A Standardized Ultrasound Scoring System for Preoperative Prediction of Difficult Laparoscopic Cholecystectomy.

PURPOSE: Laparoscopic cholecystectomy (LC) has become the treatment of choice for cholelithiasis. Still some patients required conversion to open cholecystectomy (OC). Our aim was to develop a standardized Ultrasound based scoring system for preoperative prediction of difficult LC. METHODS AND MATERIALS: Ultrasound findings of 300 patients who underwent LC were reviewed retrospectively. Four parameters (time taken, biliary leakage, duct or arterial injury, and conversion) were analyzed to classify LC as easy or difficult. The following ultrasound findings were analyzed: GB wall thickness, pericholecystic collection, distended GB, impacted stones, multiple stones, CBD diameter and liver size. Out of seven parameters, four were statistically significant in our study. A score of 2 was assigned for the presence of each significant finding and a score of 1 was assigned for the remaining parameters to a total score of 11. A cut-off value of 5 was taken to predict easy and difficult LC. RESULTS: 66 out of 83 cases of difficult LC and 199 out of 217 cases of easy LC were correctly predicted on the basis of scoring system. A score of >5 had sensitivity 80.7% and specificity 91.7% for correctly identifying difficult LC. Prediction came true in 78.8% difficult and 92.6% easy cases. US findings of GB wall thickness, distended GB, impacted stones and dilated CBD were found statistically significant. CONCLUSION: This indigenous scoring system is effective in predicting conversion risk of LC to OC. Patients having high risk may be informed and scheduled appropriately and decision to convert to OC in case of anticipated difficulty may be taken earlier.

Multifocal giant cell reparative granuloma involving maxilla and mandible: a rare entity.

Giant cell reparative granuloma (GCRG) is a rare lesion that is a reactive process, not a true neoplasm. It was originally coined by Jaffe to describe lesions, which he believed were a response to intraosseous hemorrhage from jaw trauma. Regardless, GCRG is much more distinct from giant cell tumor (GCT) of bone, both histologically and clinically. We report a patient who presented with multiple facial swelling involving the facial skeleton that showed a multiloculated cystic appearance on CT involving the maxilla and mandible. The patient refused surgery, but after 6 months of follow up there was no progression.

Neurocutaneous melanosis: Review of a rare non-familial neuroectodermal dysplasia with newer association of cerebellopontine angle cistern lipoma.

Neurocutaneous melanosis is a rare neuroectodermal dysplasia with a grave prognosis. It is actually a disorder of neuronal migration at the time of the embryogenesis hence classified as a neurocristopathy. The patients are initially identified by the skin manifestations of the disease in the form of melanocytic naevus which can be hairy or non-hairy. These patients may or may not present with neurological symptoms but often show CNS abnormalities especially on MRI of the brain and the spine. A lot has been described about the disease since the first case described by Rokitansky in 1861, but every time a new CNS pathology is being added to the long list of currently documented pathologies. Herein we describe a case of a 5 yr old boy with seizures and hairy melanocytic naevus over the trunk and back who was diagnosed as a case of Neurocutaneous melanosis on subsequent evaluation by CT and MRI. We also describe the new association of CP angle cistern lipoma with neurocutaneous melanosis.

Isolated crural hematoma mimicking retroperitoneal lymphadenopathy, a unique sign of traumatic diaphragmatic rupture: a case report.

Diaphragmatic injury following blunt thoracoabdominal trauma is rare and is usually associated with key radiological features like dependent viscera sign, collar sign, diaphragmatic thickening and defects. It may also be associated with secondary signs like intrathoracic herniation of abdominal viscera. Diaphragmatic crura, which are attached to the upper lumbar vertebra represent prominently thickened folds along the posterior diaphragm, are usually inconspicuous on routine Computed Tomography (CT) scans. We present a case of a young patient who sustained a motor vehicle accident and developed difficulty in breathing. CT scan of the patient revealed bilateral crural hematomas, with splenic and renal lacerations and no other sign of diaphragmatic injury. The patient was operated and blunt diaphragmatic rupture was confirmed at surgery.

Prevalence of nonalcoholic fatty liver disease (NAFLD) in patients of cardiovascular diseases and its association with hs-CRP and TNF-α.

