Comparative study on complications and difficulties in laparoscopy in female genital tuberculosis cases versus non-tuberculosis cases.

BACKGROUND AND OBJECTIVE: Female genital tuberculosis (FGTB) is an important type of extrapulmonary tuberculosis (TB) associated with morbidity especially infertility in developing countries. Laparoscopy may be difficult and hazardous in FGTB. The aim of the study was to observe the difficulties and complications of laparoscopy in FGTB cases. MATERIALS AND METHODS: It was a prospective study over 12 years' period on 412 cases of diagnostic laparoscopy performed on FGTB cases with infertility. All patients underwent history taking and clinical examination and endometrial sampling for acid-fast bacilli (AFB) microscopy, culture, polymerase chain reaction (PCR), gene Xpert (last 212 cases) and histopathological evidence of epithelioid granuloma. Another 412 cases of diagnostic laparoscopy in the absence of FGTB performed during same time were taken as controls from the pool of non-TB cases. Various difficulties and complications were noted in both groups and statistical analysis was done. RESULTS: Mean age, parity, body mass index and duration of infertility were 26.8 versus 25.4 years, 0.32 versus 0.28, 23.15 versus 25.28 Kg/m 2 and 4.15 versus 5.12 years, respectively. Primary and secondary infertility was seen in 78.6% and 20.38% of cases in the study group and 74.75% and 25.24% in the control group, respectively. Endometrial biopsy showed AFB microscopy in 5.3%, culture in 6.3%, epithelioid granuloma in 15.77% and on peritoneal biopsy granuloma in 6.55%, positive PCR in 368 (89.32%) and positive gene Xpert in 38 out of 212 (17.92%, out of last 212 cases). Definite findings of FGTB were seen in 171 (41.50%) cases. Probable findings of FGTB were seen in 241 (58.49%) cases. Various complications were difficulty in the creation of pneumoperitoneum or insertion of trocar and cannula in 16.74% and 13.10% of cases as compared to 1.94% and 1.69% in the control group. Excessive bleeding was seen in 5.09% versus 0.97% cases, respectively. Various injuries observed were bowel injury in 1.69% versus 0.24% cases (small bowel in 1.21% vs. 0.24%, large bowel in 0.48% vs. 0.1%), while bladder injury was seen in 0.97% versus 0.24% cases, subacute intestinal obstruction was seen in 5.8% versus 0.72% cases respectively while flare up of TB was seen in 5.09% versus 0% in cases and controls, respectively. Wound infection was seen in 8.48% versus 1.25% cases, respectively. INTERPRETATION AND CONCLUSION: FGTB is associated with increased complications and difficulties as compared to laparoscopy in other cases.

Differential location of growth factors and pancreatic stellate cell activation in chronic pancreatitis.

Pancreatic fibrosis is characterized by the activation of pancreatic stellate cells leading to the expression of smooth muscle actin (α-SMA). Normal pancreatic tissue has predominantly quiescent stellate cells in periductal and perivascular locations, which do not express α-SMA. We aimed at studying the immunohistochemistry (IHC) expression pattern of α-SMA, platelet-derived growth factor (PDGF-BB) and transforming growth factor (TGF-ß) in the resected specimen of chronic pancreatitis. Twenty biopsies from resected specimens of patients with chronic pancreatitis were included. The expression was measured in comparison to positive control biopsies (breast carcinoma for PDGF-BB and TGF-ß and appendicular tissue for α-SMA) and scored based on a semi-quantitative system based on staining intensity. The percentage of positive cells was used for objective scoring, which ranged from 0 to 15. The scoring was done separately for acini, ducts, stroma and islet cell. All patients had undergone surgery for refractory pain and the median duration of symptoms was 48 months. On IHC, α-SMA was not expressed in the acini, ducts or islets, but had high expression in the stromal regions (vs. acini, ducts and islet, p < 0.05), TGF-ß1 was also expressed maximally in islet cells; however, the distribution among all locations was statistically similar. α-SMA expression in the pancreatic stroma is an indicator of the concentration of activated stellate cells in the stroma, a site for genesis of fibrosis under the influence of growth factors in the local milieu.

