Unilateral Angiokeratoma of Fordyce With Unilateral PEAKER: A Rare Presentation of an Uncommon Disease.

Angiokeratomas are benign vascular lesions that can occur anywhere in the body. Fordyce angiokeratomas, also known as genital angiokeratomas, often develop on the vulva in women and the scrotum in males. A subtype of genital angiokeratoma in males is called penile angiokeratoma (PEAKER). In females, clitoral angiokeratoma (CLANKER) is the embryologic equivalent. As a result of the underlying pathophysiology, these lesions are often bilateral. Unilateral Fordyce angiokeratoma instances are infrequent, and unilateral PEAKER cases have never been previously documented. We describe a case of Fordyce's unilateral angiokeratoma with unilateral PEAKER. To the best of our knowledge, such a variation in presentation of this rare disease has not been previously reported.

Impact of Pelvic Bone Anatomy on Inguinal Hernia and the Role of Radiological Pelvimetry.

Introduction One of the most prevalent disorders treated by general surgeons is inguinal hernias. Many of the etiological factors that lead to hernia development are unknown. This study looked at the role of pelvic bone anatomy in the development of inguinal hernia. The pubic tubercle's location (as measured by the Radoievitch angle) and its relationship to the formation of inguinal hernia, as well as its function in the pathophysiology of various forms of inguinal hernia, were investigated. Materials and methods From October 2019 to June 2021, a prospective case-control study with 70 individuals over the age of 18 years in each arm was conducted in the Department of General Surgery at our tertiary care institution. Plain digital X-ray radiography of the pelvis, including bilateral hips, was taken in the anteroposterior (AP) view with the patient in the supine position, and the Radoievitch angle and Ami line were measured using suitable measuring instruments. The required information for patients in both groups was tallied and examined in a data sheet. Results Between the case and control groups, there was a statistically significant difference in the mean Radoievitch angles and the mean length of the Ami line (42.46 +/-2.442 degrees vs 40.91 +/-2.547 degrees; p<0.05); (8.54+/-1.059 cm vs 7.27+/-1.034 cm; p<0.05). There was a statistically significant increase in the Radoievitch angle of patients with bilateral hernias compared to unilateral hernias (p-value <0.01), as well as indirect hernias compared to other forms of hernias (p-value <0.05). Conclusion The probability of having an inguinal hernia was higher when the Fruchaud region was increased, as indicated by a larger Radoievitch angle or a longer Ami line. A low-lying pubic tubercle increased the likelihood of bilateral and indirect inguinal hernias. Pelvimetry is an easy test that should be considered on a routine basis and can be applied accurately in all patients. Surgeons can employ pelvimetry to identify patients who are more likely to benefit from non-mesh repairs.

Serum TSH Level as a Simple Efficient Tool to Assess the Risk of Thyroid Malignancy in Euthyroid Patients with Indeterminate Cytology - A Cohort Study.

Context: A significant number of fine-needle aspiration cytology (FNAC) for thyroid nodules is reported as indeterminate. Expensive molecular testing can give a clue to the possibility of malignancy in this group. The effectiveness of serum thyroid-stimulating hormone (TSH) levels as a diagnostic tool in euthyroid patients with indeterminate cytology has not been previously studied, especially in the Indian population. Aims: This study was conducted to evaluate the predictive efficacy of serum TSH in the early diagnosis and treatment of malignancy. Settings and Design: This is a retrospective cross-sectional study on a cohort of patients who presented to our department with complaints of thyroid swelling and underwent thyroidectomy. Methods and Material: Euthyroid patients who underwent thyroid surgery for newly diagnosed thyroid nodules with FNAC reported as indeterminate cytology were included in our study. Based on the histopathological report, the patients were divided into two groups and into quartiles based on TSH values. Statistical Analysis Used: The mean difference in the numerical variables between groups was compared using the independent two-sample 't' test for parametric data and Mann-Whitney 'u' test for non-parametric data. A logistic regression analysis was done with age, sex, TSH level and nodule size as dependant variables and malignancy as the independent variable. Results: There were 211 patients in group A and 93 in group B. Patients with malignancy confirmed on final histopathology showed higher serum TSH levels compared to benign nodules (2.93 ± 1.067 vs 1.73 ± 1.051, P = <0.001). The mean TSH levels of all types of malignant nodules correlated with our test model (>2.185 mIU/L). Conclusions: Serum TSH above 2.185 mIU/mL is a good predictor of malignancy in indeterminate nodules. It is an inexpensive, safe and reliable diagnostic screening test for the risk of malignancy in an indeterminate nodule.

