A large cirsoid aneurysm of the scalp with multiple arterial supply: illustrative case

BACKGROUND

Cirsoid aneurysm of the scalp is a rare arteriovenous fistula having a traumatic, congenital, iatrogenic, or idiopathic etiology. Its presentation can range from a small swelling to a large pulsatile mass with tinnitus, headache, and scalp necrosis.

OBSERVATIONS

A 67-year-old female presented with a gradually increasing swelling on her forehead and head since childhood and no history of trauma. Examination revealed 12 × 5 cm tortuous midline swelling. Computed tomography angiography revealed a mass of tortuous vessels in the right frontoparietal region of the scalp with no bony defect or intracranial extension. Contrast-enhanced computed tomography of the head showed no intracranial pathology. The diagnosis of cirsoid aneurysm was made, and surgery was planned. A bicoronal incision was made. The feeding arteries were dissected and ligated. The nidus was carefully separated, cauterized, and excised in toto. Inadvertently, a buttonhole in the skin was created while dissecting the nidus, which was sutured. The patient developed a small area of scalp necrosis on the 10th postoperative day, which was debrided and sutured. At the 6-month follow-up, no signs of recurrence were present.

LESSONS

A large cirsoid aneurysm of the scalp with multiple arterial supplies can be treated successfully with surgery. Meticulous dissection and hemostasis are warranted to avoid perioperative complications.

Gallstone among Patients Presenting to the Department of Surgery in a Tertiary Care Center: A Descriptive Cross-sectional Study

Introduction: Gallstone is the most common biliary pathology. Once thought of as a disease of the western world, the incidence and burden of cholelithiasis are increasing in Asia. Its literature from Nepal is however still primitive. The study aimed to find out the prevalence of gallstone among patients presenting to the Department of Surgery in a tertiary care centre. Methods: A descriptive cross-sectional study was conducted among patients presenting to the Department of Surgery after receiving ethical approval from the Institutional Review Committee (Registration number: 625). The study was conducted from 1 June 2022 to 1 November 2022. Patients with age more than 18 years were included and patients less than 18 years of age, having common bile duct stones, suffering from biliary malignancy or having an immunocompromised state were excluded. Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated. Results: Among 1700 patients, gallstone was seen in 200 (11.76%) (10.23-13.29, 95% Confidence Interval). Among the 200 patients, 133 of them (66.50%) were females. Multiple gallstones were present in 118 (59%) cases whereas 82 (41%) cases had a single stone. Conclusions: The prevalence of gallstone was found to be similar as compared to other reported literature.

Spontaneous splenic hematoma secondary to dengue infection: a rare case report

Dengue infection may have various surgical complications. Splenic hematoma is a rare complication of dengue hemorrhagic fever and may be life-threatening.

Case Presentation

A 54-year-old male, diagnosed with dengue infection detected at another hospital, presented on the 10th day of fever with left upper abdominal pain for 7 days without history of trauma. Urgent ultrasonography of the abdomen revealed findings suggestive of a splenic subcapsular hematoma, which was confirmed by computed tomography scan. The grade II splenic hematoma was being managed conservatively. Unfortunately, the patient developed hospital acquired pneumonia and died from septic shock.

Clinical Discussion

Hemorrhagic manifestations are seen in the febrile and critical phase of dengue, but the spleen is infrequently involved. Splenic hematoma can lead to splenic rupture, which can be rapidly fatal. Specific treatment guidelines of such hematomas are needed in the context of dengue infection, as the treatment modality is controversial.

Conclusion

Patients must be carefully evaluated for the complications and surgical manifestations of dengue as abdominal pain and hypotension from splenic hematoma may be misinterpreted as components of dengue hemorrhagic fever and dengue shock syndrome.

