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Necrotising fasciitis is a rare infection of the skin and underlying soft tissue. It primarily involves the extremities and rarely the breast. Primary necrotising fasciitis of the breast in a non-lactating, healthy female is rarer still. The authors present the case report of a patient presenting with primary necrotising fasciitis of the breast after sustaining a penetrating injury. The patient was managed successfully with serial debridement and negative pressure wound therapy (NPWT). To our knowledge only 19 such cases have been reported in the indexed literature so far. This is also the eighth case globally of primary necrotising fasciitis of the breast in a non-lactating female without any associated immunosuppression, which is the basis of reporting this case.

This review aims to outline the current perspectives of surgery in the COVID 19 pandemic associated with the pitfalls in implementing the emerging guidelines to continue patient care without compromising safety, both from the surgeons' and the patients' points of view. The fight between the surgeon and the pandemic will be a dragging one since the post-pandemic infflux of surgical patients coupled with the ‘new normal’ practices to prevent COVID 19 spread requires pertinent resources, well-trained personnel, and co-operation among different departments. Emergency surgeries and cancer care have continued all this while, undoubtedly, with unwanted delays and distress. While we continue to prepare ourselves and work in a whole new environment, surgeons are facing the increased chances of litigations and compromised safety. We review what we have come to understand about safe surgical practices during and after the pandemic and the unanswered questions., Highlights • The healthcare workers are under immense pressure and stress due to the COVID 19 pandemic. • The struggle to deliver in this new normal environment is making healthcare more prone to error. • Surgeons, should be aware of the wider perspectives and pitfalls during this pandemic to avoid costly mishaps.

Tuberculosis (TB) is an infectious disease that can affect any organ system of the body. Abdominal TB can be gastrointestinal, lymph nodal, visceral or peritoneal. The gallbladder (GB) is rarely involved in abdominal TB as a primary organ. Extensive research literature on gallbladder TB is limited to case reports. There has been no review on this rare abdominal pathology. GB tuberculosis is a difficult diagnosis preoperatively. It is a rare differential among the more common gallbladder pathologies such as cholelithiasis, or a gallbladder malignancy. Typical histopathology of the resected specimen helps to establish this rare diagnosis. Subjecting every specimen to histopathological examination followed by medical treatment offers the chance of cure. Through this review, the authors attempt to provide an insight into this disease entity.

Introduction: Coronary microvascular disease (CMD) affects small arteries that feed the heart and is more prevalent in postmenopausal women. Since CMD and Coronary artery disease (CAD) have distinct pathologies, but are treated the same way, the majority of the patients with CMD do not receive a proper diagnosis and treatment, which in turn results in higher rates of adverse future events such as heart failure, sudden cardiac death, and acute coronary syndrome (ACS). Previously, we performed full metabolite profiling of plasma samples using GC-MS analysis and tested their classification performance using machine learning approaches. This initial proof-of-concept study showed that plasma metabolite profiles can be used to develop diagnostic signatures for CMD. In the current study, we hypothesize that plasma metabolite and protein composition is different for postmenopausal women with no heart disease, with CAD, or with CMD. Methods: We obtained plasma samples from 70 postmenopausal women who are healthy, women who have CMD, and women who have CAD at the time of blood collection. In addition to GC-MS metabolite profiles, we performed LC-MS metabolomic profiling, and proteomic profiling of a panel of 92 proteins that were implicated in cardiometabolic disease. We identified a combination of metabolites and proteins, and further tested their classification performance using machine learning approaches to identify potential circulating biomarkers for CMD. Results: We identified a comprehensive list of metabolites and proteins that were involved in endothelial cell function, nitric oxide metabolism and inflammation, which significantly different in plasma from women with CMD. We further validated difference in the level of several protein biomarkers, such as RAGE, PTX3, AGRP, CNTN1, and MMP-3, which are statistically significantly higher in postmenopausal women with CMD when compared with healthy women or women with CAD. Conclusion: Our research identified a group of potential molecules that can be used in the design of easy and low-cost blood biomarkers for the clinical diagnosis of CMD.

