaire-based study reporting stress was associated with predisposing psychosocial (OR 5.01, 95% CI 2.44-10.29) and academic-related (OR 3.17 95% CI 1.52-6.68) factors in medical students. [16] The reason for stress in medical students is broad, with common factors including high workload, parental expectations, exam frequency, extensive curriculum, financial pressure, isolation, and frequent self-reflection on plans which cumulatively result in a detrimental effect on academic performance (r = -0.099, p > 0.05). [17] To help alleviate or reduce stress the involvement in sporting and social activities has had positive effects. [14] The use of exercise has particularly been helpful in students, with the population reporting improved capability to cope with stress and emotional trauma of medical school.
[18] Our study validated these claims; of the 170 medical students who stated they took part in physical activity, 74.3% were found to have insignificant levels of stress in their life. In contrast in participants who denied physical activity, 42.2% were Our results indicated that medical student involvement in physical activity results in a significant decrease in observed stress levels. Besides, a longer total duration of exercise per week can result in further improvement in stress levels. Medical students are likely to experience more stress than the general population and management are of this pathology is of utmost importance. We recommend that curriculum changes be considered to allow more exercise dedicated time for medical students. Besides, medical students should be screened for stress and be given appropriate help if deemed at risk. As with other cross-sectional studies, our analysis was limited due to the inference between causality and temporality. Although physical activity likely relieves academic or psychosocial stressors, given our study design we cannot conclude this with certainty. Prospective cohort studies may be performed in the future to help correlate physical activity with the incidence of psychological symptoms. We also believe recall bias may have occurred due to the distribution of a self-administered questionnaire. Given our study involved a single medical school, generalization of results to academic institutions across the globe may be difficult.
May -July 2020 | Vol 1 No 2 | Pg 104 Pakistan Journal of Surgery & Medicine categorized to have stress. There was a significant difference between those who did or did not exercise (p=0.015). Confounding factors were evaluated within the 3rd portion of the questionnaire. Open-ended questions were inquired from medical students concerning activities utilized by them to de-stress. Medical students stated that they participated in personal hobbies, social interaction, meditation, mental imagery, breathing, and extracurricular activities to help alleviate stress. These activities were analyzed concerning the presence of stress with involvement in personal hobbies the only significant factor to reduce stress in participants (p 0.044, OR 0.547, 95% CI = 0.26-0.87). Physical activity was found to significantly reduce stress levels in medical students in our study and the prevalence of stress was approximately two times more in participants who did not participate in physical activity. Besides, a positive correlation was found between the total duration of exercise per week (>4 hours vs <2 hours) and reduction in stress levels (mean difference of PSS score -2.94, p=0.028). Hence our study associates physical activity with a reduction in stress level.

CONFLICT OF INTERST
The author declared no conflict of interest

HOW TO CITE
The views and opinion expressed in this article are those of the authors and do not necessarily reflect the official policy or position of any other agency, organization, employer or company. working doctors was selected. The technique was non-probability. After informed consent, each doctor was given the NRCWE's Copenhagen short questionnaire consisting of 39 questions. The analysis of data was entered in SPSS 21. The frequency of obtained data was calculated and demographic variables were elaborated. Independent t-test sampling was applied, and tables and pie chart were drawn. Results: This study included worse working conditions in terms of stress, burnout, work-family conflict, and social support from superiors. High levels of stress and burnout were found. Doctors were almost satisfied with their jobs (scores near to average but less than average). Male doctors were found to be more satisfied with their jobs than female doctors. Keywords: work environment, burnout, stress. According to "Karasek's Job Strain model", high strain jobs result in anxiety, depression, and physical illness. In Japan, the incidence of mental health problems is on the rise in the professional population and thus, the primary prevention of mental health problems and maintenance of emotional well-being are the most important priorities of authorities and the workers themselves.

Assessment of psychosocial work environment of doctors
[3] Out of all mental health problems, depression is the most common one mental health among employees that is characterized by persistently low mood, decreased interest, feeling of poor self-worth, suicidal behaviors, and vegetative symptoms.[2, 3] It can be highly associated with the environment; a person is living or working in. A study

ABSTRACT INTRODUCTION
Psychosocial work environment assessment informs us about the psychological and social issues faced by the employees. When one works at a place, a safe environment and occupational health are the foremost challenges faced by an individual. The reason for the demand for a safe and healthy environment at the workplace is continuously evolving due to the nature of work and the impact on the people doing it. The well-being of a human is influenced by the environment and type of work. The International Labor Association defines psychosocial There is a lack of regional & local data with regards to the psychosocial work environment of doctors, highlighting the need to conduct this study. It focused on the qualitative assessment of six variables which included stress levels, satisfaction from the job they are doing, self-rated health, burnout, work-family conflict, and social support from the superiors at work. We hope that our study will add to existing national and international literature and in the long run, will help in the improving psychosocial work environment of doctors.
May -July 2020 | Vol 1 No 2 | Pg 107 Pakistan Journal of Surgery & Medicine conducted (2016) among post-graduate residents in German hospitals reported depression among 9% of the participants. The distress level varied significantly among specialties with the most significant stress among Surgeons and Anesthesiologists. [4] Besides depression among doctors, other mental health issues were burnout, emotional exhaustion, and stress. In another study among Japanese psychiatrists in 2013, emotional exhaustion was found to have an association with the workplace environment too. Emotional exhaustion has been shown to have an inverse relationship with an appreciation of the magnitude of personal achievement. [5] Moreover, another study conducted to assess the magnitude of mental disorders in European countries showed that organizational justice and workplace social conditions particularly bullying were significantly associated with stress levels. [6] The time duration of job/service was another factor affecting health in various aspects. Physicians employed for a lesser time were in a healthier state as compared to doctors who had been working for a long time. [7,8] Demands at work Inter-personal working relationship with colleagues Workforce organization questionnaire, which consisted of thirty-nine questions. The psychosocial work environment was evaluated with fourteen parameters from the NRCWE questionnaire (version 1) which focused on three main areas viz a viz; i. ii.
iii. We analyzed the socio-demographic and self-rated emotional well-being and job attributes of the respondents. We analyzed data using the analyses of covariance, partial correlations, Cronbach's alphas, linear regression models and one-sample t-tests were utilized for data analysis. The variables that determine the psychosocial work environment and the quality of life were categorized into four domains.

