Radiological Approach to Diagnosis of Peribiliary Lesions

Peribiliary region is the anatomical space adjoining the intra and extrahepatic biliary system and comprises of portal vein, hepatic artery, nerves and lymphatics. This region is prone to several pathologies ranging from congenital, infective, inflammatory, traumatic and neoplastic. Due to the wide spectrum of abnormalities, it is often difficult to reach a final diagnosis. This review focusses to draw a roadmap to help reach a diagnosis of abnormalities encountered in this region by highlighting the characteristic imaging features associated with these abnormalities.

Migraña Abdominal: variaciones en el diagnóstico y tratamiento entre gastroenterólogos y neurólogos pediatras / Abdominal migraines: variations in diagnosis and care between pediatric gastroenterologists and neurologists

Resumen: Introducción: La migraña abdominal (MA) es infrecuente y poco estudiada. Nuestro objetivo fue investigar el diagnóstico y tratamiento de niños y adolescentes con MA y compararlos entre gastroen terólogos y neurólogos pediatras. Pacientes y Método: Todos los cuadros de MA (1-18 años) de un hospital de EE. UU, con diagnóstico de MA o sus variantes (ICD-9 346.2 o IC-10 G43.D, G43.D0, G43.D1) entre 2011-2017 fueron revisados. La información sobre diagnóstico, intervalo desde inicio de síntomas, criterios diagnósticos, pruebas diagnósticas, tratamiento y resultado se analizaron. Re sultados: Sesenta y nueve historias médicas fueron identificadas. La edad media al diagnóstico fue 9,7 años. El 48% de los pacientes fueron del sexo femenino. Cincuenta (72,4%) pacientes fueron tratados solo por gastroenterólogos pediatras, y 10/69 (14,5%) por neurológos pediatras exclusivamente. 6/69 (8,7%) fueron inicialmente evaluados por gastroenterología y posteriormente referidos a neurología, y 2/69 (2,9%) fueron inicialmente evaluados por neurología y luego referidos a gastroenterología. 3/10 (30%) de las MA diagnosticadas por neurólogos no mencionaban que el paciente tuviera dolor abdominal, sin embargo, todos los diagnósticos realizados por gastroenterólogos presentaron dicho síntoma (p=0,0035). 5/50 (10%) de las historias médicas de gastroenterología y ninguna de las histo rias de neurología mencionaban los criterios de Roma. Conclusiones: La mayoría de los niños fueron diagnosticados por pediatras gastroenterólogos. Los gastroenterólogos rara vez utilizaron los criterios de Roma. Pacientes evaluados por neurología son frecuentemente diagnosticados con MA, incluso sin presentar dolor abdominal (criterio necesario para el diagnóstico). Se recomienda educación para el correcto y oportuno diagnóstico de la migraña abdominal.

Abstract: Introduction: Abdominal migraine (AM) is uncommon and understudied. Our objective was to investigate the diagnosis and treatment of children and adolescents with AM and compare with that of pediatric gastroenterologists and neurologists. Patients and Method: All AM cases (1-18 years) from a USA hospital with diagnosis of abdominal migraine or its variants (ICD-9 346.2 or IC-10 G43.D, G43.D0, G43.D1) between 2011 and 2017 were reviewed. Information on diagnosis, interval from onset of symptoms, diagnostic criteria, diagnostic tests, treatment, and outcome were analyzed. Results: 69 medical records were identified. The mean age at diagnosis was 9.7 years, and 48% of patients were female. 50/69 (72.4%) patients were exclusively treated by a pediatric gastroenterologist and 10/69 (14.5%) exclusively by a pediatric neurologist. 6/69 (8.7%) were initially evaluated by gas troenterology and referred to neurology, and 2/69 (2.9%) were initially evaluated by neurology and then referred to gastroenterology. 3/10 (30%) of the AM diagnosed by neurologists did no report ab dominal pain (AP), however, all diagnoses made by gastroenterologists did (p = 0.0035). 5/50 (10%) of the gastroenterology medical records and no neurology medical records mentioned Rome criteria. Conclusions: Most of the children were diagnosed by pediatric gastroenterologists. Gastroenterolo gists rarely use the Rome criteria. Patients evaluated by neurologists are frequently diagnosed with AM even without AP (a criterion that is required for its diagnosis). Education is recommended for the correct and timely diagnosis of AM.

