Fibrolamellar hepatocellular carcinoma presenting as cholestatic jaundice: An unusual presentation of a rare disease

Fibrolamellar hepatocellular carcinoma is a rare primary hepatic tumor that usually occurs in youth. The common presenting features are vague abdominal pain, nausea, vomiting and weight loss. We present a case report of a young male who presented with cholestatic jaundice and on evaluation was diagnosed to have fibrolamellar hepatocellular carcinoma. He underwent successful surgical resection of the tumor. In young individuals presenting with unexplained cholestasis, fibrolamellar hepatocellular carcinoma should be considered.

Is “Transcolumnar” a better Terminology than “Transverse” in Judet-Letournel Classification of Acetabular Fractures?

@#Acetabular fractures are among the most complex and challenging injuries for orthopaedic surgeons. The choice of surgical treatment in acetabular fracture is important for optimal outcomes. It requires an understanding of the precise outline of the fracture by appropriate classification because it is important for decision making. For this purpose, the classification proposed by Judet and Letournel in 1963 remains the gold standard despite its shortcoming, which are attributed to the inclusion of multiple criteria including anatomical, directional and geometrical. This complex classification remains challenging especially to lesser experienced surgeons. In this article, a new method for classification of acetabulum fractures is proposed. It places posterior column with posterior wall fractures to simple fractures instead of complex fractures in Judet and Letournel classification. More importantly the proposed new classification renames “transverse fracture” as “transcolumnar fracture” to better represent anatomical structure rather than morphology. It is expected that by coining the new term “transcolumnar ”it will be easy to understand different types of acetabular fractures. Especially the confusion between “transverse” and “both column fractures” would not be a concern in future.

Immune-mediated tuberculous uveitis - A rare association with papulonecrotic tuberculid

The tuberculids are a group of distinct clinicopathological form of skin lesions representing hypersensitivity reaction to hematogenous dissemination of Mycobacterium tuberculosis or its antigen from an underlying active or a silent focus of tuberculosis elsewhere in the body in an individual with a strong antituberculous cell-mediated immunity and by definition do not show bacilli on special stains and are culture-negative. Ocular involvement can occur in tuberculosis, both due to direct invasion by the bacilli as well as an immune-mediated reaction; however, immune-mediated tuberculous uveitis occurring as a hypersensitivity response in association with PNT has hardly been reported in the literature. Here we report one such rare case.

Epidemiology of animal bite reported at animal bite clinic during 2015-16 at a tertiary care centre of Himachal Pradesh.

Background: One health approach for rabies prevention in humans can be done only by targeting the animal source of the virus. Animal bite is the most common mode of transmission of virus to human being. Objective: to describe the epidemiology of animal bite among those attending the animal bite clinic of a tertiary care center of district Kangra, Himachal Pradesh. Methods: This hospital based descriptive study was carried out from March 2015 through February 2016 at Animal Bite Clinic of Department of Community Medicine, Dr. Rajendra Prasad Govt. Medical College, Tanda, Kangra, Himachal Pradesh. A preformed and pre tested closed ended questionnaire was used. World Health Organization’s category of animal bite was used to categorize the patients. Results: Males outnumbered females and around 30% were below 20 years of age followed by third decade. Majority of victims were students (31%) and in 61.1% the wound was localized in the lower extremities. Dogs bite was reported in 86% cases. Stray animal bite resulted in 94.2% of category III bites. More than half of the victims were aware of local remedy to be done after bite and practiced it within 30 minutes of bite. Conclusions: Agent, host and environmental factor of animal bite studied in this study indicate that vaccination of animal, abolishing environment favorable for stray animals and awareness of early management of animal bite cases can lead to goal of elimination of rabies.