METHODOLOGY
We got approval from the institutional review board vide letter number SKZMDC/DPHCM/399/19.

Ethical Consideration:
A cross-sectional study was conducted among the doctors of Shaikh Zayed Hospital (SZH), Lahore from March 2017 to June 2017, to evaluate the psychosocial determinants affecting the work environment. A consecutive (convenient) sampling method was used.
A sample size of 100 working doctors (n=100) was selected, belonging to any age group, irrespective of marital status and designation in the hospital.

Study population:
We used the National Research Centre for the Working Environment (NRCWE), Denmark's short Data Collection:

Data Analysis
This study included a total of 100 participants. In the present study, males accounted for 44% of the subjects while females accounted for 56% of the subjects. The unmarried category comprised 27% males and 20% females while 17% of males and 36% of females came under the married category.Applying t-test sampling showed worse working conditions regarding stress, burnout, work-family conflict, social support from superiors, job satisfaction, and self-rated health. Not even a single variable reported better working conditions; which highlights psychosocial factors faced by doctors at work are pretty concerning Thus, these psychosocial factors resulted in high stress and burnout scores(4.44 and 4.67 respectively). Male and female doctors had the same scores nearly as shown in table 1. The p-value of 0.7 and 0.91 between men and women respectively also showed no difference. The job satisfaction among doctors compared to all other professions score is pretty much near to average score i.e. the standard scores which were taken as a reference which reported less bad condition so doctors are nearly satisfied with their jobs work-family conflict was found to be present in both men and women but men showed greater mean score (3.47>2.91) than women which meant that men were found to have more conflicts with their family than women.Both sexes were found to be deprived of social support from senior doctors in our statistical analysis [ Table 02]. Doctors reported poor health, both men and women. Stats showed no difference but mean scores reported better health in men than in women [ Table 02-4]. Self-rated health and job satisfaction in men are better than women.
May -July 2020 | Vol 1 No 2 | Pg 108 Pakistan Journal of Surgery & Medicine and leisure activities, h. physical environment (pollution, noise, traffic, climate) We used version 21 of SPSS software for data entry and analysis.   Table 3: T Test Sampling result When a doctor works in a hospital, he/she is exposed to various physical as well as mental risk factors. The environment was found to be one of the major risk factors in a study as well.

DISCUSSION
[1] Our study was based on NRCWE Copenhagen Psychosocial questionnaire comprising of 39 questions. These questions tend to check the reliability of this questionnaire. Various studies at different institutions have been carried out at different times to check the validity and reliability of this questionnaire and its scales. [9,10] The study conducted by us aimed to determine the levels of various factors in the work environment of doctors. Among many of these variables, one measured by us was stress. Job stress has become one of the main factors reducing efficiency that may, in turn, cause physical and physiological adverse effects on workers. As per research conducted in Iran, the mean job stress was found to be above average i.e 100.34 ± 12.78 in a doctor, compared to 4.44 in our study. [11] In our study, male and female doctors had nearly the Table 4: To compare multiple means, simple ANOVA test done from SPSS burnout, and 6% for high burnout. [15] Burnout and stress at the workplace also has to be found in a connection with musculoskeletal disorders. [16,17] Doctors consider stress as a part of their lives. Job stress is a result of low payment, maltreatment, bullying, and harassment. There is a big interlink between the working environment and stress. Burnout is highly prevalent among clinicians in Surgery according to CBI (Copenhagen Burnout Inventory May -July 2020 | Vol 1 No 2 | Pg 110 Pakistan Journal of Surgery & Medicine same scores, though the results were equally concerning, depicting poor work environment conditions. Levels of stress and burnout were almost equal in both genders. A p-value of 0.7 and 0.9 in males and females respectively showed no significant difference in our study. But female workers reported significantly more symptoms of anxiety, depression, post-traumatic stress disorder (PTSD), and emotional exhaustion than males as per other studies carried out in northern Uganda and Scandinavia. [12,13] Moreover, in another study carried out in Malaysia job stress was reported higher among male medical residents. [14] Burnout values in our studies showed almost uniformity among male(4.61) and female (4.60) doctors. As compared to a study where 11% of subjects met criteria for low burn out, 83% for moderate Work/Role overload, lack of support, and overwhelming nature of the disease you are treating are also found to predict variance in stress. [23] Various studies worldwide have proved this as well that stress in the medical community is found to be much raised as compared to people belonging to other professions. And if appropriate self -care, team-care and health-promoting measures are taken, reduced stress levels and burn out was found. Resultant, human performance is optimized to create healthy workplaces. [24,25]

LIMITATIONS
The sample size of the study was small i.e 100. The study population comprised of doctors of all age groups from 23 years and onward therefore, could not be restricted to any particular age group. The data was self-reported, hence, there were potential sources of biases (selective memory, attribution, exaggeration).

