OSCE as a Summative Assessment Tool for Undergraduate Students of Surgery-Our Experience.

Traditional examination has inherent deficiencies. Objective Structured Clinical Examination (OSCE) is considered as a method of assessment that may overcome many such deficits. OSCE is being increasingly used worldwide in various medical specialities for formative and summative assessment. Although it is being used in various disciplines in our country as well, its use in the stream of general surgery is scarce. We report our experience of assessment of undergraduate students appearing in their pre-professional examination in the subject of general surgery by conducting OSCE. In our experience, OSCE was considered a better assessment tool as compared to the traditional method of examination by both faculty and students and is acceptable to students and faculty alike. Conducting OSCE is feasible for assessment of students of general surgery.

Bilateral parotid swelling: a radiological review.

Bilateral parotid swelling is not an uncommon occurrence and may pose a challenge for clinicians and radiologists. Numerous causes of bilateral parotid swellings have been identified. The purpose of this pictorial review is to display this wide array with a focus on multimodality approach.

MR sialography of iatrogenic sialocele: comparison with conventional sialography.

OBJECTIVE: The objective of this study was to compare the conventional sialography with MR sialography in a series of patients with iatrogenic sialocele (sialocyst). METHODS: 50 salivary glands in 39 patients with suspected inflammatory disease of the salivary gland underwent conventional sialography and MR sialography. Out of these 39 patients, 6 patients (age range: 16-35 years; 4 males and 2 females; mean age: 23.8 years) had sialoceles and formed our study group. MR sialography findings were compared with conventional sialography findings regarding demonstration of ductal anatomy, the cyst and its communication with the ductal system. RESULTS: MR sialography demonstrated the site of communication of the sialocyst with the ductal system in all six patients. MR provided additional information over conventional sialography in five cases. In four cases, the ductal system proximal to the cyst was not opacified on digital sialography but was well visualized in all cases by MR sialography. Constructive interference in steady-state (CISS) sequence demonstrated the intraglandular ducts and communication of cysts with ducts better than half-fourier acquisition single-shot turbo-spin echo (HASTE) images. CONCLUSION: Our preliminary results suggest that MR sialography is a robust, non-invasive method for demonstrating the ductal system up to second-order branches, the site of ductal injury and the focal cystic lesion. MR provided at least the same information as conventional sialography in the evaluation of site of communication but provided additional information about the sialocyst and upstream ductal system in five cases. Being a non-invasive modality, we recommend MR sialography as the investigation of choice in the evaluation of an iatrogenic sialocyst.

Prognostic significance of location of the primary tumor in operable breast cancers.

BACKGROUND: The prognostic significance of the primary tumor site in breast cancers is not established with only a few studies having evaluated the issue. MATERIALS AND METHODS: The relevance of a primary tumor site with respect to systemic disease relapse was evaluated in 187 patients with breast cancer treated with primary surgery and adjuvant chemotherapy, in whom the location of primary tumor was classifiable in any one of the three sites, namely: outer, periareolar, and inner, quadrants. Data was obtained from prospectively maintained records of breast cancer patients treated at a single surgical unit in a tertiary care center. RESULTS: The three groups were comparable with regard to demographic, pathological tumor, and treatment characteristics. In the multivariate analysis, patients with inner and periareolar quadrant tumors had a higher hazard for systemic disease relapse, (2.53, 95% CI: 1.18-5.42; P = 0.02, and 2.73, 95% CI: 1.04-7.14; P = 0.04, respectively) as compared to outer quadrant tumors. The projected five-year survival estimates in Kaplan Meier were 87%, 61%, and 69%, respectively, for outer, periareolar, and inner quadrant. On further substratification the difference was particularly noted in high risk inner quadrant tumors: age 45, premenopausal patients, tumor size> 2 cms, positive nodes and intermediate or high grade histology, as also in patients treated with breast conservation and CMF, Cyclophosphamide, Methorexate, 5 Fluorouracil chemotherapy. CONCLUSION: The location of the primary tumor influences survival in breast cancer with inferior outcome for tumors in inner and periareolar quadrants, especially in high risk groups and those treated with conservative approaches. The role of aggressive therapies merits investigation in these patients.

