Secondary amyloidosis with concomitant gastric GIST and gastric adenocarcinoma - A case report

Secondary amyloidosis is a well-established entity and has been described in association with chronic inflammatory conditions such as rheumatoid arthritis, ankylosing spondylitis, bronchiectasis, tuberculosis, etc., It has also been reported in association with neoplasms such as Hodgkin's lymphoma, Waldenstrom's macroglobulinemia, renal cell carcinoma, lung carcinoma, etc. However, only a few case reports documenting the association of amyloidosis with gastrointestinal tumor (GIST) and gastric adenocarcinoma are available in the literature. Hereby, we report a case of a 74-year-old male who presented with colicky abdominal pain and vomiting. Ultrasonography revealed a common bile duct (CBD) stone and a small extra-luminal gastric mass. Endoscopic retrograde cholangiopancreatography (ERCP) was performed to remove the CBD stone which revealed an incidental finding of gastric ulcer. A biopsy was taken from the gastric ulcer which on histopathological examination was confirmed as adenocarcinoma leading onto total gastrectomy. During total gastrectomy, an inadvertent injury to the spleen led to simultaneous splenectomy. Multiple samples from the gastric ulcer, the extra-luminal gastric mass, and the spleen were subjected to histopathological examination. Gastric ulcer was confirmed as adenocarcinoma, gastric extra-luminal mass was confirmed as GIST, and splenic examination revealed widespread deposition of amyloid which on Congo-red stain imparted an apple-green birefringence on polarizing microscopy. To the best of our knowledge, this is the first-ever case of such an association where gastric adenocarcinoma occurred with concomitant gastric GIST and secondary amyloidosis of the spleen.

Prevalence and spectrum of haemoglobinopathies in females of reproductive age group- A first tertiary care center experience in Punjab, North India

Background: Thalassemia and hemoglobinopathies are a group of inherited conditions characterized by abnormalities in the synthesis or structure of hemoglobin (Hb). According to estimates, approximately 7% of the world population is a carrier of Hb disorders, leading to high morbidity and mortality. To reduce the burden of these highly prevalent monogenic disorders, detecting them in the carrier stage is crucial to prevent disease progression. Aim: We aimed to estimate the prevalence and spectrum of hemoglobinopathies in females in the reproductive (20–40 years) age group. Settings and Design: It was a retrospective observational study carried out for 2.5 years (from January 2018 till June 2020). Materials and Methods: All the females in the age group of 20–40 years age whose blood samples were received in the department for High-Performance Liquid Chromatography (HPLC) were included. The cases with abnormal HPLC findings were analyzed for hematological parameters including hemoglobin, RBC count, and RBC indices [mean corpuscular volume (MCV), mean corpuscular hemoglobin (MCH), mean corpuscular hemoglobin concentration (MCHC), & red cell distribution width - coefficient of variation (RDW-CV)]. Statistical Analysis: Statistical package for social science (SPSS) statistics 21 version for Microsoft Windows (Chicago, USA) was used for statistical analysis of data. The data were described in terms of range, mean ± standard deviation (SD), frequencies (number of cases), and relative frequencies (percentage) as appropriate. Results: During the study period, 72.2% of the females were affected with ?-thalassemia trait, followed by HbD Punjab trait (17.8%), HbQ India trait (2.9%), ?-thalassemia major (1.8%), and two cases (1.2%) each of HbS trait, HbD Iran trait, and compound heterozygous of HbD Punjab and ?-thalassaemia, whereas HbE trait, compound heterozygous of HbQ and ?-thalassemia, compound heterozygous of HbJ-variant and ?-thalassemia had one case each (0.6%). Conclusion: Preventive strategies are cost-effective and include population screening, premarital screening, screening of spouses, genetic counseling, and prenatal diagnosis. Educating the carrier females about the potential risk and various screening methods may help in controlling the disease.

Intranasal glioma (Nasal heterotopia): A rare cause of nasal polyp in neonates

A 3-month-old boy presented with an intranasal polypoidal mass protruding out of the nostril which was present since birth and growing slowly. The mass was non-pulsatile and soft to firm in consistency. It did not increase in size on coughing, crying, or compression of the jugular vein. Magnetic resonance imaging and contrast-enhanced computed tomography (CT) revealed a lobulated well-circumscribed soft tissue mass in the left nasal cavity with no intracranial communication. Complete surgical excision of the mass was carried out via an intranasal endoscopic approach. Histopathological examination confirmed the diagnosis of intranasal glioma.

