Infantile inflammatory myofibroblastic tumour of the sigmoid colon: a diagnostic dilemma.

An inflammatory myofibroblastic tumour (IMT) is an uncommon neoplasm composed of inflammatory cells and myofibroblasts in a fibrous stroma. They are mostly seen in the lungs and rarely involve the gastrointestinal tract. An 8-month-old infant presented with a history of lower abdominal lump for 2 months. Her CT scan confirmed a large, lobulated mass in the retroperitoneum arising from the pelvis. The mass was found to be arising from the sigmoid colon on laparotomy which was excised. Histopathology showed a cellular tumour composed of spindle cells and inflammatory lymphocytic infiltrate. Immunohistochemistry revealed positive staining for anaplastic lymphoma kinase and smooth muscle actin, confirming the diagnosis of IMT. The patient is doing well at her 6-month follow-up. Ours is the youngest case of sigmoid IMT among the only other series of eight cases reported in the literature indicating its rarity.

Major complications following central neuraxial block - A multi-centre observational study in Maharashtra (MGMM CNB Study).

Background and Aims: Major complications of central neuraxial block (CNB) are rare and their incidence in India is not known. This information is essential for explaining risk and medico-legal concerns. The present multi-centre study in Maharashtra was conducted to provide insight into the characteristics of rare complications following this popular anaesthetic technique. Methods: Data were collected from 141 institutes to study the clinical profile of CNB. Incidence of complications like vertebral canal haematoma, abscess, meningitis, nerve injury, spinal cord ischaemia, fatal cardiovascular collapse, and drug errors was collected over one year. Complications were reviewed by audit committee to assess causation, severity, and outcome. 'Permanent' injury was defined as death or neurological symptoms persisting for more than six months. Results: Spinal anaesthesia (SA) was the most frequently used CNB in 88.76% patients. Bupivacaine and an adjuvant were used in 92.90% and 26.06% patients, respectively. Eight major complications (four neurological and four cardiac arrests) were reported in patients receiving SA. In seven of eight instances, SA was responsible or contributory for complication. The pessimistic incidence of complications (included cases where CNB was responsible; contribution was likely, unlikely and could not be commented) was 8.69/lakh and optimistic incidence (included cases where CNB was responsible or contribution was likely) was 7.61/lakh. 'Pessimistically' and 'optimistically' there were three deaths including one death due to quadriplegia following epidural haematoma after SA. Five out of eight patients recovered completely (62.5%). As only eight patients had complications of different types, it was difficult to establish statistical correlation of major complications with demographic or clinical parameters. Conclusion: This study was reassuring and suggested that the incidence of major complications following CNB was low in Maharashtra.

Congenital Spigelian Hernia With Ipsilateral Ectopic Testis.

Background: The association between congenital spigelian hernia and ipsilateral ectopic testis has been debated in the literature, and the management of such cases has yet to be standardized. Both pediatric surgeons and sonographers should be aware of this entity to allow for prompt diagnosis and monitoring/repair because congenital spigelian hernias have a high risk of incarceration. Case Report: A 3-month-old male presented with left-sided abdominal wall swelling present since birth with coexisting left-sided undescended testis. Ultrasound confirmed the suspicion of a congenital spigelian hernia with undescended testis but failed to locate the ectopic testis. Diagnostic laparoscopy and open repair of the spigelian hernia were performed when the patient was 9 months of age. Left-sided orchidopexy was also performed as the left testis was located within the spigelian sac. The patient was asymptomatic at 1-year follow-up. Conclusion: The association between congenital spigelian hernia and ipsilateral ectopic testis requires the surgeon and sonographer to pay special attention to the spigelian hernia sac as it may contain the ectopic testis. Orchidopexy and hernia repair in very young children may be delayed while closely monitoring for incarceration to allow for improvement in immunity, an increase in size of the spermatic cord and vasculature, and avoidance of the stress of 2 separate surgeries. The surgical approach can be laparoscopic or open depending on the experience of the surgeon and the complexity of intraoperative findings.

Intracerebral Haemorrhage: A Rare Presentation of Phaeochromocytoma.