Frequency & predictors of pancreatitis in symptomatic primary hyperparathyroidism

Background & objectives: The frequency and predictors of pancreatitis in primary hyperparathyroidism (PHPT) are not well understood. The objective of the present study was to evaluate the frequency of pancreatitis in patients with PHPT and its association with clinical and biochemical parameters of the disease. Methods: In this retrospective study all consecutive patients with PHPT registered in the PHPT registry (www.indianphptregistry.com) from the year 2004 to 2013 were included. The clinical, biochemical and radiological parameters related to pancreatitis were evaluated in histologically proven PHPT patients. Results: A total of 218 patients (63 men; mean age: 40.6±14.4 yr) underwent surgery for PHPT during the study. Pancreatitis occurred in 35 [16%, 18 acute and 17 chronic pancreatitis (CP)] patients and male:female ratio was 1:0.94. Skeletal manifestations were seen less frequently in PHPT with pancreatitis as compared to that of PHPT without pancreatitis. PHPT with pancreatitis had significantly higher serum calcium (12.4±2.0 vs. 11.7±1.5 mg/dl, P <0.05) in comparison to PHPT without pancreatitis. PHPT with acute pancreatitis (AP) had higher serum calcium (P <0.05) and parathyroid hormone (PTH) (P <0.05) levels than PHPT with CP. Curative parathyroidectomy improved the symptoms associated with pancreatitis as there was no recurrence in AP group, whereas recurrence was observed only in about 10 per cent patients of the CP group. Interpretation & conclusions: Pancreatitis was observed in 16 per cent of PHPT patients with male predominance in the study population. No recurrence of AP was observed after curative surgery. It may be proposed that serum amylase with calcium and PTH should be measured in all patients of PHPT with pain abdomen to rule out pancreatitis.

Bacteriological profile and antibiotic sensitivity pattern of neonatal septicaemia in a rural tertiary care hospital in North India.

Background: There is not much published literature on neonatal septicemia available for the Sub‑Himalayan region of North India. Hence, we undertook this study to find out the bacteriological profile and antibiotic sensitivity pattern of neonatal septicemia in the neonatal Intensive Care Unit. Material and Methods: Blood cultures were performed for all clinically suspected neonatal septicemia cases for 1‑year. Identification of all pathogenic isolates was followed by antibiotic sensitivity testing. Results: We did blood cultures for 450 neonates and 42% were culture positive. Early onset sepsis were 92 (49%) and 96 (51%) were late onset sepsis. Gram‑positive isolates were 60% and 40% were Gram‑negative. Staphylococcus aureus (40%), coagulase negative Staphylococcus species (16%), non‑fermenter group of organisms (NFGOs) (15%), and Klebsiella pneumoniae (10%) were the main isolates. Nasal cannula 101 (54%), birth asphyxia 91 (48%), and prematurity 73 (38%) were the prominent risk factors associated with septicemia. Gram‑positive organisms were highly resistant to penicillin (87%) whereas Gram‑negative isolates showed high resistance to third generation cephalosporins (53–89%) and aminoglycosides (50–67%). The S. aureus isolates were methicillin‑resistant in 41% whereas extended spectrum beta lactamase production was seen in 48% Gram‑negative isolates. Conclusion: Our study highlights the recent emergence of Gram‑positive organisms as predominant cause of neonatal septicemia in this part of Sub‑Himalayan region, along with the review of literature which shows similar results from North India and rest of the world too. Though Gram‑negative bacteria still remain the main cause of mortality in neonatal septicemia, we want to dispel the common notion among practitioners that they are the predominant isolates in neonatal septicemia.

Prompt diagnosis and extraordinary survival from Naegleria fowleri meningitis: A rare case report.

Primary amoebic meningoencephalitis is a rare fatal meningitis caused by free living amoeba Naegleria fowleri, found in freshwater ponds and lakes. It infects children and young adults with exposure due to swimming or diving. We report a case of N. fowleri meningitis in a 6‑year‑old boy who presented with signs and symptoms of acute bacterial meningitis. No history of travelling or swimming was present. However, the boy frequently played with water stored from a “kuhl” (diversion channels of water). Wet mount of cerebrospinal fluid (CSF) revealed amoeboid and actively motile flagellate forms of trophozoites. CSF culture done on 1.5% non‑nutrient agar plates with a lawn culture of Escherichia coli kept at 37°C for 15 days did not reveal any growth. The test of flagellation on passing CSF in distilled water was however positive in 3 h. Water of the “kuhl” from the stored tank also showed actively motile trophozoites similar to the forms obtained from the CSF. Based on our reports, the boy was immediately treated with amphotericin B, rifampicin and fluconazole for 21 days. Repeat CSF examination after 14 days did not reveal any trophozoites in wet mount and patient was discharged after 3 weeks of successful treatment.