Isolated pancreatic myeloid sarcoma: A potential mimicker of pancreatic adenocarcinoma

Myeloid sarcoma (MS) is an extramedullary proliferation of immature myeloid cells which may occur as a progression of myelodysplastic syndrome (MDS), myeloproliferative neoplasm (MPN), or myelodysplastic syndrome/myeloproliferative neoplasm (MDS/MPN) and as acute myeloid leukemia (AML) relapse. Rarely may it be de novo. Lymph nodes, skin, lungs, intestine are the commonly involved sites. However, an isolated pancreatic MS is seldom reported in the literature. Herein, we report one such case which was misdiagnosed as pancreatic adenocarcinoma on the clinico-radiological examination which misled us away from preoperative diagnostic sampling, and a Whipple pancreaticoduodenectomy was performed. Histopathological examination in conjunction with immunohistochemistry revealed the final diagnosis of isolated MS of the pancreas. We emphasize that although rare, a clinical suspicion along with preoperative histopathological examination may lead to early diagnosis, targeted management, and a better clinical outcome in such cases.

Homeopathic Approach In Iron Deficiency Anaemia

In present global worming most common disease in women is anaemia.This condition also seen in during pregnancy also. In my study also find out which miasmas are more prominent during pregnancy may be responsible for iron deficiency anaemia.

Comparison of Bone-Patellar Tendon-Bone Graft, Semitendinosus–Gracilis Graft and Semitendinosus–Gracilis with Preserved Tibial Insertion Graft in Anterior Cruciate Ligament Reconstruction in Sports Persons

@#Introduction: Bone-patellar tendon-bone (BPTB) and semitendinosus–gracilis (STG) are the commonest grafts used for ACL reconstruction. However even after having been debated for years, there is no consensus about the ideal graft. Moreover, the literature is deficient about STG graft with preserved tibial insertion (STGPI) which preserves the proprioception. Our aim is to compare the outcome of BPTB, free STG and STGPI grafts after ACL reconstruction in professional sports persons. We compared the outcome in terms of mechanical stability, functional outcome, return to sports activity and degenerative changes. Materials and Methods: Professional sports persons aged between 16-50 years operated for ACL tear using BPTB, free STG and STGPI grafts with minimum follow-up of two years were identified from hospital records. Patients with associated knee injuries were excluded. Patients, divided in three groups according to graft used, were compared in terms of mechanical stability (arthrometric examination KT-1000 score), functional outcome (Lysholm Score), return to sports activity (Tegner score and difference in thigh circumference) and degenerative changes (KL grading). Results: BPTB graft group was found to be better than free STG and STGPI graft groups in terms of KT-1000 score. There was no statistically significant difference among the groups in terms of Lysholm score, Tegner score, difference in thigh circumference and KL grading. Conclusion: BPTB graft is better than free STG and STGPI grafts in terms of knee stability. When compared for patient reported outcome, return to sports activity, osteoarthritic changes and graft failure there is no significant difference among the three types of grafts.

Predictors for Anterior Cruciate Ligament (ACL) Re-injury after Successful Primary ACL Reconstruction (ACLR)

@#Introduction: Few authors have addressed risk factors related to an ipsilateral graft rupture and contralateral anterior cruciate ligament (ACL) injury after return to sports (RTS) following primary ACL reconstruction. Material and Methods: Patients with ACL re-injury to either knee after successful primary ACLR were included in Group I and those with no further re-injury were included in Group II. Variables including age, gender, side, body mass index (BMI), thigh atrophy, anterior knee laxity difference between both knees measured by KT-1000 arthrometer, mean time of return to sports (RTS), graft type, type of game, mode of injury, Tegner Activity Score, hormone levels, femoral tunnel length (FTL), posterior tibial slope (PTS) and notch width index (NWI) were studied. Binary logistic regression was used to measure the relative association. Results: A total of 128 athletes were included with 64 in each group. Mean age in Group I and II were 24.90 and 26.47 years respectively. Mean follow-up of Group I and Group II were 24.5 and 20.11 months respectively. Significant correlation was present between ACL re-injury and following risk factors; PTS of >10º, KT difference of >3.0mm, thigh atrophy of >2.50cm and time to RTS <9.50 months P value <0.05). No correlation was found with age, sex, BMI, type of game, Tegner Activity Score, mode of injury, NWI, size of graft, FTL and hormone levels. Conclusion: Possible risk factors include PTS of ≥ 10º, KT difference of ≥ 3.0mm at 1 year follow-up, thigh atrophy of ≥ 2.50cm at 1 year follow-up and RTS <9.5 months after primary ACLR.