Acute Pancreatitis among Patients Visiting the Department of Surgery in a Tertiary Care Centre: A Descriptive Cross-sectional Study

Introduction: Acute pancreatitis is the inflammation of pancreatic parenchyma characterised by severe abdominal pain and nausea. It is a common gastrointestinal disease requiring hospital admission. The death rate for mild acute pancreatitis is low but severe acute pancreatitis can reach up to 40%. This study aimed to find the prevalence of acute pancreatitis among patients attending the Department of Surgery in a tertiary care centre. Methods: This descriptive cross-sectional study was conducted from 1 October 2021 to 30 March 2022. The study was conducted after receiving ethical approval from the Institutional Review Committee (Registration number: 454). Patients with age more than 18 years were included and patients less than 18 years of age including those suffering from chronic pancreatitis, pancreatic malignancy or immunocompromised states were excluded. Convenience sampling was done. Point estimate and 95% Confidence Interval were calculated. Results: Among 1560 patients, the prevalence of acute pancreatitis in our study is 120 (7.69%) (2.92-12.46, 95% Confidence Interval). Out of them, 57 (47.50%) were males and 63 (52.50%) were females. Out of total, hypertension found in 52 (43.33%) was the most common co-morbidity observed followed by diabetes mellitus 18 (15%). Similarly, 80 (66.67%) patients had mild pancreatitis whereas 40 (33.33%) had moderate pancreatitis and 8 (6.67%) had severe pancreatitis. Conclusions: The prevalence of acute pancreatitis among hospital admissions in the department of surgery in a tertiary care centre was found to be similar to other studies done in a similar setting.

Large posterior mediastinal ganglioneuroma with intradural cervical spine extension: A rare case report and review of literature

Introduction

Ganglioneuroma (GN) is a rare benign tumor of ganglion cell origin and can occur anywhere along the sympathetic chain. These tumors can grow to a significant size without any symptoms unless they exert a mass effect on the region they grow and start showing symptoms. Spinal extensions are rare and they may produce neurological symptoms warranting further investigation.

Case presentation

We described a case of posterior mediastinal ganglioneuroma in a 4-year-old boy with cervical extension who presented with quadriparesis. The radiological scan revealed large ganglioneuroma having an intradural extramedullary extension with a large posterior mediastinal component compressing and displacing the surrounding structures. He underwent consecutive surgeries for complete excision of the tumor following which he regained his power in his upper and lower limbs over the period of 2 months.

Conclusion

Para spinal mass with consistent radiological features suggests ganglioneuroma but confirmation should be done with biopsy. Complete excision of the tumor is the treatment of choice with close follow-up for clinical improvement and recurrence.

Colorectal carcinoma presenting as spontaneous colocutaneous fistula - A rare case report and review of literature

INTRODUCTION AND IMPORTANCE

Colon cancer presenting as spontaneous enterocutaneous fistula are rare with only few cases reported in the literature. Such presentation signifies locally advanced disease with poorer outcomes. Enterocutaneous fistula increases morbidity and mortality in cancer and may potentially delay the definitive care. It poses a difficulty in management in terms of patient optimization, determining the type of resection (palliative or curative) and the operative timeline.

CASE PRESENTATION

A 47 years old female presented with complaints of foul smelling discharge from a fistulous opening in right iliac fossa with occasional per rectal bleeding for the past six months. Imaging showed ascending colon mass breaching the peritoneum with fistulous tract opening into subcutaneous plane. Exploratory laparotomy with right hemicolectomy and en bloc resection was performed.

CLINICAL DISCUSSION

Cutaneous fistula can be caused by traumatic, postoperative etiologies and about 20 % are of spontaneous etiologies. Colon cancer has the ability to mimic any abdominal disease with a wide spectrum of presentations. The locoregional extension from the bowel creates a passage of colonic contents to evacuate from the external opening. The fistulous tract of colon cancer is less likely to close spontaneously and may require surgical intervention following appropriate resuscitation. Due to features suggestive of bowel obstruction an early single stage surgery was performed in our case.

CONCLUSION

There are no existing guidelines for colon cancer with colocutaneous fistula because they are the same for benign fistulas (resuscitation, control of output, eradication of the infection, nutritional optimization, surgery) along with a multidisciplinary oncology team approach.

A rare case of retroperitoneal extension in Fournier's gangrene: A case report and review of literature

Introduction and importance

Retroperitoneal extension is a rare and fatal complication of Fournier's gangrene (FG) which mandates immediate surgical intervention for better outcome.

