Medullary carcinoma of jejunum presenting as perforation peritonitis: A case report

Small intestinal medullary carcinoma (MC) is a newly recognized subclass of small intestinal carcinomas and is an exceptional entity for this site. A search of the literature for similar cases arising in the small intestine revealed only six previously reported cases. Here we present a case of MC arising in the jejunum of a 65-year-old male. The patient presented to the emergency with features of perforation peritonitis with liver metastasis and no known predisposing factors like inflammatory bowel disease and celiac disease. Studies conducted on this tumor's colonic counterpart have shown microsatellite instability (MSI) and B-type Raf kinase (BRAF) mutations; however, few exceptions are known. Also, this subtype of carcinoma is known to have a better prognosis than its other histological subtypes.

Intestinal mucormycosis in a patient with COVID-19: A case report

The novel coronavirus disease (COVID-19) has spread to all the continents posing a serious threat to global health. It can present with myriad symptoms and complications including susceptibility to fungal co-infections. We hereby describe a case of mucormycosis in a 17 year old COVID-19 positive female with no known comorbidities presenting with abdominal pain and distention and ultimately developing intestinal perforation. Early identication of the symptoms is essential to make a correct and early diagnosis to prevent complications.

Omental desmoplastic small round cell tumor with metastasis

Desmoplastic small round cell tumor (DSRCT) is a very rare diagnosis with about 200 cases reported in literature. DSRCT is a recently described histopathological entity by Gerald and Rosai in 1989. Abdominopelvic cavity especially peritoneum is the most common site. We report a case of a huge omental DSRCT with lymph node metastasis which was initially misdiagnosed as gastrointestinal stromal tumor on radiology. A 26-year-old male presented with complaints of upper abdominal swelling associated with constant dull pain. On examination there was a large 15 × 12 cm intraabdominal mass in the epigastric and umbilical region. Imaging studies were suggestive of neoplastic mesenchymal etiology. Image-guided fine-needle aspiration cytology (FNAC) was suggestive of mesenchymal neoplastic etiology. On laparotomy, there was a huge 20 × 15 cm mass arising from omentum with multiple omental and mesenteric seedlings and mesenteric, peripancreatic and perigastric lymphadenopathy. The patient underwent debulking surgery with uneventful post-operative recovery. Histopathological examination with immunohistochemistry revealed a diagnosis of DSRCT of omentum and small bowel mesentery with lymph node metastasis. Patient then received adjuvant chemotherapy with multiple chemotherapeutic drugs as per P6 protocol and has stable disease at 1 year follow up.

Myocardial bridging – Sudden unexpected death of a young girl: A case report

Myocardial bridging (MB) is a relatively uncommon congenital anomaly where a segment of the coronary artery dips inside the myocardium and takes a tunneled course under a bridge of the myocardium. This leads to the compression of the coronary artery during systole resulting in hemodynamic changes and their clinical manifestations. However, it is an incidental finding but can present with multiple complications like myocardial ischemia, infarction, and sudden death, primarily when associated with other risk factors like left ventricular hypertrophy of the heart. Therefore, a careful examination of the heart is essential for evaluating the clinical significance of the MB. Here, we presented a case of a 30-year-old young female who had a sudden death, and her histological examination of the heart showed MB of left anterior descending coronary artery (LAD).

Plasma ghrelin levels after laparoscopic sleeve gastrectomy in obese individuals

Background & objectives: Ghrelin is an orexigenic gut hormone expressed by the gastric fundus. Laparoscopic sleeve gastrectomy (LSG) procedure involves resection of the gastric fundus leading to a decreased appetite and weight loss. This study was undertaken to determine the levels of plasma ghrelin after sleeve gastrectomy in obese patients. Methods: The study was conducted on 90 morbidly obese patients [body mass index (BMI) >40 kg/m[2]] and severely obese patients (BMI >35/kg/m[2]) who underwent sleeve gastrectomy. The patients were followed up for six months. Weight loss parameters and plasma ghrelin levels were assessed pre- and postoperatively. Results: A significant weight loss and decrease in BMI were observed at three and six months postoperatively. A significant decrease in plasma ghrelin levels over six months of follow up postoperatively was also seen. Interpretation & conclusions: These preliminary findings indicated inhibition of ghrelin production after LSG leading to a decrease in the plasma ghrelin levels within a few days of surgery and sustainable weight loss in obese patients.

