A Novel Approach to Grade 2 Closed Olecranon Fractures (Oestern and Tscherne Classification) Through Percutaneous Tension Band Wiring: A Case Report.

Introduction: Olecranon fractures with compromised overlying skin such as superficial and deep abrasions and puncture wounds pose a challenge to manage as they are at a higher risk of wound and hardware-associated complications such as wound dehiscence, infection, gaping, and prominent hardware. Management of such fractures requires a holistic approach with special attention to the skin and soft tissues. Case Report: This case highlights a 28-year-old male with a history of falls from a bike resulting in the right comminuted displaced olecranon fracture with multiple superficial abrasions which was managed with a thorough wound wash, antibiotics for 3 days after which percutaneous tension band wiring was performed through a 3 cm incision to prevent any wound complications. Rehabilitation and physical therapy were started immediately and the patient restored the complete range of motion at the elbow thus resuming his activities of daily living. Conclusion: Utilizing a percutaneous technique for fixation in closed olecranon fractures with compromised overlying skin is considered an innovative, secure, dependable, and effective approach.

A Rare Case of Psoas Abscess Secondary to Mucinous Adenocarcinoma of the Appendix: A Case Report.

INTRODUCTION: Iliacus and psoas muscles are located in an extraperitoneal location forming the iliopsoas compartment. Iliopsoas abscess is a myositis involving this compartment. Pseudomyxoma peritonei is characterized by an abundant extracellular collection of mucin in the peritoneal cavity. When this collection is retroperitoneal, it is termed as pseudomyxoma extraperitonei. We present to you the case of a 52-year-old female with psoas abscess secondary to mucinous adenocarcinoma of the appendix, which was later diagnosed as pseudomyxoma extraperitonei. CASE PRESENTATION: A 52-year-old female presented with pain in the right flank with discharging sinuses since one year. She had previously undergone two surgeries in the past 1 year for drainage of the abscess and had taken first line anti-tubercular treatment for around 6 months. She was managed in our institute by an open drainage of the abscess. The culture reports showed an infection with E. coli. The histopathology sections showed abundant pools of extracellular mucin with strips of columnar epithelium which indicated the pathology to be a mucinous adenocarcinoma. A contrast-enhanced computed tomography scan of the abdomen and pelvis showed a ruptured appendix mucocele and a collection in the right psoas muscle showing fistulous communication with the cecum and extending to the suture site in the right flank. Anti-tubercular treatment was stopped and an oncology opinion was taken. The patient was managed with a palliative ileostomy. CONCLUSION: It is important to keep in mind diagnostic possibilities other than tuberculosis of the spine when managing a patient with an iliopsoas abscess. These include pathologies of the gastrointestinal and genitourinary tract, which need to be diagnosed and managed early.

Practical consensus recommendations regarding the management of sentinel lymph node issues in early breast cancer.

Axillary lymph node involvement is a very important poor prognostic factor in the clinical staging and management of breast cancer patients. Traditionally, axillary lymph node dissection (ALND) has been used for determining the status of the axillary lymph nodes. More recently the sentinel lymph node biopsy (SLNB) procedure has gained wider acceptance as the standard of care, having the advantage of being less invasivewhile providing good accuracy. This expert group used data from published literature, practical experience and opinion of a large group of academic oncologists to arrive at these practical consensus recommendations in regards with the use of the two different procedures and other issues in patients with early breast cancer for the benefit of community oncologists.

Secondary inguinal hydatidosis mimicking irreducible inguinal hernia: report of a rare case.

Peritoneal hydatidosis secondary to liver hydatid disease is not uncommon but peritoneal hydatidosis herniating to the inguinal canal is rare, with fewer than five cases reported in the literature. We describe a 54-year-old man who presented with a progressively enlarging soft, cystic swelling in the right inguinal region. Clinical examination suggestive of irreducible right inguinal hernia and ultrasonography revealed it to be a cystic swelling within the hernial sac. The swelling was excised en bloc and open mesh hernioplasty was performed. Cyst biopsy revealed hydatid disease; hence, the patient was put on adjunctive albendazole chemotherapy for 3 months.

Surgical outcome of safe surgery system trabeculectomy combined with cataract extraction.