CONCLUSION
The NCRWE psychosocial survey is an appropriate instrument to quantify the psychosocial dynamics in the workplace of healthcare providers. This complete appraisal of the psychosocial working environment aids in tailoring interventions for the precise requirements of various professional groups.

MATERIALS AND METHODS
via an open or endoscopic approach. Other newer techniques also include ultrasound-guided steroid injection combined with mini scalpel-needle release, nerve hydro-dissection, z-elongation of the transverse carpal ligament and radial extracorporeal shock waves. [1][2][3] We conducted this randomized control study to compare the efficacy between 'endoscopic' and 'open' carpal tunnel release surgeries. The study was performed in a single-center, in the department of Neurosurgery in ADK hospital, Maldives. We analyzed a total sample size of thirty patients with CTS who underwent surgical decompression of the carpal tunnel. To make sure our inclusion criteria were specific and purposeful, we paid close attention to their symptoms; we selected the patients, who had classical symptoms of carpal tunnel syndrome, as elaborated by the Katz hand diagram diagnostic criteria. [4] In addition to this, other causes of pain in the forearm, hand, or fingers (abnormalities such as the cervical spine or other hand / upper limb problems) were ruled out. In this way, we established an exclusion criterion, and confirmed CTS as the primary and only causative factor of their symptoms. The patients who had history of trauma to the hands, previous carpal tunnel surgery of either hand or joint diseases were excluded. Informed consent was obtained from every patient.Open surgery was performed in 15 patients, while the other 15 under went endoscopic surgery. The type of operation for each patient was randomized in accordance with patient preference and availability of the surgeon for a specific time. Both sets of patients were given local anesthesia in the Operation Theater (OT). For the endoscopic surgery, we used a single-portal endoscopic technique at the wrist. The endoscopic incision was a single 2 cm incision at the proximal wrist crease perpendicular to the digits. Comparatively, the incision in the open procedure extended from a point 1.5 cm distal to distal wrist crease in between 3rd and 4th digits up towards the fingers and was 1.5 cm in length. Post-operatively for both procedures, tight dressing was applied to avoid the collection of hematomas. Patients were advised to elevate the hand for 1 day and change the dressing every 3rd day until suture removal in 12 days. Immediate movement of fingers in all ranges was recommended, as well as using the fingers for daily tasks if no pain was felt. No physical therapy was considered; however, paracetamol for 5 days was prescribed. Both were day surgeries and the outcome was evaluated based on the following indicators: operative duration, bleeding, pain score on day one, the requirement of non-steroidal anti-inflammatory drugs (NSAIDs), infection, wound status/cosmesis, injury to the median nerve, chronic regional pain syndrome, patient satisfaction, time spent in hospital and days taken to return to work. patient satisfaction, time spent in hospital and days taken to return to work.

RESULTS
form or another; as such, most of the females were traditional workers from villages, however, 2 were

DISCUSSION
Out of the 30 patients, 24 were female and 6 were male and the age range of them was between 35-69 years. All of the patients admitted to performing heavy work with the hands for a number of years in one  urban dwellers doing modern household work. All the males had employment in heavy work such as construction, boat driving, and fishing. All of them had undergone conservative medical treatment prior to decompression; 18 females and 4 males had taken only medication, while the rest also incorporated steroid injections into their treatment regime. The manpower required for the open procedure was only 2, however, for endoscopic was 5. The average operative duration for open surgery was 9.9 minutes compared to 52 minutes spent on the endoscopic procedure[ figure 1]. This was mainly due to the slow learning curve for the endoscopic procedure. There was no significant difference with regards to wound infection, cosmetic outcome, chronic regional pain syndrome, median nerve injury and patient satisfaction.
taken to return to work.

