A Rare Case of Hematometrocolpos due to Transverse Vaginal Septum along with Distal Vaginal Atresia in an Adolescent Girl.

Primary amenorrhoea due to Müllerian malformations is rare, with 1 in 4500 cases and 2%-8% of cases presenting as infertility. Obstructive Müllerian anomalies present as hematometra and hematocolpos during puberty. Timely surgical intervention is required to relieve acute pelvic pain and restore functional anatomy. A 15-year-old girl presented to OPD with complaints of severe pain in her lower abdomen and lower back for the last 2-3 weeks, not relieving on medication. She has not attained menarche and has been having cyclical pain and low backache for 7-8 days every month for the last year. Physical examination showed a suprapubic lump with vaginal agenesis. Magnetic resonance imaging revealed hematometrocolpos due to transverse vaginal septum and distal vaginal atresia. Pull-through vaginoplasty along with complete excision of transverse vaginal septum was performed. Vaginal dilator therapy was done after the healing of the sutures. In follow-up, the patient attained menstruation with a patent vagina. Obstructive Müllerian anomalies should be identified early by detailed clinical examination and targeted investigations to prevent long-term morbidity and infertility.

Monitored Anesthesia Care (MAC) as an Alternative to General Anesthesia (GA): Prospective Double-Blinded Randomized Controlled Study Comparing Efficacy and Safety of Dexmedetomidine and Ketamine Infusions with Ultrasonography (USG) Guided Pectoral Nerve Block (PECs) for Postoperative Analgesia in Breast Surgery.

BACKGROUND AND PURPOSE: PECs blocks are usually combined for breast surgery under general anesthesia (GA) to provide postoperative analgesia rather than primary anesthesia technique. MATERIAL AND METHODS: A prospective, interventional, single-center, double-blind, randomized, parallel-group, active-controlled, Helsinki protocol-compliant clinical study was conducted in a tertiary care teaching center after obtaining the Ethics Committee's approval and patients' written informed consent. Forty-eight American Society of Anesthesiologists physical status I/II patients aged 18-60 years, undergoing elective unilateral breast surgery were enrolled. Patients were block-randomized (computer-generated) to two equal groups (24 patients each), with one of them receiving Dexmedetomidine and the other one Ketamine. For concealment, sequentially numbered, sealed, opaque envelopes were used. The study was double-blinded for both the anesthesiologist and outcome assessor anesthesiologist. Obese patients (body mass index > 30), those with infection at block site, coagulopathy and known hypersensitivity to local anesthetics or study medications as well as individuals who refused participation in research were all excluded. The Dexmedetomidine group received a bolus of 0.5 mcg/kg over ten minutes, followed by an infusion of 0.3 mcg/kg/hour, while the Ketamine group received a bolus of 0.5 mg/kg over ten minutes, followed by an infusion of 0.3 mg/kg/hour. Postoperative analgesia was compared using a visual analogue scale (VAS) at regular intervals. When VAS exceeded four, 1 mg/kg intravenous Pethidine was administered as a rescue analgesic. RESULTS: Sub-anesthetic low-dose Ketamine was more effective than low-dose Dexmedetomidine in prolonging PECs block analgesia, which was statistically significant (p value < 0.001). The Ketamine group had lower rescue analgesic Pethidine consumption and longer first-rescue analgesia demand time. There was no significant hemodynamic difference between the study groups. CONCLUSION: Ketamine was more efficient than Dexmedetomidine for postoperative analgesia.

Skin Metastases in Ovarian Malignancy: A Case Report with Literature Review.

Ovarian cancer is the most lethal gynecologic malignancy, mostly diagnosed in the advanced stage with multiple sites of metastases. Routes of spread are direct through exfoliation, lymphatic channels, and less commonly hematogenous spread. Skin metastasis in ovarian malignancy is a rare occurence, its incidence range from 1.9% to 5.1% and the most common sites are the abdominal wall and chest wall. The incidence of metastasis to breast and/or axillary lymph nodes is very rare, ranging from 0.03% to 0.6%. We report the case of a 60-year-old female with stage IV B undifferentiated ovarian carcinoma with multiple cutaneous metastases involving the skin over the left breast, scalp, and mediastinal lymph nodes, which are rare sites of metastases. The incidence of cutaneous metastasis in ovarian cancer is 1.9%-5.1% and the overall survival after diagnosis ranges from 2 to 65 months.

Surgical Site Infections in Elective and Emergency Abdominal Surgeries: A Prospective Observational Study About Incidence, Risk Factors, Pathogens, and Antibiotic Sensitivity at a Government Tertiary Care Teaching Hospital in India.

