Heavy and trace metals in carcinoma of the gallbladder

BACKGROUND

Carcinoma of the gallbladder is the commonest malignancy of the biliary tract in northern India The etiologic relation of specific metals (heavy and trace) and their compounds to neoplasia has been a topic of investigation for some time but not adequately described for carcinoma of the gallbladder. The aim of the present study was to evaluate the relation of heavy and trace metals to this malignancy.

METHODS

The levels of selenium, zinc, copper, manganese, cadmium, chromium, lead, and nickel were estimated in serum, bile, gallstones, and gallbladder tissue using atomic absorption spectrophotometry. The tests were carried out in 30 patients with gallbladder cancer and 30 sex-matched patients with cholelithiasis.

RESULTS

Selenium and zinc levels were significantly reduced (p < 0.001) and copper concentration was found to be significantly higher (p < 0.001) in serum, bile, and gallbladder tissue from patients with carcinoma of the gallbladder. Lead, cadmium, chromium, and nickel levels were elevated in serum and bile in patients with carcinoma of the gallbladder.

CONCLUSIONS

The present study demonstrated a significant decrease in serum, biliary, and tissue levels of selenium and zinc but increased copper, lead, cadmium, chromium, and nickel levels in patients with carcinoma of the gallbladder, indicating a strong relation between the concentrations of these metals and gallbladder cancer.

Interstitial laser hyperthermia, a new method in the management of fibroadenoma of the breast: A pilot study

BACKGROUND AND OBJECTIVE

This study attempts to evaluate the effect of interstitial laser hyperthermia in breast fibroadenomas as an outpatient procedure.

STUDY DESIGN/MATERIALS AND METHODS

In an uncontrolled prospective study, 27 patients younger than 35 years were subjected to laser phototherapy of their breast fibroadenomas. Under real-time ultrasound monitoring, Nd:YAG laser (1,064 nm wavelength) was used at 2 W for 300 sec (600 J) in a continuous wave mode to produce interstitial hyperthermia. Follow-ups were done at 2, 4, and 8 weeks. Subsequently, excision biopsy of residual lumps was performed.

RESULTS

There was significant decrease in clinical and sonographic sizes (P < 0.001). Follow-up ultrasound showed a progressive change of hyperechoic texture, from a heterogeneous to a nearly homogeneous one. There were minimal scars (2-3 mm) and no keloid or abscess formation.

CONCLUSION

Interstitial laser hyperthermia is a safe, precise, and minimally invasive outpatient procedure for in situ destruction of breast fibroadenomas.

Accessory Breast in the Perineum

A rare case of functional accessory breast in the perineum presenting in labour is reported. It showed a well-formed nipple and pregnancy induced changes. The organ was completely excised postpartum. Histopathology confirmed normal breast tissue.

A dangerous pleural effusion

Bilothorax is a rare complication of biliary peritonitis and, if not treated promptly, can be life-threatening. We report a case of a middle-aged woman who had undergone a bilio-enteric bypass and subsequently a biliary leak developed, which finally led to intra-abdominal biliary collection and spontaneous bilothorax. The clinical course was rapid and mimicked venous thromboembolism, myocardial infarction and pulmonary oedema, which led to a delay in diagnosis and management and finally death. We high-light the fact that bilothorax, although a rare complication of biliary surgery, should always be considered as a probable cause of massive effusion and sudden-onset respiratory and cardiovascular collapse in the postoperative period. A chest X-ray and a diagnostic pleural tap can confirm the diagnosis. Once detected, an aggressive management should be instituted to prevent organ failure and death.

Psychological Stress on Wound Healing: A Silent Player in a Complex Background

Stress is hard to define and is further complicated by varied perceptions in the population and differing responses in different situations. Psychological stress brings about certain physiological changes through manipulation of the neural, humoral and immunological systems. Observational studies have showed that fear and anxiety before surgery can complicate normal wound healing. Two different pathways appear to be involved: one directly through hypothalamic-pituitary-adrenal axis and sympathetic-adrenomedullary axis, and another indirectly through negative psychological stressors such as anxiety, depression and social isolation. The pathogenesis includes decreased expression of pro-inflammatory cytokines, resulting in poor angiogenesis, matrix regeneration and delayed healing. Prolonged immunological activation in itself is a stressor and can precipitate a sickness behaviour syndrome manifested by disturbed sleep, anorexia, reduction in activity, increased responsiveness to pain and addiction to alcohol and tobacco. It has been observed that cortisol release suppresses pro-inflammatory cytokine release, while down-regulation of cortisol causes unabated inflammatory response. In individuals with chronic wounds, on the other hand, it is thought that physical stress has different effects such as foul odor, pain, exudate and social and familial isolation, which may act independently as psychological stressors. This article attempts to appraise the influence of psychological stress on the immunological system and its effect on wound healing.

