Correlation of HRCT Scoring System with PFT Parameters in Interstitial Lung Disease Associated with Systemic Sclerosis Patients

Objectives. Interstitial lung disease (ILD) with features of pulmonary fibrosis and honey-combing is a significant cause of morbidity and mortality in patients with systemic sclerosis (SSc). High resolution computed tomography (HRCT) is the established non-invasive gold standard technique for the diagnosis of SSc related ILD. The present study was designed to characterise HRCT features of ILD in SSc and to correlate pulmonary function test (PFT) parameters with HRCT semi-quantitative scores. Methods. This is an observational, cross-sectional study including 36 patients of SSc who underwent HRCT chest. All the patients were females. Severity and extent were assessed using four HRCT features: ground-glass opacity (GGO), mixed GGO and reticular opacity, reticular fibrosis and honey-combing. Thirty-three patients were able to perform PFT. Total HRCT score, inflammatory index and fibrosis index were correlated with PFT parameters. Results. Interstitial lung disease was found in 33 patients (91.6%), 24 patients (66.6%) had mixed GGO along with reticular inter-lobular septal thickening. Majority of the patients (64%) had non-specific interstitial pneumonia (NSIP) pattern. Usual interstitial pneumonia (UIP) pattern was seen in 25% of the cases. One patient had overlapping features of both UIP and organising pneumonia. There was predominant lower lobe involvement. Among the 33 patients who were able to perform PFT, 85% had abnormal results (predicted forced vital capacity [FVC]<80%). Total HRCT score showed significant negative correlation with PFT parameters 枛 FVC (r=�48, P=0.004) and forced expiratory volume in one second (FEV1) (r=�28, P=0.1), respectively. The ratio of FEV1 and FVC had significant positive correlation with total HRCT score (r=0.5, P=0.002). Inflammatory index and fibrosis index had significant negative correlation with predicted FVC% (P<0.05). Conclusions. Mixed pattern (GGO and reticular opacity) was the most common HRCT finding. HRCT semi-quantitative scoring system is sensitive in assessing the severity and extent of ILD qualitatively and quantitatively in SSc patients.

Assessment of cosmetic outcome of oncoplastic breast conservation surgery in women with early breast cancer: A prospective cohort study.

BACKGROUND: The aim of this study was to assess the cosmetic outcome of patients undergoing oncoplastic breast conserving surgery in Indian population. MATERIALS AND METHODS: A prospective cohort of 35 patients who were eligible for breast conservation surgery was included in the study from year 2007 to 2009. Patients with central quadrant tumors were excluded from the study. A double ‑ blind cosmetic assessment was done by a plastic surgeon and a senior nurse not involved in the management of patients. Moreover, self‑assessment was carried out by the patient regarding the satisfaction of surgery, comfort with brasserie, social and sexual life after oncoplastic surgery. RESULTS: In this study, 35 patients underwent oncoplastic breast conservation surgery by various techniques. The cosmetic outcome scores of the surgeon and nurse were analyzed for inter rater agreement using inter‑class Correlation Coefficients. There was a good association between them. The risk factors for poor cosmetic outcome was studied by univariate analysis and significant correlation was obtained with age, volume of breast tissue excised and estimated percentage of breast volume excised (P < 0.05). Moreover, 96% of patients were moderately to extremely satisfied with the surgery. Patients were offered an option for cosmetic correction of contralateral breast by mastopexy or reduction mammoplasty however, none of them agreed for another procedure. CONCLUSIONS: Oncoplastic breast surgery helps to resect larger volume of tissue with wider margins around the tumor. It helps to achieve better cosmesis and extends the indications for breast conservation. Most of the patients were satisfied with mere preservation of the breast mound rather than a symmetrical contralateral breast.

Second echelon node predicts metastatic involvement of additional axillary nodes following sentinel node biopsy in early breast cancer.