PURPOSE: To determine the efficacy of safe surgery system trabeculectomy combined with manual small incision cataract surgery/phacoemulsification in primary glaucoma coexistent with cataract. METHODS: This is a retrospective analysis of 105 cases who underwent single-site combined surgery between January 2008 and December 2009. Safe surgery system trabeculectomy with diffuse and posterior application of mitomycin C was performed in all cases. Cataract extraction was done either by Manual Small Incision Cataract Surgery (MSICS) or phacoemulsification. Main outcome measures were success rate of trabeculectomy, as determined by four different IOP goals and incidence of postoperative complications. Analysis was performed using R-2.15, and the significance was tested at 5% level. RESULTS: The minimum follow-up period was 12 months. The overall success rates (with or without medication) when safe surgery system trabeculectomy was combined with MSICS were 91, 70, and 51% for IOP ≤18, ≤15, and ≤12 mm Hg, respectively, and target IOP was achieved in 72% cases. The mean IOP reduction was 43.8% with MSICS and 42.08% with phacoemulsification. The surgical outcome was not significantly different for both techniques. Postoperative complications were infrequent and comparable. CONCLUSION: The Safe Surgery System Trabeculectomy combined with cataract surgery offers excellent IOP control with minimal postoperative complications. It offers an effective and improved solution for primary glaucoma coexistent with cataract found in developing countries.

Percutaneous drainage of gastric remnant dilatation after laparoscopic Roux-en-Y gastric bypass.

Roux-en-Y gastric bypass is a commonly performed bariatric procedure worldwide. Gastric remnant dilatation is an uncommon early complication of this procedure that can be fatal if treatment is delayed, as it can cause peritonitis and death. Herein we report a gastric bypass patient who presented with profound shock 3 months after the surgery. After resuscitation and evaluation, she was diagnosed as having a massive dilatation of gastric remnant, which we managed with percutaneous drainage.

Resistance to Antituberculosis Drugs in Pulmonary Tuberculosis.

BACKGROUND: Incidence of drug resistance and pattern of susceptibility to antitubercular drugs in pulmonary tuberculosis amongst soldiers and their families was studied for four years at a military hospital in northwest India. METHODS: Identification and susceptibility tests were carried out as per procedures laid out in laboratory manual of Tuberculosis Research Centre (TRC), Chennai. RESULTS: Of the 172 strains of Mycobacterium tuberculosis (MTB) isolated from sputum samples, 150 (87.21%) were sensitive and 22 (12.79%) showed resistance to one or more antitubercular drugs. Acquired drug resistance was observed in 7 (31.82%) and primary drug resistance in 15 (68.18%) cases. Among 22 drug resistant cases, who were on short course chemotherapy (SCC), resistance to single drug was observed in 12 (54.54%), two drugs in 7 (31.82%) and to three or more drugs in 3 (13.64%) isolates. Fourteen (18.14%) strains were resistant to Streptomycin, 8 (4.65%) to Rifampicin, 11 (6.40%) to Isoniazid, 1 (0.58%) to Pyrazinamide and 2 (1.16%) to Ethambutol. Multidrug resistance was observed in 5 (2.91%) cases, of which resistance to Isoniazid and Rifampicin was present in 2 (1.16%) and their combination with other drugs in other 3 (1.74%) isolates. CONCLUSIONS: Drug susceptibility pattern to antitubercular drugs is discussed and compared with studies from other centres.

Evaluation of communication skills of physicians about asthma.

OBJECTIVE: Communication skills in medical practice are important. To assess the communication skills of physicians about asthma, we undertook this study. METHODS: One thousand four hundred and twenty one physicians attending the annual conference of association of physicians of India volunteered to participate in the study. They were divided into three categories. 'Teachers' group 1, (n = 131), 'Clinicians', group 2, (n = 951) and 'Students' group 3, (n = 339). Questionnaire containing ten most frequently asked questions by asthmatic patients were given to the physicians. A panel of three patients assessed the replies of these question and graded them as 'Convincing', 'Just convincing' and 'Not convincing'. RESULTS: Replies of only 2% of physicians were graded as convincing, 15.6% just convincing and 82.4 as not convincing. Among group 1 none gave a convincing reply while replies of 2.2% of group 2 and 2.4% of group 3 were graded as convincing. The difference in results was not significant statistically on comparing the three groups (p > 0.1). CONCLUSIONS: Communication skills are the integral part of patient care and management. Our study demonstrated lack of effective communication skills among physicians.

Inhibition of phosphoenolpyruvate carboxykinase (PEPCK) gene expression by troglitazone: a peroxisome proliferator-activated receptor-gamma (PPARgamma)-independent, antioxidant-related mechanism.