Efficacy of combination of oral mifepristone and vaginal misoprostol in termination of pregnancy up to 63 days of gestation

Background: Unsafe and illegal abortions are one of the major problems in women health in India. Despite legal approval for medical termination of pregnancy in 1971, unsafe abortion still remains the third leading cause of maternal deaths in the country, contributes eight percent of such deaths annually. The objective of this study was to study efficacy of Mifepristone 200 mg orally followed 36-48 hours later by Misoprostol 800 microgms per vaginally in women undergoing medical termination of early pregnancy (up to 63 days of gestational age).Methods: The present study included 60 pregnant women requesting termination of pregnancy in the first trimester. Women who fulfilled the inclusion criteria were included in the study. Women without medical or surgical contraindications to Mifepristone and Misoprostol were included. Patients with previous caesarean sections were also included.Results: In our study 60 women were included, majority were in age group 20-29 years of age and majority of cases were primipara or multipara. The success rate in terms of complete abortion was 97%, 2% needed surgical evacuation and 1% lost to follow up. Side effects were nausea, vomiting, diarrhoea, abdominal cramps, pyrexia etc. The method proved to be safe, effective, cheap, non-invasive and has minimal or no complications.Conclusions: Medical termination of pregnancy with oral mifepristone and vaginal misoprostol is an effective method for first trimester abortion. The prerequisite for the method is patient counselling, patient participation and willingness for regular follow up and to report any complication. Hence this method comes out to be a safe alternative to surgical method which is invasive and costly.

Role of hippocampal volumetry in drug resistant epilepsy

Background: Hippocampus is a brain structure located deep in the temporal lobe. The structure is crucial for learning and memory and is a natural inhibitor of seizure activity in brain. In drug resistant epilepsy (DRE), there is shrinkage of the hippocampus leading to poor seizure control.Methods: Patients meeting the diagnostic criteria for drug resistant epilepsy between the age group of 10-60 years were enrolled in the study. Epileptic non drug resistant controls and normal healthy individuals were taken from same cohort. Selected patients underwent MRI Brain and their hippocampal volumes were estimated manually. Coronal oblique sections, perpendicular to the long axis of hippocampus were taken and hippocampal volume (HV) were calculated using region of interest approach with manual delineation . Results: There was increment in detecting hippocampal atrophy from 30% to 46.6% in DRE patients when manual hippocampal atrophy was used in addition to visual assessment. The mean right and left hippocampal volumes in drug resistant epilepsy cases were found to be 2.17+0.57 cc and 1.52+0.54 cc respectively. Left HV was found to be statistically significantly smaller than right side (p value < 0.05). DRE patients had smaller mean bilateral HV than healthy controls, the difference being 33%. The left HV loss was almost double the right HV loss among DRE cases. The hippocampal volumes were reduced in DRE patients compared to epileptic non-resistant patients; however the difference was found to be less than that of normal healthy controls.Conclusion: Manual hippocampal volumetry detected more patients with hippocampal atrophy in our study compared to visual assessment. Manual hippocampal volumetry should be routinely done in patients with Drug resistant epilepsy.

Estimation and comparison of thrombocyte count by peripheral blood smear method and automated method in women with pregnancy

Background: Thrombocyte is important and very essential component of blood and have significant role in maintenance of hemostasis. Thrombocyte count is an important investigation done in various acquired and congenital coagulable states which include conditions like pregnancy. Thrombocyte count is routinely done by automated hematology analyzer method. The automated hematology analyzer counters are not usually available at all centres especially in peripheral and rural side though thrombocytes can also be assessed from the peripheral blood smears, which can be easily and precisely done at any set up. Aim and objective of this study was to compare the thrombocyte estimation by peripheral blood smear method and automated hematology analyzer in pregnant women.Methods: Thrombocyte estimation was done from samples taken from 120 normal pregnant women between December 2018 to March 2019, where samples were Ethylene Diamine Tetra Acetic acid (EDTA) anticoagulated. Thrombocyte was counted manually using PBS (Leishman stain) and hematology analyzer (Sysmex XN1000 series). Thrombocyte counts were expressed in Mean and standard Deviation. Statistical analysis was done by student’s t test using MS excel and SPSS version 17.Results: Thrombocyte count by PBS have mean value of 2.04 lacs/mm3 with standard deviation of 0.56 lacs/mm3 and by automated method have mean value of 1.89 lacs/mm3 and standard deviation of 0.71 lacs/mm3 with p value 0.010. Thus, there was no statistically significant difference found between two methods.Conclusions: Estimation of thrombocyte count on the basis of manual thrombocyte count is a reliable technique and can be used to validate automated thrombocyte counts. It can also be used in under resourced laboratories, where there are no automated counters of good precision available. In fact, all the tests showing abnormal thrombocyte counts must be reported only after cross examining on PBS.