Phaeochromocytoma is a rare childhood adrenal medullary catecholamine secreting tumour, arising from the chromaffin cells of the sympathetic origin derived from the neural crest cells. Only a few cases have been reported in the literature so far. We report an uncommon presentation in a 5-year-old boy with intracerebral haemorrhage, hemiplegia, and paroxysmal hypertension. Magnetic resonance imaging of the brain showed chronic and acute hemorrhagic infarcts in the left cerebral hemisphere and no vascular anomaly seen on cerebral venogram. Computed tomography scan abdomen showed a mass in the lesser sac and urinary catecholamines were elevated. The patient underwent exploratory laparotomy and the mass was excised in toto. Histopathological examination (HPE) confirmed the diagnosis. This case illustrates the need for keeping in mind atypical presentations of phaeochromocytoma especially in children; as it is a treatable cause of hypertension and early diagnosis with adequate management can prevent morbidity and fatal outcomes.

Extra-Axial Cerebello-Pontine Angle Medulloblastoma in an Infant: A Rare Case Report with Review of Literature.

Medulloblastoma is a fairly common neoplastic growth seen majorly in children, presenting as an intra-axial midline mass arising from the cerebellar vermis. However, its presentation as an extra-axial mass in the cerebellopontine angle (CPA) is extremely rare, such that, only 39 cases have been reported in the world literature till 2016. Only one case has ever been reported of an extra-axial CPA medulloblastoma in an infant; who was aged 1 year. We present a case report of an 8-month-old infant, with an extra-axial CPA medulloblastoma and discuss its management strategy.

Duplication cyst with midgut volvulus in a neonate: an unusual presentation.

Incomplete intestinal fixation or malrotation of gut with midgut volvulus is one of the important causes of bilious vomiting in neonates. The incidence of malrotation of gut in population is 4% and that of duplication cyst is 1:4500. Patients with malrotation are prone to develop midgut volvulus due to their narrow mesenteric base demanding urgent surgical intervention. Common associated anomalies are intrinsic duodenal obstruction, internal hernias, caecal volvulus, anorectal malformations and Hirschsprung's disease. The present case refers to a 4-day-old neonate who presented with malrotation of gut with reverse volvulus and an associated gastrointestinal duplication cyst, which is a rare association with only few reported case reports. After imaging with ultrasound and contrast radiograph, the baby underwent prompt surgical intervention in the form of Ladd's procedure with resection and anastomosis of jejunal duplication cyst.

Testicular Loss in Children Due to Incorrect Early Diagnosis of Torsion.

Background. Testicular torsion is a common surgical emergency in children that requires a high index of suspicion, early diagnosis, and exploration. Most children present early to their primary pediatricians or physicians. The aim of this retrospective study is to determine the surgical outcome of testicular torsion with early as well as delayed presentation or referral at our pediatric surgical unit. Methods. Records of 50 patients who presented with testicular torsion at our pediatric surgical unit over the span of 10 years (2007-2017) were reviewed retrospectively. The duration and characteristics of symptoms, initial consultation with primary care health professional, time duration between the initial consultation and referral to a tertiary care center, clinical findings prior to surgery, and operative findings were noted. Results. Fifty patients were in the age group ranging from 38 days to 18 years. All the patients consulted the primary care health professionals within 3 to 6 hours after the onset of testicular pain. The patients presented to our hospital within the range of 3.5 hours to 10 days of onset of initial symptoms. Out of 50 patients who presented to our hospital with torsion testis, 45 (90%) patients underwent orchidectomy as the testicle was gangrenous and 5 patients underwent orchiopexy as the testicle was viable. Conclusion. The risk of testicular loss is very high if there is delay in the initial diagnosis of testicular torsion. Greater effort in educating the primary health care professionals may reduce this delay. Primary objective of treating the acute scrotum should be prevention of testicular loss than treating symptoms.

Pituitary Prolactinoma with Amyloid Deposits: Surgery or Dopamine Agonists? Review of Previous Reports and New Recommendations for Management.

BACKGROUND: Pituitary adenomas, macro and micro, are a common occurrence in most neurosurgical centers. Prolactinomas are the most common pituitary tumors and are often treated nowadays with dopamine agonists such as cabergoline, with good results. AIMS AND OBJECTIVES: To suggest new therapeutic guidelines for treating Prolactinomas with Amyloid deposits on preoperative detection of Amyloid deposition in Pituitary tumors, based on MRI characteristics. MATERIALS AND METHODS: We report a case of a pituitary prolactinoma with amyloid deposits in a 45-year-old male who underwent a transsphenoidal excision of the adenoma. Although on magnetic resonance imaging scans, no amyloid was reported, at histopathology, spherical amyloid within the pituitary tumor was found in abundance. The patient underwent surgery without any trial of cabergoline due to rapid deterioration of vision. CONCLUSION: Prolactinomas with amyloid deposits are known not to respond to dopamine agonists (cabergoline) by a reduction in size and may ,in fact increase in volume. Therefore, we recommend that in prolactinomas not responding to medical therapy, deposition of amyloid has to be considered as a cause for failure of medical therapy and surgery and then has to be offered pronto.

