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Gastrointestinal stromal tumour (GIST) is the most common non-epithelial mesenchymal tumour and comprises 0.1-3% of all GI tract tumours. They express tyrosine kinase and are potentially malignant. Therefore, early diagnosis and surgical resection is the key for good outcome. This is a retrospective analysis of medical records of five patients of gastroduodenal GIST who were managed in the department of surgery between 2014 and 2015. Demographic profile, clinical presentation, laboratory parameters, diagnostic imaging, treatment details, histopathology and long-term outcome was analysed. Patients were followed up regularly in surgery outpatient clinic. Last follow up was in December 2022. All were female; three of them presented with melena and two with lump abdomen. Patients with gastric GIST underwent sleeve resection in two and antrectomy in one patient. Patient with duodenal GIST underwent excision of tumour with primary repair of duodenum. Fifth patient had metastatic duodenal GIST; Imatinib was started in view of irresectable disease at presentation. However, there was tumour progression and she expired seven months after treatment initiation with Imatinib. Histopathology revealed low grade GIST in two, intermediate grade in one and malignant in one. Patient with malignant GIST received Imatinib for 2 years. All four patients are well on follow up with no sign of local and distant recurrence.

Background HRBC is a phase III randomized open label study of adjuvant radiotherapy in patients with breast cancer. In this study we compared a 3 weeks radiation schedule with 2 weeks. Materials and methods Patients with breast cancer, stage I-III, post mastectomy or after breast conservative surgery who needed adjuvant locoregional radiotherapy were randomized to 34Gy in 10 fractions over 2 weeks (study arm) or 35Gy in 15 fractions over 3 weeks to the chest wall and 40Gy/15#/3wks to breast and supraclavicular fossa (control arm). Boost dose when indicated was 8Gy/2# in both the arms. Patients were planned on simulator with 2 tangential fields to breast/chest wall and incident supraclavicular fossa field. Acute toxicity was assessed using a RTOG grading system. Assessment was carried out weekly during radiotherapy and at 4 weeks after treatment by the physician. Cosmetic outcome was assessed using Harvard/NSABP/RTOG scale. The toxicity between the two arms was compared using Fisher’s exact test. The trial was approved by institutional ethics committee. This trial is registered with ClinicalTrials.gov, number NCT04075058. Results This study included 1121 patients. Median follow up was 35 months (range 6-84 months). Mean age was 48 year (range 24-80 years). The patient characteristics were comparable between the two arms except for more mastectomies in the 3 week arm and more node positive patients in the 2 week arm. There were more oestrogen receptor positive tumors in the 3 week arm. Acute skin toxicities were comparable between the two arms. Grade 2 and 3 skin toxicity was 98(17%) and 82(15%); and 16(3%) and 10(2%) in the 3 week and 2 week arm (p=0.15), respectively. Cosmetic outcome was significantly better in 2 week arm 94% as compared to 90% in the 3 week arm (p=0.016). Conclusion The two radiation schedules were comparable in terms of acute skin toxicity. Cosmetic outcome was better in the 2 week schedule. Citation Format: Budhi Singh Yadav, Divya Dahiya, Manish Gupta. Hypofractionated Radiotherapy in patients with Breast Cancer (HRBC): Acute toxicity data of a phase III randomized study [abstract]. In: Proceedings of the 2022 San Antonio Breast Cancer Symposium; 2022 Dec 6-10; San Antonio, TX. Philadelphia (PA): AACR; Cancer Res 2023;83(5 Suppl):Abstract nr GS5-12.

Objectives Aspirin is an anti-inflammatory drug commonly used as an analgesic and in cardiovascular disorders. However, many studies have highlighted its anti-cancer properties, especially in colorectal, lung, head and neck, and breast cancers. In this work, we tried to study the effect of aspirin on the TNF-α-mediated cell survival and death pathways in two cell lines representing two different subtypes of breast cancer. TNF-α-mediated stimulation of a cell can result in its proliferation via the NF-κB pathway or its death via either apoptosis or a programmed form of necrosis called necroptosis. The latter is believed to come into the picture only when apoptosis is inhibited. Methods In this work, we studied the effect of aspirin on the TNF-α-mediated cell survival pathway and observed a decrease in expression of the NF-κB pathway regulators, its nuclear translocation, and phosphorylation in a dose-dependent manner. The effect of aspirin on the TNF-α-mediated cell death showed significant cytotoxicity at the higher doses (5–20 mM) of aspirin in both the breast cancer cell lines. The effect of aspirin on necroptosis was investigated after stimulating the cells with TNF-α and inhibiting apoptosis using Z-VAD-FMK. Results Though no significant effect was noted in breast cancer cell lines, the above protocol successfully induced necroptosis in L929, i.e., a positive control cell line for necroptosis having an intact necroptosis machinery. Even when combined with the chemotherapeutic drugs, the above regime failed to induce any significant necroptosis in breast cancer cells but was found effective in L929. Conclusions Overall, the findings show that while aspirin has the potential to inhibit the TNF-α-mediated cell survival pathway, it does not help sensitize breast cancer cells to necroptotic cell death induction.

