Current Approach for Diagnosis and Treatment of Adrenal Tuberculosis-Our Experience and Review of Literature.

Addison's disease was first described by Thomas Addison in 1855. He demonstrated the destruction of bilateral adrenal gland by tuberculosis (TB) in six patients. Since then, the incidence of TB has declined in the Western world, but in developing countries, it is still the most common cause of adrenal insufficiency. Because of the introduction of antituberculous chemotherapy, the incidence of adrenal TB has been declined in the past decades. The most common symptoms are nonspecific; therefore, diagnosis is often delayed, and patients may first present with a life-threatening adrenal crisis. The most commonly identified organism for adrenal failure in adrenal TB is Mycobacterium tuberculosis infection. Adrenal TB involves bilateral adrenal glands more frequently than unilateral glands. Computed tomography (CT) scan and magnetic resonance imaging (MRI) are useful investigations to differentiate between tuberculous Addison's disease and the other causes of adrenal insufficiency. In CT scans or MRI, features of adrenal TB are bilateral adrenal enlargement and peripheral rim enhancement with or without calcifications. Antituberculous drugs, biochemical monitoring of adrenal function, and steroid therapy are essential for the management of adrenal TB and adrenal insufficiency. Here, we describe a case of adrenal TB with abscess formation followed by a review of the current literature of adrenal TB for better diagnosis and management of this condition.

Solid Pseudopapillary Neoplasm - Case Series and Review of Literature.

Solid-pseudopapillary neoplasm (SPN) is a variety of solid and cystic tumors of the pancreas. It was first described by Frantz in 1959. It is an unusual form of pancreatic carcinoma, with unknown etiopathogenesis, which accounts for about 0.17 to 2.7% of all pancreatic tumors. Here, we are describing 5 cases of pancreatic solid pseudopapillary neoplasm, out of 180 pancreatic tumors, operated in our institution in the 5-year period (2015-2020). Also, we have reviewed all available case series (from 2006 to 2020) in the literature, of pancreatic pseudopapillary neoplasm, for demographic information, etiopathogenesis, diagnosis, and extent of operation to establish the optimal management of this condition. Retrospective analysis of pancreatic tumors was carried out from February 2015 to January 2020. A total of 180 patients underwent pancreatic resection in this period for pancreatic tumor, out of which, the solid pseudopapillary neoplasm was confirmed in 5 cases (2.76%). Among these 5 cases, 4 cases (80%) were female and one (20%) male, with age group range from 14 to 45 years (mean age - 28 years). Abdominal pain was the most frequent presenting symptom (60%). Mean tumor diameter was 6.9 cm (range, 2-18 cm). Two patients were diagnosed preoperatively by CECT and MRI findings, and three patients were diagnosed preoperatively by percutaneous/USG-guided and CT-guided FNA cytology. Two patients underwent pancreatoduodenectomy; one patient underwent enucleation; and two patients underwent spleen preserving distal pancreatectomy. Four patients are alive and on regular follow-up, while one patient died on the 5th post-operative day due to post-operative sepsis.

Comparison of closed incision negative pressure wound therapy with conventional dressing for reducing wound complications in emergency laparotomy.

OBJECTIVE: The aim of this study was to compare the post-operative effects of closed incision negative pressure wound therapy with conventional dressing in emergency laparotomy. METHODS: This study was conducted from 1st November 2018 to 31st March 2020 in ABVIMS & Dr. R.M.L. Hospital, New Delhi. The potential candidates for the study were patients of 18 years and above who were admitted in surgical emergency and underwent emergency laparotomy by a midline incision. Fifty random patients were alternatively allotted to group A (25 patients) and group B (25 patients). In the patients of group A, closed incision negative pressure wound therapy (ciNPWT) was applied on midline closed wound after an exploratory laparotomy procedure. The patients in group B, standard dry gauze dressing was done. RESULTS: The mean age of patients in group A and group B were 46.76±12.20 and 41.96±8.33 years, respectively (p-value-0.11). The wound infection was present in 12% of cases in group A and 32% in group B, but when we calculate the p-value, it was found to be statistically non-significant (p-value-0.08). Similarly, seroma formation and wound dehiscence were found less in group A as compared to group B but not reached up to a statistically significant limit (p-value 0.55 and 0.38 respectively). The frequency of dressing change was 1-2 per week in 92% of cases in group A while it was 3-4 per week in 68% of cases in group B. The mean time of the frequency of dressing change was 1.24±0.72 per week and 4.28±1.90 per week in both the groups respectively (p-value <0.001). There was no significant (p>0.05) difference in the duration of hospital stay between group A (mean hospital stay 8.20±2.34 days) and group B (mean hospital stay 8.21±3.37 days). CONCLUSION: Closed incision negative pressure wound therapy has no advantages over conventional dressing in terms of post-operative complications and hospital stay. However, it reduces the frequency of dressing change significantly, which reduces the mental stress of the patient and the burden of changing daily dressing.