Bespoke GelFoam Wafers: A Practical and Inexpensive Alternative to Oxycel for Hemostasis during Neurosurgery.

BACKGROUND: Since the beginning of neurosurgery, intraoperative parenchymal bleeding has been a major problem. Achievement of hemostasis is the endpoint of any cranial or spinal neurosurgical exercise and is mandatory to avoid postoperative hematomas which mar the ultimate outcome of the surgery. Several biosurgical agents are used to achieve this goal. Agents such as oxidized cellulose, gelatin foam, fibrillar collagen, fibrin sealants, and antifibrinolytic agents are used, each having a different mechanism of action. MATERIALS AND METHODS: The authors describe a simple technique for substituting oxidized regenerated cellulose (Surgicel) for lining the surgical cavities after excising brain lesions, with customized gelfoam wafers fashioned on the surgical trolley. This has been used in over 8000 cases with excellent hemostatic results over the last 25 years. No complications are noted with use of these wafers. RESULTS: In a randomized trial done by us, similar hemostatic effect was found between oxycel and the gelfoam wafers described by us with satisfactory outcomes of surgeries. No previous use of such custom-fashioned wafers has been described for neurosurgical hemostasis in the literature.

Spontaneous Intracranial Extradural Hematoma Secondary to Hypofibrinogenemia: A Rare Case Report.

Spontaneous extradural hematoma is a well-documented but fairly rare condition, which can be associated with conditions such as vascular malformations, sickle cell disease, metastasis to the skull, infectious diseases of the skull, coagulation disorders, and use of anticoagulants. Of these, very few cases are of life-threatening extradural hematomas in adults, where hypofibrinogenemia is the cause of bleed, without any history of trauma. In this report, we have discussed the management of such a patient.

Prevalence of excessive internet use and its association with psychological distress among university students in South India.

BACKGROUND: Excessive internet use, psychological distress, and its inter-relationship among university students can impact their academic progress, scholastic competence, career goals, and extracurricular interests. Thus, a need exists to evaluate the addictive internet use among university students. OBJECTIVES: This study was set up to examine the internet use behaviors, internet addiction (IA), and its association with psychological distress primarily depression among a large group of university students from South India. METHODS: Totally 2776 university students aged 18-21 years; pursuing undergraduate studies from a recognized university in South India participated in the study. The patterns of internet use and socioeducational data were collected through the internet use behaviors and demographic data sheet, IA test (IAT) was utilized to assess IA and psychological distress primarily depressive symptoms were evaluated with Self-Report Questionnaire-20. RESULTS: Among the total n = 2776, 29.9% (n = 831) of university students met criterion on IAT for mild IA, 16.4% (n = 455) for moderate addictive use, and 0.5% (n = 13) for severe IA. IA was higher among university students who were male, staying in rented accommodations, accessed internet several times a day, spent more than 3 h per day on the Internet and had psychological distress. Male gender, duration of use, time spent per day, frequency of internet use, and psychological distress (depressive symptoms) predicted IA. CONCLUSIONS: IA was present among a substantial proportion of university students which can inhibit their academic progress and impact their psychological health. Early identification of risk factors of IA can facilitate the effective prevention and timely initiation of treatment strategies for IA and psychological distress among university students.

Internet Use Patterns, Internet Addiction, and Psychological Distress Among Engineering University Students: A Study from India.

BACKGROUND: Internet addiction (IA) among university engineering students and its association with psychological distress can impact their educational progress, academic competence, and long-term career goals. Thus, there is a need to investigate the IA among engineering students. OBJECTIVES: This study was a first such attempt to explore internet use behaviors, IA, among a large group of engineering students from India, and its association with psychological distress primarily depressive symptoms. METHODS: One thousand eighty six engineering students aged 18-21 years pursuing bachelors in engineering from the south Indian city of Mangalore participated in the study. The socio-educational and internet use behaviors data sheet was used to gather demographic information and patterns of internet use, Internet Addiction Test (IAT) was utilized to assess IA, and Self-Report Questionnaire (SRQ-20) assessed psychological distress primarily depressive symptoms. RESULTS: Among the total N = 1086, 27.1% of engineering students met criterion for mild addictive internet use, 9.7% for moderate addictive internet use, and 0.4% for severe addiction to internet. IA was higher among engineering students who were male, staying in rented accommodations, accessed internet several times a day, spent more than 3 h per day on internet, and had psychological distress. Gender, duration of use, time spent per day, frequency of internet use, and psychological distress (depressive symptoms) predicted IA. CONCLUSIONS: A substantial proportion of engineering students have IA which can be detrimental for their educational progress in university studies and long-term career goals. Early identification and management of IA and psychological distress among engineering students is crucial.