BACKGROUND: In many patients with early breast cancer, the sentinel lymph node (SLN) is the sole site of regional nodal metastasis. This subgroup of patients may not benefit from completion axillary lymph node dissection (CALND). AIMS: This pilot study evaluates the status of 2nd echelon (station) lymph nodes in the axilla as a predictor of additional positive nodes in the axilla in the presence of sentinel node metastasis. SETTINGS AND DESIGN: Cross-sectional study of 40 breast cancer patients. MATERIALS AND METHODS: Forty patients with invasive breast cancer underwent SLN biopsy followed by 2nd echelon lymph node biopsy in the same sitting. SLN mapping was performed using a combined technique of isosulfan blue and 99 mTc-sulfur colloid. SLNs (Station I) were defined as blue and/or hot nodes. These nodes were then injected with 0.1 ml of blue dye using a fine needle and their efferent lymphatic was traced to identify the Station II nodes. Then a complete ALND was performed. All the specimens were sent separately for histopathological evaluation. RESULTS: SLNs (Station I nodes) were successfully identified in 98% (39/40) patients. Of the 17 patients with a positive SLN, 8 (47%) patients had no further positive nodes in the axilla, 9 (53%) patients had additional metastasis in nonsentinel lymph nodes upon CALND. Station II nodes were identified in 76% (13/17) patients with a positive SLN. Station II nodes accurately predicted the status of the remaining axilla in 92% patients (12/13). STATISTICAL ANALYSIS: We calculated the Sensitivity, Negative predictive value, Positive predictive value, False negative rate and Identification rate. CONCLUSION: Station II nodes may predict metastatic involvement of additional nodes in the axilla.

Role of skeletal scintigraphy in soft tissue sarcoma: Improving the diagnostic yield.

BACKGROUND: The presence of skeletal metastases significantly influences the therapeutic strategy adopted for soft tissue sarcoma. However, literature on the prevalence of skeletal metastases in soft tissue sarcoma is limited and none of the available data is based on the Indian patient population. AIM: To determine the prevalence of skeletal metastases at presentation in patients of soft tissue sarcoma and to rationalise the use of preoperative skeletal scintigraphy in such patients. METHODS AND MATERIAL: Preoperative bone scans were evaluated in 122 patients with soft tissue sarcoma (median age, 34 years; range, 4-83). The scans were classified into 3 grades: Grade 1: metastases very likely; Grade 2: equivocal; Grade 3: normal or benign lesion. In all the patients studied, the ability of the patient to localize the site or sites of pain was recorded and that was correlated with the site of metastases in scintigraphy. RESULT: Seventeen (13.9%) patients had Grade 1 scan; 16 of them had bony pain that was not readily explainable by trauma or other local factors. Ten ( 8.1%) patients had Grade 2 scan, five of them had bony pain which was not readily explainable by trauma or other local factors. Ninety-five patients (77.8%) had Grade 3 scan. Of these, 9 had localised bone pain which could be definitely associated with trauma or joint degeneration. CONCLUSION: The prevalence of skeletal metastases at presentation in patients with soft tissue sarcoma is low (13.9%). The low rates of skeletal metastases in bone pain-free patients (0.9%) versus the high rate in symptomatic patients (76.1%) supports the use of bone scanning in symptomatic patients only.

Mesenteric and portal vein thrombosis presenting as acute intestinal obstruction.

Acute bowel infarction is a major complication in patients with superior mesenteric vein and portal vein thrombosis. However, in some patients, sufficient collaterals can prevent acute bowel infraction. We present a case of mesenteric vein and portal vein thrombosis with intestinal obstruction due to acute bowel oedema and ischaemic adhesion without infarction or stenosis.

Neuropsychiatric manifestations in patients of primary hyperparathyroidism and outcome following surgery.