DISCUSSION
May -July 2020 | Vol 1 No 2 | Pg 115 Pakistan Journal of Surgery & Medicine patients after endoscopic carpal tunnel release (ECTR) had better results on the Semmes-Weinstein Monofilament Test (SWMT) in sensation testing when compared to the OCTR. However, conflictingly they found that ECTR patients had a worse Levine-Katz Questionnaire result in both symptoms and function. [5] In 2006, Atroshi et al., stated that endoscopic surgery in carpal tunnel syndrome resulted in less post operative pain in the scar and proximal palm and related limitation of activity than open surgery, but the differences were generally small. [6] Zamborsky et al., also claimed ECTR showed faster recovery in patients undergoing the surgery in the first 2 weeks, with faster relief from pain and faster improvement in functional activities. They also report an alternative mini-OCTR technique with a smaller incision and claim that in this    [5] They also found that OCTR and ECTR. The advantages included a minimally invasive procedure, good visualization of the operating field, a less technically challenging procedure, a low wound complication rate, and a good appearance. [5] In our study, we have evaluated additional factors other than what was discussed above, such as manpower, time taken per surgery as well as the occurrence of bleeding during the surgery. We believe the difference in these factors between the two surgeries is due to the novelty of ECTR, as it requires more training and experience concerning learning to work with the equipment and consequently surgeon comfort. We, of course, had some limitations in our study. One of them being our randomization method -we did not employ a systematic method (for example with sealed envelopes) and it was not double-blinded to remove any bias in terms of surgeon skill, the severity of the CTS case. In our study, we did not measure post-op grip or thenar strength, and we did not measure sensations or pain after the patient was released from the hospital and made no follow-ups. Another limitation is a small sample size and so factors such as "return to work period" could be affected by patient status (for example -their wealth and hence not needing to go back to work urgently, or decreased pain tolerance for open surgery and so couldn't go back to work as soon). case, the palmar fascia remains intact, further decreasing the incidence of post-operative pain. [6] Our study describes pain on day 1 of surgery, but it is important to keep in mind that other studies have recorded pain at different periods, for example, Zhang et al. collected the results 2 years post-surgery. [5] There were minor complications in approximately 7% of the cases evaluated by Vasiliadis et al. (i.e. 183 minor complications from 2442 hands). The meta-analysis revealed that ECTR resulted on average in a lower rate of minor complications when compared with OCTR. The summary effect indicates that ECTR is associated with an average relative decrease in odds of minor complications of 50% compared to OCTR. Contrastingly though, further analysis of minor complications revealed that ECTR was associated with a higher rate of transient nerve problems.
[4] Another study by Sayegh et al. exclaims that when comparing the complications of open versus endoscopic techniques, there is an increased risk of nerve injury during endoscopic carpal tunnel release. [7] The possible explanation for this is the limited exposure of the carpal ligament before ligation. [8] It is important to highlight that this is a minor complication causing symptoms such as neurapraxia, numbness, paraesthesia and, the reported incidence of serious complications, such as irreversible major injury to the nerve, has been low in ECTR. [4,6] In regards to symptom relief and improvement in health-related quality of life, both OCTR and ECTR seem to be equal amounts effective. [9] However, there is a statistically and clinically significant reduction in time out of work or daily activities with ECTR; patients treated with ECTR returned to work or to daily activities on average 10 days earlier than those in the OCTR group. [4] In the systemic review done by Vasiliadis et al., only 12 ECTR and 12 OCTR cases experienced a major complication (from 1366 ECTR and 1199 OCTR cases treated), however, interestingly the meta-analysis did not reveal any differences between ECTR and OCTR in regards to major complications.
[4] In 2006, a study by Benson et al. showed that the incidence of structural damage to nerves, arteries, or tendons, for OCTR is 0.49%, and for ECTR, it is 0.19%. [9] It is important to note that there are two types of endoscopic techniques -single portal and dual portal, and there is a very real possibility that differences in the techniques may alter the results of studies. [5] A third option was explored by

CONCLUSION
In conclusion, our results show that OCTR had lesser operating time with less manpower, less bleeding during surgery, and lesser time spent in the hospital afterward. However, the endoscopic procedures showed that patients had a better pain score, lesser use of NSAIDs, and were able to return to work after the procedure quicker. The results are backed up by multiple other similar studies.[2, 4, 6-7] However, it is important to note that similar comparative studies have also shown that one procedure is not particularly better than the other in terms of safety (i.e. long recovery, major complications, and recurrences). [6,9] Introduction: Bezoars are rare accumulations of indigestible contents within the gastrointestinal tract. These are commonly found in patients with previous psychiatric illness, learning disabilities, and gastric surgery. Computed tomography (CT) is the noninvasive imaging modality of choice as it can not only diagnose but recognize associated complications as well. Case discussion: We present a case of a young 16 years old female who presented with nausea, dull abdominal pain, and distension. She underwent a Contrast-enhanced CT scan and was diagnosed as a case of gastric bezoar with gastric perforation and frank pneumoperitoneum. The patient underwent exploratory laparotomy and repair of the stomach. Per operative, findings were consistent with trichobezoar. The patient recovered well after surgery. Discussion: Bezoar is an accumulation of partially digested foreign material in the gastrointestinal (GI) tract. Bezoar can occur in any part of GIT, however, are most common in the stomach. Multiple risk factors are recognized however can occur without the risk factor. Bezoars are classified into several main types. Proper clinical history, examination, and imaging can play an important role in its diagnosis. Conclusion: Nonspecific abdominal pain in young female patients with a psychiatric disorder can result from uncommon causes such as bezoars and is important for clinicians and radiologists to be aware of this uncommon entity. Keywords: bezoar, gastric, pneumoperitoneum.