Preoperative Preparation of Hyperthyroidism for Thyroidectomy - Role of Supersaturated Iodine and Lithium Carbonate.

INTRODUCTION: Thyroidectomy is effective and safe procedure for permanent cure of hyperthyroidism (HT). Iodine preparations are widely used before operation to prevent excess blood loss. Ideal regimen for refractory HT is debated. This retrospective case-control study is designed to study the efficacy of various regimens of preoperative preparations. MATERIALS AND METHODS: Case records, anesthesia charts, and follow-up details of hyperthyroid patients undergoing thyroidectomy were reviewed and compared with an age- and sex-matched euthyroid patients operated during the same period. Iodine preparations were not used for preoperative preparation. Study group was subdivided based on preoperative regimens of anti-thyroid medications. RESULTS: Of the 168 patients in the study group, procedure time, duration of hospital stay, and overall complication rate were high compared to euthyroid group. Operative blood loss was not high in the study group. There was no difference in rate of complications in the subgroups of the study cohort. CONCLUSION: Iodine preparations are not mandatory in preoperative preparation of HT. Lithium carbonate is effective in preoperative preparation of refractory HT. Rate of postthyroidectomy complications is not different in patients receiving thionamides alone or in combination with ß-blocker.

The Outcome of Papillary Thyroid Cancer Associated with Graves' Disease: A Case Control Study.

INTRODUCTION: Thyroidectomy is now a less popular therapeutic option for Graves' disease. The frequency of thyroid nodule and the cancer risk of these nodules accompanying Graves' disease are controversial. The outcome of thyroid cancers coexisting with Graves' disease is debated. STUDY DESIGN: Designed as retrospective case control study of papillary thyroid cancers associated with Graves' disease and those with euthyroid background. Pathological characteristics and outcome of papillary thyroid cancers in the two groups were compared. RESULTS: The tumour characteristics did not differ significantly in the groups. The patients were followed for a mean period of 77.32 months and found significant incidences of disease progression in patients with papillary thyroid cancer associated with Graves' disease (p = 0.034; OR 2.747, CI 1.078-7.004). Disease progression as new distant metastases mostly in skeletal locations was high in this group compared to euthyroid group (p = 0.027; OR 4.121, CI 1.008-15.600). There was higher incidence of cumulative metastatic diseases in papillary thyroid cancer associated with Graves' disease. CONCLUSION: Papillary thyroid cancers associated with Graves' disease show aggressive biological behaviour and favoured site of distant metastases was osseous locations. Early diagnosis by routine screening of Graves' disease patients with ultrasound imaging and aspiration studies is recommended.

Correlation between the Cernea Classification of External Branch of Superior Laryngeal Nerve in Relation to the Ultrasound-based Volume of Thyroid Gland.

INTRODUCTÍON: Goiter is a very common problem dealt with by surgeons. Surgical treatment of thyroid requires removal of a part (hemi) or whole of the gland (total thyroidectomy). The external branch of the superior laryngeal nerve (EBSLN) is an important but less researched structure to be preserved during surgery. Various studies have described the incidence of different types of EBSLN, but have not described regarding the relationship between the change in volume of the gland to the nerve. MATERIALS AND METHODS: A prospective analysis of 100 patients who underwent total thyroidectomy in our department was done. All patients underwent preoperative ultrasonography and the volume of the gland was calculated. Intraoperatively, the EBSLN was identified and preserved prior to ligating the superior thyroid vessels. The nerve was classified as per the Cernea classification. The gland was divided into high and low volume, taking 20 ml as the cutoff. The incidence of Type 2 nerve in a low-volume gland was compared with that of a high-volume gland. RESULTS: In 100 patients (200 nerves), 191 nerves were identified. The nerve was type 1 in 56/200 (28%), Type 2a in 116/200 (58%), and Type 2b in 19/200 (9%) patients. In large-volume glands, Type 2 nerve was more common (87%). CONCLUSION: Dissection of thyroid gland requires expertise to preserve the EBSLN. Large volume glands pose a more difficult challenge, as the gland is more closer to the nerve.