In Situ Fixation of Symptomatic Fibrous Non-union Hoffa Fracture: A Case Report

@#Femoral condyle fracture in coronal plane, also known as Hoffa fracture, is a rare fracture. Non-union of Hoffa fracture is even rarer. We present a case of fibrous nonunion of a Hoffa fracture in which the fractured fragment, though not freely movable, led to painful walking. Since the fragment was un-displaced and non-movable we fixed the fractured fragment in situ. Patient regained full range of motion of the knee and was asymptomatic on follow-up.

Randomized Control Study of Oral Versus Vaginal and Sublingual Misoprostol with Mifepristone for First-Trimester MTP.

Objective: To compare the outcome of two regimes of mifepristone and misoprostol (oral vs vaginal and sublingual administration of misoprostol) for medical termination of early pregnancy (within 49 days). Study design: A randomized controlled study was conducted. On 75 women undergoing medical termination of pregnancy (MTP) within 49 days of amenorrhea (7 weeks). These women were divided into two groups – Group 1: received tablet mifepristone 200 mg orally followed by tablet misoprostol 600 mcg oral after 48 h. Group 2: received tablet Mifepristone 200 mg orally followed by misoprostol tablet 800 mcg, two tablets administered per vaginum and two tablets advised to be taken sublingually after 12 h. An ultrasonography pelvis was performed on all patients pre-MTP to confirm the location and age of gestation and post-MTP on day 15 to confirm no retained products of conception. Statistical analysis was done by two proportion tests for individual side effect with the null hypothesis. Results: The complete abortion rates in Group 1 were 91.4% as compared to 90% in Group 2. Only 11.4% of women in Group 1 and 12.5% in Group 2 had bleeding for more than 15 days. The duration and amount of bleeding were statistically similar in both groups. Conclusion: We concluded that after 48 h of administration of mifepristone, oral 600 mcg of misoprostol is as efficient as 800 mcg of misoprostol (administered vaginally, 400 mcg and sublingually, 400 mcg) in inducing medical abortion of pregnancy within 49 days of amenorrhea.

ICU management of severe malaria.

Malaria is very common in India. First step in management of malaria is to establish the diagnosis. It is established by using traditional smear or method like dipstick antigen captures assay which is simpler, accurate and doesn't require expertise. Next step is to look for signs and symptoms, which help cases of severe malaria should be admitted in intensive care unit (ICU) and antimalarial chemotherapy should be started through parenteral route. Complications like coma, anemia, renal failure, pulmonary edema, disseminated intravascular coagulation are not very uncommon. These complications should be anticipated and treated in time. There is no role of corticosteroids, mannitol in the treatment of cerebral edema. Therapeutic monitoring of severe malaria should involve quantitative estimation of parasite load.

Management of dengue fever in ICU.

Dengue virus infection can cause a wide spectrum of illness. Thrombocytopenia with concurrent haemoconcentration differentiates dengue haemorrhagic fever from classical dengue fever. Only cases with shock or unstable vitals signs need admission in the pediatric intensive care. The management is essentially supportive and symptomatic. The key to success is frequent monitoring and changing strategies. A rise in hematocrit of 20% along with a continuing drop in platelet count is an important indicator for the onset of shock. Patients in grade I and II should be closely monitored for signs of shock. The management of dengue shock syndrome (grade III and IV) is a medical emergency needing prompt and adequate fluid replacement for the rapid and massive plasma losses through increased capillary permeability. Early and effective replacement of plasma losses with plasma expanders or fluid and electrolyte solutions results in a favourable outcome in most cases. The ideal fluid management should include both cystalloids and colloids (including albumin). Cystalloids are given as boluses as rapidly as possible, and as many as 2 to 3 boluses may be needed in profound shock. Colloidal fluids are indicated in patients with massive plasma leakage and in whom a large volume of cystalloids has been given. Frequent recording of vital signs and determinations of haematocrit are important in evaluating the results of treatment. Apart from correction of electrolyte and metabolic disturbances, oxygen is mandatory in all patients of shock. Some patients develop DIC and need supportive therapy with blood products (blood, FFP and platelet transfusions). Polyserositis, in the form of pleural effusion and ascitis, are common in cases of dengue shock syndrome, and if possible, drainage should be avoided as it can lead to severe hemorrhages and sudden circulatory collapse. The prognosis depends mainly on the early recognition and treatment of shock.