CASE REPORT
A 16 years old female presented to the diagnostic center of Shaukat Khanum memorial hospital and research center with complaints of nausea, dull abdominal pain, and distension for 48 hours. On examination, the abdomen was tender, bowel sounds were absent. Her mother further gave a history of early satiety and anorexia. The patient's mother told us that she has observed her daughter chewing her hair at times. On workup her CBC, RFTs, and LFTs were within the normal as a case of gastric bezoar on Contrast-enhanced CT (CE CT) abdomen and pelvis.
range. Previous sonographic reports showed the possibility of left hemi-abdominal mass. Her contrastenhanced CT examination was performed on a 160 slice canon CT scanner on an emergent basis, which showed frank pneumoperitoneum [Fig 1a]. The stomach was distended with mottled air lucencies suggesting trichobezoar [Fig 1b]. CT was reviewed in multiple planes and gastric perforation with a defect in greater curvature was discovered along with mild abdominal free fluid. The rest of the abdominal organs were unremarkable. After urgent reporting, the informed consent was obtained from mother of child. The patient underwent exploratory laparotomy. Per operative, findings were consistent with trichobezoar and the bezoar was removed along with primary gastric repair with 2/0 vicryl sutures in two layers. Abdomen was lavaged with copious saline and closed in single layer Proline with insitu 28 fr drain [Fig 2]. The patient recovered well after surgery and discharged on fifth day. She was healthy on follow up visits and was referred for psychiatric counseling.  The word bezoar can trace its origins to Arabic ("bazahr") and Persian ("pad-zahr"), has been known to human kind for ages. [4,5] Bezoar was believed to have medicinal properties and was hailed as catholicon. [6] A bezoar is accumulation of partially digested or non-digested foreign material in the gastrointestinal (GI) tract. [3,5] They can occur anywhere from the esophagus to the rectum, however, they predominate the stomach. [3,7] Females in any age group are common patients. [7] Trichobezoars are frequently seen in women, with only few cases reported in males and is common among ages of 13-20 years. [8,9] Certain risk factors ,identified in adults include gastric surgeries, achlorhydia, chronic illnesses like diabetes (and other endocrinopathies) chronic gastropresis and patients on mechanical ventilation. Trichobezoars are frequent in children ,psychiatric patients and mentally retardates. [5] The symptomatology of bezoar varies depending upon its location in gastro-intestinal tract but the most common presentation is with signs and symptoms of intestinal obstruction. [8] On examination, a tender mass may be palpable in abdomen but this is not a definite occurance. [8,9] Investigations include abdominal radiographs which however are of limited use and can only help in diagnosis of bowel obstruction (if present). Sonography is of limited sensitivity in diagnosing gastric bezoar as in our case.

May
[1] Contrast studies of the gastrointestinal tract and computed tomography scan are gold standard. In our patient previous ultrasound raised suspicion of left hemi-abdominal mass however it was inconclusive. CT scan proved to be the diagnostic modality of choice and revealed trichobezoar causing gastric distension and perforation. Multiple studies have confirmed the role of CT scan in evaluating diagnosing bezoars and also picking up obstruction. [11,12] CT scan identifies bezoar as, well-defined oval intra-luminal mass with air bubbles, identifies its level of accumulation and presence or absence of GI obstruction. Gastric food particles can at times be confusing to differentiate from bezoar for an inexperienced radiologist. Small bezoars appear as round, floating and of lower density then food residues unlike large bezoars which show internal air locules and tend to fill lumen.Barium studies are indicated, however it may limit endoscopic visualization. Upper GI Endoscopy also remains investigation of choice in long standing cases as it can be used both for diagnostic and therapeutic purposes. [13] GI bezoars are uncommon cause of bowel obstruction and a rarely reported cause of gastric perforation, accounting for only 4 % of all admissions for small-bowel obstruction. [14] GI obstruction is more commonly seen in Phytobezoars. Apart from obstruction, prolong history of gastric bezoar can also lead to ulceration and perforation. It is due to pressure necrosis of stomach, weakening the stomach wall and ultimately perforation which is preventable if diagnosed and treated early. Many studies have reported perforation in bezoar only picked up during surgical intervention as in our patient. [15] Hence early diagnosis is imperative for early cure and to prevent complications. It is worthwhile that Ripollés T et al reported that concurrent gastric and intestinal bezoar was found in 53% of their subjects hence whole GI track should be visualized pre and peroperatively. [1] May -July 2020 | Vol 1 No 2 | Pg 120

