CYP1A2*1F Gene Variant, Alkaline Salt Tea Intake and Risk of Esophageal Squamous Cell Carcinoma.

Unlike many other cancers, the relationship of CYP1A2*1F (rs762551) polymorphism with esophageal squamous cell carcinoma (ESCC) risk has not been assessed so far. To evaluate its association with ESCC, we conducted a case control study in Kashmir, India, a high risk region. We recruited 404 histopathologically confirmed ESCC cases and 404 controls, individually matched for sex, age and residence to the respective cases. Information was obtained on dietary, lifestyle and environmental factors in face to face interviews using a structured questionnaire from each subject. Genotypes were analyzed by polymerase chain reaction, restriction fragment length polymorphism and sequencing randomly selected samples. Conditional logistic regression models were used to calculate odds ratios (ORs) and 95% confidence intervals (95% CIs). We found that mutant genotype (AA) of CYP1A2*1F polymorphism was associated with ESCC risk (OR = 3.11; 95% CI: 1.72-5.36). A very strong ESCC risk was observed in subjects who drank >1250 ml of salt tea daily and harbored mutant genotype of CYP1A2*1F (OR = 14.51; 95% CI: 5.33-39.47). The study indicates that CYP1A2*1F polymorphism is associated with ESCC risk and the risk is modified in salt drinkers. However, more replicative and mechanistic studies are needed to substantiate the findings.

Prolonged Impacted Denture in the Esophagus: A Case Report and Review of the Literature.

Foreign body ingestion and aspiration is among the most common causes of emergency department visit associated with high morbidity and mortality. Ingested and aspirated denture is rare conditions being scarcely reported in the literature. We herein report a 57-year-old man who presented with 2-day history of liquid and solid dysphagia who was diagnosed to have impacted denture in esophagus since 3 years prior to presentation. He was diagnosed to have esophagus adenocarcinoma and had undergone esophageal radiotherapy. The denture was removed successfully using esophagoscopy and the patient was discharged after 48-hour care with good condition. To prevent accidental ingestion, dentures should be made to fit properly. Damaged or malfitting dentures should be discarded and replaced. Patients should be strongly advised against wearing them during sleep-time.

Impact of clinico-radiological parameters on the outcome of treatment in brain tuberculosis.

OBJECTIVES: The Aim of this study was to evaluate the impact of clinico-radiological parameters on the outcome of the treatment in brain tuberculosis. MATERIALS AND METHODS: This study was conducted in the Department of Neurosurgery and Neurology Skims Srinagar India for a period of two years from November 2009 to November 2011. A total of 61 patients presenting with brain tuberculosis admitted at skims during these two years were included in the study. Patients having clinical, laboratory and radiological findings suggestive of brain tuberculosis were included in the study. On correlating the CT characteristics-tuberculomas, basal exudates and hydrocephalus with sequelae at 6,12 and 18 months - focal deficit, cognitive impairment, and diplopia. RESULTS: It was seen that basal exudates correlated with all the three neurological sequelae i.e.; with focal deficit (P = 0.001), cognitive impairment (P = 0.011), and diplopia (P = 0.021). Hydrocephalus correlated well with cognitive impairment (P = 0.031) and tuberculoma correlated with none of these clinical characteristics. CONCLUSION: We concluded that the mortality and neurologic sequelae were directly related to the clinical stage of disease at presentation. Correlating the CT characteristics we concluded that basal exudates correlated with all the three sequelae i.e.; with focal deficit, cognitive impairment, and diplopia. Hydrocephalous correlated well with cognitive impairment and tuberculoma correlated with none of these clinical characteristics.

Correlation of transrectal ultrasonographic findings with histo pathology in prostatic cancer.

OBJECTIVE: To estimate the incidence of hyperechoic, hypoechoic, isoechoic, prostatic cancer in TRUS (transrectal ultrasound guided) guided prostatic specimens. MATERIALS AND METHODS: Four hundred and ninety three patients with raised serum prostatic specific antigen (PSA) and abnormal DRE findings were subjected to TRUS-Guided prostate biopsy. Lateralized sextant biopsy plus prostatic cores from suspicious areas were obtained. RESULTS: Out of 493 patients who were enrolled in the study, 65 (13.18) patients showed hyperechoic lesions on TRUS and 211 (42.79) patients had hypoechoic lesions on TRUS. CONCLUSION: Our study has revealed that hyperechoic lesions on transrectal ultrasonography have more chances of prostatic cancer as reported in previous literature, so we suggest that we should take additional biopsy of hyperechoic lesions and perhaps it should be part of the standard protocol in patients suspected cancer prostate.