Clinical utility of TIRADS and ultrasound elastography in characterization of thyroid nodules

Background: Thyroid nodules are a common entity in an iodine deficient population, however malignant nodules are relatively uncommon with excellent prognosis. Ultrasound elastography is a useful tool for characterization of nodules and allows selection of tumors for FNAC. This study aimed to evaluate the diagnostic value of strain elastography and acoustic radiation force impulse (ARFI) imaging in differentiating malignant from benign thyroid nodules.Methods: This study included 100 thyroid nodules evaluated using ultrasound TIRADS classification. Strain elastography evaluated the nodules using the elasticity score and strain ratio followed by VTI and shear wave velocity generated from ARFI data to characterize the nodules. Final diagnoses were obtained from cytological and/or histological evaluation. The diagnostic performance of the two elastography methods was analyzed and compared by multiple receiver operating characteristic curve analysis.Results: Of the 100 thyroid nodules observed in 100 patients (82 females and 18 males), 22% were malignant nodules and 78% were benign. The cut off values for elasticity scores, mean SR, VTI grade and mean SWV for predicting malignant thyroid nodules were greater than or equal to score 2, 2.4, grade 3, 2.5m/s respectively. The area under the receiver operating characteristic curve for elasticity score, mean SR, VTI grade and mean SWV was 0.79, 0.78, 0.89 and 0.84, respectively (P>0.05) and the accuracy was 74, 81.6, 88 and 87.5%, respectively (P>0.05). The accuracy of the combined use of conventional sonography, strain elastography and ARFI imaging was 85.6% respectively, which was higher than that of conventional sonography (P>0.05).Conclusions: Strain elastography and ARFI imaging have high sensitivity and specificity for differentiating malignant from benign thyroid nodules and therefore have good clinical utility in evaluating these lesions.

Breast cancer-related lymphedema in postmastectomy patients receiving adjuvant irradiation: A prospective study

AIM: Inflammation plays a lead role in the tumor microenvironment and promotes metastasis. Single-nucleotide polymorphism (SNP) in the tumor necrosis factor (TNF) gene locus may alter the expression of genes and proteins. The objective of the study is to find the distribution of genetic polymorphism in the sites of TNF-α −308G>A and TNF- β +252A>G in breast cancer and evaluate polymorphism effects on plasma levels. MATERIALS AND METHODS: The study group consisted of 109 invasive ductal primary breast cancer patients and 75 age-matched healthy female controls. Plasma cytokine concentrations were measured by the MILLIPLEX® MAP Human Cytokine/Chemokine Panel magnetic bead kits. The genotyping procedure for SNP included allele-specific polymerase chain reaction for TNFα and restriction fragment length polymorphism for TNFβ. RESULTS: Odds ratio with 95% confidence interval showed that these polymorphisms were not a causative risk factor, and both polymorphisms were consistent with Hardy–Weinberg equilibrium. Plasma TNFα and TNFβ median concentrations were significantly higher in cases when compared to controls (P < 0.01). When plasma TNFα levels were grouped under polymorphic subtypes, patients with mutant TNF- α −308A allele showed significantly higher values (P < 0.001). In addition, plasma TNFα values were significantly elevated in mutant TNF-β +252G allele (P < 0.01). CONCLUSION: This study demonstrated that there is no significant association between SNPs and breast cancer susceptibility in South Indian population. However, plasma TNFα level is significantly elevated with mutant-recessive TNF-α −308 A and TNF-β +252 G alleles of patients.

