Birt-Hogg-Dubé syndrome presenting with bilateral pneumothorax, skin, kidney, liver, and brain lesions.

Birt-Hogg-Dubé syndrome (BHDS) is a rare hereditary autosomal dominant condition characterized by benign cutaneous lesions, lung cysts, and increased risk of spontaneous pneumothorax and renal cancer. We report a case of a young Indian boy with bilateral pneumothorax as the first symptom of BHDS. Detailed history examination and investigation showed multiple facial lesions; his computerized tomography was suggestive of renal angiomyolipoma, hepatic angiomyolipoma, pulmonary cyst with pneumothorax, and small bilateral subependymal soft tissue density lesion with calcification in the brain, all of which were collectively suggestive of BHDS. Identification of the above commonly presented clinical features as a syndrome is important for even a primary care physician so as to ensure the timely management and if required referral to a higher center.

A prospective case-control study of disability, quality of life, and functional impairment of shoulder movements after latissimus dorsi myocutaneous flap reconstruction in breast cancer patients.

Objectives: Dysfunction of shoulder movements could be a limiting factor to the use of Latissimus dorsi (LD) flap. This study aimed to assess the impact of LD flap reconstruction on shoulder dysfunction and the quality of life. Material and Methods: This study comprised 28 early breast cancer cases who underwent breast conserving surgery (BCS) with LD flap and 40 controls. Subjective and objective assessments were done a year later. Results: Mild and moderate disability were found in 85.71% and 14.3% cases vs. 100% and 0% controls (p= 0.316) respectively. Physical and emotional functioning were 84.29 ± 5.61 and 66.67 ± 6.05 in cases vs. 86.67 ± 8.38 and 70.0 ± 6.84 in controls (p= 0.36, 0.23) respectively. Pain score in cases was 23.8 ± 15.6 vs. 12.17 ± 8.4 in controls (p= 0.018). LD muscle strength in extension was 4.39 ± 0.35 in cases vs. 4.88 ± 0.22 in controls (p <0.001), 4.43 ± 0.18 for adduction in cases vs. 4.65 ± 0.24 in controls (p= 0.006). ROM of shoulder in flexion was 151.61 ± 4.86° in cases and 153.88 ± 2.36° in controls (p= 0.08), 40.36 ± 3.52° in cases vs. 49.13 ± 1.86° in controls for extension (p <0.001), in abduction it was 150.54 ± 3.69° in cases vs. 150.00 ± 0.00° in controls (p= 0.518), in adduction was 30.89 ± 4.0° in cases vs. 38.13 ± 1.11° in controls (p <0.001), in external rotation was 73.57 ± 3.63° in cases vs. 77.63 ± 2.36° in controls (p <0.001), and internal rotation was 69.46 ± 3.56° in cases vs. 79.00 ± 1.26° in controls (p <0.001). Conclusion: We conclude that functional impairment should not be a determining factor for LD flap in breast reconstruction surgery.

Detection of drug-resistant Mycobacterium tuberculosis in pericardial fluid culture and its correlation with cartridge based nucleic acid amplification test and adenosine deaminase activity.