Evaluating peripheral vascular injuries: is color Doppler enough for diagnosis?

BACKGROUND: Vascular injury poses a serious threat to limb and life. Thus, diagnosis should be made immediately with minimally invasive methods. Doppler is a good aid in diagnosis of vascular injury. METHODS: The present prospective study was conducted on 150 patients who presented with soft signs (the signs which are suggestive but not confirmatory) of vascular injury. They were subjected to color Doppler examination before exploration. The patients with the features of vascular injury on color Doppler were subjected to exploration. On the other hand, those who had normal Doppler were subjected to CT- angiography. Then, the findings of the exploration were matched with those of color Doppler. The data were analyzed using the SPSS statistical software. RESULTS: Out of the 150 Doppler examinations, 110 (73.33%) were reported as positive, while 40 were reported as negative for vascular injury. These were subjected to CT-angiography and seven of them had the features of vascular injury on CT-angiography. All the patients with positive Doppler or CT angiography findings were subjected to exploration. Doppler had a sensitivity of 94% and specificity of 82.5% in diagnosis of vascular injury using Binary classification test. CONCLUSIONS: Color Doppler is an easily available, reliable, and handy method of diagnosing a vascular injury. It has a very high sensitivity and specificity in diagnosis of vascular injuries.

The Efficacy of Rigid Bronchoscopy for Foreign Body Aspiration.

The aim of the current study was to determine the pattern, presentation and management of foreign body aspiration in our  population.  This prospective study comprised 55 patients with foreign body aspiration admitted to our department from January 2009 to December 2011. All patients underwent rigid bronchoscopy under local or general anesthesia. The patients' demographic information along with clinical characteristics and their outcome were recorded and reported. The mean age of the children was 13.3±3.6 years. There were 32 (58.2%) females and 23 (41.8%) males. The frequent symptom was an attack of chocking followed by cough. The predominant sign was wheezing. Rigid bronchoscopy was successful in removing foreign body from 52(94.5%) patients. Three (5.5%) patients who had undergone thoracotomy with bronchotomy needed exploration, after failure of bronchoscopy to remove the foreign body. There was no mortality in our series. Average hospital stay was 12 hours. It could be concluded that rigid bronchoscopy is modality of choice in management of foreign body aspiration especially in pediatric population.

Delayed presentation of traumatic diaphragmatic hernia: a diagnosis of suspicion with increased morbidity and mortality.

BACKGROUND: Diaphragmatic rupture due to blunt or penetrating injury may be a missed diagnosis in an acute setting and can present with a delayed complication with significantly increased morbidity and mortality. OBJECTIVES: The objective of this study is to better understand why diaphragmatic tears with delayed presentation and diagnosis are so often missed and why traumatic diaphragmatic tears are difficult to diagnose in emergency settings and how they present with grievous complications. PATIENTS AND METHODS: Eleven patients with diaphragmatic hernias with delayed presentation and delayed diagnosis were operated within the last five years. All patients presented with different complications like gut gangrene or respiratory distress. RESULTS: Out of eleven patients who were operated on for diaphragmatic hernia, three patients (27%) died. Three patients required colonic resection, one patient needed gastrectomy and one patient underwent esophagogastrectomy. CONCLUSIONS: A small diaphragmatic tear due to blunt trauma to the abdomen is difficult to diagnosis in acute settings due to ragged margins and possibly no herniated contents and usually present with a delayed complication. Therefore a careful examination of the entire traumatized area is the best approach in treating delayed presentation of traumatic diaphragmatic hernia prior to development of grievous complications.

The diagnostic efficacy of adenosine deaminase in tubercular effusion.