Thyroid tuberculosis.

Thyroid tuberculosis is a rare disease. Its incidence is low even in countries where prevalence of pulmonary tuberculosis is high (0.1-0.4%). In literature, there are only a few cases which were diagnosed as thyroid tuberculosis. It can be explained by a high resistance of the thyroid gland to infectious processes. However, the prevalence of tuberculosis has increased worldwide and thyroid involvement can be a primary manifestation of the disease. The incidence of extrapulmonary tuberculosis has been showing a progressive increase in the recent years(Barnes and Weatherstone, 1979). The most frequent clinical presentation is a solitary thyroid nodule that may present as a cystic nodule. It may also present as thyroid abscess with pain, fever and other non-specific signs and symptoms. ATT results in complete cure therefore it is important to differentiate it from other form of thyroiditis. Patients are usually euthyroid, but cases of hypothyroidism and hyperthyroidism are described. For accurate diagnosis of thyroid tuberculosis, clinical and radiological features are nonspecific and histological examination is required for confirmation of diagnosis. PCR may help in diagnosis. The authors encounter 3 cases of thyroid tuberculosis in last 5 year which are described in this article. The aim of this study is to review all the cases published in literature to describe clinical presentation, appropriate diagnostic method and possible treatment options of the disease.

Evaluation of risk factors for prognosticating blunt trauma chest.

<b>Introduction:</b> Blunt trauma chest contributes to significant number of trauma admissions globally and is a cause of major morbidity and mortality. Many scoring systems and risk factors have been defined in past for prognosticating blunt trauma chest but, none is considered to be gold standard. </br> <b>Aim:</b> This study was conducted to reassess the significance of available scoring systems and others indicators of severity in prognosticating blunt trauma chest patients. </br> <b>Materials and Methods:</b> In this prospective observational study from November 2016 till March 2018, 50 patients with age more than 12 years with blunt chest trauma who required hospitalization were included. Nine risk factors were assessed namely- age of the patient, duration of presentation after trauma, number of ribs fractured, bilateral thoracic injury, evidence of lung contusion, associated extra thoracic injury, need for mechanical ventilation, Revised trauma Score (RTS) and Modified Early Warning Sign Score (MEWS). Severity of blunt thoracic trauma was assessed on following outcomes-SIRS, ARDS and Death. The inferences were drawn with the use of statistical software package SPSS v22.0. </br> <b>Results:</b> The age of 50 patients included in our study with a range of 15 to 76 years, the median age was 35.5 years. Statistically significant association was observed between occurrence of SIRS and multiple ribs fractured (p-value- 0.049), associated extra-thoracic injury (p-value-0.016) and higher MEWS score (p-value-0.025). ARDS occurrence was statistically significantly associated with all the risk factors except age.Death occurred more in patients with delayed duration of presentation to hospital (p-value <0.001), multiple ribs fractured (p-value-0.001), bilateral thoracic injury(p-value<0.001), associated extra-thoracic injury (p-value-0.004), patients who required ventilatory support (p-value<0.001), low RTS (p-value-0.006) and high MEWS (p-value-0.005) on admission. This association was found statistically significant. </br> <b>Conclusion:</b> High MEWS, associated extra-thoracic injuries and multiple rib fractured can very well predict poor outcome in terms of SIRS, ARDS and death. Aggressive treatment protocols should be established for better outcome in these patients with blunt trauma chest.