BACKGROUND: Pericardial effusion is the accumulation of fluid in the pericardial cavity. In nations with high tuberculosis (TB) load, TB is the most common cause of pericardial effusion. 1-2% of patients with pulmonary TB develop Pericardial TB worldwide. Multi-drug-resistant (MDR) TB, including extrapulmonary TB (EPTB) cases, are rising in number. Adenosine Deaminase (ADA) is an enzyme in lymphocytes and myeloid cells, which has certain immune functions in the body. ADA levels are increased in inflammatory conditions, like pleural, pericardial, or joint effusions, of bacterial etiology, granulomatous conditions, neoplasms, and autoimmune pathologies. TB is the only lymphocytosis involving disease with increased ADA levels. MDR EPTB is rare, but cases are on the rise, and tuberculous pericardial effusion is one such example. Hence, it is important to know the percentage of cases detected by a culture that can be identified by cartridge-based nucleic acid amplification test (CBNAAT), their resistance patterns, and to identify potential markers like ADA, which can help in early identification of cases. The objectives of this study were to identify the Mycobacterium tuberculosis (MTB) bacilli in culture, and correlate them with cartridge-based nucleic acid amplification test (CBNAAT) results and their drug-resistance, in the Pericardial tubercular effusion, and to find if Adenosine Deaminase (ADA) levels can be used as a predictor of the presence of MTB in pericardial fluid. METHODOLOGY: We enrolled 52 patients with moderate to large tuberculous pericardial effusion, based on pericardial fluid analysis, CBNAAT, and culture methods, between January 2021 and December 2021. RESULTS: The mean age of the patients was 41.85 + 17.88 years, with a median of 38 years. Males made up 57.7% of the total patients. MTB was detected in 16 (30.8%) patients in the CBNAAT evaluations. 14 (87.5%) of the CBNAAT-positive TB patients were sensitive to Rifampicin, whereas the remaining 2 (12.5%) were resistant to Rifampicin on CBNAAT. MTB was found to be growing in 8 (15.38%) drug sensitivity test cultures. Out of these 8, 6 were sensitive to first-line drugs, whereas 2 were resistant to both Isoniazid and Rifampicin. The presence of cough was found to have a significant difference between CBNAAT-detected MTB positive and negative patients (p = 0.020), whereas an insignificant difference was found for the presence of hypertension, diabetes mellitus, obesity, dyspnea, or fever. There was also an insignificant difference between the number of patients positive for the Tuberculin skin test, between the two groups. ADA was significantly higher in the MTB-detected CBNAAT group (85.91 + 37.60U/L vs 39.78 + 24.31U/L, p = 0.005), whereas the total leukocyte count, lymphocytes, neutrophils, random blood sugar levels, and serum protein levels had no significant difference. The area under the Receiver Operator Curve (CBNAAT positive: dependent variable; ADA: test result variable) was 0.854 (null hypothesis rejected), with a standard error of 0.078. CONCLUSIONS: Culture is the gold standard method to diagnose tuberculosis. Detection of MTB on pericardial fluid culture is very uncommon, though in our study, culture came out positive in 16% of patients, and 4% were resistant to rifampicin and isoniazid. Higher ADA levels in pericardial fluid are an indicator of tuberculous pericardial effusion.

Primary Right Adrenal Teratoma in a Postmenopausal Female: a Case Report and Review of Literature.

Non-seminomatous germ cell tumors with structural components from all three cellular lineages are called teratomas. We report a rare case of a primary right adrenal teratoma in a postmenopausal female, presenting with abdominal pain. Ultrasound revealed a complex cystic shadow in the perihepatic region superior to the upper pole of the right kidney, which was suggestive of a complex supra-renal space-sequence-occupying lesion. Computerized tomography revealed a large-sized mature single multilobulated complex cystic lesion in the right hypochondrial lumbar region arising from the right adrenal gland. A right-sided transperitoneal adrenalectomy was performed. The resected mass (18 × 13 × 10 cm) was well encapsulated. Cut surfaces showed cystic mass filled with necrotic gray-white pultaceous material, along with a solid white gelatinous area. Microscopic sections showed a tumor which displayed differentiation along various tissue lineages. After immunohistochemical examinations, the tumor was confirmed to be a mature cystic teratoma. Mature teratomas show a good prognosis, and surgical resection and follow-up remain the standard approach.

The unpredictable resorption of bioresorbable scaffolds-A tale of two ABSORBs.