Neonatal osteomyelitis of the first rib causing lung abscess.

Rib osteomyelitis (OM) is a rare disease that occurs in ∼1% or less of all haematogenous OM. Acute OM of the rib has rarely been reported and its treatment is difficult. Prompt recognition and aggressive treatment will reduce mortality and morbidity in a new born.

Transcatheter Edge-to-Edge Treatment of Functional Tricuspid Regurgitation in an Ex Vivo Pulsatile Heart Model.

BACKGROUND: Although associated with left heart pathologies, functional tricuspid regurgitation (FTR) is often left untreated during left heart surgery. Hence, owing to its degenerative character, reoperation is often needed, encompassing an impressive (25% to 35%) mortality rate. Thus transcatheter approaches to FTR are raising great interest. OBJECTIVES: The authors evaluated the post-treatment effectiveness of the edge-to-edge technique using the percutaneous mitral valve repair device in an ex vivo pulsatile model of FTR. METHODS: The devices were implanted in 11 porcine hearts simulating FTR. In each heart, single-clip treatments involved grasping leaflet pairs in the medial or commissural position (6 combinations). Two-clip treatments were then performed considering all possible 15 combinations of leaflet pairs and medial/commissural grasping. Cardiac output, mean pulmonary pressure, and mean diastolic valve pressure gradient were evaluated in physiological and simulated pathological conditions (FTR), and post-treatments. RESULTS: Grasping the septal and anterior leaflets allowed for the best post-procedural outcome, ensuring a complete re-establishment of physiological-like hemodynamics. Septal and posterior grasping induced a significant recovery from FTR, although less marked. Conversely, grasping the anterior and posterior leaflets did not reduce FTR, and was detrimental in some specific cases. CONCLUSIONS: This experimental work demonstrated that the transcatheter edge-to-edge repair technique is a feasible approach for FTR. The study investigated this approach to develop a selective, specific structural intervention methodology for treating FTR, considering the several biomechanical factors that alter proper functionality of valvular substructures. These results can be used to guide the development of edge-to-edge repair techniques in treatment of FTR.

Engineering assessment of the longitudinal compression behaviour of contemporary coronary stents.

AIMS: There have been recently reported clinical observations of significant longitudinal compression or "stent shortening" in certain contemporary drug-eluting stents (DES), when re-crossed with other devices such as post-dilatation balloons, stent delivery systems or intravascular ultrasound (IVUS) catheters. The aim of this study was to understand the effect of stent design on longitudinal compression for coronary stents, when subjected to certain forces in vitro. This goal was achieved by experimentally evaluating the longitudinal strength of 14 contemporary stent designs under a clinically relevant compression force using a bench test method developed for this purpose. The results from the study are intended to provide an indication whether there is a quantifiable difference in the ability of the different stent platform designs to resist longitudinal compression in a deployed configuration. METHODS AND RESULTS: A test method was developed to evaluate the longitudinal compression behaviour of coronary stents. The test method was used to compare the longitudinal compression of four stent design families including a total of 14 commercialised stent platforms under a clinically relevant longitudinal compression force. The nominal expansion diameter of stents used in this study was 3.0 mm with stent lengths ranging from 28-30 mm. A test method was also developed to estimate a value of the clinically relevant longitudinal compression force to which a deployed stent may be subjected in a situation when a catheter tip is caught while trying to cross a freshly deployed stent. That force was determined to be 50 gram force (gf) (0.49 N). Based on the results of the testing it was noted that three of the four design families (13 of the 14 stents tested) demonstrated a longitudinal compression in the range of 1.25-5.30 mm (longitudinal compression of 4.46%-18.93% compared to the nominal expanded stent length), with the exception of the offset peak-to-peak stent platform having results clearly outside of this grouping. The stent in the offset peak-to-peak design category (Element stent platform) had an average longitudinal compression of 13.20 mm (longitudinal compression of 47.07%), thus demonstrating a markedly lower resistance to longitudinal compression. CONCLUSIONS: Stent design is a primary driver determining the longitudinal compression behaviour of coronary stent platforms. The results of this study comparing the longitudinal compression performance of four different commercial stent design families indicate that the tendency of a deployed stent to undergo longitudinal compression is associated with the stent design concept. It was determined that the particular 2-link offset peak-to-peak design evaluated in this study had the lowest compression resistance compared to the other stent design families.