NMR spectroscopy-based analysis of gallstones of cancerous and benign gallbladders from different geographical regions of the Indian subcontinent.

Analysis of the chemical composition of gallstones is vital for the etiopathogenesis of gallstone diseases that can ultimately help in the prevention of its formation. In the present study, gallstones from seven different regions of India were analyzed to highlight the major difference in their composition. Also, gallstones of different pathological conditions i.e., benign (chronic cholecystitis, CC) and malignant gallbladder disease (gallbladder cancer GBC) were characterized. The type of polymorphs of cholesterol molecules was also studied to provide insight into the structure of gallstones. 1H solution state NMR spectroscopy 1D experiments were performed on a total of 94 gallstone (GS) samples collected from seven different geographical regions of India. Solid-State NMR spectroscopy 13C cross-polarization magic angle spinning (CPMAS) experiments were done on the 20 CC GS samples and 20 GBC GS samples of two regions. 1H NMR spectra from the solution state NMR of all the stones reveal that cholesterol was a major component of the maximum stones of the north India region while in south Indian regions, GS had very less cholesterol. 13C CPMAS experiments reveal that the quantity of cholesterol was significantly more in the GS of CC in the Lucknow region compared with GBC stones of Lucknow and Chandigarh. Our study also revealed that GS of the Lucknow region of both malignant and benign gallbladder diseases belong to the monohydrate crystalline form of cholesterol while GS of Chandigarh region of both malignant and benign gallbladder diseases exists in both monohydrate crystalline form with the amorphous type and anhydrous form. Gallstones have a complicated and poorly understood etiology. Therefore, it is important to understand the composition of gallstones, which can be found in various forms and clinical conditions. Variations in dietary practices, environmental conditions, and genetic factors may influence and contribute to the formation of GS. Prevention of gallstone formation may help in decreasing the cases of gallbladder cancer.

Primary giant aggressive amelanotic duodenal melanoma.

Primary malignant melanoma of the gastrointestinal tract is extremely rare. A 35-year-old man presented with complaints of abdominal pain and weight loss. Contrast enhanced computed tomography showed a large mass involving the duodenum and the superior mesenteric vessels. Upper gastrointestinal endoscopy demonstrated a large, friable mass along the duodenal wall and biopsy was suggestive of malignant melanoma. A detailed physical examination and whole body imaging (positron emission tomography and computed tomography) did not reveal any other lesion. The patient underwent a pancreaticoduodenectomy with segmental resection and anastomosis of the superior mesenteric vein as well as a segmental colectomy. His postoperative recovery was uneventful. The histopathology of the operative specimen showed a malignant amelanotic melanoma arising from the duodenum with lymph nodal involvement. He received oral temozolomide. However, he developed liver metastasis at six months and again at ten months, which was managed with radiofrequency ablation both times. He is doing well at 32 months of follow-up review. Multimodality treatment including surgery, adjuvant chemotherapy and salvage therapy appears to be a promising tool for achieving long-term survival in such patients.

Bacterial isolates from mechanically ventilated patients with nosocomial pneumonia within intensive care unit of a tertiary care center.