Phosphoenolpyruvate carboxykinase (PEPCK) is the rate-limiting enzyme of gluconeogenesis. Enhanced expression of the PEPCK gene in liver is present in most models of diabetes, and is thought to contribute to the increased hepatic glucose output seen in this disease. Recently, we showed that troglitazone, the first thiazolidinedione (TZD) used clinically, inhibits expression of the PEPCK gene in isolated hepatocytes. We have pursued the molecular mechanism whereby troglitazone exerts this inhibition. TZDs are known to bind and activate peroxisome proliferator-activated receptor-gamma (PPARgamma), a nuclear receptor, which regulates expression of target genes. Initially, we examined the abilities of three other TZDs (rosiglitazone, englitazone, and ciglitazone) to inhibit expression of the PEPCK gene. Despite the fact that these agents are ligands for PPARgamma, they displayed little if any inhibitory activity on the expression of this gene. GW1929 [N-(2-benzoyl phenyl)-l-tyrosine], another potent PPARgamma ligand that is unrelated structurally to TZDs, had no inhibitory effect on PEPCK gene expression, while a natural PPARgamma ligand, the prostaglandin metabolite 15-PGJ2 (15-deoxy-Delta(12,14)-prostaglandin J2), displayed only modest inhibitory activity. Treatment of hepatocytes with ligands for other isoforms of PPAR also had no significant effect on PEPCK gene expression. Troglitazone has an alpha-tocopherol (vitamin E) moiety that is not present in other TZDs, and treatment of hepatocytes with vitamin E led to an inhibition of PEPCK gene expression. These observations support the conclusion that troglitazone inhibits the expression of the PEPCK gene by a PPARgamma-independent, antioxidant-related mechanism.

Reciprocal regulation of glycogen phosphorylase and glycogen synthase by insulin involving phosphatidylinositol-3 kinase and protein phosphatase-1 in HepG2 cells.

The effect of insulin on glycogen synthesis and key enzymes of glycogen metabolism, glycogen phosphorylase and glycogen synthase, was studied in HepG2 cells. Insulin stimulated glycogen synthesis 1.83-3.30 fold depending on insulin concentration in the medium. Insulin caused a maximum of 65% decrease in glycogen phosphorylase 'a' and 110% increase in glycogen synthase activities in 5 min. Although significant changes in enzyme activities were observed with as low as 0.5 nM insulin level, the maximum effects were observed with 100 nM insulin. There was a significant inverse correlation between activities of glycogen phosphorylase 'a' and glycogen synthase 'a' (R2= 0.66, p < 0.001). Addition of 30 mM glucose caused a decrease in phosphorylase 'a' activity in the absence of insulin and this effect was additive with insulin up to 10 nM concentration. The inactivation of phosphorylase 'a' by insulin was prevented by wortmannin and rapamycin but not by PD98059. The activation of glycogen synthase by insulin was prevented by wortmannin but not by PD98059 or rapamycin. In fact, PD98059 slightly stimulated glycogen synthase activation by insulin. Under these experimental conditions, insulin decreased glycogen synthase kinase-3beta activity by 30-50% and activated more than 4-fold particulate protein phosphatase- activity and 1.9-fold protein kinase B activity; changes in all of these enzyme activities were abolished by wortmannin. The inactivation of GSK-3beta and activation of PKB by insulin were associated with their phosphorylation and this was also reversed by wortmannin. The addition of protein phosphatase-1 inhibitors, okadaic acid and calyculin A, completely abolished the effects of insulin on both enzymes. These data suggest that stimulation of glycogen synthase by insulin in HepG2 cells is mediated through the PI-3 kinase pathway by activating PKB and PP-1G and inactivating GSK-3beta. On the other hand, inactivation of phosphorylase by insulin is mediated through the PI-3 kinase pathway involving a rapamycin-sensitive p70(s6k) and PP-1G. These experiments demonstrate that insulin regulates glycogen phosphorylase and glycogen synthase through (i) a common signaling pathway at least up to PI-3 kinase and bifurcates downstream and (ii) that PP-1 activity is essential for the effect of insulin.

Variation of axillary temperature and its correlation with oral temperature.