Structural heterogeneity of yolk spheres in hierarchical follicles from hen ovary: a histochemical study.

1. Four types of yolk spheres with variable structure, chemical composition and frequency of occurrence in yolk plasma of hierarchical follicles (F(4), F(3), F(2) and F(1) with diameters of 10.0, 15.5, 20.0 and 35.0 mm, respectively) of the hen ovary were identified using histochemical methods for localising lipids, carbohydrates and proteins. 2. Yolk spheres of the first type (YS(1)) had a phospholipoprotein membrane surrounding fluid matrix which stained lightly for phospholipids, proteins and acidic mucopolysaccharides. Two types of droplets were observed in the matrix of YS(1). Spheres of the second type (YS(2)) had a lipoprotein- and acidic mucopolysaccharide-rich peripheral region and a single large droplet in its fluid matrix. Droplets of YS(2), unlike YS(1), showed three regions and metachromatic staining with ninhydrin-Schiff reagent. The third type of sphere (YS(3)) had a homogeneous matrix staining for proteins, neutral lipids and florescent yellow with alcian blue and differentially with ninhydrin-Schiff reagent; it was bounded by a phospholipids- and acidic mucopolysaccharide-containing thick peripheral region. Its fluid matrix also showed toluidine-blue-positive, densely packed granules and small droplets. The fourth type (YS(4)) was seen only in bromophenol blue and Nile blue preparations, revealing the presence of proteins and neural lipids in their matrix and peripheral regions. 3. Quantitative data on the relative abundance of yolk spheres in F(4) to F(1) follicles revealed more YS(3) (51.1 to 64.7%) than YS(1) (16.2 to 28.3%) and YS(2) (19.1 to 23.2%). The percentage of YS(1) increased and that of YS(3) decreased as follicle size increased.

A phase II study of sequential neoadjuvant gemcitabine plus doxorubicin followed by gemcitabine plus cisplatin in patients with operable breast cancer: prediction of response using molecular profiling.

This study examined the pathological complete response (pCR) rate and safety of sequential gemcitabine-based combinations in breast cancer. We also examined gene expression profiles from tumour biopsies to identify biomarkers predictive of response. Indian women with large or locally advanced breast cancer received 4 cycles of gemcitabine 1200 mg m(-2) plus doxorubicin 60 mg m(-2) (Gem+Dox), then 4 cycles of gemcitabine 1000 mg m(-2) plus cisplatin 70 mg m(-2) (Gem+Cis), and surgery. Three alternate dosing sequences were used during cycle 1 to examine dynamic changes in molecular profiles. Of 65 women treated, 13 (24.5% of 53 patients with surgery) had a pCR and 22 (33.8%) had a complete clinical response. Patients administered Gem d1, 8 and Dox d2 in cycle 1 (20 of 65) reported more toxicities, with G3/4 neutropenic infection/febrile neutropenia (7 of 20) as the most common cycle-1 event. Four drug-related deaths occurred. In 46 of 65 patients, 10-fold cross validated supervised analyses identified gene expression patterns that predicted with >or=73% accuracy (1) clinical complete response after eight cycles, (2) overall clinical complete response, and (3) pCR. This regimen shows strong activity. Patients receiving Gem d1, 8 and Dox d2 experienced unacceptable toxicity, whereas patients on other sequences had manageable safety profiles. Gene expression patterns may predict benefit from gemcitabine-containing neoadjuvant therapy.

Effects of monosodium glutamate on food acceptance and toxicity of selenium in rats.