Purpose: To assess the feasibility of accelerated hypofractionated radiotherapy with simultaneous integrated boost (SIB) in patients with breast cancer.Materials and Methods: A total of 27 patients after breast-conserving surgery were included in this study. Patients were planned on a four-dimensional computerized tomogram, and contouring was done using RTOG guidelines. The dose was 34 Gy/10#/2 week to the breast and 40 Gy/10#/2 week to the tumor bed as SIB with volumetric modulated arc technique. The primary endpoint was grade 2 acute skin toxicity. Doses to the organs-at-risk were calculated. Toxicities and cosmesis were assessed using RTOG/LENT/SOMA and HARVARD/NSABP/RTOG grading scales, respectively. Disease-free survival (DFS) and overall survival (OS) were calculated with Kaplan-Meier curves.Results: The mean age of the patients was 42 years. Left and right breast cancers were seen in 17 (63%) and 10 (37%) patients, respectively. The mean values of ipsilateral lung V16 and contralateral lung V5 were 16.01% and 3.74%, respectively. The mean heart doses from the left and right breast were 7.25 Gy and 4.37 Gy, respectively. The mean doses to the contralateral breast, oesophagus, and Dmax to brachial plexus were 2.64 Gy, 3.69 Gy, and 26.95 Gy, respectively. The mean value of thyroid V25 was 19.69%. Grade 1 and 2 acute skin toxicities were observed in 9 (33%) and 5 (18.5%) patients, respectively. Grade 2 hyperpigmentation, edema, and induration were observed in 1 (3.7%), 2 (7.4%), and 4 (14.8%) patients, respectively. Mild breast pain and arm/shoulder discomfort were reported by 1 (3.4%) patient. The median follow-up was 51 months (range, 12 to 61 months). At four years, breast induration, edema, and fibrosis were observed in 1 (3.7%) patient. Cosmesis was excellent and good in 21 (78%) and 6 (22%) patients, respectively. Local recurrence and distant metastases occurred in 1 (3.7%) and 2 (7.4%) patients, respectively. DFS and OS at four years were 88% and 92%, respectively.Conclusion: With this radiotherapy schedule, acute and late toxicity rates were acceptable with no adverse cosmesis. Local control, DFS, and OS were good.

Objective: Primary hyperparathyroidism (PHPT) is associated with increased cardiovascular morbidity and mortality with inconsistent results on the reversibility of cardiovascular changes after parathyroidectomy (PTx). The present study was undertaken to evaluate both structural and functional cardiac changes and their reversal after PTx in patients with PHPT. Material and Methods: Thirty patients of symptomatic PHPT without cardiovascular risk factors were evaluated prospectively by means of 2D echocar- diography (ECHO) and Multigated Acquisition (MUGA) study before surgery and six months after curative parahyroidectomy. Results: Nine of 30 patients had hypertension which improved in two after PTx (p 0.20). Two patients had left ventricle hypertrophy on 2D ECHO pre- operatively which improved after PTx (p< 0.001). Left ventricular ejection fraction (LVEF) did not show significant change before and after PTx on 2D ECHO. Nine out of 30 patients had hypertension which improved in two after PTx (p 0.20). Two patients with left ventricle hypertrophy on 2D ECHO preoperatively improved after PTx (p< 0.001). Left ventricular ejection fraction (EF) did not depict significant change before and after PTx on 2D ECHO. Whereas, four out of six patients with preoperative EF 180 ms indicating diastolic dysfunction, of which ten showed improvement after PTx (p= 0.007). Conclusion: The present study analyzed preoperative and postoperative cardiac function using both 2D ECHO and MUGA study. MUGA study provided a more objective assessment of the cardiac function by determining left ventricular ejection fraction and diastolic dysfunction.

