Biomedical subjects
Publications and source records attributed to Chintamani.
TB of the parotid is rare and only about 100 cases have been reported in the world literature. Often the diagnosis is made only after the surgery performed for a suspected neoplasm. We describe three patients with diffuse form of parotidTB without any evidence of tubercular focus elsewhere. Fine needle aspiration cytology confirmed the diagnosis in two cases, while the third case was diagnosed only after surgery.
BACKGROUND: An important factor contributing to the high mortality in patients with severe head trauma is cerebral hypoxia. The mechanical ventilation helps both by reduction in the intracranial pressure and hypoxia. Ventilatory support is also required in these patients because of patient's inability to protect the airway, persistence of excessive secretions, and inadequacy of spontaneous ventilation. Prolonged endotracheal intubation is however associated with trauma to the larynx, trachea, and patient discomfort in addition to requirement of sedatives. Tracheostomy has been found to play an integral role in the airway management of such patients, but its timing remains subject to considerable practice variation. In a developing country like India where the intensive care facilities are scarce and rarely available, these critical patients have to be managed in high dependency cubicles in the ward, often with inadequately trained nursing staff and equipment to monitor them. An early tracheostomy in the selected group of patients based on Glasgow Coma Score(GCS) may prove to be life saving. Against this background a prospective study was contemplated to assess the role of early tracheostomy in patients with isolated closed head injury. METHODS: The series consisted of a cohort of 50 patients admitted to the surgical emergency with isolated closed head injury, that were not considered for surgery by the neuro-surgeon or shifted to ICU, but had GCS score of less than 8 and SAPS II score of more than 50. First 50 case records from January 2001 that fulfilled the criteria constituted the control group. The patients were managed as per ATLS protocol and intubated if required at any time before decision to perform tracheostomy was taken. These patients were serially assessed for GCS (worst score of the day as calculated by senior surgical resident) and SAPS scores till day 15 to chart any changes in their status of head injuries and predictive mortality. Those patients who continued to have a GCS score of <8 and SAPS score of >50 for more than 24 hours (to rule out concussion or recovery) underwent tracheostomy. All these patients were finally assessed for mortality rate and hospital stay, the statistical analysis was carried out using SPSS10 version. The final outcome (in terms of mortality) was analyzed utilizing chi-square test and p value <0.05 was considered significant. RESULTS: At admission both tracheostomy and non-tracheostomy groups were matched with respect to GCS score and SAPS score. The average day of tracheostomy was 2.18 +/- 1.0038 days. The GCS scores on days 1, 2, 3, 4, 5, 10 between tracheostomy and non-tracheostomized group were comparable. However the difference in the GCS scores was statistically significant on day 15 being higher in the tracheostomy group. Thus early tracheostomy was observed to improve the mortality rate significantly in patients with isolated closed head injury. CONCLUSION: It may be concluded that early tracheostomy is beneficial in patients with isolated closed head injury which is severe enough to affect systemic physiological parameters, in terms of decreased mortality and intubation associated complications in centers where ICU care is not readily available. Also, in a selected group of patients, early tracheostomy may do away with the need for prolonged mechanical ventilation.
BACKGROUND: Breast cancer is the second most common malignancy among women, next to cervix cancer. Understanding its pathogenesis, morphological features and various risk-factors, including family history holds a great promise for the treatment, early detection and prevention of this cancer. PATIENTS AND METHODS: In an attempt to evaluate the clinico-morphological patterns of breast cancer patients, including their family history of breast and/or other cancers, a detailed analysis of 569 breast cancer cases diagnosed during the years 1989-2003 was carried out. Mean and standard deviation and Odds ratios along with 95% confidence intervals were estimated. Chi2/Fisher's exact test were employed to test for proportions. RESULTS: Mean age of the patient at presentation was 47.8 years, ranging from 13-82 years. Among the various histo-morphological types, Infiltrating duct carcinoma (IDC) was found to be commonest type i.e. in 502 cases (88.2%), followed by infiltrating lobular carcinoma (ILC) in 21 cases (3.7%) and other types forming 9(1%). Out of 369 cases where TNM staging was available, stage IIIB (35.2%) was the commonest. Lymph node positivity was observed in 296 cases (80.2%). Out of 226 cases evaluated for presence of family history, 47 cases (20.7%) revealed positive family history of cancer, among which breast or ovarian cancer were the commonest type (72.0%). Patients below 45 years of age had more frequent occurrence of family history as compared to above 45 years. Amongst familial cases, Infiltrating duct carcinoma was the commonest form accounting for 68.8% cases while ILC was found to be in a higher proportion (12.5%) as compared to non- familial cases (5.4%). CONCLUSION: Among the various determining factors for development of breast cancer and for its early detection, family history of cancer forms one of the major risk factor. It is important to take an appropriate history for eliciting information pertaining to occurrence of cancers amongst the patients' relatives there by identifying the high risk group. Educating the population about the risk factors would be helpful in early detection of breast cancer.
