Tissue Harmonic Imaging Compared with Conventional BMode Ultrasound, Biphasic CECT and Tissue Diagnosis in Evaluation of Pancreatic Masses

Background: Tissue harmonic imaging (THI) is a newer method that can diagnose and differentiate various types of pancreatic masses. The aim of this study was to evaluate the efficacy of tissue harmonic imaging for detection and differentiation of pancreatic masses and its comparison with conventional B-mode ultrasound, biphasic CECT abdomen and tissue diagnosis. Methods: 31 patients who presented with a suspicion of pancreatic mass clinically or radiologically were enrolled in this study. All patients underwent both conventional B-mode ultrasound abdomen and THI. Biphasic CECT abdomen was done for diagnostic reference. Pancreatic lesions were documented regarding site, size, internal architecture, and status of peri-pancreatic vessels. The USG diagnosis was compared with biphasic CECT and tissue diagnosis. Results: There was statistically significant difference between THI and conventional B-mode USG in visualization of image quality (p<0.001) and solid-cystic differentiation (SCD) (p=0.001). Taking tissue diagnosis as the standard, out of the 25 (80.6%) cases which were diagnosed as malignant on USG and biphasic CECT, 18(72%) cases were confirmed to be malignant on tissue diagnosis. There was no statistically significant difference between biphasic CECT and USG (conventional B-mode and THI) in the diagnosis of benign and malignant masses in pancreas (p=1). Conclusions: THI is superior to conventional B-mode USG in the Sonography of pancreatic masses because THI has better overall image quality, lesion conspicuity, visualization of lesion margin and fluid–solid differentiation. It should be routinely utilized as part of the diagnostic workup of patients with pancreatic masses.

Reversible Cerebral Atrophy in Infantile Tremor Syndrome.

Background: We report changes in MRI brain of children with Infantile Tremor Syndrome (ITS) at the onset of illness and following treatment. Case characteristics: Three children with infantile tremor syndrome were assessed for changes in brain neuroimaging at admission and at follow-up visit. On MRI, all children had mild to severe diffuse cerebral atrophy, which reverted back to normal on follow-up visits. Outcome: Children with infantile tremor syndrome have reversible diffuse cerebral atrophy on neuroimaging.

Complete Fistula of the Second Branchial Cleft Managed by Single Neck Incision-our Experience and Review of Literature.

Introduction: Branchial fistulas and cysts, involving soft tissues of the neck, are quite uncommon anomalies of embryonic development that are commonly encountered by pediatric surgeons. Approximately 17% of all cervical masses in the pediatric age group are due to branchial anomalies. Although branchial cleft cysts are usually benign, infection, discharge, mass effect, and other surgical complications account for its morbidity. Aim: To assess 10 rare cases of a complete second branchial fistula which were diagnosed and treated in last 5 years by single neck incision in the Department of Surgery S. N. Medical College, Agra. Material and Methods: 10 cases of complete second branchial fistula were reported and managed in our institute. The age group of patients was from 2 to 12 months of age. These patients presented with an intermittent serous and mucoid discharge from an external opening in the lower aspect of the neck since birth. Most of the patients presented with opening on the right side of the neck. A pre-operative fistula gram done in all cases revealed the internal opening of tracts up to the peritonsillar fossa. In all cases, complete excision of the tracts was done by single step neck incision. Results: All the 10 patients underwent surgery with satisfactory results. Regular follow-up was done at biweekly for 1 month followed by monthly intervals up to 12 months. None developed any complications and no patient had recurrence. Conclusion: Although second branchial fistulae are common, complete fistulae with internal opening up to tonsillar fossa are rare, single step management of these cases merits the publication of this series. The report also guides on the need to perform a pre-operative fistulogram for the management of these cases.

Use of Dorsal Dartos Pedicled Flap Single or Double Layered in Preventing the Fistula Rate Following Tubularized Incised Plate Repair in Distal Hypospadias: A Prospective Randomized Study.