Lack of Association of B-type Raf Kinase V600E Mutation with High-risk Tumor Features and Adverse Outcome in Conventional and Follicular Variants of Papillary Thyroid Carcinoma.

INTRODUCTION: Somatic B-type Raf kinase (BRAF) V600E mutation in exon 15 was frequently found in high frequencies associated with papillary thyroid cancer (PTC). The phenotype of these cancers expressed aggressive clinical and pathological features. The present study aimed to assess the prevalence of BRAF V600E mutation among conventional and follicular variants of PTC and its association with aggressive tumor factors and outcome. STUDY DESIGN: Patients who were operated and received further treatment for PTC during 2012 were included in the study. BRAF V600E mutation analysis was done by extracting genomic DNA from tumor tissue. RESULTS: Of the 59 patients included in the study, 51% harbored BRAF V600E mutation, but the mutation status was not associated with aggressive tumor factors and adverse outcome. CONCLUSION: BRAF V600E mutation was not significant predictor of aggressive tumor behavior in conventional and follicular variants of PTC.

Is intraoperative parathyroid hormone monitoring necessary in symptomatic primary hyperparathyroidism with concordant imaging?

INTRODUCTION: Symptomatic primary hyperparathyroidism (PHPT) is still seen frequently in referral centers all over India. These patients require parathyroidectomy and this study aimed to assess the roll of intraoperative parathyroid hormone (PTH) assay when concordant results of two localization studies were available. STUDY DESIGN: We analyzed the case records of patients who underwent parathyroidectomy for PHPT from January 2005 to June 2015. RESULTS: Of 143 patients included in the study, technetium 99m methoxyisobutylisonitrate dual phase scintigraphy showed true positive images in 93.7% and high definition ultrasonography in 84.6% of patients. Concordance in localization studies was observed in 121 (84.6%) patients, successful parathyroidectomy was done in 117 (96.7%) patients with concordant localization studies. Intraoperative PTH monitoring showed 97.84% sensitivity and 75% specificity and predicted failure in 2 patients with concordant imaging. However, re-exploration was not successful in these patients. CONCLUSION: When concordant result is available between parathyroid scintigraphy and anatomical imaging surgical cure rate is high in trained hands. Re-exploration is unlikely to be successful since these patients require higher imaging.

Inflammatory diseases of the non-lactating female breasts.

UNLABELLED: Chronic inflammatory diseases of the non-lactating breasts cause considerable difficulty in diagnosis and treatment. There is a spectrum of aetiological factors ranging from infection to autoimmune disorders. The disease causes considerable morbidity and psychological distress in relatively young females. The study aimed to analyse the spectrum of chronic disease and to formulate a treatment protocol. METHOD: Female patients with histological confirmation of inflammatory disease of the breast in the non-lactational phase were included in the study. The patients were categorized based on histological findings supplemented with immunohistochemical staining with CD3 and CD20 antibodies. RESULT: Out of 50 patients included in the study, 38 patients (76%) were diagnosed as idiopathic granulomatous mastitis (IGM) and 12 (24%) patients as periductal mastitis (PD). The possible aetiology of IGM was localized autoimmunity as evidenced by the infiltration of CD3 positive T lymphocyte. Systemic prednisolone was given for 6 months and 95.6% patients were disease-free after 24months. Out of 15 patients who did not receive prednisolone, only 2 patients were disease-free after 24 months (p = .003). CONCLUSION: Idiopathic granulomatous mastitis is an uncommon inflammatory disease of the non-lactating breast. The combination of limited surgical treatment and systemic prednisolone given for 6 months effectively controls the disease as well as prevents recurrence.

Lithium-induced parathyroid dysfunction: A new case.

Lithium salts are widely used in psychiatric practice and are known to induce thyroid dysfunction. Lithium-induced parathyroid dysfunction is rare. We are reporting a case of hyperparathyroidism in a 28-year-old female patient who was on lithium carbonate for 2 years, when she developed osteopenia and girdle girdle-type muscle weakness. Biochemical parameters showed hyperparathyroidism with shift of calcium creatinine clearance ratio to 0.013, indicating an error in threshold of calcium sensing receptor. The patient eventually required parathyroidectomy and the histology of the gland showed atypical features.

Hypocalcaemia following total thyroidectomy: An analysis of 806 patients.