Amyloidosis Presenting as Severe Bleeding Diathesis

Bleeding is one of the rare presentations of Amyloidosis. The mechanism behind spontaneous or peri- interventional bleeding in patients of amyloidosis is complex and involves multiple co-existing factors like coagulation factor deficiency, abnormal synthesis of coagulation factors due to advanced liver dysfunction, acquired Von Willebrand disease, platelet dysfunction, amyloid angiopathy and other unknown mechanisms. We present a case of middle aged female, presenting with spontaneous retroperitoneal haemorrhage, on further investigations was found to have systemic amyloidosis and secondary severe factor X deficiency (2.7 % of normal by one stage factor assay method). Factor X deficiency (both inherited and acquired) is known to present with the most severe bleeding phenotype. The management option for such acute spontaneous haemorrhage is limited and mostly supportive in nature. Definitive treatment is directed towards the primary pathology and requires chemotherapy and hematopoietic stem cell transplantation.

Amyloidosis Presenting as Severe Bleeding Diathesis

Bleeding is one of the rare presentations of Amyloidosis. The mechanism behind spontaneous or peri- interventional bleeding in patients of amyloidosis is complex and involves multiple co-existing factors like coagulation factor deficiency, abnormal synthesis of coagulation factors due to advanced liver dysfunction, acquired Von Willebrand disease, platelet dysfunction, amyloid angiopathy and other unknown mechanisms. We present a case of middle aged female, presenting with spontaneous retroperitoneal haemorrhage, on further investigations was found to have systemic amyloidosis and secondary severe factor X deficiency (2.7 % of normal by one stage factor assay method). Factor X deficiency (both inherited and acquired) is known to present with the most severe bleeding phenotype. The management option for such acute spontaneous haemorrhage is limited and mostly supportive in nature. Definitive treatment is directed towards the primary pathology and requires chemotherapy and hematopoietic stem cell transplantation.

Hyperphosphaturic Mesenchymal Tumor induced Osteomalacia– A Case Report.

Hyperphosphaturic Mesenchymal Tumor (HMT) is a very rare benign tumor of the soft tissue or bone which produces tumor induced osteomalacia, also called as oncogenic osteomalacia. This activity can only be stopped by the surgical removal of the tumor. We present a 23 years old man who presented with long standing bony pains without any relief by a variety of medications. The clue to the diagnosis was taken from pelvis skiagram, Magnetic Resonance Imaging (MRI) of the body, PET scan and the blood chemistry.

Study of Antioxidant Enzymes, MDA and Lipid Profile in Cerebral Malaria.

Cerebral malaria (CM) is the most important complication of falciparum malaria. However, its pathophysiology is not understood. Malaria infection is accompanied by increased production of reactive oxygen species (ROS) and the malaria parasites are sensitive to oxidative damage. So, we conducted a case-control study to estimate antioxidant activity, lipid peroxidation in 36 patients with CM. In present study, catalase (CAT), reduced glutathione (GSH) and lipid peroxidation product malondialdehyde (MDA) were increased significantly and superoxide dismutase (SOD) was decreased significantly in CM patients at the time of admission with respect to control group. After treatment, SOD activity was increased and MDA level was decreased; rest of the parameters did not show any significant change. So, the antioxidant enzyme has a prognostic role in CM.

Tissue engineering in Oral & Maxillofacial surgery.

A recent innovation in dentistry is the preparation and use of platelet rich plasma, a concentration of platelets and growth factors found in platelets. These polypeptide growth factors as well as other bioactive substances are released from platelets upon activation, which play a pivotal role in initiating and sustaining wound healing and tissue repair mechanism. In order to improve wound healing and bone regeneration, attempts were made to increase the concentration of wound healing initiating factors in the form of platelet concentrate. Platelet derived polypeptide growth factors as well as other bioactive substances are released from platelet upon activation which plays a pivotal role in initiating and sustaining wound healing and tissue repair mechanism. This article is an attempt to highlight the uses of Platelet rich plasma (PRP) in Oral & Maxillofacial Surgery and the preparation of PRP gel in the immediate preoperative period in a laboratory centrifuge.