Microsporum gypseum dermatophytosis in a patient of acquired immunodeficiency syndrome: A rare case report.

Microsporum gypseum, a geophillic dermatophyte is rarely isolated from patients with acquired immunodeficiency syndrome. We report tinea corporis due to Microsporum gypseum, an uncommon aetiological agent, in a patient with acquired immunodeficiency syndrome from our region. The clinical presentation resembled psoriasis characterised by atypical, scaly and hyperkeratotic lesions.

Oncologists should measure life, not death: a newer perspective of cancer statistics.

We discuss why we should measure parameters of 'life' and not 'death' in choosing a therapy for cancer and what are the flaws and difficulties in measuring cancer specific deaths. We then submit those parameters which can be measured with high precision and validity in cancer patients and so should be recorded to guide us in deciding the best therapy.

Clinical Results of Coracoacromial Ligament Transfer in Acromioclavicular Dislocations: a Review of Published Literature

Acromioclavicular joint dislocations are common injuries; which typically occur with trauma in young men. Treatment recommendations for these injuries are highly variable and controversial. There are greater than 100 surgical techniques described for operative treatment of this injury. One of the most widely recommended methods of surgical recons- truction for acromioclavicular joint dislocations is to utilize the coracoacromial ligament for stabilization of the distal clavicle. Several modifications of this procedure have been described which have involved adjunct coracoclavicular fixation or fixation across acromioclavicular joint. Although the literature is replete with descriptive papers; there is paucity of studies evaluating the surgical outcome of this procedure. We systematically reviewed the eng language published literature in peer reviewed journals (Medline; EMBASE; SCOPUS) and assigned a level of evidence for available studies. We critically reviewed each paper for the flaws and biases and then evaluated the comparable clinical outcomes for various procedures and their modifications. The published literature consists entirely of case series (Level IV evidence) with variability in surgical technique and outcome measures. On review there is low level evidence to support the use of coracoacromial ligament for acromioclavicular dislocation but it has been associated with high rate of deformity recurrence. Adjunct fixation does not improve clinical results when compared to isolated coracoacromial ligament transfer. This is in part because of the high incidence of fixation related complications. Similar results are reported with coracoacromial ligament reconstruction for acute and chronic cases. The development of secon- dary acromioclavicular joint symptoms with distal clavicle retention is poorly reported with the incidence rate varying from 12to 32. Despite this; the retention or excision of distal clavicle did not affect overall clinical results except in the patients with pre existing acromioclavicular joint osteoarthritis who have inferior results with retention of distal end of clavicle. Further well designed clinical trials with validated outcome measures are required to fully evaluate the clinical results of this procedure

Comparative efficacy of diffusible and volatile compounds of tea rhizospheric isolates and their use in biocontrol

An attempt was made to study in vitro production of antifungal substances by various strains of Bacillus subtilis and Pseudomonas corrugata. These strains were isolated from the rhizosphere of established tea Camellia sinensis L. located in North West Indian Himalayan regions viz Himachal Himalayas and Garhwal Himalayas. Selected strains were checked for their biocontrol potential against two phytopathogenic fungi Fusarium udum and Alternaria solani and the antagonists were found to cause inhibition in radial growth of the fungi. This diffusible effect was attributed to the production of diffusible and volatile compounds which were found to be potent antifungal in nature. The antifungal substances in bacterial strains were found to be extracellular; proteinacious in nature. The colony forming units (cfu) of pathogenic fungi were reduced by the diffusible and volatile compounds produced by antagonists. The inhibition in cfu was more by volatile compounds than by diffusible compounds. The volatile compounds included aldehydes; alcohols; ketones; sulphides and HCN