Introduction: Hypospadias is defined as an anomaly involving the ventral aspect of the penis with variable location of meatus from the tip with or without chordae. Objective: To study the role of dorsal dartos pedicled flap for reducing the fistula rate in tubularized incised plate (TIP) repair for distal hypospadias. Methods: Between November 2012 and August 2015, a total of 65 patients with distal penile hypospadias age between 1 and 18 years were included in this study. Patients were divided into 2 groups. Group (A) had 35 patients in which a single layer of dartos flap was used to cover the neourethra during TIP repair while in Group (B) which had 30 patients, the dartos flap was split into two halves and used to cover the neourethra in a double breasting fashion. Patients were followed regularly up to 6 months postoperatively. Results: The success rate shows no statistically significant difference between Group A 35 (94.29%) and B 30 (96.67%) P > 0.05. All successful patients had a satisfactory cosmetic result with a conical glans and vertical slit-like meatus. These results were compared with our 30 cases done previously without using a dartos flap which had a success rate of only 80%. Conclusion: Dartos pedicled coverage of TIP repair offers a significant reduction in fistula rate after TIP in distal hypospadias even though single or double layers of dartos coverage had no significant difference in results.

Mayer-Rokitansky-Küster-Hauser Syndrome with Imperforate Anus: A Rare Association and an Innovative Surgical Management.

Mayer-Rokitansky-Küster-Hauser (MRKH) syndrome is one of the rare disorder of Mullerian agenesis leading to non-development of uterus and vagina. Its association with anorectal malformation is rare. We report a case of MRKH syndrome with recto-vestibular in a female child. The child had undergone a sigmoid loop colostomy in the neonatal period. On clinical examination of the perineum, a fistula was present in the vestibule just below the urethral opening, but no vaginal canal was found. It was managed with an innovative surgical technique, preserving the fistula and lower rectum to function as vagina.

Comparative Study of Real-Time PCR with Culture in the Diagnosis of Tubercular Lymphadenopathy.

One-third of the world’s population is estimated to be infected with M.tuberculosis. Timely and accurate diagnosis is pivotal in the management of the disease. Conventional tests, although accurate, are time consuming as compared to the more promising latest molecular techniques like real-time PCR which are rapid, reproducible and reliable. Objective : The aim of the study is to compare the real-time PCR with culture method in the diagnosis of tubercular lymphadenopathy. Material and Methods: Present study included 40 patients belonging to the age group 0-40 years and presenting as cervical lymphadenopathy, attending the indoor and out-patient of Department of TB & Chest Diseases, S.N. Medical College, Agra (U.P.) from Jan’2009 to June’2010. All patients were subjected to routine investigations, e.g. hemogram, montoux test, Chest skiagram, AFB staining, and sputum examination. Lymph node aspirate were subjected to decontamination, DNA isolation and Real time PCR( q PCR). Also specimen were simultaneously put to culture on L.J. Media. Results of both modalities compared. Results: Conventional culture method was able to detect M.tuberculosis in 75% of the cases as compared to real-time PCR which was positive in 77.5% with comparable sensitivity (100% vs 96.7%) and specificity (100% vs 87.5%). Conclusion: Conventional culture method is gold standard in the diagnosis of tuberculosis since long but recent molecular assays like Real-time PCR is one of the latest addenda to the armamentarium for the rapid and accurate diagnosis of M.tuberculosis. Needless to say, early diagnosis is advantageous to the management of tuberculosis.

Effect of chronic exposure to biomass fuel smoke on pulmonary function test parameters.

Background: Life in a typical Indian household revolves around the cooking area, and Indian women spend much of their time there. Cooking stoves in most households are nothing more than a pit, a chulha (a U-shaped construction made from mud), or three pieces of brick. Cooking under these conditions entails high levels of exposure to cooking smoke. Aim of this study was to evaluate the effect of Chronic Exposure to Biomass Fuel Smoke on Pulmonary Function Test Parameters. Methods: 60 non-smoking women without any history of any major chronic illness in the past were selected for this study. The study group comprised of 30 rural female subjects who were chronically exposed to biomass fuel smoke combustion and 30 age matched urban female subjects exposed chronically to clean fuel combustion (Liquified Petroleum Gas–LPG) in Haryana (India). All the subjects were evaluated for pulmonary function tests by RMS Medspiror. Results: Biomass exposure index came out to be 85.68±3.69 for women cooking on biomass and LPG index was 64.17±6.97 for women cooking on LPG. This implies significant chronic exposure of women to biomass fuel smoke. The lung function parameters were significantly lesser in biomass exposed rural women [FEV1 (p<0.01), FVC (p<0.01), FEF25-75 (p<0.01), FEV1/FVC ratio (p<0.01), PEFR (p<0.01), MVV (p<0.01)] than the LPG exposed urban women. The evaluation of PFT suggested obstructive type of pulmonary disease. Conclusion: The derangement in pulmonary function parameters in women exposed to biomass smoke pollutants could be due to chronic significant exposure as suggested by high Biomass exposure Index. Inadequate ventilation in cooking area without chimney/vent also contributed to pulmonary function derangement and COPD.