Food acceptance and toxic effects of feeding sodium selenite (Se) alone and in combination with monosodium glutamate (MSG), a taste enhancer were studied in the laboratory rat. Dose-dependent stimulation of daily food intake was observed with MSG offered in no-choice or bi-choice with the plain food. Consumption of pellets containing 0.05, 0.5 and 1.0% Se was significantly low than the plain or MSG containing pellets but their active ingredient was sufficient to cause mortality of rats. Food pellets containing both MSG and Se in no-choice feeding trial were not preferred by the rats, as their consumption remained low as compared to pellets containing only MSG. However, prior feeding on MSG containing pellets for two days increased the amount of intake of Se-containing pellets. No mortality of rats feeding on pellets containing different concentrations of MSG was recorded. Feeding on Se-containing pellets caused dose-dependent mortality on the third day of the trial. As compared to rats feeding on Se-containing pellets, the mortality rate was reduced in those provided Se in combination with MSG but the intake of active ingredient of Se in both these trials did not differ significantly. Decrease in death rate of rats feeding on Se in combination with MSG containing pellets suggested that addition of MSG to seleniferous food probably provide protection to some extent from the toxic effects of selenium. However, combination of excess doses of MSG and Se in food pellets caused mortality of all experimental animals.

Second echelon node predicts metastatic involvement of additional axillary nodes following sentinel node biopsy in early breast cancer.

BACKGROUND: In many patients with early breast cancer, the sentinel lymph node (SLN) is the sole site of regional nodal metastasis. This subgroup of patients may not benefit from completion axillary lymph node dissection (CALND). AIMS: This pilot study evaluates the status of 2nd echelon (station) lymph nodes in the axilla as a predictor of additional positive nodes in the axilla in the presence of sentinel node metastasis. SETTINGS AND DESIGN: Cross-sectional study of 40 breast cancer patients. MATERIALS AND METHODS: Forty patients with invasive breast cancer underwent SLN biopsy followed by 2nd echelon lymph node biopsy in the same sitting. SLN mapping was performed using a combined technique of isosulfan blue and 99 mTc-sulfur colloid. SLNs (Station I) were defined as blue and/or hot nodes. These nodes were then injected with 0.1 ml of blue dye using a fine needle and their efferent lymphatic was traced to identify the Station II nodes. Then a complete ALND was performed. All the specimens were sent separately for histopathological evaluation. RESULTS: SLNs (Station I nodes) were successfully identified in 98% (39/40) patients. Of the 17 patients with a positive SLN, 8 (47%) patients had no further positive nodes in the axilla, 9 (53%) patients had additional metastasis in nonsentinel lymph nodes upon CALND. Station II nodes were identified in 76% (13/17) patients with a positive SLN. Station II nodes accurately predicted the status of the remaining axilla in 92% patients (12/13). STATISTICAL ANALYSIS: We calculated the Sensitivity, Negative predictive value, Positive predictive value, False negative rate and Identification rate. CONCLUSION: Station II nodes may predict metastatic involvement of additional nodes in the axilla.

Effect of preoperative short course famotidine on TILs and survival in breast cancer.

BACKGROUND: Histamine receptor antagonists have been shown to induce tumor-infiltrating lymphocytes (TILs) in colonic cancers and improve survival. The role of histamine receptor anatagonists in breast cancer is unclarified. AIM: To evaluate the role of histamine receptor antagonists in inducing (TILs) in breast cancer. METHOD: Forty-five patients with operable breast cancers (25 cases who received preoperative famotidine and 20 controls) were studied for the effect of famotidine in inducing TILs and survival in breast cancer. RESULTS: Significant TILs were seen in 75% (18/24) of cases as opposed to 35% (7/20) controls. In logistic regression analysis the only variable found to be predictive of TILs was famotidine, odds ratio 7.324 (1.693-31.686) P=0.008. In Cox's regression presence of TILs was favorably associated with improved disease free survival at a median follow up of 35.56 months. The hazard ratio for disease relapse was 3.327 (1.174-9.426) P=0.024 in TIL negative as compared to TIL positive patients. Famotidine use alone was not significant in the original model, however, on incorporation of quadrant of involvement in addition to other established prognostic factors in the above multivariate model, it assumed borderline significance with a hazard ratio for disease free survival 3.404 (1.005-11.531, P=0.049). CONCLUSIONS: Preoperative short course famotidine induces TILs in breast cancer. Patients with TILs demonstrable in tumor specimens had an improved disease free survival. Famotidine may improve disease free survival in breast cancer and these findings need validation in larger population subsets.

