Ductal Carcinoma in Situ: A Detailed Review of Current Practices.

Ductal carcinoma in situ is a challenge for breast surgeons, beginning with its difficult radiological detection and continuing with its contentious multimodal treatment and management. It is becoming more common as a result of widespread screening mammography and usually manifests as a cluster of calcifications. Patients are usually asymptomatic or present with a small, palpable lump. It is, however, a premalignant lesion that has the potential to progress to invasive carcinoma and is treated similarly with multimodal therapy. Treatment options currently include total or simple mastectomy with sentinel lymph node biopsy or lumpectomy with radiation. Tamoxifen and human epidermal growth factor receptor two suppression therapy are examples of adjuvant therapy. A review of consensus guidelines and literature was performed, in which we included the available online literature on the concerned topic from 2000-2022. This article is not a complete review of all the available literature; rather, it is a comprehensive review of the topic and its current management guidelines.

A Review of the Current Literature on Pleomorphic Adenoma.

Pleomorphic adenomas (PA) are the most common benign salivary gland tumors. They arise from the major salivary glands, as well as the minor salivary glands. They may arise rarely from the palate, oral cavity, neck, and nasal cavity also. Yet, the fourth, fifth, and sixth decades of life are the most common for them to manifest. Forty percent of them occur in males and 60% in females. It is a benign mixed tumor, which has three components: an epithelial component, a myoepithelial cell component, and a mesenchymal component. A fibrous capsule separates these cells from the surrounding tissues. It generally presents as a slowly progressing painless swelling, which is well-delineated, nonsymptomatic, and not involving the facial nerve. Salivary gland tumors can be accurately diagnosed before surgery using fine-needle aspiration (FNA), ultrasonography (USG), and computed tomography (CT) scan. Calponin, cluster of differentiation 9 (CD9), glial fibrillary acidic protein (GFAP), Mcl-2, metastasis suppressor gene (NM23), p63, S-100, smooth muscle actin (SMA), and SRY-box transcription factor 10 (SOX10) exhibit the majority of the positive reactions in pleomorphic adenomas. The diagnostic marker pleomorphic adenoma gene 1 (PLAG1) is frequently employed since it is specific for pleomorphic adenoma. Although benign, these epithelial tumors have a propensity to recur and undergo malignant transformation if incompletely excised, leading to increased morbidity in these patients. A review of the consensus guidelines and literature was conducted, and the online literature on the subject from 2002 was included. This article is not a complete review of all the available literature; rather, it is a comprehensive review of the topic.

Modified Palomo Procedure Is an Effective Intervention for Improving Serum Testosterone Levels and Semen Parameters in Patients With Varicocele: A Prospective Study.

BACKGROUND: A varicocele can be defined as an abnormal venous dilatation and/or tortuosity of the pampiniform plexus. It is generally reported that varicoceles are present in 15% of the general male population and 35% of men as a cause of primary infertility and in up to 80% of men as a cause of secondary infertility. Differences in venous drainage anatomy between the left and right internal spermatic veins, venous valve incompetence resulting in venous blood reflux, and increased hydrostatic pressure are the most commonly cited theories. Various surgical and non-surgical techniques are in use for treating patients with varicocele. Here we used a modified Palamo procedure to treat the patients and observed the outcome. METHODOLOGY: A total of 40 patients with varicocele were recruited for the study. A preoperative evaluation, along with serum testosterone levels and semen analysis, was done. A modified Palomo technique was used to treat varicocele. A postoperative follow-up with serum testosterone levels and semen analysis was done to observe improvement. RESULTS: The mean (±SD) left testis size, right testis size, testosterone, sperm concentration, sperm vitality and sperm progressive motility were found statistically significantly higher in patients after surgery as compared to patients before surgery (p<0.05). However, there was statistically insignificant mean difference in semen volume between patients before surgery and patients after surgery (p>0.05). CONCLUSION: Modified Palomo procedure can be used to treat varicocele with good improvement in serum testosterone levels and semen parameters.

Evaluation of Factors Predicting Successful Outcome in Patients Undergoing Expectant Management of Uncomplicated Acute Appendicitis.