Cardiotoxicity Profile of Snake Bite.

The present study was conducted in 80 cases of snake bite to understand their possible, biochemical and electrical cardio toxic effects. All patients were subjected to routine and specific investigation (ECG, X Ray, SGOT, CPK, CPK - MB, Troponin levels). Subjects were included in three groups, haemotoxic, neurotoxic and non - envenomed group. They were subjected to investigations at the time of admission, 24 hours and 72 hours after the admission. No significant statistical change occurred in cardiac enzymes in all groups at the time of admission. Significant statistical change occurred in LDH, CPK-MB at 24 hours and 72 hours after admission in haemotoxic group. Significant statistical change occurred in Troponin levels and CPK and SGOT at 24 hours after admission but no statistical change occurred at 72 hours after admission. But there was no statistical significant change in biochemical parameters in a neurotoxic group. At admission, there was tachycardia in 29 cases (53.7%) in haemotoxic group and in 16 cases (29.7%) at 24 hours which was statistically significant. At admission there was bradycardia in 10 cases (18.5%). In neurotoxic group there was tachycardia in 6 (60%) cases at admission and in 2 cases (20%) at 24 hours. There was bradycardia in 1 case in neurotoxic group. No significant change occurred in all groups at 72 hours. The present study showed significant statistical ECG changes at admission in the non - envenomated, neurotoxic and hemotoxic groups in the form of tachycardia or bradycardia. Also significant statistical ECG changes in the form of tachycardia was observed 24 hours after admission in hemotoxic group. It could be concluded that snake bites especially haemotoxic group carry the risk of inducing cardio toxic effects but these effects are not fatal.

Assessment of maternal-fetal and neonatal healthcare practices in an eastern Madhyapradesh district.

Background: Adequate knowledge about the maternal and child health care is meager in rural areas of India. Paying less attention to the maternal-neonatal health plays a crucial role in infant mortality. Aims & Objective: This study was designed to assess the awareness and practices of parents in relation to maternal-fetal and neonatal healthcare. Material and Methods: A total of 230 parents were included and the study was conducted over a period of one year. A pre-set questionnaire was used to obtain the data. Results: Diminished antenatal and post natal care caused by poor personal hygiene and lack of environmental sanitation was found among most cases. 71.3% were using hand pumps as water source and 76% were using open field for defecation. 50.7% female did not have antenatal checkups. Almost 90% of mothers received tetanus toxoid vaccine during gestational period. 34.7% deliveries were conducted by untrained dais at home. 98% children vaccinated against polio virus. 48% of the mothers initiated breastfeeding immediately after delivery. Majority of the mothers (42%) started complementary feeds to their children at the age of 6 months. 89.1% of mothers fed their children with additional feeds. Maximum (63%) number of parents did not possess the Below Poverty Line (BPL)/Deendayal Antyodaya Yojna Card. Conclusion: There is an imperative situation to educate the mothers and dais with respect to the maternal fetal health care. Also, flourishing new interventions are required to bring down the neonatal morbidity and mortality.

Achalasia cardia with esophageal varix managed with endoscopic ultrasound-guided botulinum toxin injection.

Achalasia cardia is a motility disorder of the esophagus characterized by failure of relaxation of the lower esophageal sphincter. Nitrates and calcium channel blockers, pneumatic dilatation, botulinum toxin injection and surgical myotomy have been described in literature as possible management options. We present a patient who presented with achalasia and was co-incidentally diagnosed to have cryptogenic cirrhosis with portal hypertension and had esophageal varices. This clinical combination precluded the use of pneumatic dilatation and surgical myotomy.We injected botulinum toxin into the lower esophageal sphincter using a celiac plexus neurolysis needle under endoscopic ultrasound guidance; the clinical response was good.

Narrow band imaging cholangioscopy in hilar cholangiocarcinoma.