CONCLUSION
Bezoar should be considered in differential diagnosis in any young female, presenting with pain abdomen , S/S of intestinal obstruction with psychiatric disorders. CT scan is gold standard for early diagnosis and with prompt treatment,many complications can be prevented. These bezoar induced gastric perforations can be managed by primary repair with good results. advancements in a different way. They start with defining Society 1.0 as the hunter-gatherer stage of human development. This is followed by the second agrarian stage (Society 2.0) and third industrial stages (Society 3.0). We are now moving beyond the fourth information age (Society 4.0). [18] In each of these four phases, dehumanization was the major outcome. In contrast to this trend, personalisation is expected to play a major role in IR 5.0 -perhaps humans and machines will dance together, metaphorically.
[19] Whether IR 5.0 has already started or not remains controversial. Economic experts believe that with the advent of crypto currencies IR 5.0 has "already" arrived.
[20] Bill Gates believes that after Modern Pandemic I, schools will open but large gatherings like filling a stadium with 70,000 people will not be possible. He posits that people will not be able to spend money like before and half of all employment may be online like in Microsoft China. Social distancing, Post COVID-19 Industrial Revolution 5.0. The dawn of Cobot, Chipbot and Curbot Perspective mask and sanitizers may become norms for the future society. [11] Scholars and futurists have already started the discussion on IR 5.0.[21,22] The current scope contains two visions for IR 5.0 i.e. human-robot co-working and the bioeconomy.
[21] The main principle of bio-economy is biologization. This is the use and production of complex biological molecules and systems at an industrial scale.  , buffalos, cattle, goats, sheep, and pigeons.[2-4] The Wildlife Conservation Society documented the transmission of COVID-19 from human beings to a four-year-old tiger named Nadia in New York city. [5] COVID-19 cuts through income barriers and has hit the unlikeliest of places and individuals. The wife of Canada's prime minister has tested positive for the virus. [6] The Italian chief of army staff has tested positive. [7] An adviser to Iran's supreme leader has died of COVID-19. [8] German Chancellor Angela Merkel has given a stark warning that up to 70 percent of the country's population could contract the coronavirus. [9] Stock markets around the world have since seen an unprecedented meltdown. [10] The famous philanthropist Bill Gates believes that "no one who lives through pandemic will ever forget it and its impossible to overstate the pain that people are feeling now and will continue to feel for years to come". [11] Until it's mitigation, it is a time bomb. [12] Hence, like a bomb, this viral bomb can change the landscape of the current world. It may even lay down the foundation for the Industrial Revolution 5.0 (IR5.0). IR5.0 is the "use of sophisticated machinery to make the work of human beings easier and faster". [13] The first three industrial revolutions began roughly one century after each other. IR 1.0 involved mass-scale mechanization and began in the 1770s. [14] IR 2.0 introduced electrification and began in the 1870s. [15] IR 3.0 spearheaded automation and began in the 1970s. [16] However, IR 4.0, which saw widespread digitization, started in 2001; it was only three decades after IR 3.0 and at the dawn of the third millennium. [17] IR4 is internet technologies and big data. [18] Japanese researchers classify these industrial May -July 2020 | Vol 1 No 2 | Pg 122 Pakistan Journal of Surgery & Medicine Muhammad Iftikhar Hanif,Linta Iftikhar IR5.0.[23,24] The Japanese introduced Society 5.0, which is based on a high degree of convergence between cyberspace (virtual space) and the physical space (real space). [25] The internet of things, or IoT is a system of interrelated computing devices, mechanical and digital machines, objects, animals or people that are provided with unique identifiers (UIDs) and the ability to transfer data over a network without requiring human-to-human or human-to-computer interaction. [26] Whereas, AI is the ability of a digital computer or computer-controlled robot to perform tasks commonly associated with intelligent beings. Big data is a field that treats ways to analyse, systematically extract information from, or otherwise deal with data sets that are too large or complex to be dealt with by traditional data-processing application software. Finally, Society 5.0 is the Big Data collection by IoT and its conversion through AI to provide comfort in people's lives. [18,26] Unlike IR 5.0, the concept of "Society 5.0" (Super Smart Society) is already under discussion. [27] It was conceptualised as a society where advanced IT technologies, IoT, robots, AI, and augmented reality (AR) would be actively used in people's everyday life, in the industry, health care, and other spheres of activity. [18,28] The emphasis is not progress, but is placed on the ordinary use of technology for the benefit and convenience of the individual. [28] AI, AR, and 3D printing will be used to convert robots into personalized and customized cobots (collaborative robots). The bioeconomy will be driven towards paperless and bankless market, preferably termed curbot (currency and bank-less systems). Medical microchips have been in use for the purpose of identification, physical access control, contact less retail payment, and even the tracing of kidnapping victims. [29] The authors prefer to label this proposed development as a chipbot (a human with implanted chips) and there are additional sources that verify this reported remedy about implanting human being with microchips. [30] The internet of things (IoT) has been around for years. The Internet of Bodies (IoB) is an extension of the IoT. [29,30] IoB basically connects the human body to a network through devices that are ingested, implanted, or connected to the body in some way. [31,32] Once connected, data can be exchanged, and the body and devices can be remotely monitored and controlled.Another common name for the IoB is embodied computing, where the human body is used as a technology platform. [32] In fact, the number of human beings with chip implants (chipbots) is progressively increasing along with the worldwide May -July 2020 | Vol 1 No 2 | Pg 123 Pakistan Journal of Surgery & Medicine growth trends in curbots and cobots. COVID-19 has forced the world into a lock down with minimum scientific evidence. [33] Considering the significant impact of COVID 19 on human life, the authors believe that it can be a trigger factor for IR 5.0 . Future researchers can define IR5.0 properly but just after a lapse of 20 years (after IR4.0), the new Industrial Revolution 5.0 can emerge to change the world. [13,16,18,21] The Triad of IR 5.0 (consisting of Curbot, Cobot & Chipbot interactions) in a post-COVID era can be responsible for drastic changes in community norms of the world[ figure 1]. Research and innovations will open a new era of social distancing (self-isolation, quarantine, lock down, and curfew), personal hygiene, personal protective equipment (PPE), treatment (vaccines, plasma, anti-viral ventilator support, and emergency care), early detection, non-touch techniques (QR-Pay, cryptocurrency, tele-medicine). IR 4.0 moves towards IR 5.0 when customers have the ability to customize what they want. Simply, it is the cooperation between human beings and machine. IR 5.0 is already showing its emerging trend through the interaction and collaboration between man and machine. [34] 3D printing is being considered as a turning point for   [35] With emerging 5G technology, sensors on any device will be able to connect to the internet regardless of Wi-Fi availability -enabling mobile devices 24/7 access to bandwidth. The applications are vast -from smart medical devices, such as pacemakers and insulin pumps that monitor the body and apply the appropriate treatment in real time, to a connected Internet of autonomous vehicles. [36] Industry 4.0 valuates best quantity and mass production whereas Industry 5.0 valuates life standard, creativity and high-quality custom-made products. [36] Industry 5.0 will change the definition of the word "robot". Robots will no longer be just a programmable machine that can perform repetitive tasks but will transform into an ideal human companion for some scenarios (e.g. spies or bodyguards). Providing robotic productions with the human touch, the next IR will introduce the next generation of robot (cobots) that will already know, or quickly learn, what to do as boss, subordinate, colleagues or security guards. These collaborative robots will be aware of the human presence and will therefore be able to take care of safety and risk criteria. Industry 5.0 will bring unprecedented challenges in the field of Human-Machine Interaction (HMI) as it will put machines very close to the everyday life of a person. [36] The authors believe that when robot will be replaced by cobots and by augmented AI, human minds will be controlled by super-minds (preferably super masters) through nanotechnology used to convert human beings into homeobots/chipbots. This synergism of cobot, chipbot, and curbot will result in the real IR. 5.0[ figure  2]. The actualization of IR5.0 will encompass a wide range of domains and applications. The chipbot will be the hypothetical human that will result after COVID-19 through implantable nanotechnology chips. This will be enabled by mass vaccination using assisted hidden technology in vials. The crypto currency robots (curbots) will be technology assisted mobile banking robots that replace or complement the real physical currency or banks. This will lay the foundation of the cashless market. The need to open tele-medicine centres in developing countries after pandemics will be self-explanatory. Terminologies in tele-medicine will change as predicted and virtual specialist hospital based on remote presence will develop more rapidly. They will be a new source of hope for patients and physicians as they will allow adherence to strict social distancing guidelines and access to expert opinions and treatments. [36][37][38] Tele-cardiology and other highly May -July 2020 | Vol 1 No 2 | Pg 124 Pakistan Journal of Surgery & Medicine specialized applications are already progressing (even in developing countries) and will significantly reduce morbidity and mortality by their introduction in rural settings. [38] The physical interaction between the young and the elderly will be discouraged initially but will later become a societal norm. Drones will be used to link hospitals and hostile humans. Roboscope (noninterventional robots) will be replaced by Roboop (interventional robots). [39] Once human beings have been conquered, the race to conquer space will start. This will initiate the new era of IR6.0 within next ten years. Like the earlier industrial revolutions, IR6.0 will likely neglect human beings and perhaps result in some unrest. Fortunately, there is ample time to ensure that the contributions of IR 5.0 can minimize or subvert the negative externalities of IR6.0.