BACKGROUND: A wide variety of psychiatric symptoms ranging from mild personality changes to severe depression and psychosis have been described in patients of PHPT. However, the psychiatric profile in Indian patients remains a mystery. It remains to be seen if surgery can alleviate the psychiatric morbidity and improve the quality of life of patients. Although, the pathophysiology remains largely unknown, we attempted to see if psychiatric morbidity correlated with serum calcium values. OBJECTIVE: a) To study the nature and severity of neuropsychiatric manifestations in patients of hyperparathyroidism before surgery and their outcome after surgery b) To study their correlation with levels of serum calcium. MATERIAL AND METHODS: This prospective study documented the occurrence of psychiatric symptoms among 14 patients of primary hyperparathyroidism (group I). 13 patients of gall stone disease (group II) and 12 patients of thyromegaly, undergoing total thyroidectomy (Group III) constituted the control groups. The relationship between such symptoms and degree of hypercalcemia was also studied. Assessment of psychologic symptoms, using the CPRS scale (validated in Hindi) and the scale for Memory and Intelligence for use in Hindi speaking population was carried out preoperatively and at 1 wk, 6 wk, 3, and 6 months postoperatively. OBSERVATIONS: The hyperaparathyroid group had significantly higher levels of total serum calcium and PTH preoperatively, with biochemical normalization postoperatively. The preoperative CPRS rating of the 14 patients with primary hyperparathyroidism revealed pronounced psychiatric symptoms, with a mean total CPRS score of 20 +/- 8.7, compared with 10.5 +/- 6.9(II) and 12.7 +/- 5.6 (III) in the control groups. Statistically significant improvement was seen in the CPRS score, maximally at 6 weeks post operatively for the following symptoms: Sadness, lassitude, ache and pains, and fatigability. There was no memory and intelligence impairment in any of the groups pre or post operatively. No correlation was found between the serum calcium levels and the psychiatric morbidity. CONCLUSIONS: The psychologic symptom distress is multidimensional and symptoms significantly improved by 6 weeks post parathyroidectomy. There was no memory and intelligence impairment in any of the groups pre or post operatively. No correlation was found between serum calcium levels and psychiatric morbidity.

Laparoscopy assisted hemi-colectomy for ileo-caecal tuberculosis.

Laparoscopy assisted hemicolectomy for ileo-caecal tuberculosis is being evaluated the world over. Several procedures are performed laparoscopically, including the laparoscopic hemicolectomy, for benign and malignant diseases. Abdominal tuberculosis is one of the commonest causes of intestinal obstruction in India. We have evaluated the role of laparoscopic resection of ileocaecal tuberculosis and successfully performed the procedure in five patients. The clinical profiles of patients and operative procedure are discussed in this article with a brief review of the literature.

Oesophageal leiomyoma presenting as a mediastinal mass.

A 28 year old male presented with complaints of retrosternal pain, discomfort and dysphagia of 4 years duration. Barium swallow and oesophagoscopy were suggestive of extrinsic compression of thoracic oesophagus. CT scan of chest was suggestive of a large mediastinal lymph node mass. Thoracotomy and open biopsy showed a benign mesenchymal tumor on frozen section. A transthoracic oesophagectomy with gastric pull up and cervical oesophago-gastric anastomosis was performed. The postoperative course was uneventful and the patient discharged on the tenth postoperative day.

Symptomatic outcome after laparoscopic cholecystectomy.