BACKGROUND: Hepatocellular carcinoma (HCC) has variable etiological risk factors. Radiofrequency ablation (RFA) and surgical resection (SR) are frequently used as curative treatment options. In the present study, we assessed the etiological factors and efficacy of RFA and SR in patients with unifocal HCC in a real-life setting. METHODS: Of 870 patients with HCC seen over a period of nine years, 785 patients were assessed for stage and etiological risk factors. Of these, 110 (14%) patients with single HCC who were either treated with RFA (n = 72) or SR (n = 38) were evaluated for their outcomes in terms of overall survival (OS) and disease-free survival (DFS) over 3 years. RESULTS: Of 785 patients [median age 60 (range 51–65) years, males (n = 685, 87.3%)] with HCC, viral hepatitis [HBV and HCV with or without alcohol = 502 (63.9%)] was the most common etiology; nonalcoholic steatohepatitis (NASH) and alcohol as an etiology showed increase over the years. About 677 (86.2%) patients had evidence of cirrhosis; NASH and HBV were predominant causes in noncirrhotic patients. Even though the groups were not matched, in 110 patients subjected to either RFA [mean tumor size, 2.2 (1.9–2.8) cm] or SR [mean tumor size, 7.1 (4.8–9.7) cm], tumor progression was observed in 49 (68%) and 16 (42%) patients in RFA and SR groups, respectively, with superior DFS in the SR group (P < 0.01). Of total 31 deaths, 20 (27.8%) deaths were in the RFA group and 11 (28.9%) in the SR group with no difference in OS at 3 years. CONCLUSION: Viral hepatitis with or without alcohol is the commonest etiological factor for HCC in Northern India; NASH and alcohol are increasing over the years. In a real-life setting, in patients with unifocal HCC, there is no difference in overall 3-year survival subjected to SR or RFA with better DFS in the SR group.

Objective: Primary hyperparathyroidism (PHPT) is a systemic disease which, along with bone and stone disease, also causes several subjective symptoms which impairs the quality of life (QoL). However, NIH guidelines do not include non-specific physical and neuropsychological symptoms as an indication of parathyroidectomy. SF-36 is one of the most commonly used tools for assessing QoL; it measures both physical health (PH) and mental health (MH). Material and Methods: This is a prospective observational study including 50 patients of symptomatic PHPT. Patients were categorized into normocalcemia (8.5-10.4 mg/dL), mild hypercalcemia (10.5-11.9 mg/dL), moderate hypercalcemia (12-13.9 mg/dL), and severe hypercalcemia (>14 mg/dL). QoL was assessed by using SF36 survey both pre-operative and three months after parathyroidectomy. Results: There was an overall improvement in QoL of individual groups both in PH and MH components (p< 0.001). The improvement was more substantial for bodily pain, role physical, vitality and mental health. Although QoL was affected in patients with mild hypercalcemia, it was more affected in patients with severe hypercalcemia. The improvement in MH scores was dependent on the level of pre-operative calcium; however, the improvement in PH scores was independent of pre-operative calcium (p= 0.698). Conclusion: This study showed improvement in all aspects of PH and MH of SF-36 after parathyroidectomy, even in normocalcemics. Despite the fact that current guidelines for the management of PHPT do not include QoL as an indication for parathyroidectomy, we propose that parathyroidectomy should be considered, if patient is fit for surgery.

A 49-year female presented to surgery outpatient clinic with the awareness of a right lower abdomen asymptomatic lump for one week. Contrast enhanced computed tomography of the abdomen demonstrated a 10x11x15cm heterogeneous lesion anterior to the ileocecal junction with the possibility of leiomyosarcoma. Patient was prepared for laparotomy and intraoperative there was a large tumour arising from the medial wall of cecum. Right hemicolectomy was performed, and histopathology came as a desmoid tumour of the cecum. The patient had an uneventful postoperative course and is well on one year follow up.