Dec 2019
Wuhan seafood market, thought to be the source of outbreak, closed.

Jan 2020
China reported 44 patients with pneumonia of unknown aetiology.
WHO issued its first guidance on the novel coronavirus with reference to other coronaviruses such as Severe Acute Respiratory Syndrome (SARS) and Middle East Respiratory Syndrome (MERS).
China reports second death.

Mar 2020
Global cases surpass 600,000. It took 9 weeks to reach 100,000 and it increased 6 times in 3 weeks. Spain (832) and Italy (889) hit new record for the number of deaths in one day.

Mar 2020
Global cases surpass 700,000. As we look back on the spread of this pandemic, countries that were proactive in taking strict social distancing like Singapore and South Korea, managed to control the pandemic appropriately while the countries which delayed in acting like US and Italy their figures of mortality are disastrous.While most of the countries now are in some sort of lockdown, these strict measures may well in be place over the coming several months or perhaps even a year. These social distancing measures have made people retreat in their homes, business to shut down, global economic crisis and exacerbation of the health of the vulnerable group of people. So, what's next?

FLATTENING THE CURVE
Health authorities around the globe are talking about "flattening the curve" meaning to reduce the rate at which new infection arise in order to avoid the overburden on the healthcare system and preventing it to collapse. That's the reason lock down and social distancing have been implemented.

IMMUNITY TO COVID-19
Lots of talk going around so called "herd immunity" which means that when enough of the global population becomes acquire the immune response to virus, further progression can be dampened. There are two possible pathways, neither of them is proven for COVID-19. First is the individual gets infected and acquires the immune response and second is by getting vaccinated without getting sick. A number of trials and attempts at vaccine

MASS TESTING
Given the economic burden of the disease all countries do not have the resources to do mass testing. The theory behind it is that without knowing the actual burden of the disease (those that get infected whether symptomatic or asymptomatic) scientist cannot draw conclusions and identify population at risk.

CONCLUSION
COVID-19 pandemic is not a sprint rather it is a marathon with destination not visible at this particular moment and time. Collective efforts and resilience of millions of people is the need for the hour. Lockdowns and strict social distancing cannot be sustained forever but timing is the key to it, as letting up too soon may worsen the situation further.

