Neuroendocrine tumors (NETs), also known as carcinoid tumors of the extrahepatic biliary tree, are extremely rare malignancies and account for 0.2% to 2% of all carcinoids of the gastrointestinal tract. The most common sites include NET in the common bile duct (CBD), followed by the perihilar region, cystic duct, and common hepatic duct (CHD). A review of the literature showed only eight cases of NETs of the cystic duct and we, hereby, present the ninth case of NET of the cystic duct in a 50-year-old woman. This was discovered incidentally after she underwent a laparoscopic cholecystectomy for her symptomatic gallbladder stones. The etiology is not known but the NETs are thought to arise from argentaffin cells (Kulchitsky cells) in the gastrointestinal tract or respiratory tract. It is possible that the rarity of these in this region may be explained by the very limited number of Kulchitsky cells there. Most of the patients are clinically asymptomatic, and the diagnosis is mostly made during surgery performed for other indications. Therefore, early recognition should be sought by differentiating the primary duct carcinoma of the bile or the cystic duct, if suspected or shown on the imaging studies because of the different therapeutic options and prognosis.

Objective: To compare the frequency of perineal trauma in women undergoing the spontaneous vs the Valsalva-type pushing in the second stage of labour. Study Design: Randomized controlled trial Duration of Study with Dates: The study was carried out from 15-12-2020 to 19-03-2021. Setting: Department of Obstetrics and Gynaecology, Combined Military Hospital, Lahore.National University of Medical Sciences NUMS. Material and Methods: A total of 154 labouring females were enrolled in the study. These females were randomly assigned to one of two groups, A (the Valsava-type pushing method group) and B (the spontaneous pushing group). After the delivery of the placenta, the patients were all examined for any perineal trauma as per the operational definition. Results: Patients ranged between 18-40 years of age with a mean age of 26.3±4.0 years in Group A and 27.0±3.3 years in Group B. All the patients were between 38-40 weeks of gestation at the time of enrollment with mean gestational age being 39±0.7 weeks for group A and 38.9±0.7 for group B. There were 61 primigravida (39.6%, 34 in Group A and 27 in Group B) and 93 multigravida (60.4%, 43 in Group A and 50 in Group B). All women delivered vaginally in the cephalic presentation. The mean length of the second stage of labor was 25.7±29.0 min for the Valsalva pushing group and 31.6±37.5 min for the spontaneous pushing group. The mean fetal weight was 3.1±0.3 kg for both groups. 43 (55.8%) patients in the Valsalva pushing group and 46 (59.7%) in the spontaneous pushing group underwent an episiotomy during delivery. 9 (11.7%) patients in each group sustained perineal trauma (x2 = 0.0, p = 1.0). No one in the sample suffered greater than a second degree laceration. Out of the nine patients that did incur perineal trauma in the Valsalva type pushing group, 4 (44.4%) were first degree perineal tears and 5 (55.6%) were second degree perineal tears while among those in the spontaneous pushing group, 2 (22.3%) fell in the first degree tear category and 7 (77.7%) in the second degree tear category (x2 = 1.0, p = 0.317). Conclusion: Our findings suggest that there is no association between the rate of perineal trauma among patients who underwent the directed Valsalva- type method of pushing and those that employed the spontaneous pushing method during the second stage of labour. Keywords: Perineal trauma, Perineal tears, Second stage of labour, Pushing methods in labour, Valsalva- type pushing, Directed pushing, Spontaneous pushing

Drug-induced immune thrombocytopaenia (DITP) is a type of thrombocytopaenia caused by medications. It is one of the common causes of unexplained thrombocytopaenia. It is caused by the formation of autoantibodies against a particular drug and is commonly observed with medications like heparin and beta-lactam antibiotics. One of the rare causes of DITP is eptifibatide, a widely used antiplatelet agent for pretreatment in cardiac catheterisation. These patients can be asymptomatic or develop complications like skin bruising, epistaxis and even intracranial haemorrhage. We present a case of a 64-year-old man who developed eptifibatide-induced profound thrombocytopaenia leading to extensive skin bruising. He was treated with platelet transfusions followed by prompt improvement in platelet count.

Heparin-induced thrombocytopenia (HIT) is a life-threatening complication most commonly caused by unfractionated heparin. We present a rare case of enoxaparin induced HIT leading to saddle pulmonary embolism during medical treatment of femur fracture repair on prophylactic enoxaparin. No relevant relationships by Adil Cheema, source¼Web Response No relevant relationships by Muhammad Talha Khan, source¼Web Response No relevant relationships by Danish Thameem, source¼Web Response

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