Bioresorbable stents represent a revolutionary treatment for coronary artery disease. Such a device offers the prospect for complete naturalization of artery lumen after strut resorption and restoration of vasomotion while curtailing the duration of dual anti-platelet therapy. The prototype bioresorbable scaffold (BRS-ABSORB GT1) demonstrated good feasibility and safety in the initial studies compared to metallic drug eluting stent but later fell out of favor due to multiple report of stent thrombosis and target lesion failure. Unpredictable resorption of struts turned out to be one of the "Achilles heel" of the BRS and stent strut were still visible in vessel on optical coherence tomography (OCT) at 3 years. We report a case of differential resorption of two ABSORB BRS implanted simultaneously in the same patient by the same operator. Follow up coronary angiogram revealed only minimal plaques on right coronary artery (RCA) and left anterior descending artery (LAD). The BRS were identified on cine-angiogram by their radio-opaque markers at both ends. The OCT run in LAD artery revealed "ghost remnants" of BRS struts in LAD, whereas the RCA BRS had completely healed with minimal "ghost" struts. The ghost remnants of BRS resembled the original "Check box" appearance on OCT during the index implantation.

Variations in the Termination of the Popliteal Artery: A Multidetector Computed Tomography Angiography (CTA)-Based Retrospective Study.

BACKGROUND: Comprehension of the intrucate anatomy and variations in the termination of the popliteal artery (PA) is increasingly essential for endovascular interventionists, plastic surgeons, vascular surgeons, and orthopedic surgeons, due to the rise in procedures like embolectomy, vascular grafting, free fibular flap surgery, and high-tibial osteotomy. Few studies from India have reported on the variant anatomy of PA termination, and none have used 128-slice tomography. This study aimed to observe the terminal branching pattern of the PA and the morphology of its terminal branches using 128-slice computed tomography angiography (CTA) and to analyze its relation to gender and laterality. METHODOLOGY: A retrospective review of CTA images of 181 lower extremities from 100 patients (137 males and 44 females), aged five to 75 years, was conducted. RESULTS: The usual type I-A pattern was found in 75.69% of cases, while 24.31% exhibited variant patterns. Type III was the most common variation observed (19.34%), with type III-A being the most prevalent (11.05%). Types II-B and II-C were not observed. Among 84 bilaterally examined cases, 19.05% had unilateral variations and 15.48% had bilateral variations, with 8.33% showing bilaterally similar variations and 7.14% dissimilar variations. No significant difference in branching patterns was found between genders or sides. The mean length of the tibial-peroneal trunk (TPT) in the type I-A pattern was 3.00 ± 0.99 cm (right side: 3.21 ± 1.02 cm; left side: 2.82 ± 0.93 cm; males: 2.9 ± 1.00 cm; females: 3.37 ± 0.85 cm), with statistically significant differences between sides and genders. In the type II-A pattern, the mean TPT length was 7.16 ± 3.75 cm. An exceptionally long TPT (12.97 cm) was noted in one case of the III-B pattern. CONCLUSION: There is a high prevalence of variation in the termination pattern of the PA. Knowledge of these variations is crucial for any interventions in this region to avoid postoperative vascular complications and reduce patient suffering.

Cerebral venous sinus thrombosis due to desogestrel intake in a young lady: A case report.

Cerebral Venous Sinus Thrombosis (CVST) is a subtype of venous thromboembolism, which occurs in the dural venous sinuses. Blockage of the venous drainage of the brain leads to the development of hemorrhages. Strokes can hence develop in any individual, irrespective of age or sex. CVST is a very serious condition requiring immediate thrombolysis to prevent residual neurological deficits. We report the case of a lady aged 25 years, who presented to the emergency department with a severe diffuse headache for 4 days, associated with vomiting. This was followed by multiple episodes of seizures and altered sensorium the previous day. She had been taking desogestrel for the past 2 months. On examination, the patient was unconscious and febrile (102.8 F). On admission, Glasgow Coma Scale score of E2V2M3 and bilateral extensor plantar response were noted. Signs of meningeal irritation were absent. Her pupils were mid-dilated, sluggishly reactive to light, and papilledema was present bilaterally. Based on imaging studies, she was diagnosed with a case of CVST. Her homocysteine levels were elevated. She recovered on appropriate treatment and was discharged on Ryle's feeding tube after 26 days of hospital stay with a Glasgow Coma Scale score of E4V5M6 and a flexor plantar response. The case emphasizes the need to rule out CVST in young adult females on oral contraceptive pills (OCP) presenting with severe neurological dysfunction. Vigilant screening, clinical suspicion and timely management can help cut down the associated mortality and morbidity in such cases.