Neoadjuvant chemotherapy in squamous cell carcinoma of the esophagus using low dose continuous infusion 5-fluorouracil and cisplatin: results of a prospective study.

BACKGROUND: Surgery is the treatment of choice for localized esophageal squamous cell carcinoma (ESCC). Despite curative surgical resection, the majority of patients develop local and systemic recurrence with poor 5-year survival. AIMS: To study the role of low dose continuous infusion (CI) 5-fluorouracil (5-FU) and cisplatin as neoadjuvant chemotherapy in ESCC. SETTINGS AND DESIGN: A non-randomized prospective study conducted over a period of two years (1996-1998) in the Department of Surgery, All India Institute of Medical Sciences, India. MATERIAL AND METHODS: Twenty-two patients with ESCC were included in the study. Chemotherapy consisted of a continuous 30-day infusion of 5-FU (350 mg/m2/day) and cisplatin (7.5 mg/m2/day), 5 days/week for 4 weeks. All patients had surgery following chemotherapy. RESULTS: A full course of chemotherapy was completed in 18 patients (82%). Chemotherapy was not completed due to non-compliance (n=2), thrombophlebitis (n=1), and vomiting (n=1). Grade-1 haematological and hepato-toxicity was observed in four patients. Thirteen patients developed thrombophlebitis. After chemotherapy, improvement in dysphagia was observed in 13 of 22 (59%) patients. Radiological partial response was observed in 8 patients (36.4%). 19 patients underwent surgical resection (86.4%) with zero mortality. Post-operative morbidity was observed in six patients (27%). Complete and partial pathological response was observed in two (11%) and one patient (5.5%) respectively. The overall median survival was 18 months and 4-year survival was 42%. CONCLUSIONS: Low dose CI 5-FU and cisplatin is well tolerated with minimal toxicity. Histopathological response rates and survival figures are comparable with the more toxic neoadjuvant chemotherapeutic regimens.

Traumatic abdominal wall hernia: a reappraisal.

Traumatic abdominal wall hernia, a rare cause of hernia, has a confusing clinical picture and requires a high index of suspicion for prompt diagnosis and management. Such hernias, if missed, can result in high morbidity and may prove fatal. Distinction from a pre-existing hernia is important as well. We report our experience in two such cases, which had presented in a span of 9 months, and submit a brief analysis of 50 reviewed cases.

Early versus delayed laparoscopic cholecystectomy for acute cholecystitis: a prospective randomized trial.

BACKGROUND: The role of laparoscopic cholecystectomy for acute cholecystitis is not yet clearly established. The aim of this prospective randomized study was to evaluate the safety and feasibility of laparoscopic cholecystectomy for acute cholecystitis and to compare the results with delayed cholecystectomy. METHODS: Between January 2001 and November 2002, 40 patients with a diagnosis of acute cholecystitis were assigned randomly to early laparoscopic cholecystectomy within 24 h of admission (early group, n = 20) or to initial conservative treatment followed by delayed laparoscopic cholecystectomy, 6 to 12 weeks later (delayed group, n = 20). RESULTS: There was no significant difference in the conversion rates (early, 25% vs delayed, 25%), operating times (early, 104 min vs delayed, 93 min), postoperative analgesia requirements (early, 5.3 days vs delayed, 4.8 days), or postoperative complications (early, 15% vs delayed, 20%). However, the early group had significantly more blood loss (228 vs 114 ml) and shorter hospital stay (4.1 vs 10.1 days). CONCLUSIONS: Early laparoscopic cholecystectomy for acute cholecystitis is safe and feasible, offering the additional benefit of a shorter hospital stay. It should be offered to patients with acute cholecystitis, provided the surgery is performed within 72 to 96 h of the onset of symptoms.