Background Surgical site infections (SSIs), the third most common nosocomial infection, endanger hospitals and patients. SSIs must be monitored continuously. This present study examined SSI incidence, risk factors, pathogens, and antibiotic sensitivity in emergency and elective or planned abdominal surgeries. Methods The Dr. S.N. Medical College General Surgery Department in Jodhpur, India, operated on 100 patients. The sample was divided into two 50-person groups. Group A includes emergency surgery patients, while Group B includes elective surgery patients. The samples were aseptically collected and processed according to microbiological methods. Data were processed with IBM SPSS Statistics for Windows, version 20 (released 2011; IBM Corp., Armonk, New York, United States). Results Out of a sample size of 100 patients, 17 individuals experienced SSIs. SSI incidence was 16.66% in male patients and 18.18% in female patients. In addition, the rate of SSIs was 26% in the emergency group and 8% in the planned group. The association was stronger among elderly individuals, diabetics (33.33% in Group A and 12.5% in Group B), and anemics with a history of smoking. The association was higher in those who underwent surgery for more than 60 minutes (34.37% in Group A and 18.8% in Group B). The incidence of SSIs was higher in emergency cases compared to elective surgeries, with rates of 26% and 8%, respectively, but was statistically insignificant. The infection rate in clean cases during planned surgery was 3.70%, while clean contaminated cases during planned surgery had a wound infection rate of approximately 13.04%. In emergency surgery, no clean case was operated on, but the SSI rate in the emergency group was 9.09%, 22.22%, and 47.36% in the clean-contaminated, contaminated, and dirty cases, respectively. In Group A, Escherichia coli was the predominant organism found in SSI wounds, while in Group B, Staphylococcus aureus was the predominant organism, accounting for 46.15% and 50% of infections, respectively. Amikacin and metronidazole exhibited the highest efficacy against E. coli, with amikacin demonstrating the highest sensitivity. Conclusion SSIs are more common in emergencies than planned procedures. Age, gender, diabetes, hypertension, smoking, and prolonged surgery are risk factors for SSIs. Effective antibiotic policy and infection control can greatly prevent SSIs.

Mondor's Disease: A Rare Cause of Chest Pain.

Mondor's disease is an uncommon cause of breast and chest pain. It is characterized by cord-like thickening of the superficial veins of the anterior chest wall mimicking many life-threatening illnesses such as pulmonary thromboembolism and myocardial infarction. The disease may have been caused by trauma, other hypercoagulable states, or underlying breast diseases such as infection or carcinoma breast, but, in most cases, its etiology remains unknown. Mondor's disease is usually self-limited and can be managed conservatively. Although a rare and benign diagnosis, Mondor's disease should be a part of the differentials of chest pain, and its diagnosis can be made on the basis of a thorough clinical examination alone, which reduces not only costs but also the risks of further testing for patients presenting with chest pain. We highlight the case of a 40-year-old premenopausal female patient who presented to the outpatient department with stretching aching chest pain on the left side, which got aggravated on movements of the arm and relieved on rest. Mondor's disease is not considered a differential diagnosis for chest pain due to a lack of awareness about it. Creating awareness of this condition through this case report would help to reduce unnecessary investigations and valuable time spent and would help identify a serious underlying cause, especially early stage carcinoma of the breast.

Acute Appendicitis in Situs Inversus Totalis: A Case Report.

Left-sided acute appendicitis (LSAA) is a rare cause of acute pain in the abdomen and is associated with developmental anomalies such as situs inversus (viscus) totalis (SIT) and midgut malrotation (MM). Due to the rarity along with the atypical presentation, diagnosis of LSAA is difficult, and if it is not managed timely, complications of appendicitis such as perforation can result. Imaging including contrast-enhanced CT scans and ultrasound aids in establishing the diagnosis. In case of a diagnostic dilemma, a diagnostic laparoscopy is an optimal option that offers diagnostic as well as therapeutic benefits. Operative intervention, preferably laparoscopic, is the standard treatment of LSAA. We report a case of appendicitis in a 36-year-old man with SIT detected radiologically who presented with pain in the left side of the lower abdomen for two days. Minimal tenderness was noted on the left iliac fossa during per abdominal examination. Abdominal ultrasonography was showing probe tenderness in the left iliac fossa, and contrast CT of the abdomen was suggestive of appendicitis with SIT. The patient was managed by laparoscopic appendicectomy. Therefore, we conclude that LSAA should be listed in the differentials of the various causes of left-sided pain in patients with SIT or MM. Clinical diagnosis is often difficult, and CT scan is crucial to establish the diagnosis as well as confirm rotational anomalies. Surgery, preferably laparoscopic, represents the appropriate treatment of LSAA.

Raynaud's Phenomenon and Limb Hypertrophy Presenting Phacomatosis Pigmentovascularis: A Rare Association.