Context Primary hyperparathyroidism (PHPT) results from the hypersecretion of parathyroid hormone from parathyroid tumors. A transcription factor, namely Paired box1 (PAX1), is active in parathyroid gland development. Objective We aimed to study potential epigenetic-mediated mechanism of PAX1 gene in sporadic parathyroid adenomas. Methods In parathyroid adenomas tissues, we analyzed the DNA methylation via bisulfite-specific polymerase chain reaction (BSP) and histone modifications via chromatin immunoprecipitation in regulating the differential expression of PAX1. Results The results showed that mRNA and protein expression of PAX1 was significantly reduced in parathyroid adenomas. Bisulfite sequencing demonstrated hypermethylation in the promoter region of PAX1 (35%; 14/40) and lower levels of histone 3 lysine 9 acetylation (H3K9ac) were observed on the promoter region of PAX1 (6-fold; P < .004) in parathyroid adenomas. Furthermore, upon treatment with a pharmacologic inhibitor, namely 5′aza-2 deoxycytidine, in rat parathyroid continuous cells, we found re-expression of PAX1 gene. Conclusion Our study not only reveals expression of PAX1 is epigenetically deregulated but also paves a way for clinical and therapeutic implications in patients with PHPT.

Primary hyperparathyroidism (PHPT) in India is mostly symptomatic with renal and skeletal complications. Evidence on mortality outcomes following parathyroidectomy from India, where the disease is predominantly symptomatic is limited. This was a prospective study to evaluate mortality outcomes in the Indian PHPT registry over the past 25 years (n = 464). Pre- and postoperative parameters and mortality data were obtained from medical records and/or by verbal autopsy, a method validated by WHO for data collection in settings where several deaths are noninstitutional. Patients were divided into survivor (SG) and nonsurvivor groups (NSG) to ascertain differences in presentation and the effect of parathyroidectomy. The overall mortality was 8.8% at a median follow-up of 8 years (IQR 1–13) after parathyroidectomy. Chronic kidney disease was the most common background cause of death (43.5%), followed by pancreatitis (28.2%). NSG had significantly more frequent renal dysfunction (91.9% vs 73.9%), anaemia (50 vs 16.6%) and pancreatitis (24.3 vs 6.4%). PTH (61.9 vs 38.3 pmol/l) and baseline creatinine (97.2 vs 70.7 µmol/l) were significantly higher and eGFR lower (66.7 vs 90.7 ml/min/1.73m2) in the NSG than SG. By Cox proportional modelling, renal dysfunction [HR 2.88 (1.42–5.84)], anaemia [HR 2.45 (1.11–5.42)] and pancreatitis [HR 2.65 (1.24–5.66)] on univariate and renal dysfunction [HR 3.33 (1.13–9.77)] on multivariate analysis were significant for mortality. Survival curves demonstrated a significantly higher mortality with lower eGFR values. Nonsurvivors in PHPT had greater prevalence and more severe baseline renal dysfunction than survivors. Survival after parathyroidectomy was significantly associated with estimated glomerular filtration rate at baseline.

Claudin-low breast cancers are recently described entities showing low expression of certain claudins and cell adhesion molecules. Claudins constitute the backbone of tight junctions (TJs) formed between 2 cells. Their dysregulation plays a vital role in tumorigenesis. First part of the article focuses on the role of claudins in the TJ organization, their structural-functional characteristics, and post-transcriptional and translational modifications. The latter part of the review attempts to summarize existing knowledge regarding the status of claudins in breast cancer. The article also provides an overview of the effect of claudins on tumor progression, metastasis, stemness, chemotherapy resistance, and their crosstalk with relevant signaling pathways in breast cancer. Claudins can act as 2-edged swords in tumors. Some claudins have either tumor-suppressive/ promoting action, while others work as both in a context-dependent manner. Claudins regulate many important events in breast cancer. However, the intricacies involved in their activity are poorly understood. Post-translational modifications in claudins and their impact on TJ integrity, function, and tumor behavior are still unclear. Although their role in adverse events in breast cancer is recognized, their potential to serve as relevant targets for future therapeutics, especially for difficult-to-treat subtypes of the above malignancy, remains to be explored.

Introduction: Focused parathyroidectomy is the gold standard treatment for primary hyperparathyroidism (PHPT) due to single gland disease with a comparable success rate as that of conventional four gland exploration. It is also associated with fewer surgical complications. Despite these benefits, there is still controversy about the high recurrence following the focused approach. Aim: The aim was to analyse our experience regarding the success rate of focused parathyroidectomy for PHPT. Methods: This was a retrospective analysis of 192 patients of PHPT between January 2017 and August 2020 who underwent focused parathyroidectomy without intraoperative parathormone analysis, and had a minimum follow up of six months. Demographic profile, biochemical (pre and postoperative), radiological, operative and histological detail of all patients were recorded. Parathyroidectomy was considered curative if the patient maintained normal serum calcium and parathormone (PTH) levels six months after surgery. Persistent hyperparathyroidism was considered if hypercalcemia or high PTH levels persisted, or recurrent disease when a patient had rising serum calcium and / or PTH levels six months after curative parathyroidectomy. Results: No patient had pain and wound-related complications after parathyroidectomy. Two patients had voice change in the immediate postoperative period which recovered subsequently; no patient had documented vocal cord paralysis. The persistent disease was present in two patients; both required neck exploration. Five patients had recurrence of PHPT within six months of parathyroidectomy; all of them had hyperplasia on the final biopsy. The overall cure rate was 97.92%. Conclusion: Therefore, we propose focused surgery for sporadic PHPT should be considered as a preferred treatment with acceptable recurrence rate and surgical complications. KEYWORDS:focused parathyroidectomy, parathyroidectomy, primary hyperparathyroidism