Kinetic resolution of 1-chloro-3-(1-naphthyloxy)-2-propanol, an intermediate in the synthesis of beta-adrenergic receptor blockers.

(R)- and (S)-1-chloro-3-(1-naphthyloxy)-2-propanol are intermediates in the synthesis of beta-adrenergic blocking agents and antihypertensive drugs such as propranolol and nadoxolol. Herein, improvement in the preparation of racemic 1-chloro-3-(1-naphthyloxy)-2-propanol generated from 1-naphthol and epichlorohydrin are reported. In addition, kinetic resolution studies have been conducted to obtain both (R) and (S)-1-chloro-3-(1-naphthyloxy)-2-propanol. These compounds were obtained in highly optically pure form by the stereoselective hydrolysis of its acyl derivatives using whole cell preparations containing enzymes from native sources. The results were compared with those obtained using commercial lipases.

Feasibility and safety of day care laparoscopic cholecystectomy in a developing country.

BACKGROUND: Although day care laparoscopic cholecystectomy (DCLC) has been shown to be safe in centres with adequate infrastructure for day care surgery, its feasibility and safety in developing countries has never been studied. Because of differences in the quality of health care delivery, western guidelines for day care surgery cannot be universally applied to developing countries. PATIENTS AND METHODS: Patients less than 65 years who were graded I and II on the American Society of Anesthesiologists physical status score, irrespective of their educational status, living within 20 km, and willing to make their own arrangements for a return to hospital in case of problems were selected for DCLC. Follow up was done by patients calling the hospital the morning after surgery. RESULTS: 50% of the eligibility criteria were new; 313/383 patients were suitable for DCLC. The commonest cause for rejection was that the patient lived out of the defined area (50%). Altogether 92% were discharged within eight hours of surgery. The reasons for failure to discharge were the presence of abdominal drains in four (2%), nausea and vomiting in nine (3%), and conversion to open surgery in five (2%). Ten patients (3%) were readmitted; of these only two (<1%) had complications needing re-exploration. Analysis of results showed that the inclusion and discharge criteria were valid and that the readmission and complication rates as well as the ease and accuracy of follow up were comparable to published data. DCLC reduced waiting times and increased patient turnover and may have a positive impact on resident training. CONCLUSIONS: DCLC is safe, feasible, and has potential benefits for health care delivery in developing countries. Each surgical service needs to develop their own guidelines based on local patient demography.

Pseudocyst of adrenal gland.

Cysts of the adrenal gland are uncommon. We report a case of symptomatic pseudocyst of adrenal gland in an adult male, which was excised through retropertoneoscopic route. Surgery was uneventful and patient returned to pre-operative activity within seven days of operation. At ten months of follow up patient is asymptomatic and doing well.

Purification and characterisation of an ester hydrolase from a strain of Arthrobacter species: its application in asymmetrisation of 2-benzyl-1,3-propanediol acylates.

An ester hydrolase (ABL) has been isolated from a strain of Arthrobacter species (RRLJ-1/95) maintained in the culture collection of this laboratory. The purified enzyme has a specific activity of 1700 U/mg protein and is found to be composed of a single subunit (Mr 32,000), exhibiting both lipase and esterase activities shown by hydrolysis of triglycerides and p-nitrophenyl acetate respectively. Potential application of the enzyme concerns the asymmetrisation of prochiral 2-benzyl-1,3-propanediol esters besides enantioselective hydrolysis of alkyl esters of unsubstituted and substituted 1-phenyl ethanols.

Radiation-induced chromatid breaks and deficient DNA repair in cancer predisposition.