Phacomatosis pigmentovascularis is a rare dermal disorder attributed to the presence of various nevi. These lesions exist since birth, so the patient remains well aware of them. Various systemic involvements may be associated with the nevus, but the association of Raynaud's phenomenon is seldom reported. Our patient came with similar features and, on workup, no neurovascular compression was present, such as cervical rib or thoracic outlet syndrome. Therefore, he was managed conservatively and experienced improvement following the treatment. The objective of reporting this case is to highlight the association of Raynaud's phenomenon with such nervous lesions.

Epidemiology, Clinical Features, and Outcome of Liver Abscess: A Single-Center Experience.

Introduction Liver abscesses are rare, but whenever they occur, it is predominantly among males over 60 years of age. The paradigm in the treatment has changed, and percutaneous drainage is now the initial treatment for drainage of the abscesses. Open surgery is reserved for patients with septated abscesses and those greater than 5 cm. Objective  To study the etiological, clinical, pathological, and demographic characteristics of individuals with liver abscesses and to evaluate the outcome associated with different treatment strategies. Methods This clinico-epidemiological study was carried out at a tertiary care hospital in Jodhpur. One hundred patients with liver abscesses were studied. Patients were assigned to three groups: Group 1 - medical management alone (in non-aspirable uncomplicated abscess), Group 2 - USG-guided needle aspiration or pigtail percutaneous catheter drainage plus medical management (in unruptured aspirable abscess), Group 3 - open surgical drainage plus medical management (In ruptured abscesses). Of the total patients, 36% were treated with medical therapy alone, 45% with USG-guided needle aspiration, 10% with USG-guided percutaneous catheter drainage, and 9% with open surgical drainage. Results In our study, fever and hepatomegaly were the commonest presentations, observed in 91% and 62% of cases, respectively. Escherichia coli (E.coli) was the predominant organism cultured in 28 (43.75%) patients followed by Klebsiella growing in 24 (37.50%) patients. The right lobe was affected more (83%) than the left lobe and in the majority (83%), a solitary abscess was present. The mean age of liver abscess presentation was 40.72 years, with a 5.67:1 male-to-female ratio. Alcohol consumption was reported by 33% of patients, the majority of whom were men. Serum bilirubin was elevated in 56% of liver abscess patients, while it was normal in 44%. The mean serum bilirubin was 2.08 mg/dl. The mean value in group 1, group 2, and group 3 was 1.44 mg/dl, 2.23 mg/dl, and 2.57 mg/dl, respectively. Liver abscesses were identified in 76% of patients with right lobes; 83% had solitary liver abscesses and 17% had numerous abscesses. Abscess culture showed E. coli in 21 (32.81%) and Klebsiella in 17 (26.56%) patients. Conclusion Right-sided solitary pyogenic liver abscess caused by E.coli is the most common liver abscess, with fever and hepatomegaly as the most common presentation. Non-aspirable liver abscesses, regardless of aetiology, can be successfully treated by medical therapy alone. Needle aspiration or catheter drainage is standard for liver abscesses. Thus, needle aspiration has replaced the surgical exploration of liver abscesses.

A Comparative Study of Analgesic Efficacy of Epidural Ropivacaine With Dexmedetomidine Versus Ropivacaine With Ketamine in Adult Patients Undergoing Elective Lower Limb Surgery.

INTRODUCTION: Adjuvating of the epidural block with local anaesthetics during lower limb surgeries improves Intraoperative as well as postoperative analgesia. A comparison of epidural ropivacaine plus dexmedetomidine (RD) versus ropivacaine plus ketamine (RK) was done in terms of quality of the motor and sensory blockade, changes in hemodynamic parameters, and efficacy of analgesia. METHODS:  A prospective randomized parallel double-blind study was conducted on 68 patients of the American Society of Anaesthesiologists (ASA) grade 1 and 2, ages 18 to 75 years, which were divided into two groups (RD and RK; 34 patients in each group). After receiving a loading dose through an epidural catheter consisting of 20ml of 0.5% ropivacaine, the epidural infusion was started after an hour of surgery at 5ml/hrs of 0.2% ropivacaine with 1µg/ml dexmedetomidine in Group RD and at 5ml/hrs of 0.2% ropivacaine with 0.5mg/ml ketamine in Group RK for 48 hours. Both groups were compared regarding the onset of sensory and motor block, resolution of sensory and motor block, hemodynamic parameters, analgesic efficacy, and total rescue analgesic requirement in 48 hours. RESULTS: A significant difference was observed in the time of resolution of sensory blockade which was 9.77±2.38 hrs in the RD group as compared to 7.79±1.82 hrs in the RK group (p-value 0.0003) and the time of resolution of motor block was 6.53±2.44 hrs in the RD group compared to 4.58±0.83 hrs in the RK group (p-value 0.001). CONCLUSIONS: Epidural dexmedetomidine significantly increases the duration of analgesia and duration of the motor blockade in comparison to ketamine.