"Poor man's risk factor": correlation between high sensitivity C-reactive protein and socio-economic class in patients of acute coronary syndrome.

OBJECTIVE: Inflammation has been proposed as one of the factors responsible for the development of coronary artery disease (CAD) and high sensitivity C-reactive protein (hs CRP) at present is the strongest marker of inflammation. We did a study to assess the correlation of hs-CRP with socio-economic status (SES) in patients of CAD presenting as acute coronary syndrome (ACS). METHODS: Baseline hs-CRP of 490 patients of ACS was estimated by turbidimetric immunoassay. Patients were stratified by levels of hs-CRP into low (<1 mg/L); intermediate (1-3 mg/L) or high (>3 mg/L) groups and in tertiles of 0-0.39 mg/L, 0.4-1.1 mg/L and >1.1 mg/L, respectively. Classification of patient into upper (21.4%), middle (45.37 percent) and lower (33.3%) SES was based on Kuppuswami Index which includes education, income and profession. Presence or absence of traditional risk factors for CAD diabetes, hypertension, dyslipidemia and smoking was recorded in each patient. RESULTS: Mean levels of hs-CRP in lower, middle and upper SES were 2.3 +/- 2.1 mg/L, 0.8 +/- 1.7 mg/L and 1.2 +/- 1.5 mg/L, respectively. hs-CRP levels were significantly higher in low SES compared with both upper SES (p = 0.033) and middle SES (p = 0.001). Prevalence of more than one traditional CAD risk factors was seen in 13.5%, 37.5% and 67.67 percent; in patient of lower, middle and upper SES. It was observed that multiple risk factors had a linear correlation with increasing SES. Of the four traditional risk factors of CAD, smoking was the only factor which was significantly higher in lower SES (73%) as compared to middle (51.67 percent;) and upper (39.4%) SES. We found that 62.3%, 20.8% and 26.5% patients of low, middle and upper SES had hs-CRP values in the highest tertile. Median value of the Framingham risk score in low, middle and upper SES as 11, 14 and 18, respectively. We observed that at each category of Framingham risk, low SES had higher hs-CRP. CONCLUSION: We conclude from our study that patient of lower SES have significantly higher levels of hs-CRP despite the fact that they have lesser traditional risk factors and lower Framingham risk. These findings add credit to our belief that inflammation may be an important link in the pathophysiology of atherosclerosis and its complications especially in patients of low SES who do not have traditional risk factors.

Genetics of mental retardation.

Mental retardation can follow any of the biological, environmental and psychological events that are capable of producing deficits in cognitive functions. Recent advances in molecular genetic techniques have enabled us to understand more about the molecular basis of several genetic syndromes associated with mental retardation. In contrast, where there is no discrete cause, the interplay of genetic and environmental influences remains poorly understood. This article presents a critical review of literature on genetics of mental retardation.

Acute liver failure.

Acute liver failure in children is associated with a high mortality. Most cases in our setup are due to water borne hepatotropic viruses HAV and HEV. The clinician must be aware of the earliest and the subtle signs of acute liver failure to identify cases early enough and institute supportive therapy. Focus of therapy has to be on prevention, early recognition and appropriate management of complications. Despite good intensive care, about 40-60% children with liver failure die. As and when liver transplantation becomes available in India, it would be an attractive option.

Upper gastrointestinal bleeding: etiology and management.

Upper gastrointestinal bleeding is a potentially fatal condition at times due to loss of large volumes of blood. Common sources of upper gastrointestinal bleeding in children include mucosal lesions and variceal hemorrhage (most commonly extra hepatic portal venous obstruction) and, in intensive care settings infections and drugs are other etiological factors associated with bleeding. Massive upper GI bleeding is life threatening and requires immediate resuscitation measures in the form of protection of the airways, oxygen administration, immediate volume replacement with ringer lactate or normal saline, transfusion of whole blood or packed cells and also monitoring the adequacy of volume replacement by central venous lines and urine output. Upper GI endoscopy is an effective initial diagnostic modality to localize the site and cause of bleeding in almost 85-90% of patients. Antacids supplemented by H2- receptor antagonists, proton pump inhibitors and sucralfate are the mainstay in the treatment of bleeding from mucosal lesion. For variceal bleeds, emergency endoscopy is the treatment of choice after initial haemodynamic stabilization of patient. If facilities for endoscopic sclerotherapy (EST) are not available, pharmacotherapy which decreases the portal pressure is almost equally effective and should be resorted to. Shunt surgery is reserved for patients who do not respond to the above therapy. Beta blockers combined with sclerotherapy have been shown to be the most effective therapy in significantly reducing the risk of recurrent rebleeding from varices as well as the death rates, as compared to any other modality of treatment. Based on studies among adult patients, presence of shock, co-morbidities, underlying diagnosis, presence of stigmata of recent hemorrhage on endoscopy and rebleeding are independent risk factors for mortality due to upper GI bleeding. Rebleeding is more likely to occur if the patient has hematemesis, liver disease, coagulopathy, hypotension and or anemia. There is a great need for conducting therapeutic trials as well as identifying predictors of outcome of upper GI bleeding in children to develop evidence based management protocols.