UNLABELLED: Unilateral axillary temperature is recorded in unconscious patients and children due to its easy approach. OBJECTIVE: To evaluate variation of axillary temperature on the two sides and its correlation with oral temperature. SUBJECTS: One hundred and 46 healthy men and women, aged 12 through 52 years. METHODS: Axillary temperature from both sides and oral temperature were recorded using digital electronic thermometer in supine position with due precautions. RESULTS: Difference in temperature on the two sides of axilla was found to vary by as much as 0 degree F to 3.4 degrees F. Therefore, the data was grouped into higher and lower temperature ranges. The difference between mean oral and mean higher axillary temperature was found to be 0.5 degree F +/- 0.6 degree F (r = 0.564) while that in comparison to mean lower axillary temperature was 1.0 degree F +/- 0.89 degree F (r = 0.64). The difference between mean oral and mean axillary temperature was 1.0 degree F +/- 0.80 degree F (r = 0.84). CONCLUSIONS: Based on our observations, it is found that an average of temperature of both sides of axilla represents the axillary temperature more accurately and to get the correct oral equivalent of axillary temperature one should add 1 degree F to the mean axillary temperature.

Diagnostic dilemma: aspergillosis.

Two cases of varied forms of Aspergillosis are reported who were being diagnosed and treated on different lines. One case, who was treated on lines of allergic bronchitis, had very high total eosinophil count and, fleeting pulmonary infiltrates over a period of 5 years along with history of cough, fever and weight loss. Aspergillus fumigatus was grown on sputum culture. On the background of a long standing history of bronchial asthma with evidence of peripheral as well as central eosinophilia, fleeting pulmonary infiltrates and A. fumigatus grown on sputum culture, we kept the diagnosis of Allergic Bronchopulmonary aspergillosis (ABPA) and put the patient on steroids and Itraconazole. Patient showed good response to therapy. Another case, a 50 year old male, presented to us with clinical picture of subacute myelitis. Being a known case of ABPA and on steroid therapy for long duration, we kept the diagnosis of invasive aspergillosis. Growth of Aspergillus fumigatus on sputum culture on three occasions and MR imaging of spine further supported our view. Aspergillosis of the lung do not have characteristic clinico-radiological features of permit the diagnosis and should be considered in the differential diagnosis of tuberculosis, pneumonia, bronchiectasis, lung abscess and bronchial asthma.

Adequacy assessment of oxygen therapy.

OBJECTIVES: Oxygen administration in the wards is usually not according to prescription and therefore the patients requiring oxygen therapy does not get optimal benefits. We planned to assess the need and adequacy of oxygen therapy as was given in wards of SMS Hospital, Jaipur. METHODOLOGY: We studied sixty-six patients in medical and surgical wards who were receiving oxygen therapy through various modes of delivery. Oxygen therapy system was checked in detail and oxygen saturation (SaO2) was measured by pulse oximetery. RESULTS: In our study, we found that no oxygen was flowing from cylinder head in 24 cases (35.5%) while in another 23 cases (35.2%) oxygen was flowing at lower than prescribed flow rates. Leakage in tubes and connections were found in nine cases (13.4%). None of our case was receiving oxygen as per prescription. After correction of faults, all patients showed improvement in SaO2. The criteria of starting oxygen therapy were met only in 47 patients (69%) as per American College of Chest Physicians (ACCP). CONCLUSIONS: Oxygen therapy should be administered according to guidelines. Proper monitoring of oxygen therapy is recommended to ensure adequate oxygenation and to save precious oxygen from wastage. Pulse oximeter is a simple, noninvasive and reliable method to assess it.

Troglitazone inhibits expression of the phosphoenolpyruvate carboxykinase gene by an insulin-independent mechanism.

Troglitazone is an oral insulin-sensitizing drug used to treat patients with type 2 diabetes. A major feature of this hyperglycemic state is the presence of increased rates of hepatic gluconeogenesis, which troglitazone is able to ameliorate. In this study, we examined the molecular basis for this property of troglitazone by exploring the effects of this compound on the expression of the two genes encoding the major regulatory enzymes of gluconeogenesis, phosphoenolpyruvate carboxykinase (PEPCK) and glucose-6-phosphatase (G6Pase) in primary cultures of rat hepatocytes. Insulin is able to inhibit expression of both of these genes, which was verified in our model system. Troglitazone significantly reduced mRNA levels of PEPCK and G6Pase in rat hepatocytes isolated from normal and Zucker-diabetic rats, but to a lesser extent than that observed with insulin. Interestingly, troglitazone was unable to reduce cAMP-induced levels of PEPCK mRNA, suggesting that the molecular mechanism whereby troglitazone exerted its effects on gene expression differed from that of insulin. This was further supported by the observation that troglitazone was able to reduce PEPCK mRNA levels in the presence of the insulin signaling pathway inhibitors wortmannin, rapamycin, and PD98059. These results indicate that troglitazone can regulate the expression of specific genes in an insulin-independent manner, and that genes encoding gluconeogenic enzymes are targets for the inhibitory effects of this drug.