Role of nicotine in gallbladder carcinoma: a preliminary report

OBJECTIVE

To assess the role of nicotine in gallbladder carcinoma and its association with the stage and degree of cancer differentiation.

METHODS

Tissue samples from gallbladder were obtained from 20 patients with gallbladder cancer and 20 age- and gender-matched patients with cholelithiasis who served as the control group. Gallbladder tissue (2 g) was extracted and analyzed for nicotine content using capillary gas chromatography. Nitrogen was used as the carrier gas. Standard curves of nicotine in methanol were made by injecting the internal standards.

RESULTS

A significantly higher tissue nicotine concentration was observed in the gallbladder carcinoma group than that in the control group (179.63 ng/mg vs 6.00 ng/mg, P < 0.001). The stage and degree of cancer differentiation did not seem to affect the nicotine levels. Gallbladder tissue contained a significantly higher nicotine concentration in smokers with cancer compared with those in the control group (1570.00 ng/mg vs 232.25 ng/mg, P < 0.001). Interestingly, non-smokers in cancer group also had a higher nicotine concentration than the control group (161.50 ng/mg vs 4.00 ng/mg, P = 0.002).

CONCLUSION

Nicotine is selectively concentrated in malignant gallbladder tissue irrespective of smoking status, showing its strong association with gallbladder cancer.

A hernia in the inguinal region is not always an inguinal hernia

A male patient of 60 years presented with a swelling in the left groin of 10 months duration. Past records showed bilateral lumbar sympathectomy and omentopexy done 20 and 6 years back, respectively, for Buerger's disease. Abdominal examination revealed a huge hernial swelling in the left groin extending from the symphysis pubis to anterior superior iliac spine measuring 25 x 18 cm. On exploration, the contents were intestines and omentum, which were coming out through a defect of 5 x 3 cm in the lower fibers of the conjoint muscle 4 cm cephalad to the deep ring, a finding which made the final diagnosis as an incisional hernia. We present this interesting case as a very rare complication of omentopexy, probably not reported previously, and an unusual case of an incisional hernia presenting as an inguinal hernia which is very difficult to diagnose unless encountered before. Its rarity and clinical challenge is highlighted.

A swollen middle finger in a middle-aged farmer

Hand tumors are not common and a swollen finger poses considerable diagnostic dilemma. We present a case of a middle-aged farmer who had presented with a painless swelling of the middle finger of the right hand without any neurovascular deficit or evidence of metastasis. An X-ray of the finger showed cortical expansion and bony erosion of the proximal phalanx. A fine needle aspiration cytological examination was inconclusive. He underwent a digit amputation in view of subsequent morbidity and chances of recurrence following local excision. Biopsy proved it to be a giant cell tumor of the proximal phalanx. Following six months of treatment he is doing well. We herein highlight an unusual tumor of the finger and its diagnostic and treatment challenges.

Adjuvant chemoradiotherapy in pancreatic adenocarcinoma--are we forcing a milestone?

Survival for pancreatic ductal adenocarcinoma is low and the role of adjuvant therapy remains controversial, with the European studies indicating survival benefit of chemotherapy over chemoradiation, whereas the American reports indicate an undoubted benefit with chemoradiation. Whatever is the mode of adjuvant care, two things are obvious in the management of this disease: surgery is the mainstay of treatment and a complete resection is the only hope of cure. Secondly, irrespective of the adjuvant treatment modality, survival advantage is limited and five-year survival has failed to reach that of other malignancies. The mixed results obtained from the various adjuvant therapy trials indicate that a uniform protocol is yet to be reached. A milestone is said to have been reached when a treatment or a treatment modality revolutionizes the outcome of a disease. As of now the adjuvant treatment in pancreatic adenocarcinoma is still evolving. Maybe a fresh look is needed at the biological aspect of the disease to add a new thought in its management, as has happened with other human malignancies.

Duodenojejunal junction web masquerading as Wilkie's syndrome: report of a case

Wilkie's syndrome (superior mesenteric artery syndrome) is a rare cause of obstruction to the third part of duodenum due to compression between the superior mesenteric artery and the abdominal aorta. Pathologies like malignant growth in the mesenteric root, the presence of a lymph nodal mass compressing the terminal duodenum, dissecting aortic aneurysm, and intestinal malrotation may mimic the condition, but are not true etiologies of the syndrome. A duodenojejunal web causing narrowing of the duodenojejunal junction and mimicking Wilkie's syndrome has not been described before in the literature. We herein report a case of gastroduodenal obstruction due to a web in the duodenojejunal junction in a young female patient, which closely mimicked Wilkie's syndrome but was finally diagnosed postoperatively. We highlight the first case of its kind in an adult and discuss the challenges in both the diagnosis and management.