Psychosocial aspects of seropositive HIV patients.

Acquired immunodeficiency syndrome, has become a serious global health problem with an enormous biomedical impact and diverse psychological and clinical manifestation. A study was conducted wherein seropositive HIV patients admitted in a medical ward were assessed for demographic profile, presenting physical illness, mode of contacting the infection, psychiatric morbidity and associated psychosocial factors. The results revealed male preponderance and heterosexual unprotected exposure as the common mode of contacting the illness. It was observed that majority of the patients presented with tuberculosis. Psychiatric assessment revealed a high rate of depressive and anxiety syndromes. Thus it was concluded that the HIV-infected population has a higher prevalence of psychiatric disorders as compared to the general population. The reason for this includes psychological, biological and social factors.

Heart rate & blood lactate response in amateur competitive boxing.

The heart rate (HR) and blood lactate response were studied on 26 senior national level boxers in competitive bouts to explore the aerobic-anaerobic metabolism as well as the training status of the players. The aerobic capacity (VO2 max) of the players were determined using graded running protocol on a treadmill. Heart rate and blood lactate concentration were measured during warm up and boxing rounds. The mean relative VO2 max of the heavy weight category boxers was lower (P < 0.05) than the other two weight categories. No interweight category as well as inter-round differences were observed in the heart rate and blood lactate concentration of the boxers, excepting in the 48-57 kg category, the mean lactate levels in the second and third rounds were higher (P < 0.05) than in the first round. When all weight categories were pooled the mean HR and blood lactate levels were 178 beats/min and 8.24 mMol/l respectively. The study highlights that in amateur boxing, irrespective of the weight category and aerobic capacity, the anaerobic adaptability of the boxers was the same. The training requirements of the boxers demand that they should be also to tolerate a high blood lactate level (approx. 9.0 mMol/l) and a high HR (approx. 180 beats/min) over a total duration of one bout.

Evaluation of a sports specific training programme in badminton players.

We studied the effect of a short three week programme, dominated by specific training, on the aerobic capacity (VO2 max) and ventilatory anaerobic threshold (VanT) of badminton players and also to evaluate the intensity of the specific training on the basis of heart rate and blood lactate concentration. The study was conducted on five women badminton players (age 13-14 yr; height 160-165 cm and weight 47.0-51.5 kg) who were semifinalists in the 1988 subjunior or junior national championships. The VO2 max and VanT were determined at the commencement and at the cessation of the training. The VO2 max was evaluated on an automatic analyser during a graded running protocol on a treadmill and VanT was determined by the gas exchange method from the VE-VO2 relationship. The three week programme was dominated by specific training, apart from other conditioning programme. The mean VO2 max was found to improve from 2.11 l/min (43.8 ml/kg/min) to 2.24 l/min (46.4 ml/kg/min), while the VO2 at VanT improved from 1.48 l/min (30.8 ml/kg/min) to 1.68 l/min (33.7 ml/kg/min). The improvement in both was statistically significant. The mean heart rate and blood lactate concentration during the specific training were 161 b/min and 3.9 mM/l respectively while training with the shuttlecock and 185 b/min and 6.2 mM/l respectively during shadow practice. The findings indicated that the intensity of specific training was quite high, varying from aerobic-anaerobic transition level to aerobic overload region and was able to alter the VO2 max and VanT of the players, even with a short precompetition training.