Case presentation

A 70-year-old male presented to the emergency department with a history of bilateral painful scrotal swelling for 7 days with fever and abdominal pain for 3 days. On his general examination, he was septic with necrotic patches in the perineum and bilateral scrotum. Imaging revealed soft tissue gas and collections in scrotum extending to the right retroperitoneum with massive collection suggestive of retroperitoneal abscess. Following resuscitation and intravenous antibiotics, immediate exploratory laparotomy was done to drain the retroperitoneal abscess followed by debridement of Fournier's gangrene. The patient remained well on follow up.

Clinical discussion

Fournier gangrene is a fulminant polymicrobial infection of the perineum, scrotum and penis which when complicated by retroperitoneal extension, has a very high mortality. Majority of patients have an immunocompromised condition. Early diagnosis with prompt surgical drainage and debridement (within 6 hours) significantly reduces the mortality.

Conclusion

High index of suspicion, careful clinical examination and timely use of imaging is crucial for early diagnosis of this rare but fatal complication of FG. Furthermore, adequate resuscitation with prompt surgical intervention is the key for a favorable outcome.

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Fournier's gangrene (FG) is a type of necrotizing fasciitis involving the perineum and genital region.

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Retroperitoneal extension of FG is a rare and fatal complication which is usually seen in immunocompromised patients.

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Retroperitoneal abscess should be suspected in patients with FG who present with abdominal pain.

Is Tertiary care Treatment Affordable to All? - Explore Alternative (s) for Healthcare Financing

BACKGROUND

Health indicators such as life expectancy at birth, infant mortality rate etc. are some of the tools to measure the social development of that country. Due to advancement in technology, disease profile etc. expenditure on health care, especially tertiary care treatment is increasing day by day, and is beyond the reach of common people. This is one of the hindrances in the social development. India is a developing country and approx. 35% population is below poverty line. Since many people now are below poverty line or in a lower income group, people do not have any feeling to save or cannot save the money for future expenditure on health; therefore the tertiary care facility is inaccessible to a major fraction of the society.

METHODS

A study was conducted at Sanjay Gandhi Postgraduate Institute of Medical Sciences (SGPGIMS) Lucknow in the month of May-June 2007 with objectives to find out the level of awareness about hospital care financing, analyze the mode and mechanism of Health care financing and to assess the affordability of the tertiary care treatment by the patients undergoing treatment at this centre. A prospective study of 154 patients by floating the structured questionnaire containing 17 questions, covering various issues of HCF was carried out.

RESULTS

While observing the HCF pattern of High cost treatment diseases related to ICU, kidney transplant, cardiovascular surgery, Haematology, Surgical Gastroenterology etc. (expenditure limit more than Rupees (Rs) 75000 so far incurred in one patient), the study revealed that the average size of family is 6 members with an income of approx. Rs. 10185 per month per family. Average expenditure so far incurred by one shows that majority 115 (75%) patients bear the expenses themselves (out of pocket) It was also observed that approx. 50% out of pocket expenditure was met by taking loan from the bank, relatives, selling of assets and mortgaging the assets. approx. 34 (22%) reported that their expenditure will be reimbursed or got advance payment. Only 40 patients out of pocket had received some sort of assistance from some of the of the sources like CM, PM Fund and other types of donation. The study further highlights that average treatment expenditure already incurred in one patient i.e. Rupees 219376/- has exceeded the per capita expenditure on health care of individual (Rs. 1500/-), & total expenditure on whole family (Rs. 9000/-) and even total estimated annual income of one member (Rs.20370/) and whole family (approx. 122220/-). Only 2 (1.2%) respondents had health insurance policy.

CONCLUSION

The present study findings reflect that the tertiary & high cost treatment is beyond the reach of majority and will have great impact on the economy and health profile of society. In view of above, it is the need of the hour to strengthen the mechanism of the HCF by mass awareness with great emphasis is to be given to meet the "out of pocket expenditure" and encourage the "health insurance" mechanism. This may help in providing the tertiary care treatment to many people; otherwise the treatment cost is unaffordable.

Drug use among the urban poor in Kolkata: behaviour and environment correlates of low HIV infection

BACKGROUND

HIV infection in injecting drug users (IDUs) has worked as a driving force for further spread of the virus in other population groups. Major metropolitan cities such as Mumbai, Kolkota, Chennai and Delhi have seen a diffusion of injecting drug use within the last decade. The prevalence of HIV infection among injectors ranges from 2% to 30%. Identifying effective interventional elements that have kept the prevalence of HIV low for the past 7 years among IDUs of Kolkata is thus of public health importance.