Prospective Study to Evaluate Efficacy of Single Versus Double Drains in Breast Cancer Patients Undergoing Surgery.

Seroma formation is a common sequel following modified radical mastectomy (MRM), which hinders healing, may prolong hospital stay, and cause a delay in adjuvant treatment. Closed suction drains have been used to prevent formation of seroma; however, the use of a single drain in the axilla along with draining the mastectomy flaps and axilla separately remains a topic of debate. This prospective randomized dual-arm study was conducted in the Department of Endocrine Surgery. All female patients with carcinoma breast diagnosed on core tissue biopsy, undergoing modified radical mastectomy, upfront or post neoadjuvant systemic therapy were included. Patients were randomized into two groups. In the first group, a single drain was placed in the axilla whereas in the second group, a drain each was placed below the mastectomy flaps and the axilla. Patients' particulars and the weight of the mass excised along with the operative details were documented. The volume of the drain was recorded daily. The flap drain was removed on postoperative day 5 and the axillary drain was removed when the drain volume was less than 30 mL/24 h for 2 consecutive days. The period of drain placement, volume of drainage, volume of seroma (if formed), and other complications (if any) were recorded. Patients in the single drain group had a significantly earlier drain removal time as compared to those with double drains (p = 0.01). The number of patients in whom seroma formation had occurred was more in the double drain group, but the difference was not significant. The average volume of aspirated seroma fluid was insignificantly more in the single drain group. The only other complication noticed was flap necrosis-in 5% patients of the double drain group. Total volume of drainage (p < 0.0001) and type of drain (p = 0.0208) were associated with higher rates of seroma formation, whereas BMI (p = 0.0516), weight of excised breast mass (p = 0.407), and age (p = 0.6379) were not associated with the rate of seroma formation. Outcomes in terms of drain volume or seroma formation were statistically indifferent between the two groups. Still, use of only a single axillary drain should be promoted, keeping in mind the earlier drain removal period, better patient compliance, and reduced hospital stay.

Intracranial Microhemorrhages in a Patient With Tubercular Meningitis (TBM): A Case Report.

Intracranial tuberculosis (TB) is the most serious form of systemic TB and constitutes an important cause of morbidity and mortality in underdeveloped countries. Central nervous system TB is a difficult diagnosis to make, and treat, especially in the developing nations. Intracranial hemorrhage is one of the rare complications of intracranial TB. We are reporting a case of a 70-year-old male patient who presented to the neurology ward with complaints of persistent high-grade fever associated with significant weight loss, night sweats, and hemolysis for two months. Cerebrospinal fluid analysis was suggestive of tubercular meningitis. He was started on first-line antitubercular therapy. After two weeks, he developed respiratory distress, and invasive mechanical ventilation was started. He was then referred to the Intensive Care Unit of the Critical Care Medicine department. Susceptibility weighted images magnetic resonance imaging (MRI) revealed multiple nodular and ring-enhancing lesions with multifocal areas of microhemorrhages in the brain parenchyma, and leptomeningeal enhancement in bilateral sylvian, perimesencephalic, prepontine and cerebellopontine angles. A tracheostomy was performed. He also developed septic shock for 72 hours, secondary to Pseudomonas aeruginosa and Acinetobacter baumannii ventilator-associated pneumonia, and Klebsiella bacteremia for which intravenous noradrenalin, Carbapenem and Colistin were administered. The patient improved within eight weeks. Our case presented with altered sensorium for the past three to four days but generally, there are other common features like headache, seizures, focal neurological deficit, and raised intracranial pressure. MRI findings of caseating tuberculomas reveal isointense to hypointense signals on both T2 and T1 weighted images with ring enhancement, which are in resemblance with the MRI findings of our case.