In vitro comparison of the effect of stent configuration on wall shear stress using time-resolved particle image velocimetry.

Time resolved particle image velocimetry was used to measure wall shear stress (WSS) and oscillatory shear index (OSI) within a 3.0 mm diameter compliant vessel model implanted with an Abbott Vascular XIENCE V stent in five configurations: baseline, over-expanded, increased vessel diameter, two overlapped stents, and increased stent length. Flow through unstented vessels was also tested for comparison. Flow conditions featured a realistic coronary pressure-flow offset and reversal at average flow rates corresponding to resting (Re=160, f=70 bpm) and exercise conditions (Re=300, f=120 bpm). Comparisons revealed that the WSS was similar for all cases behind the first strut and downstream of the device, indicating that changes in configuration have little effect downstream. However, there were notable differences within each stent revealing reduced WSS values for all cases due to the stent-imposed expansion of the vessel wall (0.20-9.29 dynes/cm2 for Re=160 and d=3.0 mm). Over-expanding the stent with a second balloon affected the alignment of the stent geometry, and led to higher WSS at the inlet and lower values at mid-stent. The overlapped stents showed disturbed flow and a WSS deficit region downstream of the overlapped region. Analysis of the longer stent showed that the WSS within the vessel recovers with distance. An overall correlation was noted between decreased WSS values and elevated OSI. Results of this study are important because decreased WSS has been implicated in endothelial cell changes and increased restenosis, and clinical research has shown that a link exists between deployment configurations and negative patient outcomes.

Safety and efficacy of carotid artery stenting in persons aged 80 years and above.

Carotid artery stenting (CAS) remains a controversial procedure in spite of an emerging abundance of trial data showing both safety and efficacy. CAS is under significant scrutiny by the Centers for Medicare and Medicaid Services as it relates to persons aged 80 years and above. We report 1-year follow up both clinically and with ultrasonography in a small cohort of patients with an average age of 85 years.

Respiration-induced kidney motion on cobalt-chromium stent fatigue resistance.

During normal breathing, the kidneys move up and down due to the diaphragm motion and the renal artery subsequently experiences bending at or close to its point of fixation to the aorta. The impact of this kidney motion on implanted stent fatigue performance was not well understood in the past. Previous study from the authors on an 18-mm long single cobalt-chromium stent showed that the change in bending angle was minor during simulated respiration-induced kidney motion on cadavers. Finite Element Analysis revealed excellent fatigue resistance of the studied cobalt-chromium stent under simulated respiratory motion for the single stent configuration. In this article, the study was extended further to the overlapped stent configuration where a physician deploys two stents overlapping at the stent ends to fully cover a long lesion. Fluoroscopic images showed that the change in bending angle during simulated respiration-induced kidney motion on cadavers was more significant when two cobalt-chromium stents were overlapped. Calculated data of the Goodman analysis for the overlapped stents migrated toward the Goodman diagram failure line, indicating lower fatigue resistance during respiration when compared to a single stent.

In vitro, time-resolved PIV comparison of the effect of stent design on wall shear stress.

The effect of stent design on wall shear stress (WSS) and oscillatory shear index (OSI) was studied in vitro using time-resolved digital particle image velocimetry (DPIV). Four drug-eluting stents [XIENCE V (Abbott Vascular), TAXUS Liberté (Boston Scientific), Endeavor (Medtronic), and Cypher (J&J Cordis)] and a bare-metal stent [VISION (Abbott Vascular)] were implanted into compliant vessel models, and the flow was measured in physiologically accurate coronary conditions featuring reversal and realistic offsets between pressure and flowrate. DPIV measurements were made at three locations under two different flow rates (resting: Re = 160, f = 70 bpm and exercise: Re = 300, f = 120 bpm). It was observed that design substantially affected the WSS experienced at the vessel walls. Averaged values between struts ranged from 2.05 dynes/cm(2) (Cypher) to 8.52 dynes/cm(2) (XIENCE V) in resting conditions, and from 3.72 dynes/cm(2) (Cypher) to 14.66 dynes/cm(2) (VISION) for the exercise state. Within the stent, the WSS dropped and the OSI increased immediately distal to each strut. In addition, an inverse correlation between average WSS and OSI existed. Comparisons with recently published results from animal studies show strong correlation between the measured WSS and observed endothelial cell coverage. These results suggest the importance of stent design on the WSS experienced by endothelial cells in coronary arteries.