BACKGROUND: Expectant management, or non-operative management (NOM), with standalone intravenous antibiotic therapy, has emerged as an effective alternative to appendectomy for the treatment of uncomplicated acute appendicitis. Various clinical, biochemical, and radiological factors have been implicated in predicting the success or failure of outcomes. Therefore, it is important to identify patients at the onset who are likely to have successful outcomes for conservative management of uncomplicated acute appendicitis. METHODS: We prospectively enrolled 85 surgical patients diagnosed with uncomplicated acute appendicitis in our study. On admission, clinical features such as duration of symptoms, pulse rate (PR), history of fever within 24 hours of admission, modified Alvarado score and adult appendicitis score, biochemical parameters such as C-reactive protein (CRP), and hematological parameters such as total leukocyte count (TLC) were recorded. Radiological imaging of patients, namely ultrasonography and contrast-enhanced CT abdomen to evaluate appendix diameter and mural enhancement, was also undertaken. The outcome of expectant management for these patients (success or failure) was recorded, and the above-mentioned factors were evaluated to find a possible correlation with successful expectant management. RESULTS: We found that among 85 patients, 77.6% had a successful NOM of appendicitis, whereas 22.4% had a failed NOM of appendicitis. The duration of symptoms, pulse rate, fever within 24 hours of admission, TLC, percentage of neutrophils, CRP level, appendix diameter, modified Alvarado score, and adult appendicitis score were found to be statistically significant predictors of successful NOM of appendicitis according to univariate analysis. According to multivariable analysis, pulse rate and appendix diameter value were found to be statistically significant predictors of successful NOM of appendicitis. With each beat per minute (bpm) increase in pulse rate, there was a 0.30% decrease in the probability of a successful NOM of appendicitis. With each mm increase in appendix diameter, there was an 82% decrease in the probability of a successful NOM of appendicitis. CONCLUSION: From our study, it can be concluded that patients who met the following criteria, i.e., duration of symptoms before presenting to surgical emergency less than two days, presence of fever within 24 hours of presenting to surgical emergency, pulse rate >90 bpm, TLC >12000 cells/dL, CRP >20 mg/L, appendix diameter >10 mm, modified Alvarado score ≥ 9, and adult appendicitis score ≥ 18, have a higher probability of failure of NOM and hence should be excluded from expectant management.

A Detailed Review of Surgical Management of Uncommon Cutaneous Disorders.

A variety of cutaneous disorders can present to the general surgeon either directly or by referral for surgical intervention. Some conditions are commonly seen and operated on by general surgeons which include lipoma, epidermoid cyst, etc. On the other hand, some are uncommon conditions like dermatofibrosarcoma protuberans and chondroid syringoma which require a high index of suspicion to diagnose. Most general surgeons are not familiar with the latest guidelines to treat such uncommon conditions. In this article, we provide a review of uncommon cutaneous disorders requiring surgical intervention that were encountered at our high-volume tertiary care center and a discussion about their etiology, presentation, diagnosis, management and follow-up with one case report of each condition. The objective of this article is to familiarize the general surgeon with these cutaneous disorders which though uncommon, will present in their practice at some point.

A Prospective Comparative Study of Laparoscopic Totally Extraperitoneal (TEP) and Laparoscopic Transabdominal Preperitoneal (TAPP) Inguinal Hernial Repair.

