Metastatic Thymic Carcinoid: Does Surgeon Have a Primary Role.

Thymic carcinoids are rare mediastinal tumours. These are aggressive tumours that often present late and have poor prognosis. Primary surgical treatment is recommended even in metastatic tumours since the role of adjuvant therapy is not well established. We present a case of metastatic thymic carcinoid managed with surgical excision.

Adenocarcinoma (somatic-type malignancy) in mature teratoma of anterior mediastinum.

Mature teratoma is a common anterior mediastinal tumour. However, occurrence of transformed malignant component within it is very rare. We report a case of a 32-year-old female presenting with dry cough and chest pain. Contrast-enhanced computed tomography (CT) showed a large thin-walled cystic lesion measuring 11.4cmx10.6cmx10.0cm in the anterior mediastinum. Right postero-lateral thoracotomy was performed and the tumour was completely excised. Histopathological examination of the excised specimen was suggestive of mature teratoma with transformed malignant component, adenocarcinoma (somatic-type malignancy).

Congenital malformation of lung parenchyma: 15 years experience in a thoracic surgical unit.

Objective. To review the surgical management of congenital malformations of lung parenchyma in a thoracic surgery unit over a period of 15 years. Methods. We carried out a retrospective analysis of records of all patients who had surgery for congenital malformations of lung parenchyma between 1995 and 2010. Results. Forty-five patients underwent surgery for congenital lung lesions out of 3735 thoracotomies performed during the study period. The lesions included 29 lung sequestrations, 12 bronchogenic cysts, 3 congenital lobar emphysema and one congenital cystic adenomatoid malformation. Only 26 (26%) cases were diagnosed preoperatively. Twenty-eight (62.2%) patients underwent lobectomy, 5 (11.1%) patients had pneumonectomy, and 10 (22.2%) patients had removal of cyst while 2 (0.45%) patients had lung resection with repair of the oesophageal connection. No mortality was recorded. One patient had post-operative complication of oesophageal fistula which was successfully managed conservatively. The follow-up was between 8 months to 14 years. All patients were asymptomatic and had no physical limitations during the follow-up. Conclusions. Surgery is curative and produces good long-term result in patients with congenital malformations of lung parenchyma. It should be offered to patients as a therapeutic option where indicated and feasible.

Rare presentation of spontaneous acquired diaphragmatic hernia.

Spontaneous acquired diaphragmatic hernia without any apparent history of trauma is a very rare condition and is very difficult to diagnose. We present a case of a 21-year-old male who presented with abdominal pain for one month and four episodes of vomiting for one day. Clinical suspicion, chest radiography with nasogastric tube in situ and computed tomography (CT) confirmed the diagnosis. The diaphragmatic defect was repaired surgically. The patient had an uneventful post-operative recovery.

Coracoclavicular and costoclavicular joints at a common juncture: a rare phenomenon / Articulaciones coracoclavicular y costoclavicular en una unión común: un raro fenómeno

Movements at the human shoulder girdle are the result of complex interplay of glenohumeral, acromioclavicular, sternoclavicular and scapulothoracic articulations. Clavicle apart from articulating with the scapula and sternum is also connected with first rib by costoclavicular ligament and with coracoid process by coracoclavicular ligament. At times the area of attachment of these ligaments on clavicle, first rib and scapula show faceted apophysis suggesting the presence of additional diarthrodial articulations. Costoclavicular joint exists between clavicle and first rib and coracoclavicular joint between clavicle and coracoids process. Both these joints are described in the literature, but the concurrent occurrence of them in the same bone has not been reported yet. We found two clavicles, one of right and other of left side, both of them showed faceted apophysis for costoclavicular and coracoclavicular joint simultaneously, which is rare phenomenon.

Los movimientos de la cintura escapular humana son el resultado de la interacción compleja de las articulaciones glenohumeral, acromioclavicular, esternoclavicular y escapulotorácica. La clavícula, aparte de la articulación con la escápula y el esternón también está conectada con la primera costilla por el ligamento costoclavicular y con el proceso coracoides por el ligamento coracoclavicular. A veces la zona de unión de estos ligamentos de la clavícula, la primera costilla y la escápula muestran procesos facetarios que sugieren la presencia de nuevas articulaciones diartrodiales. La articulación costoclavicular existe entre la primera costilla y la clavícula y la articulación coracoclavicular entre la clavícula y proceso coracoides. Ambas articulaciones están descritas en la literatura, pero la aparición simultánea de ellas en el mismo hueso no se ha informado aún. Se encontraron dos clavículas, uno del lado derecho y otra del lado izquierdo, las dos presentaron procesos facetarios para las articulaciones costoclavicular y coracoclavicular simultáneamente, lo cual es un fenómeno raro.