METHODS

A purposive sample of opioid/opiate users was studied. Primary and secondary data on drug users, law-enforcement environment, records at drug treatment centres, jail admission data related to the 'Narcotic Drug and Psychotropic Substance Act' and interventions in other risk groups were collected. Laboratory tests for HIV, hepatitis B surface antigen and syphilis were done on consenting IDUs (n=129) and non-IDUs (n=120). For univariate and multivariate analysis, IDUs were taken as cases and non-IDUs as controls.

RESULT

Of the IDUs, 2% were positive for HIV. No non-IDU was HIV-positive. Significantly more non-IDUs (10% v. 4%, p=0.05) were positive for syphilis. Sharing injection equipment within the past 6 months was reported by 71% of IDUs; sharing partners were stable and ranged from 1 to 3. More IDUs compared to non-IDUs reported being in touch with intervention programmes. The police has been tolerant to needle-syringe exchange and oral sublingual buprenorphine substitution conducted in Kolkata. Unlike in the early 1990s, non-IDUs did not switch to injecting during non-availability of brown sugar in the latter half of the 1990s and instead sought tratment. The availability of high quality heroin (>20%-50%) was low and the proportion of moderate quality heroin (>10%-20%) went up during these times due to increased police seizures. No intervention exists in jails despite the fact that a large number of drug users spend time in jail.

CONCLUSION

Stable and few injection equipment-sharing partners of IDUs, launching of early targeted interventions among IDUs and sex workers in the city, police tolerance to harm reduction activities and preference of non-IDUs for detoxification during heroin draught periods have kept HIV prevalence at a low level among drug users of Kolkata for the past 7 years. immediate launching of interventions for drug users in jails seems necessary. Similar multi-pronged strategies with targeted and environmental intervention could work in other settings as well.

Interaction of bacteriophage T4 AsiA protein with Escherichia coli sigma70 and its variant

Bacteriophage T4 produces a small protein AsiA, which inhibits transcription from sigma70-dependent promoters in E. coli by tightly binding to sigma70 and is therefore termed as anti-sigma factor. We observed that there was no inhibition of single round transcription at lac UV5 promoter when AsiA was added to preformed open complex between RNA polymerase and template DNA. However, transcription was found to proceed normally at 'extended -10' promoters in the presence of AsiA. It appears therefore that AsiA binds sigma70 at its 4.2-subdomain or in its close vicinity. Further experiments on immunoprecipitation of sigma70 and a mutant sigma70-V576G with AsiA seem to corroborate such conclusion.

Periplasmic expression of biologically active vesicular stomatitis virus phosphoprotein P in Escherichia coli

Overexpression of a clone of vesicular stomatitis virus phosphoprotein P (New Jersey serotype) using T7 promoter with phoA leader sequence and a simpler two-step purification procedure of the expressed protein has been developed. The purified protein retains its ability to activate the transcription reaction. Comparative transcriptional assay using the protein P purified from periplasmic space and from cytosol (in the form of inclusion body) of Escherichia coli establishes the fact that the former is 10 times more efficient than the latter in activating the transcription reaction in vitro.

Percutaneous retrogasserian radiofrequency thermal rhizotomy for trigeminal neuralgia

Forty patients suffering from intractable unilateral trigeminal neuralgia involving more than one division of the trigeminal nerve were treated by percutaneous radiofrequency thermocoagulation of the trigeminal sensory root. The aim of the operation was to relieve the pain without producing dense sensory deficit in the face. This goal was achieved by making selective lesions in the sensory root with gradually increasing temperature 60 degrees C to 90 degrees C. Three to four consecutive lesions each for 60 seconds have been found to produce excellent pain relief in 77.7% with good and fair results in the rest. The recurrence rate has been found to be 15% during 2 years of follow-up. Considerable dysaesthesia was observed in 5% of cases. Corneal anaesthesia was found in 5% cases while one patient developed neuroparalytic keratitis. Transient trigeminal motor weakness was observed in 10% of patients.