Cardiac tamponade and basilar artery aneurysm following leptospirosis: A case report.

Complications involving the heart are rare in leptospirosis, and cardiac tamponade is still rarer. We report the case of a 42-year-old hypertensive woman who presented with complaints of cough for 2 months and breathlessness for 1 month. One month later, she developed shortness of breath and loss of consciousness. The patient had a history of hemiparesis. Serum anti-Leptospira immunoglobulin M ELISA was positive. Ultrasound showed pericardial tamponade and hemorrhagic collection. Two-dimensional echocardiography showed minimal effusion posterior to the left ventricle and no effusion present to the right ventricle. High-resolution computerized tomography revealed patchy areas of ground glass opacities in bilateral upper and bilateral lower lobes, prominent bronchovascular markings bilaterally, and minimal pericardial thickening. Magnetic resonance imaging of the brain showed small chronic infarcts in bilateral corona radiata and basal ganglia. A magnetic resonance angiogram of the brain showed a basilar top aneurysm, which was an incidental finding. No signs of rupture of the aneurysm were seen. Digital subtraction angiography showed 50%-70% stenosis at the junction of the V3-V4 segments of the vertebral artery. The right lower limb immobilization, along with ecosprin, ivabradine, amlodipine, and fluconazole, was started, to which the patient responded well.

Cost-Effective Offloading of Diabetic Foot Ulcer in a Resource-Crunch Setting: A Case Report.

Diabetic foot ulcers (DFUs) pose a significant threat to people with diabetes, particularly in regions with limited healthcare resources, such as India. This case report focuses on a cost-effective offloading strategy for managing a chronic non-healing heel ulcer in a 55-year-old female with uncontrolled type 2 diabetes mellitus. While the gold standard for DFU management often involves total contact casts, this method may not be practical for all patients. Our approach involved repurposing used gloves and surgical paper tape for offloading, resulting in quick healing of the ulcer within six weeks. Achieving euglycemic status and sufficient wound debridement were key components of the treatment. This case highlights the importance of resource-efficient strategies in DFU management, especially in settings where traditional methods face practical limitations. Future research is needed to validate the efficacy of such approaches and pave the way for more accessible and effective treatments for DFUs.

Expanded Dengue Syndrome Presenting as Intracranial Hemorrhage, Fever, and Rhabdomyolysis: A Case Report.

Rare clinical manifestations of dengue are included under the expanded dengue syndrome (EDS), with intracranial hemorrhage (ICH) being one of them. We discuss an uncommon presentation of dengue with basal ganglia hemorrhage, hyperthermia, and rhabdomyolysis in a 53-year-old hypertensive female who presented with sudden onset syncope, left-sided weakness, and altered sensorium for days, with high-grade fever and vomiting. The Glasgow coma scale (GCS) score was 5, and the patient was intubated. Noncontrast computerized tomography (NCCT) of the brain revealed right basal ganglia bleeding with intraventricular hemorrhage. Electrocardiography (ECG) revealed sinus tachycardia. The patient had spikes of high-grade fever, rhabdomyolysis, stage III acute kidney disease, and coagulopathy. Dengue IgM antibodies were positive. Treatment was started, and the patient was in the intensive care unit (ICU) for six months, following which she was discharged. Given this, one can speculate on the importance of viral diseases presenting with ICH as these are rare and are diagnosed quite late, which can also prove to be fatal.

Monitoring Macro- and Microcirculation in the Critically Ill: A Narrative Review.