A prospective, descriptive study to identify the microbiological profile of chronic wounds in outpatients

Indiscriminate use of antibiotics for infected chronic wounds is a global problem that may contribute to delayed healing and the development of drug-resistant micro-organisms. A prospective, descriptive cohort study of 50 male and female outpatients (mean age 52.50 [+/- 14.84] years, range 18-90) with 52 chronic wounds was conducted to investigate the microbiological profile and prevalence of drug-resistant strains in chronic nonhealing wounds to develop an evidence-based approach to antibiotic therapy until drug sensitivity reports are available. Mean wound duration was 8.23 (+/- 12.35) months (range 1.5-72), average wound size was 29.70 (+/- 37.83) cm, and most patients had a lower extremity wound and diabetes mellitus (n = 20). Pus and tissue samples were cultured and tested. Most (45) wounds contained a single organism and nine different genera were isolated. Of those, 39 were Gram-negative and 11 were Gram-positive (z = 5.50, P = <0.001). The most common organisms were Pseudomonas (21 wounds) and Escherichia coli (eight wounds). Pseudomonas aeruginosa was more common in patients with diabetes mellitus, in lower extremity ulcers, and in ulcers >20 cm2 (z-test, P <0.05). The presence of two organisms was more commonly observed in postsurgical/traumatic wounds. Ten (10) out of 55 pathogens (18.18%) isolated were drug-resistant, including Pseudomonas (seven), methicillin-resistant Staphylococcus aureus (one), and extended-spectrum beta lactamase (two--E. coli and Citrobacter). Most (70%) drug-resistant pathogens were obtained from persons with diabetes mellitus. Overall sensitivity to piperacillin and tazobactum combination was high. Because the prevalence of monomicrobial flora in chronic wounds is high, if a wound infection is suspected, empiric therapy should target the most prevalent flora. The high rate of drug-resistant Pseudomonas and MRSA strains should discourage antibiotic use in chronic ulcers before obtaining culture results.

An In vivo Wound Model Utilizing Bacteriophage Therapy of Pseudomonas aeruginosa Biofilms

Bacteriophages have been used as effective therapy against bacterial biofilms on devices such as catheters, in the lungs such as in cystic fibrosis, and even in infected food. Unlike antibiotics, they are bacteria-specific and produce the desired effect without systemic complications; they can develop bacterial resistance, although in ways different from antibiotics. The present study aimed to assess the effect of bacteriophages against multidrug-resistant Pseudomonas aeruginosa in a mouse wound model. P. aeruginosa obtained from laboratory culture of burn wounds were characterized, harvested, and titrated, and biofilms were generated on sterile catheter sections (105 colony forming units/mL). Subcutaneous pockets were created on the backs of 24 male albino mice. Animals were randomized into 4 groups of 6 each. After evaluating a significant phage-bacteria interaction in vitro, 2 biofilm-laden catheter sections were implanted in subcutaneous pockets in mouse groups C and D. Sterile catheter sections only were implanted in group B. Group A had only a subcutaneous pocket without any catheter section. Phage cocktail solutions (10 \'b5L of 107 phage forming units/mL) were injected daily in group D pockets only. Groups B and C received 10 \'b5L of normal saline. After 10 days, the catheter sections were explanted from groups B, C, and D and tissue biopsy was taken from group A pockets and cultured for bacterial and phage colony counts. A significant drop in bacterial counts from 3.87 x 106 to 3.52 x 104 was observed in group D when compared with group C (3.87 x 106 to 3.85 x 105, P less than 0.05) A significant rise in the phage counts from 1 x 107 to 6.81 x 108 (P less than 0.05) also was observed in group D when compared with the baseline counts, indicating active phage proliferation and successful bacterial kill in group D. The present laboratory study could be indicative of a new treatment approach for multidrug-resistant bacterial infections, including wound infections.

Wandering Spleen and Acute Gastric Volvulus in an Elderly Woman with Acute Abdomen: A Case Report

Gastric volvulus is an uncommon clinical condition with the potentially life-threatening complication of acute gastric necrosis. A wandering spleen may also be associated with gastric volvulus and can produce a diagnostic dilemma as the cause of an acute abdomen. We present a case of an elderly woman who presented with acute abdominal symptoms. She did not have the classical Borchardt triad to diagnose gastric volvulus and had a coexisting wandering spleen. Although torsion and ischemia of the wandering spleen were initially thought to be the cause of acute abdomen, a subsequent contrast-enhanced CT (CECT) scan confirmed a coexistent mesenteric-axial gastric volvulus with gangrenous changes. We present this case to highlight a rare combination of pathologies, either of which can confuse the diagnosis or cause a delay in management. Early diagnosis with CECT is emphasized, and segmental resection is feasible when the rest of the viscus can be preserved.