OBJECTIVE: This study aims to evaluate the diagnostic efficacy of adenosine deaminase in tubercular effusions. METHODS: This study was conducted at the Department of General Medicine and Cardiovascular and Thoracic Surgery, SKIMS, for a period of two years between November 2008 and November 2010. A total of 57 patients presenting with pleural effusions during the two-year study period, who presented with clinical manifestations suggestive of tuberculosis (i.e., the presence of productive cough, low-grade fever, night sweats, weight loss, and chest pain, especially if these symptoms last (3)4 weeks) were included in the study. If the patients presented with less than two of these symptoms, and especially if the clinical manifestations were of <4 weeks duration, they were excluded from the study. RESULTS: The mean adenosine deaminase activity level in all the 57 patients was 109 U/L while the mean adenosine deaminase activity levels in pleural TB patients was 80 U/, and 64 U/L in the controls (p=0.381). Considering 40 U/L as the cut off, the results were positive in 35 out of 39 tuberculosis patients and 9 out of 18 controls. The sensitivity of adenosine deaminase for tubercular effusions worked out to be 90%, with only 50% specificity. CONCLUSION: This study suggests that the estimation of adenosine deaminase activity in pleural fluid is a rapid diagnostic tool for differentiation of tubercular and non tubercular-effusions. The sensitivity and specificity of adenosine deaminase for tubercular effusions in this study was 90% and 50% respectively.

Endorectal coil MRI and MR-spectroscopic imaging in patients with elevated serum prostate specific antigen with negative trus transrectal ultrasound guided biopsy.

BACKGROUND: The aim of this study was to see the efficacy of endorectal coil MRI and MR spectroscopic imaging in patients with elevated serum PSA and negative transrectal ultrasonography (TRUS)-guided biopsy. MATERIALS AND METHODS: This study was conducted on 87 patients presented with: • Elevated prostatic specific antigen levels >5 ng/ml • Symptoms and signs of prostatic carcinoma • Patients with negative TRUS-guided biopsy • Suspicious lesion on TRU. All the patients were subjected to TRUS and followed by TRUS-guided biopsy of the lesion identified on endorectal coil MRI and MR-Spectroscopy. TRUS-guided biopsy of prostate was done with a Siemens Sonoline Adana Scanner. The scanning was performed by mechanical probe 5-7.5 MHz. RESULTS: Out of 87 patients, 43 (49.4%) had hypointense lesion, 11 (12.6%) had hyperintense lesion. Out of 87 patients, MR-spectroscopy showed peak choline-creatine in 74 patients. Normal citrate peak was seen in 13 patients. Patients who had choline-creatine peak, among them 28 (37.8%) had peak in left peripheral zone, 23 (31.1%) had peak in the right peripheral zone, 2 (2.7%) had peak in the central zone, 17 had (23%) peak bilaterally. Four patients (5.4%) had peaks in right and central zones. The difference was statistically significant (P < 0.001). CONCLUSION: Prostatic biopsy directed with endorectal coil MRI and MR-spectroscopic imaging findings in patients with elevated serum PSA and prior negative biopsy, improves the early diagnosis of prostatic carcinoma and accurate localization of prostate cancer within the gland.

A comparative study on the effect of amiodarone and metaprolol for prevention of arrythmias after open heart surgery.

OBJECTIVES: The aim of this study was to compare the effect of amiodarone and metaprolol in prevention of atrial fibrillation in patients, following open heart surgery. METHODS: This prospective study was carried out between May 2008 to Nov. 2010, and comprised a total of 50 patients with normal preoperative sinus rhythm undergoing open heart surgery using cardio pulmonary bypass. RESULTS: Mean age of patients was 47+2.7 years, of which 60% who developed atrial fibrillation aged from 51 to 60 years. Most patients (62%) were in NYHA Class III. Patients who received amiodarone showed significant improvement in LVEF compared to those treated with Metaprolol. Amiodarone treated group exhibited lesser incidence and short-lasting atrial fibrillation, lower ventricular rate, shorter hospitalization, and lesser cost of care than those in metaprolol group. CONCLUSIONS: The present study showed that amiodarone was more efficient in controlling post-operative atrial fibrillation as compared to metaprolol. However, a larger randomized controlled trial is needed to corroborate the result of this study.

Comparison of right anterolateral thorocotomy with standard median steronotomy for mitral valve replacement.

