Endoscopic Ultrasound-Guided Random Omental Fine Needle Aspiration: A Novel Technique for the Diagnosis of Peritoneal Carcinomatosis

Background/Aims@#Diagnostic abdominal paracentesis has been described in literature to have variable sensitivity of 50%–75% for the detection of peritoneal carcinomatosis (PC). We believe that random needle aspirates from the omentum, even in the absence of obvious deposits by endoscopic ultrasound (EUS), could prove malignancy in patients with PC. @*Methods@#Consecutive patients who underwent EUS for diagnosis and staging of cancer and found to have ascites were included after obtaining informed consent. EUS-guided fine needle aspiration (EUS-FNA) from random sites in the omentum was performed through the transgastric route using a linear echoendoscope. @*Results@#Fifty-four patients underwent EUS during October 2015 to April 2017 for detection, staging, or FNA of a suspected malignant lesion. Ascites was seen in 17 patients and 15 patients who fulfilled the criteria were included. The procedure was successful in all patients. Cytology was suggestive of malignancy in 12 (80%) but not suggestive of malignancy in 3 (20%) patients. Three patients who tested negative had hyperbilirubinemia with biliary obstruction. Their ascitic fluid analysis result was also negative. @*Conclusions@#Random FNA of the omentum in patients with malignancy-related ascites is highly effective in the diagnosis of PC and could be employed during EUS evaluation of malignancies.

Improving refractive outcomes of toric intraocular lens implantation for correction of astigmatism during cataract surgery

Objectives: To evaluate whether updating corneal topography instrumentation and educating surgeons on optimum patient selection can result in improved toric IOL outcome.

Methods: A retrospective file review of patients who underwent cataract extraction and toric IOL placement over four years, between July 2010 and March 2014, at Lahey Clinic Medical Center, USA, was conducted. The patients were divided into two groups: group 1, those who had surgery between July 2010 and June 2012 and group 2 those who had surgery between July 2012 and March 2014 and the final uncorrected distance visual acuity [UDVA] outcome was compared. Corneal topography was obtained preoperatively on all patients - prior to June 2012, Nidek and Tomey topographers were primarily used, and after July 2012 Zeiss topographers were primarily used. In mid-2012, all surgeons in the department were educated on proper interpretation of topographic maps and instructed to avoid toric IOL placement if irregular astigmatism or ocular comorbities limiting vision were present pre-operatively. Uncorrected distance visual acuity and residual refractive astigmatism were noted at the 1- month postoperative visit. Data were sorted into 3 groups - Group 1, are those with good outcomes [UDVA 10/25 or better with 0.5 D or less of residual astigmatism], group 2, are those with fair outcomes [UDVA 20/30 or better with 0.75 or less of residual astigmatism], and group 3 are those with suboptimal outcomes [UDVA 20/40 or worse with 0.75 D or more of residual astigmatism]

Results: One hundred and thirty-three eyes of 96 patients [55 males, 41 females] were assessed between July 2010 and June 2012 [pre-intervention]. The age range was 50-75 years with an average between July 2012 and March 2014 [post-intervention]. The age range was 50-75 years with an average of 62.5 years. In the pre-intervention group, 72.9% of eyes had good or fair outcomes and 27% had suboptimal outcomes. In the post-intervention group, 75.7% of eyes had good or fair outcomes and 24.3% had suboptimal outcomes. Of the eye with suboptimal outcomes, ocular comorbidities were present in 50% pre-intervention and in 23% post-intervention

Conclusions: Despite reduction of toric IOL placement in patients with ocular comorbities and irregular astigmatism, there was no significant decrease in the rate of suboptimal outcomes after toric IOL placement. This suggests that other factors may be more important to address, such as improving accuracy of axis marking and alignment

Short Axillary Vein and an Axillary Venous Ladder Formed by Basilic and Brachial Veins – An Anatomical and Clinical Perspective

Knowledge of anatomic variants of veins in the arm and axilla play a key role in planning of successful venous access. Possible anatomic variants of axillary vein, brachial vein and basilic vein and their clinical implications have been well described in the literature. We report a rare case of formation of a short axillary vein associated with complex venous communications between the basilic and brachial veins forming a venous ladder in the axilla, in formalin embalmed male cadaver. Axillary vein was formed in the upper part of the axilla by the fusion of basilic vein and unpaired brachial vein, and it was about 3cm in length. The higher-up confluence of basilic and brachial veins was also associated with presence of three communicating veins between the basilic and brachial veins in the axilla. Knowledge of reported venous variations is very useful during preoperative venous mapping and also for planning and execution of various surgical invasive procedures involving these veins.