INTRODUCTION
Chest pain is one of the most common presentations to the emergency and cardiology clinics and acute coronary syndrome (ACS) is a life-threatening acute emergency. ACS comprises unstable angina and myocardial infarction (MI), which has two subtypes; ST-segment elevation MI (STEMI) and non STsegment elevation MI (NSTEMI). It remains a leading cause of morbidity and mortality globally. It can also be subdivided as inferior and anterior wall MI depending upon the leads of involvement. [1,2] There are several complications, which can cause death immediately in patients of ACS which include arrhythmias, carcinogenic shock, progressive heart coronary syndrome. [12,13] We carried out this study to look for Coronary Artery Dominance in our local population in Lahore, Pakistan. We felt the need to explore & investigate the dominant coronary artery in IWMI cases, so we can add local data to existing national and international literature.

METHODOLOGY
After getting ethical approval, this cross-sectional observational study was started in Punjab Institute of Cardiology (PIC) Lahore. PIC is a 547 bedded state of the art dedicated center for cardiovascular diseases. It is a state-run hospital, where nearly half a million patients were treated in 2018. [14] We conducted this study to find

RATIONALE FOR THIS ARTICLE
Several studies have shown that coronary artery dominance is associated with cardiovascular prognosis in patients with the acute The sample size was calculated to be 295 on sample size calculator, using the estimate of population size to be 100,000. The Confidence Interval was 95%, and the accepted margin of error was 5%. Five subjects opted out and 18 subjects didn't fulfill our criteria. A total of 227 consecutive patients admitted via the emergency department with inferior wall myocardial infarction, fulfilling the inclusion and exclusion criteria was included after obtaining informed consent. Patients were treated with thrombolytic therapy according to standard departmental protocols. As per departmental protocol, patients subsequently underwent angiography via radial artery access. Coronary artery dominance was noted.

Study Population
After informed consent, all the patients between 18-60 years of age, belonging to either gender, diagnosed with IWMI & had been given thrombolytic therapy within 24 hours of MI were included in this study. Those patients who had a history of heart failure as determined by the past medical record, patients with renal failure (serum creatinine on admission > 1.1 mg/dL), patients with a history of rheumatic heart disease, patients with hypertension more than 5 years, patients with uncontrolled diabetes (determined by HbA1C > 7%), patients with a history of previous myocardial infarction or concomitant involvement of other coronary artery areas like an anterior wall or septal wall and those who refused to give informed consent were excluded from this study.
The patients were explained about (1) the nature of the procedure, (2) the risks and benefits and the procedure, (3) reasonable alternatives, (4) risks and benefits of alternatives, and (5) assessment of the patient's understanding of elements in regional language and free will consent was obtained from the patients.
May -July 2020 | Vol 1 No 2 | Pg 134 Pakistan Journal of Surgery & Medicine the frequency of right and left coronary artery dominance in patients with inferior wall myocardial infarction (IWMI). Ours was a cross-sectional observational study, carried out at the emergency department, PIC, from March to August 2017.

Informed Consent
In the present study, a total of 227 patients were enrolled. The mean age of the patients was 45.07 ± 8.17 years. Males accounted for 51.98% (n=118) whereas females accounted for 48.02% (n=109) of the subjects[ figure 1]. The mean basal metabolic index (BMI) was 26.13 ± 3.29 as shown in tables 1 and 2. In our study, the LCX dominant artery was found in 25.55% (n=58) and RCA was found in 74.45% (n=169) of the subjects. There was no significant difference in any confounding variable concerning the dominance of the artery as shown in tables 2 to 5.
Data analysis was done on software Statistical Package for the Social Sciences (SPSS) version 21. Numerical variables were presented by mean and standard deviation and qualitative variables as frequency and percentage. Chi-Square test was applied to determine the level of significance. A P value

DISCUSSION
Acute MI is caused by plaque rupture in one of the major epicardial coronary arteries. The prognostic outcome between anterior and inferior wall MI has

Draft
May -July 2020 | Vol 1 No 2 | Pg 135 Pakistan Journal of Surgery & Medicine been extensively investigated. In co-dominance (balanced) circulation, however, the branches that run to the interventricular septum originate both from the RCA and LCX. The rate of co-dominance in the general population is around 4%. [15] Limited information exists about a similar comparison between inferior wall MI caused by RCA and LCX occlusion.
In this study out of 227 patients heart failure occurred in 27.75% (n=63) patients in which 25.39% (n=16) patients had LCX dominant artery and 74.6% (n=46) had RCA. Statistically, an insignificant risk was found between heart failure with the dominant artery. Some of the studies are discussed below showing their results. Coronary artery supply for the inferior wall is either through RCA (80%) or LCX (16%). The supplying artery to the posterior interventricular septum is labeled as a dominant vessel. [3][4][5][6][7][8][9] A study by Sohrabi et al. found out that RCA and LCX arteries were occluded in 64.7% and 35.3% of patients, respectively. The studied groups were similar in baseline characteristics except multiple-vessel disease was more prevalent with LCX occlusion (p= 0.008). There was a higher cardiac enzyme release (p< 0.001), more significant mitral regurgitation (p= 0.015), and lower left ventricular ejection fraction (p= 0.01) in patients with LCX occlusion. Multivariate analysis showed cTn-I release, the occurrence of mitral regurgitation, and lower left ventricular ejection fraction as independent factors leading to a poor outcome. [16] Nienhuis et al., showed more favorable short and longterm clinical outcomes for inferior compared to anterior MI. The extent of myocardial damage in acute left anterior descending artery occlusion is commonly larger than in either acute RCA or LCX artery occlusion simply because it perfuses a larger myocardial territory. [17]