INTRODUCTION: Gall bladder cancer (GBC) tends to present in advanced stages, therefore, early diagnosis of GBC is necessary. There is no ideal single tumor marker available presently for the diagnosis and prognosis of GBC. Platelet distribution width (PDW) is an early marker for activated platelets and has been used in a variety of tumors to assess prognosis. This study was designed to evaluate the utility of PDW in identifying GBC patients and its association with tumor markers, staging and resectability of GBC. MATERIALS AND METHODS: This cross sectional study was done on 100 patients of GBC and 100 age- and sex- matched healthy controls. PDW was evaluated and compared between GBC and healthy controls. Receiver-operating characteristics was plotted to determine optimal cut-off for identifying GBC patients and to determine sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) of PDW. Correlation between serum tumor markers (carbohydrate antigen 19-9, carcinoembryonic antigen, and carbohydrate antigen 125) and PDW were evaluated. Association of PDW with hyperbilirubinemia, staging and resectability of GBC was also studied. RESULTS: A significantly higher PDW with a median of 18.1 was observed in GBC as compared to healthy controls with median value of 13. PDW was found to have a very high sensitivity (90%), specificity (95%), PPV (94%) and NPV (90%) in identifying GBC at cut-off of 16 with area under the curve (AUC) of 0.97. An increase of PDW was observed with increasing stage and unresectable GBC. However, it was not statistically significant. Significant positive correlation was observed between PDW and all three serum tumor markers and good positive correlation with r = 0.61 was observed with CA 19-9. CONCLUSION: PDW was associated with GBC and may be considered as a cost- effective marker in adjunct to other investigations for the diagnosis of GBC.

INTRODUCTION: Carcinoembryonic antigen (CEA) and carbohydrate antigen 19-9 (CA19-9) have been reported in previous studies to assess the prognosis of gall bladder cancer (GBC) individually and in combination. However, the evidence of utility of preoperative CA 19-9, CEA and carbohydrate antigen 125 ( CA 125) in determining the resectability and prognosis of GBC is still lacking. In the present study we correlated the serum levels of tumor markers CA 19-9, CEA and CA 125 individually and combined to determine the resectability and prognosis of the GBC. MATERIALS AND METHODS: Seventy one diagnosed patients of GBC between January 2018 and September 2019 were included in the present study. Serum CA 19-9, CEA and CA 125 were determined by chemiluminescence. Receiver operating characteristic (ROC) curve was used to evaluate the role of tumor markers in determining the resectability of GBC. The Kaplan Meier survival curves were made and log rank analysis was performed to assess the prognostic role of tumor markers in terms of overall median survival. RESULTS: All the three tumor markers CA19-9, CEA and CA 125 showed high discriminatory power in determining the resectability with respective area under curve of 0.76, 0.68 and 0.78 as determined by ROC. Median survival in patients with high serum CA 19-9, CA 125 was significantly lower than patients with normal serum CA 19-9, CA 125 whereas no significant difference was observed in case of CEA. CONCLUSION: The present study suggested that CA 19-9, CEA and CA 125 can predict resectability in GBC and raised levels of CA 19-9 and CA 125 can predict poor prognosis in patients with elevated levels.

Aim:To assess the role of red cell distribution width as a marker to predict tumor burden in gallbladder cancer (GBC).Methods:One hundred and twenty-eight patients with newly diagnosed GBC were included in the study. Peripheral blood samples were obtained, and red cell distribution width (RDW) was assessed. Tumor markers and other biochemical parameters were also recorded.Statistical Analysis: Quantitative variables were summarized using mean and standard deviation or median and interquartile range based on the normality of the distribution. The association of RDW with stage of tumor was analyzed using Chi-square test. All statistical tests were interpreted for significance using a cutoff value of P< 0.05.Results:RDW showed a positive correlation with total bilirubin, total leukocyte count, and erythrocyte sedimentation rate (P< 0.002), but not with platelet count (P< 0.643). RDW showed a significant correlation with tumor markers CA 19-9 (P< 0.003), carcinoembryonic antigen (P< 0.003), and CA 125 (P< 0.002). In Stage IVB, there were significantly more patients with high RDW (78%) than normal RDW (21.8%). However, the results were not statistically significant (P< 0.073).Conclusion:In the present study, we have utilized RDW for correlation with tumor markers in carcinoma gallbladder and as a predictor of stage. We demonstrated higher levels of RDW with advanced stages of GBC. Overall, the study suggested that RDW may be utilized as a surrogate biomarker to predict tumor burden and disease in patients with GBC.