The Anterior Transverse Ligament of Knee: Morphological and Morphometric Study in Formalin Fixed Human Fetuses

The objective was to study the morphology and morphometry of transverse ligament of the knee joint in south Indian population. The present study included 53 formalin fixed foetuses which were obtained from the department of Anatomy. There were 106 knee joints which were available for the present study. A vernier caliper of 0.02 mm accuracy was used to measure the length of the transverse ligament. Among our specimens, transverse ligament of the knee was observed in 87.7% of the cases. It was observed bilaterally in 81.1% of cases. The double transverse ligaments were not observed in any of our specimens. The mean length of the transverse ligament measured 3.7 ± 1.5 mm. The statistically significant difference was not observed between the right and left sided transverse ligaments or gender with regard to its length (Student's t test; p > 0.05). The morphological and morphometric data related to the transverse ligament of the knee in human foetuses have not been reported. The present study provides additional information on the morphology and morphometry of the transverse ligament in human foetuses. We believe that the data of the present study will provide support to the foetal anatomy, concerning the surgical procedures and arthroscopy of the knee joint. The findings are enlightening not only for Orthopedic Surgeons, but also for the Morphologists and Embryologists.

A Rare Unilateral Variation in the Course of External and Internal Carotid Arteries

Vascular variations in the neck region are not uncommon. Knowledge of incidence of morphological variations in the course and branching of the carotid arteries is important for radiological interpretation and surgical correction when they are symptomatic. Internal carotid artery (ICA) is known to show elongation in its extra cranial course. Previous studies have demonstrated the incidence and clinical symptoms of this morphological entity. However, the occurrence of elongation and looping of the external carotid artery (ECA) is seldom reported in the literature. During regular dissections, we came across a rare case of unilateral morphological variation of both ECA and ICA, in a male cadaver aged about 55 years. ICA presented a curved course with convexity directed posteriorly, at the level of the C2-C3 vertebrae. ECA presented a pronounced kinking or coiling, one inch below the level of the angle of the mandible. In addition, a linguo-facial trunk arising from the ECA also presented a pronounced kinking throughout its entire length.

A Rare Case of Undescended Caecum Accompanied by Looped Retroperitoneal Appendix

Intestinal malrotations are associated with various anatomical anomalies. We report a unique case wherein the caecum was located in the right lumbar region instead of the right iliac fossa. The ileo-caecal junction was also placed higher up. The appendix was ‘uncinate’ shaped, highly coiled and retroperitoneal with the absence of mesoappendix. Both, the caecum and appendix were supplied by ascending branch of the ileocolic artery instead of the descending branch. Further, we also observed that the ascending colon was very short and sub-hepatic in position. Such type of variations is of clinical and surgical importance in diagnosis and treatment of appendicitis.

An Unusual Termination of Facial Vein and Anterior Division of Retromandibular Vein into External Jugular Vein: A Case Report

Facial vein, being the largest vein of the face forms the common facial vein after joining with the anterior division of retromandibular vein below the angle of the mandible. Usually, it drains into the internal jugular vein. During routine dissection of head and neck region of a male cadaver, aged approximately 50 years, an unusual pattern in the termination of veins on the left side of the neck was observed. The formation, course and termination of external jugular vein were normal. The anterior division of retromandibular vein joined with external jugular vein about 5 cm above the clavicle and the facial vein opened into the external jugular vein about 2.5 cm above the clavicle. In addition, there was a thin venous communication between anterior division of retromandibular vein and external jugular vein. The superficial veins of the neck are often used for cannulation; either for intravenous infusion or for central venous pressure monitoring. Furthermore, these venous segments are used as a patch for carotid endarterectomies. Hence, a thorough knowledge of the normal anatomy and their variations may be useful for performing these procedures.

Uncommon Peritoneal Anomaly of Spleen Associated with the Unusual Relationship of Spleen with the Left Lobe of the Liver

Though congenital anomalies of the spleen are quite common, the peritoneal anomalies of the spleen are very rare. In the present case, we observed two unusual phrenico-splenic ligaments connecting the spleen to the diaphragm. Apart from this, the left lobe of the liver was elongated and was related to the diaphragmatic surface of the spleen. The splenic artery had a straight course to the spleen, indicating the possible restricted movements of the spleen. Knowledge of such unusual relation of spleen is essentially important for the surgeons as the elongated left lobe of the liver might get ruptured in addition to the spleen in the fractures of the left 9th, 10th and 11th ribs. Awareness of the straight course of the splenic artery is also of importance to Radiologists performing arterial splenoportography.