Nosocomial pneumonia is a common complication in mechanically ventilated patients. A study was carried out to determine the incidence, common bacterial etiologic agents and their antimicrobial susceptibility, and outcome of such pneumonia in an Intensive Care Unit (ICU) of a tertiary care center. In Surgical ICU (SICU) 176 patients required mechanical ventilation for more than 72 hours. A total of 39 (22.1%) of these patients developed nosocomial bacterial pneumonia as determined by microbiological assays. Endotracheal aspirate cultures detected a single bacterial isolate in 22 (56.4%) patients while two and three organisms were isolated from 10 (25.6%) and 7 (17.9%) patients respectively. Fifty three (84.1%) of a total of 63 isolates were Gram negative bacilli. The most frequently encountered pathogens were Pseudomonas aeruginosa, Klebsiella pneumoniae and Acinetobacter species among the Gram negative bacilli and Staphylococcus aureus among the Gram positives. Resistance of bacterial isolates varied from 24 to 90% against commonly used antibiotics. Amikacin had the best profile, with 14% to 55% resistance against various isolates. Twenty three (59%) of 39 patients with pneumonia expired in the ICU. P. aeruginosa (25.6%) and K. pneunmoniae (17.9%) were the predominant isolates in these patients. Nosocomial pneumonia with high mortality is a frequent occurrence in mechanically ventilated patients in our ICU setting. Gram negative organisms with high levels of antimicrobial resistance are the most common isolates. Regular surveillance and monitoring of changes in antibiotic susceptibility of bacterial pathogens and appropriate therapeutic measures are likely to reduce the mortality in these patients.

Quality of life after oesophagectomy in patients with carcinoma of oesophagus: A prospective study.

Background: The present study was done to see if quality of life improves following oesophagectomy for carcinoma of oesophagus. Materials and Methods: This was a prospective study done from June 2007 to July 2009. All patients undergoing oesophagectomy and cervical anastomoses for squamous cell carcinoma and adenocarcinoma of oesophagus were included in the study. Quality of life assessment was done using EORTC QLQ C-30 and its oesophagus specific module (OES-18) before surgery and at 3, 6, 9 and 12 months. Results: There were 55 patients who underwent oesophagectomy for carcinoma of oesophagus. On the EORTC functional scale it was noted that patients undergoing transhiatal oesophagectomy showed significant improvement of emotional function only. Patients undergoing transthoracic oesophagectomy showed a decrease in functional scores in the first three months which improved later but this change was not significant. On the EORTC symptom scale, patients undergoing transhiatal oesophagectomy showed significant improvement of constipation but not in other symptoms. Patients undergoing transthoracic oesophagectomy showed an increase in symptoms for the first three months followed by a decrease which was significant with respect to scores for constipation and pain. On the EORTC oesophagus specific symptom scores, patients in both groups showed significant improvement of dysphagia and eating. Conclusion: Patients with carcinoma of oesophagus undergoing transhiatal oesophagectomy may not show significant improvement in quality of life. However there will be significant improvement in dysphagia and eating. Patients undergoing transthoracic oesophagectomy may show an initial decrease in the quality of life.

Case report. Schwannoma of both intrahepatic and extrahepatic bile ducts: a rare case.

Schwannoma of the biliary tree is extremely uncommon, with only a few cases having been reported so far. They commonly present with obstructive jaundice. Although involvement of the extrahepatic duct is common, occurrence in the intrahepatic ducts has not been reported. We report a case of combined intrahepatic and extrahepatic schwannoma in a 46-year-old man presenting with obstructive jaundice.

Diphtheria in urban slums in north India.

We recorded a reappearance of cases of microbiologically confirmed diphtheria in a tertiary care hospital in north India. Poor immunisation coverage, population migrations, and overcrowded urban slums may be contributory factors.

PIP: This article highlights the prevalence of diphtheria in urban slums in north India. In 1997, diphtheria cases reached 1326, and in a study conducted in September 1999, 4 diphtheria cases were reported in a tertiary care hospital. These cases occurred despite the vaccination programs against diphtheria. Clinical manifestation included fever, sore throat, dysphagia, and swelling in the neck of 2-10 days duration. Immunization records of these children revealed that 2 were nonimmunized and the other 2 received only 2 doses of diphtheria-pertussis-tetanus vaccine in their first year of life. Using electrocardiography, 3 of the cases were suggestive of myocarditis. Laboratory examinations, such as Albert's staining and Loeffler's serum slope, were used to confirm the diagnosis. This epidemic was found to be caused by a large population of susceptible children and adults, decline in childhood immunization, poor socioeconomic conditions, and large-scale population movements. In conclusion, the 44% dropout rate between the third dose of primary immunization and the first booster could be one factor in the emergence of diphtheria.