Optimizing Thyroxine Dosage After Total Thyroidectomy: Understanding the Factors at Play.

INTRODUCTION: Total thyroidectomy is evolving as the choice of treatment for non-malignant thyroid conditions. Therefore, an ideal method of thyroxine replacement is necessary to avoid the ill effects of under- and over-replacement in such patients. AIM: To assess the correlation between optimal thyroxine dose and potential variables like lean body mass (LBM), body surface area (BSA), body mass index (BMI), body weight, age, and sex in patients who underwent total thyroidectomies for benign multinodular goiters in our institute. MATERIALS AND METHODS: A longitudinal cohort study was undertaken at the Government Medical College Thrissur, a tertiary care provider in India, between October 2018 and September 2019. One hundred adult patients who underwent a total thyroidectomy for various benign thyroid conditions were included. They were initially given thyroxine 75 µg upon discharge and received follow-up doses every two months until they achieved euthyroid status on two consecutive visits. The variables evaluated at this stage included age, sex, actual body weight, lean body weight, BMI, and biochemical data (triiodothyronine (T3), thyroxine (T4), thyroid-stimulating hormone (TSH)). Correlation, multiple step-wise regression, and variance were carried out using EPI INFO version 7.2.2.6. RESULTS: The best predictors for optimum thyroxine dose were BSA (0.923, P < 0.01) and LBM (0.921, P < 0.01), compared with body weight (0.833, P < 0.01) and BMI (0.523, P < 0.01). In our study, the least significant factor was the age of the patient (r = 0.117, P < 0.01). There was no significant association between gender and thyroxine dose. The mean thyroxine dose was 1.87 µg/kg of the patient's body weight. CONCLUSION: The optimum thyroxine replacement based on BSA or LBM is a more ideal method than based on BMI or body weight alone.

Navigating the Cervico-Axillary Canal: A Rare Encounter With Double Dumbbell Space Sarcoma Involving the Neck and Axilla.

Space sarcomas are exceedingly rare neoplasms, and double dumbbell space sarcoma in the cervicoaxillary canal has not been previously reported. We present a case of a 63-year-old male who presented with a swelling in the neck and axilla of four years' duration, which rapidly increased in size over the last three months. Clinical examination and imaging revealed a multiseptate mass extending from the posterior triangle of the neck to the right axilla and chest wall through the cervicoaxillary canal. This lesion encased major vessels and components of the brachial plexus but did not infiltrate them. A trucut biopsy confirmed the diagnosis of well-differentiated liposarcoma. Surgical intervention was performed, achieving complete resection with preservation of neurovascular structures. This case highlights the unique challenges and complexities associated with managing double dumbbell space sarcomas in the cervicoaxillary canal. Additionally, it underscores the importance of a multidisciplinary approach to achieving successful outcomes while preserving limb function and minimizing complications. Long-term follow-up is essential for monitoring potential recurrences.

Outcomes of the Electrothermal Bipolar Vessel Sealing Device and Electrocautery in Modified Radical Mastectomy Patients.

Introduction With the rising trends in breast cancer throughout the world, the traditional modus of intraoperative tissue dissection using a scalpel, scissors, or electrocautery needs to be re-evaluated in the wake of newer modalities, such as electrothermal bipolar vessel sealing (EBVS) devices, which may theoretically reduce the postoperative complications and morbidity in these patients. Aim and objective The objective of this study is to compare an EBVS device to electrocautery (diathermy) in modified radical mastectomy (MRM), based on selected intraoperative and postoperative outcomes. Study procedure This was a comparative cross-sectional section study that included 60 patients with operable breast cancer (stages I and II, TNM classification, and post-neoadjuvant stage III disease). Patients were divided into two groups for surgery: one group underwent an MRM using the EBVS device (Group A), while the other group had the procedure performed using conventional electrocautery (Group B), as per the surgeon's choice depending on theatre slot and equipment availability. Intraoperatively, the total operative time, time for raising the flaps, time taken for breast tissue dissection, time for axillary dissection, and blood loss were recorded. Postoperative parameters included total drainage volume, number of days of drainage, seroma formation, and other complications. Patients were followed up for one month after surgery, with early postoperative complications such as wound infection, upper limb lymphedema, seroma, flap necrosis, and nerve injuries being documented. Results The groups were found to be comparable in terms of the age distribution, TNM staging, stage grouping, and nodal status of the patients. The EBVS device group demonstrated statistically significant advantages in total operative time, axillary dissection time, flap raising time, breast tissue dissection time, intraoperative blood loss, total drainage volume, and days of drainage. However, no statistically significant difference was found between the two devices in terms of seroma formation, early postoperative complications, and duration of postoperative stay at the hospital. Conclusion While the use of EBVS in MRM provides a considerable decrement in the total operative duration, duration of the various steps of surgery, intraoperative blood loss, and postoperative volume and duration of drainage, these devices do not offer an evident advantage in terms of the postoperative complications or morbidity.

Intriguing Insights From 100 Consecutive Colorectal Cancer Cases in Mid-Kerala: Sparse BRAF Gene Mutations and Mismatch Repair Deficiency (MMR-D).