Therapeutic modalities in systemic lupus erythematosus

Systemic lupus erythematosus [SLE] is a complex autoimmune disease with significant clinical heterogeneity. Its pathogenesis is complex and involves multigenic components, dysregulation of T and B lymphocytes and the presence of autoantibodies, which form the basis for inflammation, and the pathology found in the various organ systems. Traditional treatments for SLE have included non-steroidal anti-inflammatory drugs, antimalarials, corticosteroids, and cytotoxic/immunosuppressants, but a recent emphasis on the development of biological agents that inhibit autoreactive B cells, interrupt cytokine signaling and facilitate the development of regulatory T cells has become a new modality in treating the disease. This review will delve into the pathogenesis of the disease process, as well as the current and up and coming novel biological treatment and other therapies for specific disease manifestations, such as neuropsychiatric SLE and cutaneous lupus erythematosus, and detail the shift to immune targeted therapies and novel treatments being developed for specific manifestations of the disease

Students’ perspective of the MBBS Physiology curriculum.

Introduction: Rapid technological advances and information overload in the medical field calls for a redesigning of the medical curriculum especially in basic sciences. To incorpate change in the curriculum would require experts’ opinion in the area. At the same time, students’ opinion also forms an important basis for any modification. The present study is small one but it is an important step for this field. We have addressed this issue by evaluating students’ perspective of the physiology curriculum with the help of a semi-structured questionnaire. Aims & Objectives: This study was designed to • Obtain the views of students regarding the curriculum of physiology. • Invite suggestions for improvements. Materials & Methods: The study was conducted at Gian Sagar Medical College, Ram Nagar, Patiala, India using a semi-structured questionnaire. The questionnaire was given to 2nd professional MBBS students, were exposed to of basic science for further training. Results & Discussion: Our study has revealed students’ opinion about certain aspects of the existing physiology curriculum. The students emphasized that they wanted to learn only the clinical application oriented subject content and they the preferred interactive teaching methods. Most students felt the need to reemphasize these subjects in later clinical years. Their assessment is the crucial factor on how they would organize their learning. There is a need for modification in the existing curriculum though similar studies over longer duration of time should be conducted in other medical colleges to recommend changes.

Socio-demographic profile and health care seeking behaviour of rural geriatric population of Allahabad district of UP: A cross sectional study .

Background: World population ageing is enduring, the proportion of older persons has been rising steadily, from 7 per cent in 1950 to 11 per cent in 2007, with an expected rise to reach 22 percent in 2050. Globally the population of older persons is growing at a rate of 2.6 per cent per year, considerably faster than the population as a whole which is increasing at 1.1 percent annually. The issue of health care-seeking (or medical-care) behaviour is crucial to all society. Objective: To know the Socio-demographic distribution of elderly population in rural area, observe the Health seeking behaviour of the rural elderly and to know the available health care services in rural area of Uttar Pradesh. Materials and Methods: A community based Cross sectional study was conducted from October 2010 to June 2011. Persons aged 60 years and above were selected by multistage random sampling. The minimum Sample size of 400 was calculated using formula 4pq/d2 and finally a total of 411 individuals were studied. The data was analyzed by means, proportions and Chi-square test, p value less than 0.05(p<0.05) at 95% confidence interval, was consider for significant, SPSS Version 12 Statistical Software was used to analyze the data. Results: Out of the 411 elderly persons, 214 (52.1%) were males and 197(47.9%) were females. Mean age for the entire study population was 69.2 years with a standard deviation of 7.8 years. Majority of the elderly population were illiterate (70.1%). Higher proportion of females was illiterate (92.4%) as compared to males (49.5%). Among the 411 elderly persons, 188 (45.7%) sought treatment from private practitioner and private hospital, 133 (32.3%) from non registered practitioner (Quack), only 77 (18.9%) sought treatment from Government hospital and remaining 13 (3.1%) used home remedies or sought help from traditional healers. Conclusion: Majority of the geriatric subjects were in the age group of 60 to 69 years. Awareness must be generated among the elderly regarding the problems related to the ageing, strict implementation of legislation on parents’ care by their children and Promotion of income.

Sub-Brachialis Course of the Median Nerve in the Arm and its Possible Clinical Complications: A Case Report

The median nerve in its normal course in the arm crosses the brachial artery from lateral to medial side. It then passes superficial to the brachialis muscle and then enters the cubital fossa. During routine cadaveric dissection of the right upper limb, an unusual variation in the course of the median nerve was observed. The median nerve in the arm crossed the brachial artery from medial to lateral side and passed deep to the brachialis muscle. It then emerged from beneath the brachialis muscle and entered the cubital fossa. In the cubital fossa, it ran medial to the brachial artery as the normal course of the nerve. Further distribution of median nerve in the forearm and hand was observed to be normal. The anomaly reported here may result in the compression of the median nerve deep to the brachialis and hence resulting in mechanical disadvantages in the flexion at the wrist joint.