BACKGROUND: There is increasing recognition of association of nonalcoholic fatty liver disease (NAFLD) with cardiovascular disease (CVD). Metabolic syndrome is common in both NAFLD and cardiovascular diseases. Our study is designed to investigate the association of NAFLD with cardiovascular disease. METHODS: It's a cross-sectional study which included 104 patients of coronary artery disease and hypertensive heart disease. Those patients having secondary causes of steatosis were excluded. Complete cardiovascular evaluation which included assessment of metabolic syndrome, routine biochemistries, viral markers, Ultrasonography (USG) abdomen, hs-CRP and TNF-α levels were obtained for all patients. RESULTS: Of all patients with cardiovascular disease, 19.2% (20/104) had essential hypertension with hypertensive heart disease the remaining 80.8% (84/104) patients had ischemic heart disease (IHD). On USG 69.2% (72/104) had NAFLD, these 50% (36/72) had grade 1 NAFLD and the rest grade 2 NAFLD. The hs-CRP levels and TNF-α were significantly higher in patients with NAFLD (p-value <0.001) and within patients with NAFLD the levels were higher in patients with grade 2 NAFLD. Also, binary logistic regression showed that high body-mass index (BMI), raised serum triglyceride levels, increased waist circumference and hypertension were significantly associated with the presence of NAFLD. CONCLUSION: Our data indicates that NALD is highly prevalent in patients of cardiovascular disease (69.2%) and is significantly associated with metabolic syndrome and its individual components. The levels of hs-CRP and TNF-α were significantly higher in patients with NAFLD and showed an increasing trend with the severity of fatty liver.

Image-guided fine-needle aspiration of retroperitoneal masses: The role of the cytopathologist.

BACKGROUND: Retroperitoneal tumors constitute a difficult diagnostic category as they are not easily accessible. The advent of image-guided fine-needle aspiration (FNA) has resolved this problem significantly. AIMS: We present a short study based on guided aspiration of retroperitoneal tumors, in which we have tried to assess the role of image-guided fine-needle aspiration cytology as a tool for pre-operative diagnosis. MATERIALS AND METHODS: The study was conducted on patients diagnosed with retroperitoneal masses. FNA was performed under image guidance with the help of ultrasonography and/or computed tomography; smears were prepared and meticulously screened according to a fixed protocol. The results were analyzed to determine sensitivity, specificity, and diagnostic efficacy of cytopathological diagnosis using image-guided FNA techniques. RESULTS: We assessed 38 patients with retroperitoneal masses. In all cases, adequate cellular material was obtained. No major complications were encountered. Statistical analysis was carried out in 35 cases; sensitivity, specificity, and diagnostic accuracy were 100% in these cases. CONCLUSION: FNA under image guidance should be considered a first-line diagnostic approach for retroperitoneal and other abdominal tumors, although caution should be exercised in case selection. In areas where advanced tests are not available, the cytotechnologist and cytopathologist have a very important role to play in ensuring accurate diagnoses.

Clinical examination vs. MRI: evaluation of diagnostic accuracy in detecting ACL and meniscal injuries in comparison to arthroscopy.

BACKGROUND: To compare the diagnostic accuracy of clinical examination and MRI in evaluation of meniscal and ACL injuries using arthroscopic findings as reference standard. MATERIAL/METHODS: A total of 51 patients with traumatic knee injuries were identified and prospectively followed up with clinical examination, MRI and arthroscopy. Clinical examination and MRI findings were compared with arthroscopic findings. Sensitivity, specificity, PPV, NPV and diagnostic accuracy were calculated with statistical analysis. RESULTS: Out of 24 patients with arthroscopic evidence of medial meniscal injury, clinical examination and MRI correctly identified 20 and 18 patients, respectively. Clinical examination was characterized by better sensitivity and specificity with regard to diagnosis of medial meniscal tear. On arthroscopy, lateral meniscal tear was present in 13 patients; clinical examination and MRI both identified 8 of them correctly. Similarly, out of 9 patients with arthroscopic evidence of ACL tear, clinical examination and MRI correctly identified 7 and 8 patients, respectively. There were only marginal differences in sensitivity and specificity of clinical examination and MRI in diagnosis of lateral meniscal and ACL injury. CONCLUSIONS: Careful clinical examination is much better than MRI with regard to the diagnosis of medial meniscus injury and is as reliable as MRI with regard to diagnosis of lateral meniscus injury and ACL tears. MRI should be used to rule out such injuries rather than to diagnose them.

Bilateral persistent hyperplastic primary vitreous: a close mimic of retinoblastoma.

Bilateral persistent hyperplastic primary vitreous (PHPV) is a rare disorder of eye. It is one of the most important differential diagnoses of retinoblastoma, hence early and accurate diagnosis is important. We here report a case of an 11-month-old child which was referred to ocular OPD with complaints of bilateral leukocoria. Examination revealed greyish-white masses posterior to both lenses, raising the clinical suspicion of retinoblastoma. Ultrasonography demonstrated echogenic masses extending from the posterior surface of the lens to the optic disc with reduced axial lengths. These masses demonstrated flow on color Doppler evaluation. CT scan revealed hyperdense masses behind the lens without any evidence of intralesional calcification. Clinical features and imaging findings point towards the diagnosis of bilateral PHPV. PHPV is a developmental disorder of the globe in which the hyaloid vasculature fails to regress normally. While unilateral PHPV is common, bilateral PHPV is a rare entity. It is one of the most important conditions mimicking retinoblastoma; hence early and accurate diagnosis is required. Ophthalmological examination is still the best way to confirm the diagnosis. However, if the diagnosis remain unclear, further evaluation using ultrasonography, Color Doppler, and CT scan is useful.