Feasibility of same day discharge after mini-laparotomy cholecystectomy -- a simulation study in a rural teaching hospital

OBJECTIVE

Open cholecystectomy is still widely practised, more so in the developing countries, due to the high cost of laparoscopic cholecystectomy. However, the long traditional postoperative stay (7-8 days) prevents rapid turnover and adds to the waiting list. The aim of this study was to evaluate whether mini-laparotomy cholecystectomy (MLC) can be done as a day surgery or extended day surgery in a rural setting.

METHODS

A nonrandomized, uncontrolled study was done prospectively at the North Bengal Medical College and Hospital. The subjects underwent mini-laparotomy cholecystectomy under general or epidural anesthesia. Postoperatively they were encouraged to be ambulant early and to accept oral fluids. In the evening they were assessed, by preset criteria, for fitness for discharge. None were actually discharged but were observed overnight and reassessed the next morning, by the same criteria, for any adverse effects that could have occurred had they actually been discharged on the same day. They were discharged after removal of stitches. Any complications of the surgery were also noted.

RESULTS

Thirty-two patients (26 females, 6 males) formed the study group. General anesthesia was given in 19 cases and epidural in 13. Using the scoring system, 25 (78.1%) patients were considered fit for discharge on the evening of surgery. The most prominent reasons for non discharge were vomiting and pain. Re-evaluation on the following morning showed that 30 (93.75%) patients were in a position to be discharged. None showed any complication that would have required readmission. There were no significant complications pertaining to the procedure itself.

CONCLUSION

Mini-laparotomy cholecystectomy as day surgery or extended day surgery is feasible and a safe, well tolerated procedure in a wide range of age groups. It may be a good alternative to laparoscopic cholecystectomy in developing countries, where resources are limited and waiting lists are long.

Splenunculus masquerading as colonic malignancy

A 60-year-old woman presented with a hard lump of 5 x 3 cm in the left hypochondrium of 4 months duration. Clinical evaluation and investigations pointed towards a probably malignant colonic growth near the splenic flexure. She underwent an exploratory laparotomy with resection of the lump with the associated colon. Histopathology proved it to be a splenunculus. The rarity of such a case is highlighted and the diagnostic challenge it poses is discussed.

Primary retroperitoneal transitional cell carcinoma presenting as a dumb-bell tumour

We report a retroperitoneal transitional cell carcinoma arising from the primitive urogenital remnants of a 56-year-old married Indian woman. She presented with a huge cystic mass in the hypogastrium and right iliac fossa, which extended into the right thigh as a massive dumb-bell tumour. On exploration, it was found not to be arising from any known retroperitoneal structure. The mass was excised, and the histopathology confirmed transitional cell carcinoma with positive margins. Though she received postoperative chemotherapy with cyclophosphamide, adriamycin and cisplatin, she developed extensive local recurrence and hepatic secondaries, and succumbed to the disease after ten months of follow-up. We highlight the rarity of the disease, its atypical presentation as a cystic dumb-bell lump, its diagnostic challenges and aggressive behaviour, and review the literature on primary retroperitoneal transitional cell carcinomas.

Antibiotic misuse in children by the primary care physicians--an Indian experience

OBJECTIVE

To determine the misuse of antibiotics in the Pediatric outpatients department' (OPD) of a busy teaching hospital and to ascertain the probable reasons behind it.

METHODS

Over a 6 months period, new cases primarily treated with antibiotics by Medical Officers (first contact physicians in Peadiatric Medicine and Surgery OPD) were recruited in the study after obtaining written consent from the parents. Various errors of antibiotic usage were noted. All Medical Officers were asked to fill up a preformed questionnaire and the parents/guardians were interviewed on their ideas about antibiotics. Data were analyzed by the statistical software SPSS 10.

RESULTS

Antibiotics were prescribed in 2427 (84.9%) new patients. Misuse of antibiotics was documented in 36.8% patients (no indication in 35.3%, improper selection in 17.9% and incorrect dosage in 7.7%). All medical officers were aware that they overuse antibiotics. The various reasons sited were demand of the parents, reluctance to counsel due to patient overload, free supply of medicines from OPD and sympathetic grounds as follow up visits were uncertain. Majority of the parents/attendants belonged to poor socioeconomic status and did not have any idea regarding antibiotics. All parents wanted quick relief without hospitalization and only 2.3% were willing to revisit the OPD for the same illness. Both medical officers and parents felt that base line investigations were unnecessary.

CONCLUSION

Antibiotic misuse is quite common in this part of the world. Irrational use was mostly seen in over-prescribing and improper selection of antibiotic. Poor socio-economic status and overcrowding of patients in OPD were the main responsible factors.