Assessment of Quality of Life among HIV Positive People Attending Tertiary Hospital of Delhi, India.

As per global HIV/AIDS estimates, a total of 33 million [30.3 – 36.1 million] People were living with HIV in 2007. The world's second-most populous country, India, is experiencing a highly varied HIV epidemic, which appears to be stable or diminishing in some parts while growing at a modest rate in others. Quality of life (QOL) of HIV/AIDS patients is becoming an important component of overall assessment of health care and management in health care settings. It is one of the indicators effectiveness of management of PLHAS . The objective of this study was to determine the QOL of patients with HIV/AIDS in New Delhi. Purposive sampling was used to identify subjects from the antiretroviral therapy clinic (ART) in Lok Nayak hospital. 180 patients were interviewed with the WHOQOL-HIV instrument. This questionnaire included demographic data, multi-item scales and six domains namely physical, psychological, level of independence, social relationships, environment and spirituality religion. Study subjects were aged between 20-56 years. Mean age of all study subjects was 33.85±7.01 years, comprising of 34.4 females. More than 50% of the total subjects had received less than secondary school education. All domains have higher scores for women than men except the psychological domain. Correlation of scores of six domains with overall QOL score and among individual domains was statistically significant. Younger people showed poorer QOL and level of education correlated positively with all domains of QOL. Overall results indicate that quality of life of AIDS attending Lok Nayak hospital is satisfactory.

Correlation between baseline CD4 + T-Lymphocyte count and plasma viral load in AIDS patients and their early clinical and immunological response to HAART: a preliminary study.

The aim of this study was to determine the clinical, immunological and virological status of newly diagnosed AIDS cases and to monitor their clinical and immunological response to HAART after a minimum period of three months. Forty three drug naive AIDS patients were enrolled. The most common presenting complaints were weight loss (74.4%), cough (72.1%) and diarrhoea (67.4%). Mean baseline CD4 cell count was 112 +/- 60 cells/microL and mean baseline plasma viral load of 31 patients studied was 192,686 copies/mL. Baseline plasma viral load was higher among patients with lower baseline CD4 cell count. During follow-up, 80.8% patients showed clinical improvement, while a CD4 cell count increased by > or =50 cells/microL in 84.6% cases. Mean CD4 cell count increased from 126 +/- 16.6 cells/microL at baseline to 278 +/- 196.7 cells/microL.

Surgical treatment of pulmonary aspergilloma: a series of 72 cases.

BACKGROUND: The objective of this study was to evaluate the immediate and long-term result of resectional surgery in pulmonary aspergilloma. METHODS: Seventy-two patients who underwent pulmonary resectional surgery for symptomatic aspergilloma between 1990 to 2002 were studied. Seventy-nine definitive operations were carried out, including one bilateral lobectomy for recurrent lesions and six thoracoplasties to deal with post-operative complications, besides 21 pneumonectomies and 51 lobectomies. There were 10 bilobectomies as well, included in the lobectomy group. RESULTS: At a mean follow-up of 3.5 years, there were two post-operative deaths and a few complications occurred in 20 cases translating into a morbidity of 28.57% and a mortality of 2.77 percent. Major complications included were persistent air leak, persistent pleural space, empyema, bronchopleural fistula and massive haemorrhage. All events were seen in cases of complex aspergilloma; cases of simple aspergillomas had an uneventful course. CONCLUSIONS: Surgery offers definitive and long-term symptom-free survival in cases of pulmonary aspergilloma at a negligible risk; though almost one-third of those undergoing surgery develop some complications, these are largely manageable.

Delayed presentation and surgical management of a bronchial tear.

Tracheobronchial injuries following blunt trauma to the chest can be life-threatening. However, failure to diagnose can lead to various acute or chronic complications. A delayed presentation is quite rare and its surgical correction is highly challenging. We present here two cases, which came to us after four and six months of trauma respectively. In these patients, successful surgical repair of totally obstructed right main bronchus in the first case and left main bronchus in the other was carried out. The post-operative course was uneventful with improvement in the respiratory status of both the patients. High degree of suspicion and awareness of the possibility of bronchial tear are required for proper management of such cases.

Silent myocardial ischaemia in patients with type II diabetes mellitus and its relation with autonomic dysfunction.