BACKGROUND: Neoadjuvant chemotherapy (NACT) is an integral part of multi-modality approach in the management of locally advanced breast cancer. It is vital to predict response to chemotherapy in order to tailor the regime for a particular patient. The prediction would help in avoiding the toxicity induced by an ineffective chemotherapeutic regime in a non-responder and would also help in the planning of an alternate regime. Development of resistance to chemotherapeutic agents is a major problem and one of the mechanisms considered responsible is the expression of 170-k Da membrane glycoprotein (usually referred to as p-170 or p-glycoprotein), which is encoded by multidrug resistance (MDR1) gene. This glycoprotein acts as an energy dependent pump, which actively extrudes certain families of chemotherapeutic agents from the cells. The expression of p-glycoprotein at initial presentation has been found to be associated with refractoriness to chemotherapy and a poor outcome. Against this background a prospective study was conducted using C219 mouse monoclonal antibody specific for p-glycoprotein to ascertain whether pretreatment detection of p-glycoprotein expression could be utilized as a reliable predictor of response to neoadjuvant chemotherapy in patients with breast cancer. PATIENTS AND METHODS: Fifty cases of locally advanced breast cancer were subjected to trucut biopsy and the tissue samples were evaluated immunohistochemically for p-glycoprotein expression and ER, PR status. The response to neoadjuvant chemotherapy was assessed clinically and by using ultrasound after three cycles of FAC regime (cyclophosphamide 600 mg/m2, Adriamycin 50 mg/m2, 5-fluorourail 600 mg/m2 at an interval of three weeks). The clinical response was correlated with both the pre and post chemotherapy p-glycoprotein expression. Descriptive studies were performed with SPSS version 10. The significance of correlation between tumor response and p-glycoprotein expression was determined with chi square test. RESULTS: A significant relationship was found between the pretreatment p-glycoprotein expression and clinical response. The positive p-glycoprotein expression was associated with poor clinical response rates. When the clinical response was correlated with p-glycoprotein expression, a statistically significant negative correlation was observed between the clinical response and p-glycoprotein expression (p < 0.05). There was another significant observation in terms of development of post NACT p-glycoprotein positivity. Before initiation of NACT, 26 patients (52%) were p-glycoprotein positive and after three cycles of NACT, the positivity increased to 73.5% patients. CONCLUSION: The study concluded that pretreatment p-glycoprotein expression predicts and indicates a poor clinical response to NACT. Patients with positive p-glycoprotein expression before initiation of NACT were found to be poor responders. Thus pretreatment detection of p-glycoprotein expression may be utilized, as a reliable predictor of response to NACT in patients with breast cancer The chemotherapy induced p-glycoprotein positivity observed in the study could possibly explain the phenomenon of acquired chemoresistance and may also serve as an intermediate end point in evaluating drug response particularly if the adjuvant therapy is planned with the same regime.
BACKGROUND: Drains are usually left after thyroid surgery to prevent formation of hematoma and seroma in the thyroid bed. This is done to reduce complications and hospital stay. Objective evaluation of the amount collected in the thyroid bed by ultrasonography (USG) can help in assessing the role of drains. METHODS: A randomized prospective control study was conducted on 94 patients undergoing 102 thyroid surgeries, over a period of fifteen months. Patients included in the study were randomly allocated to drain and non-drain group on the basis of computer generated random number table. The surgeon was informed of the group just before the closure of the wound Postoperatively USG neck was done on first and seventh postoperative day by the same ultrasonologist each time. Any swelling, change in voice, tetany and tingling sensation were also recorded. The data was analyzed using two-sample t-test for calculating unequal variance. RESULTS: Both groups were evenly balanced according to age, sex, and size of tumor, type of procedure performed and histopathological diagnosis. There was no significant difference in collection of thyroid bed assessed by USG on D1 & D7 in the two groups (p = 0.313) but the hospital stay was significantly reduced in the non-drain group (p = 0.007). One patient in the drain group required needle aspiration for collection in thyroid bed. No patient in either group required re-operation for bleeding or haematoma. CONCLUSION: Routine drainage of thyroid bed following thyroid surgery may not be necessary. Not draining the wound results in lesser morbidity and decreased hospital stay.