Colorectal cancer (CRC) is among the most prevalent types of cancer globally. It is well established that the development of CRC primarily results from the sequential activation of oncogenes and the simultaneous inactivation of tumor suppressor genes. It has also been noted that after the initial oncogenic mutation, many subpopulations with different mutational profiles are created, causing heterogeneity among the tumors. This retrospective study analyzed 100 patients diagnosed with CRC through colectomy over an eighteen-month period at a tertiary referral center in mid-Kerala, India. Pathology records and histological slides were reviewed by two pathologists, and clinicopathological data were collected from pathology reports. Immunohistochemical analysis for BRAF mutation and possible microsatellite instability (MSI) (by mismatch repair (MMR) protein study) was conducted on tumor tissue blocks sent to an external center due to the lack of an automated platform at the hospital. The study utilized Roche's Benchmark XT platform for BRAF analysis and assessed MMR protein expression using antibodies for MLH1, MSH2, MSH6, and PMS2. The mean age of patients was 58.36 years, with a male predominance (58.0%). Most tumors were classified as T3 (71.0%, n-71) and T2/T4a (14.0% each, n-14), while nodal involvement included N0 (35.0%, n-35), N1 (26.0%, n-26), N2 (19.0%, n-19), and NX (20.0%, n-20). Histological examination revealed predominantly well-differentiated tumors (78.0%, n-78), with lymphatic invasion noted in 41.0% (n-41) and vascular invasion in 5.0% (n-5) of cases. Left-sided tumors predominated (33.0%, n-33), followed by rectal carcinoma (37.0%, n-37), and right-sided colon cancers (30.0%, n-30). Genetic profiling showed sparse BRAF mutations (1.0%, n-1) and MSI (1.0%, n-1), with some cases exhibiting loss of MMR proteins (MLH1, PMS2, MSH2, and MSH6) by immunohistochemistry (IHC). The study highlights the rarity of BRAF mutations in this cohort and emphasizes the diverse pathological and molecular characteristics observed. The discussion focuses on the implications of these findings, suggesting that CRC in this population exhibits unique clinicopathological features potentially influenced by factors beyond genetic mutations. Further multicentric studies are warranted to comprehensively explore these factors and refine risk stratification and treatment strategies for CRC patients in similar demographics.

Difficult Terrains of Research Publications Faced by Researchers: A Cross-Sectional Study.

Background The publication of scholarly work in peer-reviewed journals is a well-established method for disseminating knowledge and findings to a global audience. However, the publishing process is constantly evolving and encountering various obstacles that hinder progress. Despite a significant increase in the number of research projects undertaken, there are few studies evaluating the challenges faced by investigators in publishing their research. This study aims to identify the factors and elements that influence the publication process after the completion of research. Methods This study included 759 projects approved by the Institutional Ethics Committee (IEC) from 2016 to 2021 at a tertiary care centre in South India. A list of these approved projects was analysed for overall output in terms of publication and completion. Investigators were contacted and interviewed using a validated, 15-question survey to identify various factors influencing scientific publications. Results A total of 759 projects approved by the IEC from 2016 to 2021 were analyzed. It was found that only 36.72% of studies were completed by faculty members, and the publication conversion rate was 34.24%. A single-point analysis showed a statistically significant lower conversion rate for resident articles (p = 0.032). The 15-point analysis detailed the factors influencing publication conversion, revealing that the majority of researchers publish based on academic and research interests (68.89% and 72.12%, respectively). Various deterrents to publication, such as study design, statistical analysis, journal selection, and knowledge about journal submission, were identified. Notably, 98.4% of researchers expressed a desire to publish more in the future, highlighting the importance of this study. Conclusion The study highlights areas that require attention to facilitate and augment research. It identifies the real gaps in the publication process and suggests points of intervention needed to enhance the research environment, increase publication rates, and establish demand-based research support units in the medical education sector.

Squamous Cell Carcinoma Scalp With Intracranial Extension: Challenging Case of Multidisciplinary Care.

Squamous cell carcinoma (SCC) of the scalp is the second most common non-melanoma cancer of the skin. The incidence of squamous cell carcinoma on the scalp is on the rise, but the intracranial extension is rare. Cranial invasion is rare in SCC of the scalp, but when present, it is associated with a poor prognosis. A 62-year-old female presented with complaints of swelling over the back of her scalp for three months, which rapidly increased in size. She also had a throbbing headache, alopecia in that area, and multiple episodes of pustules in that area. On examination, she had an ulceroproliferative lesion measuring 5*5*3 cm with an irregular surface and varying consistency over the occipital area in the midline surrounded by ulcerations and crusted discharge and fixed to the bone. Contrast-enhanced magnetic resonance imaging (MRI) showed an irregular lesion with the destruction of the right parietal and occipital bones involving both inner and outer tables with intracranial and extracranial components, and the lesion was abutting the superior sagittal sinus. The treatment is surgical resection of the tumor with margin clearance. The treatment plan was designed using a multidisciplinary approach with the collaboration of oncosurgery, neurosurgery, and plastic surgery. The patient underwent wide local excision of the tumor with adequate skin and cranial bone clearance. The tumor was found to have infiltrated the dura mater overlying the superior sagittal sinus. The defect was then closed using a vault prosthetic cover and a scalp transposition flap from the left parietal area. This case report intends to highlight the need for a multidisciplinary approach to the proper management of advanced squamous cell carcinoma to decrease the morbidity and mortality in patients.

Hidden Intruder: A Rare Encounter of Dirofilaria Masquerading as a Breast Lump.

Dirofilaria, commonly known as heartworm, is a parasitic nematode that primarily infects canines. However, human infections have been reported and can present as subcutaneous nodules in different parts of the body. We present a case of a 43-year-old female who presented with a breast lump that was ultimately diagnosed as a Dirofilaria infection, a rare occurrence in humans. This case report shows that considering parasites in unusual presentations is of utmost importance, especially in regions known to have a high prevalence of such infections.