Circulatory shock is a common and important diagnosis in the critical care environment. Hemodynamic monitoring is quintessential in the management of shock. The currently used hemodynamic monitoring devices not only measure cardiac output but also provide data related to the prediction of fluid responsiveness, extravascular lung water, and also pulmonary vascular permeability. Additionally, these devices are minimally invasive and associated with fewer complications. The area of hemodynamic monitoring is progressively evolving with a trend toward the use of minimally invasive devices in this area. The critical care physician should be well-versed with current hemodynamic monitoring limitations and stay updated with the upcoming advances in this field so that optimal therapy can be delivered to patients in circulatory shock.

Psychological Assessment and Treatment Effectiveness in Mastalgia: Developing a Treatment Algorithm.

Background Mastalgia often impairs the physical, social, and sexual lives of women. It may manifest in both cyclical or acyclical patterns. The psychoneurotic association of mastalgia has been claimed for a long time in various available literature. Several treatment options have been used and are available in the market for mastalgia, but no specific guidelines are currently in place at the global or local levels. This study aims to evaluate the psychological status and effectiveness of various treatment options in women presenting with mastalgia. Methods This study was conducted in the General Surgery outpatient department from February 1 to November 30, 2021, at King George's Medical University, Lucknow, India. Females of all age groups presenting to the General Surgery outpatient department with unilateral/bilateral breast pain and/or chest wall pain were considered for this study. Pregnant patients, those with a history of allergy to drugs, or those who were lost to follow-up were excluded from the study. The psychological status of patients was assessed using the Depression Anxiety and Stress Scale (DASS-42) scale. Pain assessment was performed using a visual analog scale (VAS). Patients were divided into five categories: (i) isolated chest wall pain, (ii) isolated breast pain, (iii) both chest wall and breast pain, (iv) pain with an associated lump(s), and (v) pain and tenderness isolated over the lump, and two groups: Group-A: VAS≤4, and Group-B: VAS>4. Group B patients in Category iv were randomized into two groups: topical non-steroidal anti-inflammatory drugs (NSAIDs) or evening primrose oil+vitamin E. The next line of treatment was tamoxifen 10mg followed by danazol 100mg followed by ormeloxifene 30mg. Results The mean age of 106 participants enrolled was 31.59±10.52 years. The mean scores, using the DASS-42 scale, for depression, anxiety, and stress were 7.31±8.53, 7.08±6.57, and 11.15±8.07, respectively. The depression, anxiety, and stress scores had no significant correlation with pain scores (p =0.84, 0.99, and 0.97 for depression, anxiety, and stress, respectively), or duration (p=0.69, 0.66, and 0.85 for depression, anxiety, and stress, respectively). Twenty-nine of 43 patients (67.44%) responded to topical NSAIDs as first-line treatment, and out of the remaining, 6.98% responded to evening primrose oil + vitamin E, 18.60% to tamoxifen, and 4.65% to danazol. Twenty-nine of 32 patients (90.63%) responded to evening primrose oil+vitamin E as first-line treatment, while 6.25% and 3.12% responded to tamoxifen and danazol, respectively.  Conclusions Both topical NSAIDs and evening primrose oil + vitamin E were found effective first-line treatment options in the majority of patients. Hence, it is always advisable to start such patients on topical NSAIDs, or evening primrose oil + vitamin E, before switching over (if no resolution of pain is reported with these drugs) to higher and more severe treatment options. The duration or severity of pain did not correlate with the psychological condition of the patient.

Silico-tuberculosis amidst COVID-19 pandemic: global scenario and Indian perspective.

Inhalation of crystalline silica-rich dust particles can result in the deadly occupational lung disorder called silicosis. The risk of contracting tuberculosis (TB) and the potential for lung cancer increase due to silicosis. This review article aims to bring to light the state of silicosis and TB scenario in the world and India for evaluating hurdles in the present and future to achieve the elimination road map and assess these conditions in the backdrop of the COVID-19 pandemic. A patient with silicosis has a 2.8-2.9 times higher risk of developing pulmonary TB and 3.7 times that of extrapulmonary TB. Incidences of missed cases when TB was misdiagnosed with silicosis due to indifferent clinical manifestations of the two in the initial stages are not uncommon. The duration of silica exposure and silicosis severity are directly related to the propensity to develop TB. As per a study, an average gap of 7.6 years has been noticed in a South African population for silico-tuberculosis to develop post-silicosis. In a study done on mine workers at Jodhpur, Rajasthan, it was seen that there is no definitive relation between patients with silicosis and the possibility of having COVID-19. There is a significant need to integrate the Silicosis control program with the TB elimination program for the government. A few steps can include assessing the workplaces, periodic monitoring of the workers' health, active case surveillance, identification of hotspots, and introducing reforms to curb the spread of dust and particulate matter from industrialised areas be taken in this regard.