Ultrasound guided percutaneous nephrostomy for obstructive uropathy in benign and malignant diseases

OBJECTIVE: Analyze the success rate, complications and overall benefit of ultrasound guided percutaneous nephrostomy (PCN) for the relief of obstructive uropathy in benign and malignant diseases. MATERIALS AND METHODS: PCN was performed in 50 kidneys of 32 patients. It was performed in emergency rooms totally under ultrasound guidance by general surgeons. Seldinger technique was used in all cases. Changes in renal function after the procedure were analyzed using paired t-test. RESULTS: The procedure was successfully completed in 42 out of 50 kidneys (84 percent). There has been no major complication and 28 percent minor complications. The renal function improved significantly when PCN was performed for benign conditions (mean creatinine 3.52 mg/dL before and 2.18 mg/dL after PCN), however in malignancy there has been no significant improvement in renal function (before PCN mean creatinine 6.39 mg/dL and after PCN 5.41 mg/dL). CONCLUSION: We conclude that PCN can be effectively performed under ultrasound guidance and should be the initial procedure in acutely obstructed kidneys with pyonephrosis and poor renal function. In malignant cases, however, improvement in renal function is possible only if the procedure is carried out at an early stage.

Literature search using PubMed: an essential tool for practicing evidence- based medicine.

Efficient literature search is essential to the practice of Evidence-Based Medicine. PubMed provides free access to one of the largest searchable biomedical databases. Efficient literature search using PubMed requires a good understanding of the available search strategies and tools. In this article we present a step-by-step approach for performing literature search using PubMed. Several PubMed tools including 'Single Citation Matcher', 'Clinical Queries', 'Clipboard', 'Field Tags', and 'Cubby' are highlighted using case based scenarios.

Coexistence of Takayasu's arteritis with ulcerative colitis.

The association of ulcerative colitis with Takayasu's arteritis is rarely reported. The occurrence of the two together is possibly related to a common pathophysiology involving alteration in immune mechanisms. Takayasu's arteritis is more prevalent in Japan and South East Asia whereas Ulcerative Colitis is more in Western countries. The coexistence of these two diseases is uncommon and hence this report.

A comparison of the circadian rhythm of intraocular pressure in primary phronic angle closure glaucoma, primary open angle glaucoma and normal eyes.

PURPOSE: To evaluate the circadian rhythm of intraocular pressure (IOP) in primary chronic angle closure glaucoma (PCACG), primary open angle glaucoma (POAG), and normal eyes. METHODS: Cross-sectional study of newly diagnosed patients of POAG (60 eyes), PCACG following laser iridotomy (75 eyes), and age and sex matched normal controls (75 eyes). All subjects underwent applanation tonometry at 7 a.m., 10 a.m., 1 p.m., 4 p.m., 7 p.m., and 10 p.m. by a masked observer. Circadian rhythms were classified based upon the timing and presence of peak pressure. RESULTS: Age and gender in all three groups were comparable. Diurnal IOP fluctuations were significantly higher in PCACG (7.69+3.03 mmHg) and POAG (8.31+2.58 mmHg) groups compared to normal controls (4.83 + 2.46 mmHg). PCACG eyes and controls had similarly timed circadian rhythms, with PCACG eyes having a consistently higher IOP. At 7 and 10 a.m., IOP peaked more often in POAG eyes compared to PCACG eyes. A plateau type of circadian rhythm was most common in normal eyes. The timing of peak IOP could be significantly correlated with the type of primary glaucoma examined. CONCLUSION: Afternoon peaks were more common in postiridotomy PCACG eyes, similar to the rhythm in normal eyes. Morning peaks were more frequent in POAG eyes. Diurnal fluctuation > 6 mmHg, associated with an IOP of 21 mmHg or more was never seen in a normal eye.

Paterson Kelly syndrome in celiac disease.

The association of Paterson Brown Kelly Syndrome and celiac disease is not widely reported. Both the entities have iron deficiency anemia. This case report emphasizes the need of screening for celiac disease in patients with Paterson Kelly Syndrome.