BACKGROUND: Suction drains are routinely used after modified radical mastectomy and are an important factor contributing to increased hospital stay as the patients are often discharged only after their removal. Amongst various factors that influence the amount of postoperative drainage, the negative suction pressure applied to the drain has been reported to be of great significance. While a high negative suction pressure is expected to drain the collection and reduce the dead space promptly, it may also prevent the leaking lymphatics from closing and lead to increased drainage from the wound. Against this background a prospective randomized clinical study was conducted to compare the amount and duration of drainage between a half negative suction and full vacuum suction drainage in patients following modified radical mastectomy. The associated postoperative morbidity was also compared between the two groups. METHODS: 85 FNAC (fine needle aspiration cytology) proven cases of locally advanced breast cancer were randomized. (Using randomly ordered sealed envelops, which were opened immediately before the closure of the wound) in to 50 patients with full vacuum suction (pressure = 700 g/m2) and 35 cases in to half vacuum suction drainage (pressure = 350 g/m2) groups. The two groups were comparable in respect of age, weight, and technique of operation and extent of axillary dissection. Surgery was performed by the same surgical team comprising of five surgeons (two senior and three resident surgeons) using a standardized technique with electrocautery. External compression dressing was provided over the axilla for first 48 hrs and following that patients were encouraged to do active and passive shoulder exercises. The outcomes measured were postoperative morbidity and the length of hospital stay. Statistical methods used: Descriptive studies were performed with SPSS version 10 and group characteristics were compared using student t-test. RESULTS: Half vacuum suction drains were removed earlier than the full suction vacuum suction drains. There was no significant difference in the incidence of seroma formation in the two groups and there was a significant reduction in the total hospital stay in patients with half vacuum suction drainage systems as compared to the full suction drainage group (p < 0.001) without any added morbidity. CONCLUSIONS: Half negative suction drains provide an effective compromise between no suction and full or high suction drainage after modified radical mastectomy by reducing the hospital stay and the post operative morbidity including post operative seromas.
Port site metastasis is being increasingly reported as a complication following laparoscopic surgery for malignant disorders. Various factors have been reported to be responsible and most are associated with either a high intra-peritoneal pressure due to pneumoperitoneum or the 'chimney effect' following sudden decompression of the abdomen. Direct implantation of the offending cells at the raw surface at the port has also been implicated and the use of retrieval bags is therefore recommended. We report on a rare case of port site seeding of tuberculosis in a 65-year-old woman following laparoscopic cholecystectomy.
BACKGROUND: Neo-adjuvant chemotherapy is an integral part of multi-modality approach in the management of locally advanced breast cancer and it is vital to predict the response in order to tailor the regime for a patient. The common final pathway in the tumor cell death is believed to be apoptosis or programmed cell death and chemotherapeutic drugs like other DNA-damaging agents act on rapidly multiplying cells including both the tumor and the normal cells by following the same common final pathway. This could account for both the toxic effects and the response. Absence or decreased apoptosis has been found to be associated with chemo resistance. The change in expression of apoptotic markers (Bcl-2 and Bax proteins) brought about by various chemotherapeutic regimens is being used to identify drug resistance in the tumor cells. A prospective clinical study was conducted to assess whether chemotherapy induced toxic effects could serve as reliable predictors of apoptosis or response to neo-adjuvant chemotherapy in patients with locally advanced breast cancer. METHODS: 50 cases of locally advanced breast cancer after complete routine and metastatic work up were subjected to trucut biopsy and the tissue evaluated immunohistochemically for apoptotic markers (bcl-2/bax ratio). Three cycles of Neoadjuvant Chemotherapy using FAC regime (5-fluorouracil, adriamycin, cyclophosphamide) were given at three weekly intervals and patients assessed for clinical response as well as toxicity after each cycle. Modified radical mastectomy was performed in all patients three weeks after the last cycle and the specimen were re-evaluated for any change in the bcl-2/bax ratio. The clinical response, immunohistochemical response and the drug-induced toxicity were correlated and compared. Descriptive studies were performed with SPSS version 10 and the significance of response was assessed using paired t-test. Significance of correlation between various variables was assessed using chi-square test and coefficient of correlation calculated by Pearson correlation coefficient. RESULTS: There was a statistically significant correlation observed between clinical, immunohistochemical response (bcl-2/bax ratio) and the drug-induced toxicity. CONCLUSION: Responders also had significant toxicity while non-responders did not show significant toxicity following neoadjuvant chemotherapy. The chemotherapy-induced toxicity was observed to be a cost effective and reliable predictor of response to neo-adjuvant chemotherapy.
BACKGROUND: Squamous cell carcinoma of the scrotum is rare and its development in the scar of Fournier's gangrene is still rarer. CASE PRESENTATION: A 65-year-old gentleman presented with a small non-healing ulcer developing on right hemi-scrotum two years after the treatment for Fournier's gangrene. On histological examination it was found to be squamous cell carcinoma. He was successfully managed by surgery in the form of wide local excision and ilio-inguinal lymph node dissection followed by adjuvant radiotherapy and chemotherapy. CONCLUSIONS: Squamous cell carcinoma can develop in the scar of Fournier's gangrene after a long delay, which differentiates it from other scar carcinomas or Marjolin's ulcer.