OBEJECTIVES: The objectives of this study were to compare and analyze the results of right anterolateral thoracotomy and median sternotomy approach for primary mitral valve replacement with reference to the exposure during Valve Replacement , length of surgical incision, mean cross clamp time, mean bypass time, intensive care unit (ICU) stay, hospitalization, overall comorbidity with sternotomy; sepsis, dehiscence, healing cosmetic issues and cost effectiveness. METHODS: The present study comprised 68 patients with rheumatic mitral valve disease who underwent mitral valve replacement in the Department ofCardiovascular and Thoracic Surgery at Sher­i­Kashmir Institute of Medical Sciences from September 2009 to August 2011. RESULTS: This study comprised 64 patients with 23 (35.9%) males and 41 (64.1%) females. Sternotomy group had 10 males (31.3%) and 22 females (68.7%). Thoracotomy group had 13 males (40.6%) and 19(59.4%) females. The length of incision between the two groups was statistically significant (P<0.0001). Mean incision length were 24.6±2.1 cm and 14.8±2.3 cm in sternotomy and thoracotomy respectively. Statistically significant difference regarding duration of ICU stay was found between the two groups (P<0.0001). Scar visibility was 100% in sternotomy and around 25% in thoracotomy( P<0.0001). CONCLUSIONS: Thoracotomy through a right anterolateral aspect was easy to perform while maintaining maximum security for the patients. Besides its satisfactory cosmetic result especially in female patients, this approach proved to have several advantages. It offers a better exposure to the mitral apparatus even in patients with small left, allowing easy mitral valve replacement which is apparent from the lower cross­clamp time in the test group. The invaluable advantage of the above- mentioned thoracotomy is total eradication of the risk of deep sternal infection. The shorter hospital stay and cost effectiveness of thoracotomy approach are additional relief to the family.

Native arterio-venous fistula is the vascular access of choice for hemodialysis in end stage renal disease.

OBJECTIVES: THE AIM OF THE STUDY WAS: Is primary Arterio-venous fistula the vascular access of choice for adequate dialysis and better patient outcome in end stage renal disease. MATERIALS AND METHODS: The present study was done in the department of cardiovascular and thoracic surgery at Sher-i-Kashmir institute of medical sciences, Soura, Srinagar Kashmir. Native Arterio-Venous (AV) fistulas were made in the patients with end stage renal disease for performing hemodialysis. They were followed for patency and adequacy of blood flow during hemodialysis. All the patients were operated under local anesthesia. RESULTS: The results showed that 77% of the AV fistulas based on radial artery with side-to-side anastomosis and 80% of those with end-to-side anastomosis were functionally patent after one year. After two years, the patency rate in side-to-side and end-to-side anastomosis was 50% and 55%, respectively. In addition, the patency rate was 90% in brachial artery based AV fistula with end-to-side anastomosis, whether done primarily or secondarily, at the end of one year. However, a rapid decline was observed in the patency rate during the third year in both radial artery based and brachial artery based AV fistulas. CONCLUSIONS: We concluded that Arterialised arm superficial veins after primary AV fistula was the optimal and rational vascular access for hemodialysis providing adequate blood flow during this process. Besides, failure of primary AV fistula should be replaced by secondary AV fistula preferably based on brachial artery.

Comparing Aortic Valve Replacement through Right Anterolateral Thoracotomy with Median Sternotomy.