Replaced Right Hepatic Artery Associated with Uncommon Triplet Right Renal Vein: Embryological Perspective and Clinical Importance 45

Vascular variations in the abdomen are common and mostly asymptomatic. Knowledge of these variations are of tremendous clinical importance in patients undergoing invasive endovascular interventions such as liver transplantation, renal transplantation, and vascular reconstruction for congenital and acquired lesions and trans-arterial chemoembolization for the hepatic tumors. During regular dissection classes for the medical undergraduates, we encountered concurrent vascular variations in an elderly male cadaver. In the present case, we report multiple vascular anomalies involving the right hepatic artery and the right renal vein. The right hepatic artery branched off from superior mesenteric artery, and it was identified as a replaced right hepatic artery. The right kidney was drained by three renal veins, the uppermost among the three twisted around the superior branch of the right renal artery before terminating into the inferior vena cava. In addition, the left kidney was supplied by two renal arteries, and drained by a single renal vein.

Awareness of andropause in males: A North Indian study.

Background: According to the Indian census 2011, India has the largest population of the elderly. Very few studies have been carried out in North India to assess the awareness about andropause in men, which is why this study was conceived. Objectives: To assess the awareness about andropause and its treatment modalities among the men of Chandigarh. Materials and Methods: The present study was conducted at an Urban Health Training Center (UHTC-44 B) of Government Medical College and Hospital Sector 32, Chandigarh (GMCH) in male patients attending the outpatient department. This non-interventional individual cross-sectional study was carried out from August 2010 to August 2011 in men aged 40 years and above. Systematic, random sampling was carried out and the study sample comprised 757 men. The subjects were given pre-structured and pre-tested questionnaires that had questions pertaining to socio-demographic profile, ADAM scale, views about andropause, its treatment modalities, etc., Results: Out of the sample size of 757 men, subjects from the urban area (323; 43.1) were more in contrast to that of the peri-urban (41; 31.9) and slum areas (393; 259). Maximum number of patients belonged to the age group of 40-49 years (342; 26.3), followed by those in age group 60-69 years (141; 18.6). It was found that awareness about the term andropause was found only among 17 (2.2%) subjects, whereas the knowledge of a syndrome synonymous to that of menopause in females was even less 7 (0.9%) patients positive for andropause were found to increase with increase of age (40-49; 35.7, 50-59; 81.2, 60-69; 96.5). Only 123 (11.4%) had an idea about the treatment of andropause. The keenness to resort to treatment or seek medical advice was shown by 355 (47.3%). Subjects in the age group of less than 60 years resorted to injections (15; 4.7) and transdermal patches (6; 1.09) as testosterone-replacement therapy. Herbal medicines were especially taken by those subjects in the age group 60-70 years, (74.3%; 101). Conclusion: Awareness about andropause and its treatment modalities is less in men.

Non-apoptotic function of apoptotic proteins in the development of Malpighian tubules of Drosophila melanogaster.

Drosophila metamorphosis is characterized by the histolysis of larval structures by programmed cell death, which paves the way for the establishment of adult-specific structures under the influence of the steroid hormone ecdysone. Malpighian tubules function as an excretory system and are one of the larval structures that are not destroyed during metamorphosis and are carried over to adulthood. The pupal Malpighian tubules evade destruction in spite of expressing apoptotic proteins, Reaper, Hid, Grim, Dronc and Drice. Here we show that in the Malpighian tubules expression of apoptotic proteins commences right from embryonic development and continues throughout the larval stages. Overexpression of these proteins in the Malpighian tubules causes larval lethality resulting in malformed tubules. The number and regular organization of principal and stellate cells of Malpighian tubules is disturbed, in turn disrupting the physiological functioning of the tubules as well. Strikingly, the localization of β-tubulin, F-actin and Disclarge (Dlg) is also disrupted. These results suggest that the apoptotic proteins could be having non-apoptotic function in the development of Malpighian tubules.

Pseudoepitheliomatous, keratotic, and micaceous balanitis presenting as cutaneous horn in an adult male.

Pseudoepitheliomatous, keratotic, and micaceous balanitis is an extremely rare condition occurring over the glans in elderly characterized by silvery white plaque with mica-like crust, which can undergo malignant transformation. Herein we present a case of pseudoepitheliomatous, keratotic, and micaceous balanitis occurring in an adult male presenting as a cutaneous horn.

Abraham Maslow (1908 – 1970)

Abraham Maslow was a humanistic theorist who did exemplary work in the field of mental health. His thinking wassurprisingly original - most psychologists before him had been concerned with the abnormal and the ill. He wanted toknow what constituted positive mental health He proposed hierarchy of needs which is relevant even today. Thepresent paper presents a brief overview of his life & his work.