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BACKGROUND: A wide range of foreign bodies has been retrieved from the gut and reported. The presentation may be in the form of complications like intestinal obstruction, perforation and formation of abscesses etc but there is no case report of a half open clasp knife being retrieved from the ileum, the patient having thrived, in spite of its presence for a period of eight months. CASE PRESENTATION: A 30-year-old administrative clerk had undergone emergency abdominal surgery eight months previously under mysterious circumstances at a remote district hospital and had recovered completely. Later the blade of a knife was accidentally detected when an X ray of the abdomen was done during a routine follow-up visit to his family physician. Surgery revealed a clasp knife in the ileum, which was retrieved. The presence of an entero-enteric fistula short circuiting the loop was the secret of his earlier survival. CONCLUSIONS: To the best of our information this is the first case-report of a clasp knife in the gut and of the patient thriving in spite of its presence. We report here the dramatic sequence of events.
BACKGROUND: Radiotherapy in the radical doses can produce severe and often irreversible damage to the gut in the form of fibrosis, necrosis and fistulae formation. A previous pelvic surgery makes the gut extra-vulnerable. This is on account of adhesions to the pelvic wall, unless special care is taken during surgery to keep it out of the harms way, during adjuvant radiotherapy. These effects range from acute, to sub acute and delayed chronic manifestations like in the reported case. CASE REPORT: A spontaneous low out put enterocutaneous fistula in a 68-year-old man following surgery and adjuvant radiotherapy given 27 years back for carcinoma penis is reported. Patient is making a satisfactory progress after three years of follow-up. CONCLUSION: High dose external beam radiotherapy is known to produce deleterious side effects ranging from mild radiation enteritis to the development of internal and external fistulae. The effects may be acute, subacute or chronic. Presentation as spontaneous enterocutaneous fistula 27 years after radiotherapy is rare.
BACKGROUND: Perforation of gut by sharp metallic objects is rare and rarer still is their migration to sites like liver. The symptoms may be non-specific and the discovery of foreign body may come as a radiological surprise to the unsuspecting clinician since the history of ingestion is difficult to obtain. CASE REPORT: A unique case of a broken sewing needle in the liver causing a hepatic abscess and detected as a radiological surprise is presented. The patient had received off and on treatment for pyrexia for the past one year at a remote primary health center. Exploratory laparotomy along with drainage of abscess and retrieval of foreign body relieved the patient of his symptoms and nearly one-year follow up reveals a satisfactory recovery. CONCLUSION: It is very rare for an ingested foreign body to lodge in the liver and present as a liver abscess. An ultrasound and a high clinical suspicion index is the only way to diagnose these unusual presentations of migrating foreign bodies. The management is retrieval of the foreign body either by open surgery or by percutaneous transhepatic approach but since adequate drainage of the abscess and ruling out of a fistulous communication between the gut and the liver is mandatory, open surgery is preferred.
BACKGROUND: Bezoars usually present as a mass in the stomach. The patient often has a preceding history of some psychiatric predisposition. Presentation could be in the form of trichophagy followed by trichobezoar (swallowing of hair leading to formation of bezoar), orphytobezoar (swallowing of vegetable fibres). Rapunzel syndrome is a condition where the parent bezoar is in the stomach and a tail of the fibres or hair extends in to the jejunum. Presentation as intestinal obstruction due to a bezoar in the intestine without a parent bezoar in the stomach is rare, therefore we report it here. CASE REPORT: A 35 year old lady tailor with a previous history of receiving treatment for depression on account of being infertile- years after her marriage, presented to the surgical emergency department with features of acute intestinal obstruction. Exploratory laparotomy and enterotomy revealed a cotton bezoar in the terminal ileum without a parent bezoar in the stomach. She was managed by resection of the affected segment of the ileum and end-to-end anastomosis of the bowel. In the postoperative period the patient gave a history of ingesting cotton threads whenever she was depressed. CONCLUSION: Presence of cotton bezoar is rare and an intestinal bezoar in the absence of parent bezoar in the stomach is still rarer.
BACKGROUND: Sweat gland adenocarcinoma is a rare malignancy with high metastatic potential seen more commonly in later years of life. Scalp is the most common site of occurrence and it usually spreads to lymph nodes. Liver, lung and bones are the distant sites of metastasis with fatal results. The differentiation between apocrine and eccrine metastatic sweat gland carcinoma is often difficult. The criteria's are inadequate to be of any practical utility. CASE REPORT: Two cases of metastatic sweat gland adenocarcinoma (one of eccrine and the other one of apocrine origin) are being reported on account of the rarity and different outcome. CONCLUSION: Sweat gland carcinomas are rare cancers with a poor prognosis often presenting as histological surprises. Surgery in the form of wide local excision and lymph node dissection is the mainstay of treatment. Chemotherapy and/or radiotherapy has limited role.
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Explore the source record for details and available documents.
Explore the source record for details and available documents.