BACKGROUND: Aortic Valve Replacement (AVR) is usually done through median sternotomy. The present study aimed to compare the right anterolateral thoracotomy and median sternotomy approaches for AVR. MATERIALS AND METHODS: The present prospective study was conducted on 60 patients who had aortic valve disease and were subjected to AVR. Thirty patients underwent aortic valve replacement via right anterolateral thoracotomy (study group) and thirty patients via median sternotomy (control group). Statistical analysis was done using Mann Whitney U test and Fischer's Exact test. Statistical Package SPSS -17 was used for data analysis. RESULTS: The mean length of the incision was 18.7±1.8 cm in the patients who had undergone AVR through median sternotomy, while 7.8±0.9 cm in the study group patients. Besides, the mean bypass time was 121.8±18.6 minutes for the patients who had undergone AVR through median sternotomy, while 122.1±20.8 minutes for the study group. In addition, the mean aortic cross clamp time was 67.7±13.4 minutes for the patients who had undergone AVR through median sternotomy, while 68.0±8.9 minutes for the study group. The mean operating time was 181.6±31.5 minutes for the patients who had undergone AVR through median sternotomy, while 190.8±29.8 minutes for the study group. Patient satisfaction with respect to cosmesis was higher in the study group. Only 50% of the patients who had undergone AVR through median sternotomy in comparison to 73.3% of those in the study group were satisfied with the cosmesis. CONCLUSIONS: The right anterolateral thoracotomy approach for aortic valve replacement proved to be easy to perform whilst maintaining the maximum security for the patients. Besides its better cosmetic result especially in female patients, this approach proved to have several advantages.

Lung Contusion: A Clinico-Pathological Entity with Unpredictable Clinical Course.

Lung contusion is an entity involving injury to the alveolar capillaries, without any tear or cut in the lung tissue. This results in accumulation of blood and other fluids within the lung tissue. The excess fluid interferes with gas exchange leading to hypoxia. The pathophysiology of lung contusion includes ventilation/perfusion mismatching, increased intrapulmonary shunting, increased lung water, segmental lung damage, and a loss of compliance. Clinically, patient's presents with hypoxiemia, hypercarbia and increase in laboured breathing. Patients are treated with supplemental oxygen and mechanical ventilation whenever indicated. Treatment is primarily supportive. Computed tomography (CT) is very sensitive for diagnosing pulmonary contusion. Pulmonary contusion occurs in 25-35% of all blunt chest traumas.

The Pattern, Presentation and Management of Pardah Pin Inhalation: Report from a Single Center in Northern India.

OBJECTIVE: To describe the clinical characteristics, presentation and management of Pardah pin inhalation in female teenagers of single center in northern India. METHODS: This was a prospective cross-sectional study being performed in department of cardiovascular and thoracic surgery of Sher-i-Kashmir institute of medical sciences located in northern India from January 2009 to December 2012. We included 36 female patients with Pardah pin inhalation who were admitted to our center during the study period. All patients underwent rigid bronchoscopy under local or general anesthesia. We recorded the baseline characteristics including the demographic information, the site of the pin and clinical findings as well as the management strategies and the outcome of these patients. RESULTS: All patients were female using scarf to wrap their head and neck as religious obligation. Mean age of the patients was 14.3 ± 3.6 years. The most common symptom was chocking followed by cough being reported in all (100%) and 31 (86.1%) patients respectively. Bronchoscopy was successful in removing the pin in 31 (86.1%) patients. Pins were located in right main bronchus in 20 (55.5%) patients, and in left main bronchus in 10 (27.7%) patients. There was no mortality in our series. Pin was removed in 31 (86.1%) patients with the help of bronchoscope, but 5 (13.9%) patients needed bronchotomy for removal of the pin. Average hospital stay was 12.43 ± 1.6 hours. CONCLUSION: Rigid bronchoscopy is an ideal approach in management of Pardah pin inhalation. However some patients may need bronchotomy to remove the Pardah pin.

Esophageal Tuberculosis Presenting As Dysphagia.

Esophageal tuberculosis is rare in both immunocompromised and immunocompetent hosts with advanced pulmonary tuberculosis, even in countries with high prevalence of tuberculosis, e.g., South East Asia. This study presents a case report of esophageal tuberculosis presenting as dysphagia.

Peripheral vascular injuries due to blunt trauma (road traffic accident): management and outcome.

BACKGROUND: The present study was undertaken to analyze the pattern, presentation and management of peripheral vascular injuries due to road traffic accidents (RTA). METHODS: A prospective study of patients of peripheral vascular injuries due to road traffic accidents (RTA) between Jan. 2007 to Dec. 2011. A total of 192 patients presented with peripheral vascular injuries due to RTA during this period. All patients with vascular injury due to other causes were excluded from study. RESULTS: Most of the patients were managed by reverse saphenous vein graft followed by end to end anastomosis. Most of the patients had associated long bone fractures. Delayed presentation and associated long bone fractures had bad effect on outcome. Wound infection and thrombosis of the graft were the most important complication. Amputation rate was 4.68%. CONCLUSION: Vascular injury due to RTA requires prompt recognition and referral to a vascular center. Immediate revascularization has excellent results and less morbidity. Proper clinical examination and hand held Doppler examination are enough to reach the diagnosis.