Introduction Inguinal hernia is a common surgical problem throughout the world. Currently, the management options available are open mesh hernioplasty and laparoscopic mesh repair. Laparoscopic mesh repair can be performed by either transabdominal preperitoneal (TAPP) repair or totally extraperitoneal (TEP) repair. Many studies comparing the two procedures have been unable to establish the superiority of one procedure over the other and have yielded conflicting results. Thus, we performed this study to compare TAPP and TEP. Aim The aim of this study is to compare the clinical outcomes and safety of laparoscopic TEP and laparoscopic TAPP for inguinal hernia repair. Materials and methods Patients were randomly divided into two groups on the basis of surgical procedures. The first group of patients underwent laparoscopic TAPP mesh repair, and the second group of patients underwent laparoscopic TEP mesh repair. Their intraoperative and postoperative findings were noted. Patients were followed up at regular intervals for up to six months. Results The mean age and mean weight distribution between the two groups were not significant. The duration of surgery needed (in minutes) for TAPP was found to be significantly less compared to TEP. In the TEP group, conversion to open occurred for three subjects (6.7%) while there was no conversion in the TAPP group. Postoperative pain at 24 hrs was found to be higher in TAPP subjects compared to that in TEP subjects, but the difference was statistically insignificant. Tolerance to a liquid diet started few hours after surgery was found to be the same in both groups. Association of the duration of hospital stays with the type of surgery was not significant. Six subjects (13.2%) showed hematoma in the TEP group while five subjects (11%) in the TAPP group showed hematoma after one week of surgery. Eight subjects (17.6%) showed seroma in the TEP group while three subjects (15.4%) in the TAPP group showed seroma after one week of surgery. Two subjects (4.4%) showed superficial wound infection in both the TEP group and TAPP group after one week of surgery. Four subjects each (8.9%) showed scrotal edema in the TEP group as well as the TAPP group after one week of surgery. No subject showed port site hernia without closure of the sheath at one-week, one-month, and six-month follow-up visits. Two subjects (4.4%) each showed groin pain in the TEP group as well as the TAPP group after one week of surgery. There were no instances of bowel obstruction or mesh infection. Conclusion TEP is a more skill-demanding procedure as compared to TAPP and thus takes more time to perform. However, it is superior on account of not breaching the peritoneum. TAPP is favorable for larger hernias. The choice of procedure should be individualized according to the patient's characteristics and surgeon's preference.

Isolation and characterization of adenovirus-associated VA RNAs of human adenovirus type 7.

Two genes for virus-associated VA RNAs in the human adenovirus type 7 (Ad7) genome are compared to Ad2, Ad4, Ad5, simian VA RNAs, and pol III transcripts of Epstein-Barr virus. The newly identified VA RNA-encoding genes of Ad7 contain two relatively conserved intragenic promoter (elements A and B), the double-stranded RNA-dependent protein kinase (PK) active site-binding domain and transcriptional terminators. The conserved features extend to the VA RNA genes of simian and avian origin.

Site-specific DNA splicing: a general procedure for the creation of a restriction site at a predetermined position in a DNA sequence.

A method is described for creating any of a wide array of restriction sites at a predetermined position in a known DNA sequence. The method utilizes the exonuclease activity of BAL 31 and a specially designed bifunctional oligodeoxynucleotide linker. The desired restriction site is generated when the linker is ligated to those BAL 31-digested DNA fragments which end with the target sequence. The proper ligation product is then identified by a highly specific hybridization procedure. The method is versatile and specific and is especially useful in the isolation of functional elements of a gene.

Conservation of essential sequences in the major late promoter and tripartite leader of the simian adenovirus type 30.

We report here the cloning and sequencing of the major late promoter (MLP) and the tripartite leader (TPL) from simian adenovirus type 30 (sAd30) and the comparison of the sAd30 nucleotide (nt) sequence with that of human adenoviruses (hAd). The nt sequence homology between sAd30 and hAd2 is 75% from -66 to +190 relative to the cap site. This sAd30 MLP segment contains the upstream regulatory sequence element, TATA box, and downstream regulatory sequence elements that are homologous to hAd MLP. The sAd30 upstream regulatory sequence has a small palindromic DNA sequence GTCACGTGAC, and the TATA box contains the sequence of ATAAA instead of TATAAA. The sAd30 TPL was located on the sAd30 genome as identified by sequence homology with the hAd counterpart. The splice sites of TPL introns were confirmed by sequence analysis of cDNAs synthesized from sAd30-infected cells. There is a 74.2% nt sequence homology between the TPL of sAd30 and hAd2. The conservation of these sequence elements during evolution of Ad suggests that they are essential for the transcription and translation of Ad ML transcripts.

Sequence of the serotype-specific glycoprotein of the human rotavirus Wa strain and comparison with other human rotavirus serotypes.