Troglitazone induces expression of PPARgamma in liver.

Troglitazone is an insulin sensitizer which affects a number of target tissues. It is believed to exert these effects primarily by binding to and activating the y-isoform of peroxisome proliferator-activated receptor (PPARgamma), which in turn regulates the expression of specific genes. However, in a number of target organs, such as liver, the levels of PPARgamma are low and other isoforms predominate. In the present study, we examined whether troglitazone induces the expression of PPARgamma, thereby sensitizing cells for the action of this drug. Treatment of isolated rat hepatocytes with troglitazone induced both the mRNA and protein levels of PPARgamma in a dose-dependent fashion, with maximal levels of induction being three- to fourfold. This induction was also observed using the 15-deoxy-delta12,14-prostaglandin J2, a known natural ligand for PPARgamma, whereas ligands specific for PPARalpha were without effect. The induction of PPARgamma expression by troglitazone was also observed in livers from rats fed a diet containing troglitazone. Troglitazone had no effect on the expression of the alpha- or beta-isoforms of PPAR, the more predominant liver isoforms. These results indicate that troglitazone produces a reprogramming of PPAR isoform content in liver, which may in part underlie the mechanism whereby troglitazone sensitizes the liver to the action of insulin and/or ameliorates hyperglycemia.

Insulin action on protein phosphatase-1 activation is enhanced by the antidiabetic agent pioglitazone in cultured diabetic hepatocytes.

Effect of the antidiabetic agent pioglitazone on the insulin-mediated activation of protein phosphatase-1 was examined in diabetic hepatocytes. Streptozotocin-induced diabetes in Sprague Dawley rats caused a significant decrease in the activation of glycogen synthase in hepatocytes isolated from these animals. There was an inverse correlation between the in vivo hyperglycemic condition and the in vitro activation of glycogen synthase in liver cells (r = 0.93, p < 0.001). Long term incubation of diabetic hepatocytes with insulin and dexamethasone caused significant (p < 0.001) improvement in the activation of glycogen synthase activation. When incubated along with hormones, pioglitazone enhanced their action (p < 0.05-0.01). Diabetic hepatocytes were also characterized by 50% decrease in the activity of protein phosphatase-1, the enzyme which dephosphorylates and activates glycogen synthase. Pioglitazone potentiated the acute stimulatory effect of insulin on protein phosphatase-1 in normal hepatocytes but not in diabetic hepatocytes. Long term incubation of diabetic hepatocytes with insulin ameliorated the decrease in the protein phosphatase-1 activity in these cells. This stimulatory long-term effect of insulin was significantly (p < 0.05) enhanced by the antidiabetic agent pioglitazone.

Psychiatric morbidity among victims of bomb blast.

Thirty one victims of bomb blast in a bus caused by terrorist activity in Dausa district, Rajasthan on 22.5.96, were evaluated for psychological reactions 3 days & 2 weeks after the incident. All hospitalized & non hospitalised bomb blast victims were assessed within 3 days of injury by objective predictors (percent of burnt area, facial disfigurement, limb amputations, fractures etc.) and subjective predictors (emotional distress and perceived social support). Detailed history, physical and mental state examination of all patients was carried out and for those having scores more then 17 on GHQ-60 (Hindi version), IPIS was administered. Diagnosis was made by 3 senior consultant psychiatrists of Psychiatric Centre, Jaipur, on the basis oflCD-10. At day 3 of 31 patients studied 11 (35.45%) had psychiatric morbidity. Out of which 6 (19.35%) had acute stress reaction, 3 (9.68%) had depression and 2 (6.45%) dissociative amnesia. Most commonly reported symptoms on IPIS were depersonalisation, derealisation, sleep disturbances specially generalised sleep loss, loss of appetite, nightmares, situational anxiety, depression, mental irritability, dulness of feelings, self blame, guilt, loss of interest, suicidal ideas, and worry about money, spouse, work and children. Most common physical injury was burns, followed by hearing disturbances, wounds received due to glass <& metal pieces and non specific pains and aches. Findings of follow up have been discussed and battery of tests for evaluation of victims of acute trauma has been suggested.