Compliance to radiotherapy: A tertiary care center experience

CONTEXT: The most commonly prescribed conventional fractionation radiotherapy uses 1.8–2.2 Gy per fraction for five fractions in a week. Many times, unwanted interruptions are encountered, which ultimately affect the local control and overall survival. AIMS: The present retrospective study was carried out to study the compliance to radiotherapy at our institute and to determine various factors related to it. PATIENTS AND METHODS: The present retrospective study was carried out at the department of Radiotherapy, SMS Medical College and attached group of hospitals, Jaipur; in patients who were treated with curative intent with conventional fractionation radiotherapy over telecobalt machine from January 2017 to April 2017. Noncompliance was studied for association with various factors such as age, sex, site of primary disease, stage of tumor, distance patients had to travel to receive treatment, administration of concurrent chemotherapy, and financial burden of the treatment. RESULTS: Of 203 patients, 138 were of head-and-neck cancer, 42 of cervical cancer, and 23 of breast cancer. The cumulative incidence of noncompliance was 12.8% (15.9% for head-and-neck cancer, 7.2% for cervical cancer, and 4.4% for breast cancer). Statistically significant association was found between noncompliance and higher age of the patients (P = 0.07), male gender (P = 0.002), advanced stage (P = 0.004), administration of concurrent chemoradiotherapy (CCRT) (P < 0.001), and greater distance patients had to travel for radiotherapy (P = 0.03). CONCLUSIONS: The factors ith which noncompliance is significantly associated in the present study are higher age, male gender, advanced stage of tumor, administration of CCRT, and greater distance patients had to travel to avail radiotherapy.

Incidence of chikungunya fever in ghatampur municipality, kanpur nagar district, uttar pradesh, India

Objectives: [I] To estimate the magnitude, compare the results of two wards [Shivpuri and Achhimohal] and [ii] to formulate recommendations for prevention and control. STUDY DESIGN: Experimental study

Place And Duration: 1st October to 16th November 2006 in residents of Shivpuri and Achhimohal ward

Methodology: We selected and compared two wards; Shivpuri ward with high attack rate and the other Achhimohal one-low attack rate. We defined a case as the occurrence of fever with joint pain with or without skin rashes during the period of 1st October to 16th November 2006 in residents of Shivpuri and Achhimohal ward. We collected information on age, sex, residence, date of onset, symptomatology, history of treatment, deaths in the family. We described outbreak in time, place and person characteristics. We collected 14 random blood samples from shivpuri and 7 blood samples from Achhimohal ward for serological investigation. We conducted entomological survey for species identification

Results: We identified total 384 case-patients among 2,202 residents [overall attack rate [AR: 384/2202 [17%]; Median age: 31 year] in both the wards. [343/1173 [29%] in Shivpuri ward vs 41/1029 [4%]]; sex specific AR was 52% for females. The major symptoms were fever 384/384 [100%], arthralgia 380//384 [99%]. Severity of disease and oedema were less prevalent in children of age group 1-15 year as compared to older age group 31-45 years [109/239 [46%], 13/183 [7%]]. The attack rate was highest 88/239 [37%] and statistically significant [P<0.03] in Shivpuri ward adjacent to pond. Both wards, Shivpuri-141 of 343 [41%] and Achhimohal-23 of 41 [56%] reported consulting with unqualified private practitioners. 19/21 were positive for anti Chikungunya IgM antibodies. 38/43 households [88%] in Shivpuri ward and 6/43 households [13%] in Achhimohal ward identified three species of Aedes mosquitoes

Conclusion: Chikungunya is mosquito born and laboratory confirmed; severely debilitating disease. Recommended for aggressive Information, Education and Communication [IEC] for emptying the storage of water once in a week and rational use of drugs

State of globe: mitigating measles menace in era of MMR/V

In non vaccination ancient era, multiple epidemics of measles/german measles/variola used to occur in the cyclical trend of two to three years during spring months. Outbreaks in Faroe Islands in 1846 and in Fizi Island in 1875 are examples of this type of transmission where virgin epidemics took the highest mortality toll. According to WHO report, in the absence of immunization, 90% of the persons can be expected to develop clinical measles sometimes in their life time as noted in Greenland in 1951 epidemic and german measles in 2012 in Kangra. But the epidemiology of communicable diseases underwent tremendous change not only in the developed countries, viz America and European countries but also in the developing countries like India, Pakistan and African countries with the introduction of vaccination and thereby mortality and morbidity on account of vaccine preventable diseases in all the age groups around the world nose dived. This provided a big relief to the suffering humanity across the world. Different countries have various sets of immunization programme running in the countries; be it single dose of measles at the age of 270 days or second shot of measles or other vaccinations. Round the globe, MMR or MMRV or pentavalent vaccination with their pluses or minuses, still is the right choice to mitigate the menace of measles

Mycosis Fungoides-Spectrum of Manifestations.

Mycosis fungoides is an unusual form of cutaneous T cell lymphoma that is diagnosed by skin biopsy after years of non specific skin eruptions. In addition to skin lesions extracutaneous manifestations can also occur.