Complementary DNA was synthesized from the double-stranded RNA of the Wa strain of human rotavirus and inserted into the bacterial plasmid pBR322. Clones which contained the gene that codes for the viral glycoprotein (VP7) were identified and the nucleotide sequence was determined. The gene was 1062 base pairs in length with an open reading frame which coded for 326 amino acids. Two potential glycosylation sites were found as well as two hydrophobic regions at the N-terminus of the polypeptide. The untranslated regions at the 5' and 3' ends were 48 base pairs and 33 base pairs long, respectively. Only one nucleotide at position 493 differed from the sequence of the Wa VP7 gene described by Richardson et al. (1984, J. Virol. 51, 860-862). A strong prokaryotic promoter sequence was also found between residues 434 and 462. A comparison of the amino acid sequence of the Wa strain (serotype 1) to the Hu/5 strain of human rotavirus (serotype 2) and SA11, the simian rotavirus (serotype 3), revealed a high degree of homology (79.1% and 83.1%, respectively) between the serotypes, suggesting that rotavirus serotypes are stable. The hydrophilic regions of VP7 of the three serotypes were identified and compared for homology. Four of these regions showed variation between serotypes.

Immunogenicity of recombinant human adenovirus-human immunodeficiency virus vaccines in chimpanzees.

Recombinant human adenovirus (Ad) type 4-, 5-, and 7-vectored vaccines expressing either the HIV env or gag-protease genes were tested for immunogenicity in three chimpanzees. The first phase of the vaccination protocol consisted of a primary and two booster immunizations with Ad-HIVs by the oral route of administration, followed by a single booster immunization with Gag and/or Env subunit vaccines. The second phase of the vaccination protocol consisted of intranasal administration of Ad-HIVs previously administered by the oral route. Following the first phase adenovirus was shed into stools for only 1-7 days and modest type-specific anti-adenovirus neutralizing antibody titers were induced. Strong anti-Env binding antibody responses were detected in all three animals following the second oral booster immunization. One chimpanzee responded with a low-titered type-specific neutralizing antibody response to HIV. Cell-mediated immune responses to Env were not detected after the primary vaccination, but were detected following all booster immunizations. Administration of the Gag subunit vaccine boosted both humoral and cell-mediated immune responses to Gag antigens. In contrast, the Env subunit vaccine boosted cellular but not humoral immune responses. In the second phase of the vaccination protocol, both virus shedding and anti-adenovirus responses were enhanced. All three chimpanzees responded to the intranasal administration of Ad7-HIVs with boosted anti-HIV serum responses, including low-titered type-specific neutralizing antibodies, elicited anti-HIV antibodies at secretory sites, and stimulated cell-mediated immune responses to both Gag and Env antigens.

Radiographically diagnosed antral gastritis: findings in patients with and without Helicobacter pylori infection.

The purpose of this study was to characterize the radiographic findings of antral gastritis and to determine whether there are differences in the appearance of antral gastritis in patients with and without Helicobacter pylori infection. A search of radiology, endoscopy and pathology files revealed 90 patients with antral gastritis on double contrast upper gastrointestinal tract studies who had endoscopy with testing for H. pylori. The barium studies were evaluated to further characterize the findings of antral gastritis without knowledge of the H. pylori status of the patients or of the endoscopy or pathology findings. The radiographic findings of antral gastritis included thickened folds in 67 patients (74%), polypoid antral gastritis (a subset of patients with thickened folds) in 6 (9%), antral erosions in 21 (23%), enlarged areae gastricae in 14 (16%), crenulation of the lesser curvature in 4 (4%), mucosal nodularity in 2 (2%), a hypertrophied antral-pyloric fold in 2 (2%) and antral striae in 1 (1%). 43 patients (48%) with antral gastritis were H. pylori positive and 47 patients (52%) were H. pylori negative. Thickened folds were detected in 39 H. pylori-positive patients (91%) with antral gastritis vs 28 H. pylori-negative patients (60%) (p<0.001); polypoid gastritis in 6 H. pylori-positive patients (14%) vs 0 H. pylori-negative patients (p<0.05); enlarged areae gastricae in 14 H. pylori-positive patients (33%) vs 0 H. pylori-negative patients (p<0.0001); and antral erosions in 2 H. pylori-positive patients (5%) vs 19 H. pylori-negative patients (40%) (p<0.0001). Our experience suggests that antral gastritis caused by H. pylori infection is associated with characteristic features on double contrast studies (including thickened folds, polypoid gastritis and enlarged areae gastricae) and that this condition is rarely associated with antral erosions. Thus, radiologists can often suggest whether the patient's gastritis is caused by H. pylori on the basis of radiographic findings.