Impact of linear alkyl benzene sulphonate (LAS) on phosphatase activity in testis of the teleostean fish, Heteropneustes fossilis (Bloch).

Fishes are sensitive indicators of pollutants present in water.These pollutants cause various physical and physiological alterations in fishes. In the present work alteration in the activity of acid and alkaline phosphatase was evaluated in testicular tissue of fresh water fish Heteropneustes fossilis exposed to LC50 value of linear alkyl benzene sulphonate (LAS) for different exposure periods [24 h, 48 h, 72 h and 96 h] With increase in the concentration of chemical LAS, the activity of acid phosphatase (ACP) was reported elevated while a significant fall in the activity of alkaline phosphatase (ACP) was recorded for same exposure period. Elevated activity of ACP, one of the important hydrolases of lysosomes, is quite suggestive of bringing about gross necrosis and dysarchitecture. ALP is involved in various metabolic activities including gonadal maturation and as such decreased activity of this enzyme is definitely one of the important causative factors for reproductive impairment of the fish.

Dapsone hypersensitivity syndrome with coexisting acute hepatitis E.

A 14-year-old girl presented with fever, generalized lymphadenopathy, skin rash and hepatitis after starting dapsone. All abnormalities reversed with institution of prednisolone therapy after discontinuation of dapsone. The hepatic involvement was of hepatocellular type; it was associated with IgM anti-HEV antibodies, suggesting coexisting acute hepatitis E. We believe a causal link between the hepatotrophic viruses and dapsone hypersensitivity syndrome could exist.

Balloon dilatation of ureteric strictures.

AIMS: Evaluation of dilatation as a minimally invasive technique for the treatment of ureteric strictures. MATERIAL AND METHODS: We evaluated this technique in 16 patients with ureteric and secondary pelviureteric junction strictures from June 1998. Of these, 7 were men and 9 were women. The age range was from 14 to 40 years. RESULTS: Balloon dilatation was successful in 69% of patients. Strictures secondary to previous surgery had nearly 100% success. Of the 8 cases diagnosed as genitourinary tuberculosis, success rate was 50%. CONCLUSIONS: Factors affecting success of balloon dilatation are: a) age of the stricture b) length of the stricture and c) etiology of the stricture. In a select group of patients with fresh post-operative or post-inflammatory strictures, balloon dilatation may be an attractive alternative to surgery.

Martius' labial fat pad interposition and its modification in complex lower urinary fistulae.

OBJECTIVE: To assess the results of Martius' labial fat pad interposition and its modification using skin island in the repair of giant and recurrent vesicovaginal and urethrovaginal fistulae. PATIENTS AND METHODS: Fifteen patients of urethrovaginal and vesicovaginal fistulae underwent Martius' labial fat pad interposition and its skin island modification during 1996 to 1999. Ten of these were recurrent (66%) and five were giant fistulae (34%) i.e. more than five cms. RESULTS: Results were very gratifying with a successful repair in 14 patients (93%). Two patients had transient, low-grade stress incontinence, which did not need any additional procedure. In one patient, there was failure of repair, which was later successfully repaired using fat pad from opposite labia. CONCLUSION: Martius' fat pad interposition provides vascularity and surface for epithelialisation and also prevents overlapping of vesical/urethral and vaginal suture lines. Martius' repair has good results with low morbidity in the treatment of giant and recurrent urethrovaginal and vesicovaginal fistulae.

Changes in myosin ATPase activity in skeletal muscles of rat during cold stress.

Three skeletal muscles viz., gastrocnemius, pectoralis and diaphragm from rats acclimated to a low temperature (4 +/- 1 degrees C; 16 hr daily; maximum for 8 weeks) exhibit an increased myosin ATPase activity. An analysis of native myosin from these muscles under non-dissociating conditions reveals two myosin isozymes instead of a single isozyme expressed in control muscles. Isoelectric focusing (IEF) coupled with two dimensional sodium dodecyl sulfate polyacrylamide gel electrophoresis (2-D SDS-PAGE) confirms an increased phosphorylation of myosin light chain 2 (MLC2) in muscles from cold acclimated rats.