Accelerated coronary and peripheral vascular atherosclerosis is one of the most common and chronic complications of diabetes mellitus. A relatively recently analysed aspect of coronary artery disease in this condition is its silent or asymptomatic nature. We studied silent/asymptomatic myocardial ischaemia in unselected consecutive middle aged asymptomatic diabetics and controls by 24-hour ambulatory electrocardiographic monitoring, treadmill test and coronary angiography. Also, a relationship was sought between silent myocardial ischaemia and autonomic dysfunction. Thirty asymptomatic diabetics between the ages 35-60 without any documented evidence of coronary artery disease and as many controls (matched for age, sex, smoking habits, blood pressure, serum cholesterol and body mass index) were studied. All the diabetics and controls were subjected to treadmill test and 24-hour ambulatory electrocardiographic monitoring. Coronary angiography was done in those who were positive in treadmill test or 24-hour ambulatory electrocardiographic monitoring. Also five simple bedside tests for autonomic dysfuncton i.e. heart rate response to valsalva, deep breathing and orthostatic variation and blood pressure response to orthostatic variation and sustained handgrip were done in all the subjects. Those with two or more abnormal tests were diagnosed as having autonomic dysfunction. ST segment depression indicating silent myocardial ischaemia was seen in 14 (46.7%) out of 30 diabetics and in 3 (10.0%) out of 30 controls on both Holter and treadmill test (p=0.002). Also, diabetics had higher heart rate and greater number of supraventricular and ventricular ectopics than controls. Coronary angiography done in patients with silent ischaemia revealed higher prevalence of multivessel involvement and diffuse disease in diabetics as compared to controls. Half the diabetics (50%) and none of the control had autonomic dysfunction. Autonomic dysfunction was present in 85.7 percent of diabetics with silent ischaemia compared to 18.7 percent diabetics without silent ischaemia (p=0.001).

Role of thoracic surgery in pulmonary tuberculosis.

Surgery in pulmonary tuberculosis in one form or other gives good results. Indications for surgery include drug resistant pulmonary tuberculosis, massive recurrent haemoptysis, post-tuberculosis bronchiectasis or destroyed lung, empyema with or without bronchopleural fistula and for diagnostic purposes. In all cases a clear indication for surgery is mandatory. Processes of surgery include lung resection, thoracoplasty, decortication, thoracotomy and biopsy, thoracoscopy and ib resection for pleurocutaneous flap procedures. Adequate postoperative management is very important. Complications like atelectasis and pneumonia, empyema, bronchopleural fistula, wound infection, cachexia, etc, add morbidity and prolonged hospital stay.

Thoracoplasty: an obsolete procedure?

After the advent of chemotherapy for pulmonary tuberculosis, the operation of thoracoplasty became rare in the developed countries. However, this was not the case in developing countries like India. Between July 1992 and June 1997, we performed thoracoplasty in 139 patients. Indications of surgery were tubercular empyema (84 patients), pyogenic empyema (33 patients), post-operative empyema with bronchopleural fistula (8 patients), drug resistant pulmonary tuberculosis (2 patients) and recurrent haemoptysis (2 patients). Successful outcome in the form of control of sepsis, closure of bronchopleural fistula, sputum conversion and control of haemoptysis was achieved in most cases. There were four deaths in the entire series. We conclude that with the persisting problem of pulmonary tuberculosis in the developing countries, thoracoplasty is still an operation of continued relevance.

Intrapericardial benign teratoma with unusual presentation.

Benign teratoma, also referred as dermoid cyst, do occur in the mediastinum. However, their intrapericardial location has been reported very occasionally. This case of intrapericardial benign solid teratoma is being presented because of its rarity and its unusual presentation as a case of empyema, with features of cardiac compression and pericardial effusion.

Histological and biochemical changes in testis of zinc deficient BALB/c strain of mice.

Zinc, protein, cholesterol, phospholipids, alkaline phosphatase (AlPase), acid phosphatase (AcPase), adenosine-5-triphosphatase(ATPase) and histology were studied in testis of zinc-deficient mice. Zinc and protein decreased in the 3-week experiment whereas they increased in the 6-week experiment. Zinc is involved in several functions of the cell and is regulated by hormones. Inhibition of spermatogenesis indicates for decreased zinc levels in 3-week whereas the increase in 6-week experiment indicates for accumulation of zinc in oedomatous fluid and uncontrolled diffusion of zinc across the blood testis barrier. Glycogen decreased in the 3-week as well as 6-week experiments due to blockage of androgen and spermatogenesis. Cholesterol and phospholipids increased in the 3-week experiment and decreased in 6-week experiment as both the parameters are related to steroidogenesis. Zinc deficiency leads to aspermatogenic condition and comparatively less injury to non-germinal cells. This could have blocked the transport of material across the testis barrier and therefore might have increased AlPase levels. Increased AcPase, probably represents lysosomal enzymes, as the cell debris of disorganised epithelium are to be digested and removed. ATPase increased in 3-week experiment and can be correlated to increased demands of energy of testicular cells to overcome the insults of zinc deficiency whereas the decrease in 6-week experiment could be as a result of inhibition of spermatogenesis.