Microbiological aspects of peritonitis in patients on continuous ambulatory peritoneal dialysis.

The objective of the study was to identify the microbiological spectrum and drug-sensitivity pattern of peritonitis in patients on continuous ambulatory peritoneal dialysis. This was a prospective study done over a period of a year-and-a-half at a tertiary-care hospital in a hilly state of India. The effluent dialysate bags from 36 consecutive patients with peritonitis were studied. One hunderd ml dialysate fluid was processed under aseptic conditions by lysis centrifugation method. Microscopy and culture was done from the deposits for bacteriological, fungal, and mycobacterial isolates. They were identified by colony morphology and their biochemical reactions. Drug susceptibility testing was done by Kirby-Bauer disc diffusion method. In 36 dialysates, 33 (91.6%) dialysates were culture-positive and in 3 (8.4%), the culture was negative. A total of 36 microorganisms were isolated in 33 cultures. Among the 36 microorganisms, 19 (52.8%) isolates were gram-positive, 10 (27.8%) were gram-negative, 5 (13.9%) were fungi, and 2 (5.6%) were mycobacterial isolates. All gram-positive organisms were sensitive to ampicillin, amoxi-clavulanic acid, cefazolin, clindamycin, and vancomycin. Neither a methicillin-resistant Staphylococci aureus nor a vancomycin-resistant Enterococcus was isolated in gram-positive isolates. Gram-negative organisms were sensitive to ciprofloxacin, ceftriaxone, ceftazidime, cefepime, gentamicin, piperacillin-tazobactam and imipenem. One of the gram-negative isolate was an extended spectrum beta-lactamase producer. Gram-positive peritonitis was more frequent than gram-negative peritonitis in our continuous ambulatory peritoneal dialysis patients. Mycobacterial causes were responsible for peritonitis in patients with culture-negative peritonitis which was not responding to the conventional antimicrobial therapy.

Metastatic adenocarcinoma of the lung mimicking mucoid degeneration of the anterior cruciate ligament.

We report a case of a 63-year-old male with known adenocarcinoma of the lung who presented with knee pain which was initially diagnosed as mucoid degeneration of the anterior cruciate ligament (ACL) on magnetic resonance imaging (MRI). Due to persistent knee pain an interval MRI was performed, followed by image guided biopsy which showed metastatic adenocarcinoma of the lung infiltrating the ACL. This is the first reported case in the literature of an intra-articular metastasis mimicking mucoid degeneration of the ACL.

MRI of injuries to the first interosseous cuneometatarsal (Lisfranc) ligament.

OBJECTIVE: The objective of this study was to assess the utility of MRI in diagnosing injury to the first interosseous cuneometatarsal (Lisfranc) ligament and to additionally determine the associated patterns of traumatic soft tissue and osseous injury. MATERIALS AND METHODS: Fifteen patients (16 feet) who were referred for MRI evaluation of the Lisfranc ligament, and had operative exploration or examination under anesthesia, were included for analysis. Standard non-contrast MRI foot imaging was performed in all cases. Evaluation of the following components was performed: the dorsal and plantar bundles of the Lisfranc ligament, the plantar tarsal metatarsal ligaments, soft tissue edema and fluid, and bone marrow edema and fractures. Surgical reports were regarded as the reference standard in all cases. RESULTS: Seven of 10 cases of grade 3 Lisfranc ligament injuries at surgery were correctly graded at MRI. No cases of surgically proven complete Lisfranc ligament tears (grade 3) were interpreted as normal at MRI. All Lisfranc ligament sprains (grade 2 or 3) at surgery were detected at MRI. Two of six cases reported as grade 1 injuries at MRI were normal at surgery. No cases of surgically proven normal or sprained Lisfranc ligaments were interpreted as grade 3 tears on MRI. Four of six of our cases of normal or sprained Lisfranc ligaments demonstrated fractures; while the minority of complete Lisfranc ligament tears (3/10) contained fractures. CONCLUSION: MRI is reasonably accurate at detecting traumatic injury to the Lisfranc ligament. However, in clinically suspected cases of traumatic Lisfranc ligament injury, true positive rate for sprain is low.