Deficient repair of DNA double-strand breaks, resulting in an abnormally high frequency of chromatid breaks after G(2) exposure of cells to radiation, appears to be associated with cancer predisposition. Unrepaired DNA strand breaks contribute to genomic instability. Unrepaired chromatid breaks representing DNA strand breaks can result in chromosome deletions, translocations and gene amplifications seen in human cancers. This cytogenetic response of cells to radiation may be useful as a marker of cancer susceptibility and in identifying individuals at risk of developing cancer in cancer families.

Abdominal cocoon: report of a case.

The abdominal cocoon is a rare cause of intestinal obstruction most often found in adolescent girls from tropical and subtropical countries. It is characterized by a thick fibrotic sac covering the small bowel partially or completely, the etiology of which is unknown. A correct diagnosis is not often made preoperatively; however, following simple surgical release of the entrapped bowel, these patients usually do well. We report herein our experience of a case of abdominal cocoon with a brief review of the medical literature on this unusual disease entity.

Randomized clinical trial of micronized flavonoids in the early control of bleeding from acute internal haemorrhoids.

BACKGROUND: Patients with acute bleeding from internal haemorrhoids often have to be referred by the general practitioner to the surgeon for definitive treatment with invasive outpatient procedures. At the initial consultation, patients frequently seek postponement of immediate surgery to a more convenient time. Effective and rapid non-invasive control of acute bleeding could be of practical use in scheduling surgery to a time convenient to both patient and surgeon. METHODS: In a 90-day randomized, double-blind study treatment with a micronized purified flavonoid fraction (MPFF) was compared with placebo, in 100 outpatients who presented for treatment of acute internal haemorrhoids of less than 3 days' duration. The primary endpoint was cessation of bleeding on the third day of treatment. RESULTS: Of 50 patients randomized to each group, acute bleeding ceased by the third day in 40 (80 per cent) who received MPFF compared with 19 (38 per cent) who had placebo (P < 0.01). Mean(s.d. ) duration of acute bleeding from onset to cessation of 4.9(1.6) days was 2.1 (95 per cent confidence interval 1.2-2.9) days less than that in patients receiving placebo (P < 0.01). Continued treatment in patients with no bleeding prevented a relapse in 30 of 47 patients, compared with 12 of 30 receiving placebo (P < 0.05). CONCLUSION: Patients with acute internal haemorrhoids treated with MPFF had rapid cessation of bleeding and a reduced risk of relapse. This could be of value in the more convenient timing of treatment with invasive outpatient procedures.

XPD polymorphisms: effects on DNA repair proficiency.

XPD codes for a DNA helicase involved in transcription and nucleotide excision repair. Rare XPD mutations diminish nucleotide excision repair resulting in hypersensitivity to UV light and increased risk of skin cancer. Several polymorphisms in this gene have been identified but their impact on DNA repair is not known. We compared XPD genotypes at codons 312 and 751 with DNA repair proficiency in 31 women. XPD genotypes were measured by PCR-RFLP. DNA repair proficiency was assessed using a cytogenetic assay that detects X-ray induced chromatid aberrations (breaks and gaps). Chromatid aberrations were scored per 100 metaphase cells following incubation at 37 degrees C (1.5 h after irradiation) to allow for repair of DNA damage. Individuals with the Lys/Lys codon 751 XPD genotype had a higher number of chromatid aberrations (132/100 metaphase cells) than those having a 751Gln allele (34/100 metaphase cells). Individuals having greater than 60 chromatid breaks plus gaps were categorized as having sub-optimal repair. Possessing a Lys/Lys751 genotype increased the risk of sub-optimal DNA repair (odds ratio = 7.2, 95% confidence interval = 1.01-87.7). The Asp312Asn XPD polymorphism did not appear to affect DNA repair proficiency. These results suggest that the Lys751 (common) allele may alter the XPD protein product resulting in sub-optimal repair of X-ray-induced DNA damage.