Per oral cholangioscopy has been developed as a diagnostic modality for evaluation of bile duct lesions. Per oral cholangioscope with narrow band imaging (NBI) system can provide good quality images of bile duct lesions. There is limited data on per oral cholangioscopy using NBI in biliary tract diseases. We report our experience of NBI cholangioscopy in hilar strictures.

Bilateral chronic rupture of achilles tendon after cortico-steroid injection - a case report.

Bilateral chronic rupture of Achilles tendon after cortico steroid injection is rare . Very few Cases of Achilles tendon rupture have been described in the literature after inra / peri tendinious corticosteroid injection . A middle aged man presented with gradually increasing difficulty in climbing stairs and mild pain, swelling in lower posterior part of both legs for two month after cortico steroid injection. We report a case of bilateral chronic rupture of Achilles tendon after cortico steroid injection .

Successful resolution of bronchobiliary and biliocutaneous fistula by prolonged endoscopic transpapillary biliary drainage.

Bronchobiliary fistula is a rare condition that has been usually treated surgically. We report successful resolution of a rare case of combined bronchobiliary and biliocutaneous fistula by prolonged endoscopic transpapillary biliary drainage. The patient developed these fistulae following right hepatectomy for blunt trauma to the abdomen. Although endoscopic biliary drainage has been reported to be effective in healing of post-traumatic and post-surgical bile leaks, there are limited reports describing the efficacy of endoscopic drainage in complex biliary fistulas. This case report describes the successful closure of complex biliary fistula by prolonged endoscopic drainage.

Servelle-martorell syndrome with extensive upper limb involvement:a case report.

Servelle-Martorell syndrome is characterized by venous or ruraly arterial malformations with limb hypertrophy and bony hyperplasia. Extensive involvement of the upper limb is a rare feature of Servelle-Martorell syndrome. Cases with minimal upper limb involvement have been described in the literature. A young man presented with gradually increasing multiple swellings over the right upper limb and periscapular region with functional difficulty. The arm muscles were atrophic. The bones of forearm and hand were hypoplastic and tender. We report a case of Servelle-Martorell syndrome with extensive involvement of the entire right upper and periscapular region

Congenital Constriction Band Syndrome.

Congenital constriction bands are anomalous bands that encircle a digit or an extremity. Congenital constriction band syndrome is rare condition and is mostly associated with other musculoskeletal disorders.We report such a rare experience.

Obstructing mass lesion of epiglottis: it can be tubercular.

We report a case of 60-year old male who had difficulty in breathing as well as in swallowing. On examination, he was found to be having proliferative growth of epiglottis and right aryepiglottic fold mimicking neoplasm. So emergency tracheostomy was performed and biopsy taken. He was found to be having asymptomatic miliary mottling on routine x-ray chest PA view. Further on HRCT, it turned out to be lesion suggesting tubercular etiology. Histopathology (epiglottic biopsy) report confirmed the whole process as tubercular. The patient recovered promptly in due course with anti-tubercular treatment. Point remains to be seen that if we can avoid tracheostomy and its complications in such cases.

Clinical Spectrum of Pulmonary and Extrapulmonary Tuberculosis in End Stage Renal Disease in Jammu.

One hundred patients of End Stage Renal Disease (ESRD) (mean age 50.5 years, S.D. 14.0341) during a period of one year from April 1, 2004 to March 31, 2005 were studied. Detailed clinical history, physical examination and laboratory investigations were recorded. Chi-square and Fischer-exact tests were used for statistical analysis. Sixteen cases of tuberculosis were detected in 100 ESRD patients. Fifteen of them were pulmonary and one extrapulmonary. Increased association of tuberculosis was seen in – diabetics as underlying cause for ESRD (37.5%), lower socioeconomic status (62%), male patients (68.75%), and patients > 35 years of age (87.5%). Anorexia was most common symptom (100%), followed by fever (87.5%) and cough (68.7%). Keeping in view of high incidence and prevalence of tuberculosis, patients of ESRD should always be screened for tuberculosis, requiring a high index of suspicion.

Endoscopic ultrasound-guided biliary stent placement using Soehendra stent retriever.

Symptomatic bilary obstruction with duodenal nar-rowing requires either surgical or percutaneous biliary drainage procedure. We report a 54-year-old woman suffering from carcinoma of the head of pancreas, who had combined duodenal and bilary obstruction and underwent successful endoscopic ultrasound-guided transduodenal biliary stent placement.