AIMS: Patients with gallstones often present with multiple complaints. We wanted to study the major complaints of our patients undergoing laparoscopic cholecystectomy and the symptomatic relief afforded by the operation. METHODS: We studied 113 patients with symptomatic gallstone disease who underwent laparoscopic cholecystectomy in a single surgical unit. Patients with proven common bile duct stones, obstructive jaundice, cholangitis, present or past associated abdominal pathology or cholecystoenteric fistula were excluded from the study. The mean follow up period was 18 months (range 10-22 months). A detailed account of the symptoms of gallstones, length of post-operative stay, persistence of symptoms, development of fresh symptoms and resumption of fat containing diet were assessed. RESULTS: The male to female ratio was 1:4. Common presenting symptoms were abdominal pain (96%), flatulence or feeling of fullness of abdomen (85%), heartburn (66%), belching (62%), sour eructation (52%), vomiting (48%) and nausea (45%). Mean postoperative hospital stay was 28 hours (range 9-68 hours). Biliary pain was relieved in 99% of patients after laparoscopic cholecystectomy (p < 0.001). The non-pain symptoms which are relieved significantly (p < 0.001) included nausea (98%), vomiting (96%) and sour eructation (92%) had better outcome than belching (64%) flatulence (61%) and heart burn (59%). None of the patients developed jaundice after cholecystectomy. Fresh symptoms that developed after laparoscopic cholecystectomy were heart-burn (6%), belching (3.5%), sour eructation (1%) and vomiting (0.5%). Post-cholecystectomy post-prandial diarrhoea occurred in 20% of the patients. The patients' appreciation of a satisfactory cosmetic result of operation scars was 100 percent. Fifteen female patients (13.5%) complained of increased weight gain of more than 5 kg after laparoscopic cholecystectomy [(p > 0.05; not significant (NS)]. CONCLUSION: Laparoscopic cholecystectomy significantly relieved symptoms of gall stone disease. Biliary pain, nausea, vomiting and sour eructations had better outcome compared to belching, flatulence and heartburn, which are also relieved in majority. Postcholecystectomy post-prandial diarrhea was a significant new symptom after cholecystectomy. Pre-operative flatulence and heartburn are risk factors for poor symptom relief. All patients should be pre operatively counselled about the risk of persistence of some non-pain symptoms after laparoscopic cholecystectomy.

MIB-1 proliferative index in parathyroid adenoma & hyperplasia.

A retrospective study on 22 cases of parathyroid adenoma, 9 cases of primary parathyroid hyperplasia and 14 specimens of normal suppressed glandular tissue was undertaken to determine the usefulness of proliferative index (PI) for discriminating adenoma from hyperplasia, as an adjunct to the existing histological criteria. PI was determined by avidin-biotin-complex immunostaining after high temperature microwave antigen retrieval in paraffin sections, using monoclonal MIB-1 antibody which detects paraffin resistant analogue of cell cycle-associated Ki-67 antigen. PI expressed as percentage positive cell nuclei, was 1.36 +/- 0.62 (range 0.04-2.72) in adenoma, 1.17 +/- 0.83 (0.02-1.98) in hyperplasia and 0.03 +/- 0.02 (0.00-0.06) in normal suppressed glandular tissue. While the difference between normal suppressed glandular tissue and adenoma and hyperplasia was significant (P < 0.001), that between adenoma and hyperplasia was not. We conclude that although PI could distinguish between normal suppressed glandular tissue versus glands with primary hyperparathyroidism, it failed as an additional useful parameter for discriminating between adenoma and hyperplasia, both of which have low but similar proliferative activity.

Solid cystic tumour of the pancreas-clinico-pathological study of three cases.

During a period of four years three cases of solid and cystic (papillary) tumour of the pancreas were encountered. The patients presented predominantly with chief complaints of lump abdomen associated with dull aching pain in right hypochondrium. Radiologically diagnosis was suspected in two cases. Excessive bleeding during surgery was observed in two cases. In two survivors no recurrence or distant metastasis was noted after surgical excision (follow up 6 months to 3.5 years), third patient died after eight hours of operation.

Segmental renal dysplasia--a case report.

A case of segmental renal dysplasia presenting with loin pain, a renal mass and hypertension in a young girl of 16 years is being reported. Clinical and histological features of this rare renal anomaly are discussed.

Peritonitis in India--a decade's experience.

Generalised peritonitis is a common and dreaded surgical emergency. Its tropical spectrum continues to be different from its western counterpart. The study represents a retrospective analysis of 250 cases of peritonitis managed surgically over a decade at a large referral surgical unit at New Delhi. Perforations of the upper gastrointestinal tract viz: duodenal ulcer, enteric perforations etc. constitute the majority unlike western series where lower gastrointestinal tract perforations predominate. Despite significant delays in presentation, the overall prognosis remains comparable to the western figures. A comparatively younger age group involved may be responsible for better outcome.