BACKGROUND: Permanent hypocalcaemia following thyroidectomy causes considerable morbidity. This prospective observational study aims to define the factors likely to predict hypocalcaemia following total thyroidectomy. MATERIALS AND METHODS: Patients who were subjected to total thyroidectomy during January 2005 to December 2009 were followed up for a minimum period of 1 year. Efficacy of an intraoperative parathyroid hormone assay to predict hypocalcaemia was validated. RESULTS: Overall incidence of hypocalcaemia was 23.6% (n = 190) and that of permanent hypocalcaemia was 1.61% (n = 13). Onset was delayed up to 3(rd) postoperative day in 13 patients. Hypocalcaemia was significantly associated with thyroidectomy for Grave's Disease (P = 0.001), Hashimoto's thyroiditis (P = 0.003), and with incidental parathyroidectomy (P = 0.006). The intraoperative assay of parathyroid hormone showed low sensitivity (0.5) and satisfactory specificity (0.9) in predicting hypocalcemia. CONCLUSION: Hypocalcemia could manifest late in the immediate postoperative period and this may explain latent hypocalcemia. High incidence of hypocalcaemia noted in Grave's Disease could be due to the autoimmunity since same feature was noted associated with Hashimoto's thyroiditis and the incidence of hypocalcaemia was not high in the subgroup with toxic nodular goiter. The incidence of hypocalcemia was not affected by age or sex.

Gastric carcinoma-a rare presentation.

Over the last 10 years there has been increasing evidence of a strong association between Idiopathic Deep vein thrombosis (IDVT) and occult malignancy. A review of world literature puts this new clinical entity as 4 -25%10. This mandates screening all cases of IDVT for a hidden malignancy. We report a case of advanced gastric carcinoma presenting as upper limb DVT with pulmonary embolism.

Is total thyroidectomy justified in multinodular goitre.

Role of total thyroidectomy in treatment of patients with benign diseases of thyroid gland remains controversial. The hypothesis behind the study is that total thyroidectomy can be performed in all benign thyroid diseases with equal rate of immediate and late complications compared with those of subtotal thyroidectomy. The retrospective case control study was done by reviewing the case records of patients with benign thyroid diseases involving both lobes operated during May, 2002 to September, 2004. The minimum follow-up period was 3 years. Of the 189 patients included in the study 94 underwent total thyroidectomy and 95 patients underwent subtotal thyroidectomy. There was no incidence of permanent recurrent laryngeal nerve paralysis in both groups. Temporary unilateral recurrent laryngeal nerve paralysis occurred in 3 patients (3.2%) in total thyroidectomy group and 1 (1.1%) patient in subtotal thyroidectomy group, which was not statistically significant (p = 0.307). Temporary hypocalcaemia was noted in 10 patients of total thyroidectomy group (10.6%) and 3 patients of subtotal thyroidectomy group (3.2%). Permanent hypocalcaemia was noted in 2 patients each in total thyroidectomy group and subtotal thyroidectomy group (p = 0.991). Total thyroidectomy is an acceptable alternative to subtotal thyroidectomy in benign diseases, considering the higher rate of postoperative morbidity in recurrent goitres.

Simultaneous MR/PET imaging of the human brain: feasibility study.

The purpose of this study was to apply a magnetic resonance (MR) imaging-compatible positron emission tomographic (PET) detector technology for simultaneous MR/PET imaging of the human brain and skull base. The PET detector ring consists of lutetium oxyorthosilicate (LSO) scintillation crystals in combination with avalanche photodiodes (APDs) mounted in a clinical 3-T MR imager with use of the birdcage transmit/receive head coil. Following phantom studies, two patients were simultaneously examined by using fluorine 18 fluorodeoxyglucose (FDG) PET and MR imaging and spectroscopy. MR/PET data enabled accurate coregistration of morphologic and multifunctional information. Simultaneous MR/PET imaging is feasible in humans, opening up new possibilities for the emerging field of molecular imaging.

Bilateral aberrant internal carotid arteries with bilateral persistent stapedial arteries and bilateral duplicated internal carotid arteries.

A 5-year-old boy was evaluated for a left retrotympanic mass found at otoscopy. Subsequent petrous bone CT and MR angiographic examinations demonstrated bilateral aberrant internal carotid, bilateral stapedial artery persistence, and bilateral duplicated internal carotid arteries. Imaging findings and their clinical relevance are discussed. A second case of unilateral aberrant internal carotid artery with a persistent stapedial artery is included for comparison.