Vascular injuries: trends in management.

ABSTRACT: Vascular injury presents a great challenge to the emergency resident because these injuries require urgent intervention to prevent loss of life or limb. Sometimes serious vascular injury presents with only subtle or occult signs or symptoms. The patient may present weeks or months after initial injury with symptoms of vascular insufficiency, embolization, pseudoaneurysm, arteriovenous fistula etc. Although the majority of vascular injuries are caused by penetrating trauma from gunshot wounds, stabbing or blast injury, the possibility of vascular injury needs to be considered in patients presenting with displaced long bone fractures, crush injury, prolonged immobilization in a fixed position by tight casts or bandages and various invasive procedures. iatrogenic vascular injuries constitute about 10% of cases in most series; however the incidence is an increasing trend because more endovascular procedures such as angioplasty and cardiac catheterization are being performed routinely. Civilian trauma is more frequently seen in young males. However, it can occur at any age due to road accidents, firearms, bomb blasts and diagnostic procedures. Most of the time, civilian trauma causes less tissue damage. There is an epidemic of vascular injuries in Kashmir valley because of problems in law and order in the past two decades. This review deals with the topic in detail.

Role of liberal primary fasciotomy in traumatic vascular injury.

BACKGROUND: Vascular injury represents less than 1% of all injuries, but deserves special attention because of its severe complications. Amputation or retention of a painful functionless limb is the most untoward result of severe vascular injury or inadequate treatmet. Thus, vascular injury needs a judicious and multidimensional approach. OBJECTIVES: This retrospective study was done to asess the outcome of minor modifications of the methodology of extremity fasciotomy by making it liberal with respect to incision and definition. MATERIALS AND METHODS: Out of 55 patients in 2008, 45 patients (Group A) had either no fasciotomy or limited primary fasciotomy, 10 patients (Group B) had primary liberal fasciotomy. Another group from 2008 onwards had undergone primary liberal fasciotomy in all the 45 patients (Group C). RESULTS: In group A, we had 5 amputations and one death. In group B, there were no amputations or deaths and from group C, we had one amputation and no deaths. CONCLUSIONS: Blunt and distal traumatic vascular injury of the extremities and its repair should always combined with primary liberal fasciotomy, which although increases manageable morbidity, avoids disability (functional as well as anatomical).

The increasing rate of secondary amputation in popliteal arterial injury associated with multi-organ injuries and hypotension.

OBEJECTIVES: To study the role of hypotension and associated injuries in increasing the chances of secondary amputation in lower limb with vascular injuries. METHODS: This study was conducted in the Department of cardiovascular and thoracic surgery( CVTS ), Sher-i- Kashmir Institute of Medical Sciences, ( SKIMS ) Srinagar Kashmir India and comprised all patients sustaining vascular injury due to different causes like road traffic accident, fire arm and blast injuries or falling from height during the last five years. Following admission to our Department, the patients were divided into two groups. The first group with associated injuries was hemodynamically unstable during vascular repair or in post-operative period and the second group had no associated injuries and was hemodynamically stable during vascular repair and in post-operative period. RESULTS: During the past five years, 95 patients were operated for lower limb vascular injury in our department. Of these 25 patients had associated multi-organ injuries and were hemodynamically unstable and needed intensive care monitoring after surgical intervention. Additionally, 10 patients died due to associated multiple organ injuries, 10 needed amputation due to recurrent thrombosis of their anastomosis, and in five patients limb salvage was achieved. Seventy patients who had isolated limb vascular injuries with no associated injuries or hypotension were hemodynamically stable and were kept in low dependency unit after vascular repair. Only Four patients from this group needed amputation for thrombosis of the anastomosis. CONCLUSION: [corrected] Patients with shock and related injuries face significant rate of amputation. These patients whether with multi-organ injuries or isolated vascular injuries need judicious treatment for hypovolumic shock during surgical intervention and in post-operative period.