Xanthogranulomatous pyelonephritis: Rare presentation of a rare disease.

Xanthogranulomatous pyelonephritis is a rare chronic renal infection of unknown pathogenesis characterized by replacement of renal parenchyma by lipid filled macrophages frequently associated with an enlarged, non-functioning kidney and an obstructing calculus. We report a case of a 45 year old non diabetic female who presented with gradually enlarging renal mass with extensive retroperitoneal involvement and a non-functioning kidney with no evidence of obstructing stone or fat density and simulating malignancy. She was diagnosed as stage III Xanthogranulomatous pyelonephritis and managed with radical nephrectomy with favourable outcome.

Level of accessibility of radiological diagnostic tools of high technology and its effect on human health: study of ultrasonography, CT scan and MRI in different perspective.

The study was conducted at JNMC, Aligarh, India, to discern the obstacles/hurdles that stood in the way of the patients and the high technology diagnostic tool. For this purpose several parameters were taken eg, education/literacy, occupation and income group, etc. From the study 97% chose to undergo USG and only 3% were defaulters; 86% chose to undergo CT scan and only 14% were defaulters; 79% chose to undergo MRI and 21% were defaulters. Low cost investigations ie, USG and CT scan were more prescribed to IVth social class but MRI was mostly prescribed to IInd. Most of the defaulters were from IVth social class and showed financial problem for getting investigation. Taking into consideration the cost and sensitivity of procedure, it was found in this study that mainly cost determines the outcome. Sensitivity did not matter in patient's perspective. This was the reason that maximum defaulters were found in MRI, followed by CT scan and least in USG. Financial constraint was primary reason declared by defaulters followed by distance. Additional parameters like literacy, occupation and social standing were also found significant in the study in the sense of prescription of investigation and being defaulter.

Computed Tomography Evaluation of Craniomandibular Articulation in Class II Division 1 Malocclusion and Class I Normal Occlusion Subjects in North Indian Population.

Objective. The purpose of this study is to investigate the Craniomandibular articulation morphology and position of condyle in mandibular fossae in Angle's class I normal occlusion and Angle's class II division 1 malocclusion. Materials and Methods. The present study was conducted on 40 subjects with 20 subjects in each group, and the computed tomography images were obtained using spiral computed tomography technique. Each measurement was compared by two-factor analysis of variance (ANOVA) while changes in anterior and posterior joint spaces were done by paired t-test. Results. Statistically significant anterior positioning of condyle (P > 0.05) was observed in class I normal malocclusion, and it was significant only on right side in class II division 1 malocclusion. Conclusions. There was no difference found in the condylar process and joint morphology between right and left sides of both Angle's Class I normal occlusion and Angle's class II division 1 malocclusion. Evaluation of the position of the condyles in their respective mandibular fossae showed concentric position with a tendency towards anterior positioning for both right and left sides of the subjects with Angle's Class I normal occlusion as well as subjects with Angle's class II division 1 malocclusion.

Kirner's Deformity Misdiagnosed as Fracture: A Case Report.

Kirner`s deformity or dystelephalangy is a rare entity which presents with painless, progressive, bilateral radiovolar curving of the terminal phalanges of the little fingers. It is a clinicoradiological diagnosis. Herein, we present a case where the patient was being treated as having a fracture of the distal phalanx because of misdiagnosis of Kirner`s deformity. Given the rarity of the deformity, we believe it useful to present our case report as a contribution to the literature.

Painless left hemorrhagic pleural effusion: an unusual presentation of leaking saccular aortic arch aneurysm.

Most thoracic aortic aneurysms are asymptomatic and are detected by chance on routine chest imaging for some other reasons. Only rarely it is symptomatic due to leak and dissection which is a potentially life threatening event that commonly presents with severe pain. In this report, we present the case of a 67-year-old man who presented with shortness of breath, intermittent cough, fever, and left sided painless hemorrhagic pleural effusion. Further investigation by plain radiography, computed tomography and magnetic resonance imaging revealed a saccular aneurysm arising from the lateral aspect of the mid-transverse arch of the aorta, along with a dissecting descending aortic aneurysm with false lumen communicating with left pleural space. The patient refused any surgical procedure and was treated conservatively with blood transfusions and anti hypertensive medication. On the 8th day patient finally succumb to a fatal episode of shock. We suggest dissecting thoracic aneurysm be included in the differential diagnosis of non-traumatic hemorrhagic pleural effusion in an elderly patient presenting with dysnea, cough and fever, which otherwise suggest the clinical diagnosis of bronchogenic carcinoma. Computed tomography of the chest should be immediately performed as the diagnostic procedure of choice.

Isolated pontine tuberculoma presenting as "fou rire prodromique".

The authors present the case of a young child with "fou rire prodromique" as an initial manifestation of pontine tuberculoma. This report is the first description of fou rire prodromique as the presenting sign of CNS tuberculosis. The combination of clinical information and CT findings allowed for precise localization of the lesion and suggested tuberculoma as the possible etiology.