A Prospective Observational Study on the Outcome Assessment of Conservative Management Versus Intercostal Drainage (ICD) in Blunt Chest Injury Patients With ≤3 Rib Fractures in a North Indian Tertiary Care Center.

Introduction Trauma is the third most common cause of death in all age groups. One out of four trauma patients die due to thoracic injury or its complications. Seventy percent of thoracic traumas are due to blunt injury. This indicates the importance of chest trauma among all traumas. Quick and precise assessment bears paramount importance in deciding life-saving and definitive management. Often, the initial management in blunt injury patients is based on subjective assessment by the attending clinician. A scoring system that provides early identification of the patients at the greatest risk for respiratory failure and more likely to require mechanical ventilation and require prolonged care, as well as those with a higher mortality risk, may allow the early institution of intervention to improve outcomes. Thoracic Trauma Severity Score (TTSS) poses to be a precise tool in directing the management modality to be employed. Methodology This was an observational study including 112 patients of age >12 years, with blunt chest injury, sustaining ≤3 rib fractures, and with a stable chest wall. The patients with penetrating injury, those with blunt chest injury having flail segment, patients in the pediatric age group (<12 years), or polytrauma patients were excluded from our study. Of the 112 patients, 56 had been managed by intercostal drainage (ICD), and the rest (56) had been managed conservatively. Result Road traffic accidents (RTA) were the most common mode of injury in both groups. The percentage of the patients with one, two, and three rib fractures was 57.14%, 32.14%, and 10.71%, respectively, in the ICD group and 85.71%, 7.14%, and 7.14%, respectively, in the conservative management group (p = 0.124). The mean TTSS score was significantly more in the ICD group as compared to the conservative management group in the single rib fracture patients (p = 0.001*), as well as all patients of any number of rib fractures (p < 0.01*) (significance was defined as a value of p less than 0.05 {indicated by an asterisk}). The mean hospital stay was significantly lower in the conservative group as compared to the ICD group (p < 0.01*). The mean SF-36 (outcome) was significantly more in the conservative management group as compared to the ICD group (p = 0.020*). The mean cost of treatment was significantly more in the ICD group as compared to the conservative management group (p < 0.001*). Conclusion In our study, a TTSS (as measured by the primary care surgeon) of >7, across any number of rib fractures, was preferably predictive of management by ICD, while a <7 value was favorable for conservative management. TTSS can be used as an important tool to predict the management modality in blunt chest injury patients with ≤3 rib fractures.

A tale of two in stent restenosis in same patient: Surprising findings from optical coherence tomography.

Key Clinical Message: The morphology of in-stent restenosis (ISR) in drug eluting stents varies greatly from that of bare metal stents. Optical coherence tomography (OCT) is a useful aid for identifying the nature of ISR and planning the treatment accordingly, which may be by intravascular lithotripsy, cutting balloon or Rotablator, which can be used upfront if OCT shows calcified neoatherosclerosis. Abstract: Restenosis is the decrease in the diameter of the vessel lumen after the performance of percutaneous intervention (PCI), which may or may not involve the implantation of a stent. The morphology of in-stent restenosis (ISR) in drug eluting stents (DES) vary greatly from that of bare metal stents (BMS). We present the case of a 60-years-old lady, who was a follow up case of PCI of the left anterior descending artery with DES and left circumflex artery using BMS 16 years ago. Optical coherence tomography (OCT) revealed both neoatherosclerosis and neointimal hyperplasia in both DES as well as BMS. The morphology of ISR in DES differed from that of BMS. PCI and pharmacological strategies form the main stream of management in case of neointimal hyperplasia. Detection of pattern of ISR on OCT can direct the management of a particular patient, which may be by the use of adjunct devices like intravascular lithotripsy, cutting balloon and Rotablator, which can be used upfront if OCT shows calcified neoatherosclerosis.

Serum Vitamin D Level as a Risk Factor and Prognostic Marker for Acute Ischemic Stroke: A Case-Control Study at a Tertiary Care Centre in Northern India.

Introduction Stroke is a predominant cause of death worldwide. Major risk factors for stroke in any age group are diabetes, hypertension, heart disease, smoking, and long-term alcohol abuse. It is of utmost importance to identify the risk factors for stroke to prevent recurrence. Vitamin D deficiency is identified as a risk factor for stroke. Therefore, we attempted to look for a correlation between vitamin D levels and acute ischemic stroke. Methods This observational case-control study was conducted with 150 patients (75 cases and 75 controls). On the day of admission, the National Institutes of Health Stroke Scale (NIHSS) score was calculated, and vitamin D levels were measured for each patient. The functional outcome was determined by the modified Rankin scale (mRS). Results The most common risk factors identified in this study were hypertension (61.3%), diabetes mellitus (41.3%), and smoking (37.3%). Out of 75 patients enrolled in the study, 49.4% had significant vitamin D deficiency, and 30.6% had insufficient vitamin D levels. Our study showed a significant correlation between vitamin D sufficiency in the body and the incidence of stroke (x2=3.888 and p=0.048). A significant correlation (p=0.03) was found between the NIHSS score and vitamin D levels in patients with acute ischemic stroke. Conclusion In this observational case-control study, we concluded that the increasing severity of vitamin D deficiency was associated with more deaths and poor outcomes.

Pyopneumothorax Secondary to Pulmonary Tuberculosis Superadded by Congenital Factor XIII Deficiency: A Case Report.

Pyopneumothorax is a rare complication of pulmonary tuberculosis, contributing significantly to morbidity and mortality. Additionally, factor XIII deficiency, a rare bleeding disorder, may pose a diagnostic challenge due to normal results in routine coagulation tests. We present the case of an 18-year-old boy who presented with a history of left-sided pyopneumothorax secondary to drug-sensitive Mycobacterium tuberculosis, complicated by congenital factor XIII deficiency. After three months of intercostal drainage placement, the patient developed severe anemia and bleeding tendencies, necessitating a referral to clinical hematology. Genetic testing revealed factor XIII deficiency. This case highlights the complicated interplay between tuberculosis-related complications and a coexisting genetic disorder, highlighting the importance of comprehensive clinical assessment and multidisciplinary management.

Acute Pancreatitis as a Rare Complication of Scrub Typhus: A Case Report.

Scrub typhus is transmitted by the bite of chiggers (larvae) of Leptotrombidium deliense and is caused by the bacteria Orientia tsutsugamushi. Common symptoms include fever, headache, lymphadenopathy, and black eschar formation, while acute pancreatitis is a rare complication. We present the case of a 27-year-old gentleman, who presented with epigastric pain and constipation for three weeks, fever for four days, and vomiting for two days. Serum lipase, C-reactive protein, and serum amylase were significantly raised. Enzyme-linked immunosorbent assay anti-scrub typhus IgM was positive at 0.605 optical density. An abdominal computed tomography scan revealed a bulky pancreas. Mild fluid collection (50 × 60 × 65 mm) was seen in the peripancreatic region, along with moderate to gross mesenteric fat stranding. The left anterior and lateral renal conal fascia were thickened and edematous. The patient was managed with intravenous fluids, antipyretics, and intravenous doxycycline.