Objective: Breast cancer is the most common cancer among Indian females and chemotherapy is the most extensively used modality for these patients. Diagnosis of breast cancer is dreadful in itself and the initiation of chemotherapy causes stress and fear among patients. Breast cancer survivors (BCS) use different coping mechanisms to deal with these experiences and to handle these stressful events. The objective of this study was to assess the coping strategies being practiced by the BCS before receiving first cycle of chemotherapy. Method: This descriptive study was conducted on BCS attending Radiation Oncology and General Surgery OPD, PGIMER, Chandigarh from July 2018 to December 2019. Sixty two BCS were recruited using purposive sampling. Results: 51.7% participants were above 50 years of age, 56.5% had grade III breast cancer and 56.7% had left breast involvement. 62.9% were on neo-adjuvant chemotherapy and duration of confirmed diagnosis for 83.9% of them was less than a year. Most of the participants used positive coping strategies to overcome the stress related to diagnosis and chemotherapy. Out of the 46 coping activities participants retorted positive action for 31 coping activities whereas action was negative for 13 activities. Remaining two activities had equal number of positive and negative responses. Escape avoidance ‘hoped a miracle would happen’; ‘Wished that the situation would go away or somehow be over with’ were used by all the participants. Though not dominant, negative coping activities were still used by the participants to deal with stressful situations. Conclusion: BCS were predominantly using positive coping activities. In order to further increase this there is a need among medical professionals to make BCS aware and discourage the use negative coping behaviors. BCS can also be nudged to adopt positive coping styles by involving family and society in the provision of care.

Extrahepatic portal venous obstruction (EHPVO) and temporomandibular joint (TMJ) ankylosisis are significant problems in Asian countries. Both EHPVO and bilateral TMJ ankylosis may have rare association due to protein C and S deficiency which may cause hypercoagulability as well as reduced fibrinolytic activity. Ankylosis arising in early childhood is associated with facial asymmetry, feeding difficulty and speech development alterations. It is also associated with great challenges of endoscopic management in extra hepatic portal vein obstruction (EHPVO) with variceal bleed as well as air way management during surgical management and post-operative recovery. Recently a case series had shown association of TMJ ankylosis with EHPVO due to protein C deficiency which might be an etiological factor for both EHPVO as well as TMJ ankylosis. This case report documents a case of 14 year young girl who had TMJ ankylosis due to ear infection and EHPVO with esophageal varices had multiple episodes of upper GI bleed with mild deficiency of protein C and S, successfully managed with proximal splenorenal shunt to prevent further episodes of upper GI bleed, as endoscopic management is not feasible due to TMJ ankylosis.

Severe presentation of primary hyperparathyroidism (PHPT) which, although, common in the Asian population, is albeit rarely encountered in the present era.We present a 23-year-old lady whose symptoms began in 2016 with generalized body aches. Subsequently, her husband noticed a reduction in her height and she developed gradual protrusion of chest. Meanwhile, she conceived in November 2019 and delivered a full-term healthy baby girl. She breastfed her baby for 18 months during which her symptoms worsened. On examination, she measured only 123 cm, having lost nearly 23 cm in height. She had a short neck, pectus carinatum-like deformity of chest, protruded abdomen, kyphosis, and scoliosis. Investigations revealed PTH-dependent hypercalcemia, diffuse cortical thinning, brown tumors, codfish vertebrae, and bilateral nephrolithiasis. A diagnosis of primary hyperparathyroidism (PHPT) was made with the grave clinical picture bearing a striking resemblance to that of Captain Charles Martell, the first ever recorded case of PHPT in the world.The index case highlights the fact that PHPT, if left undiagnosed and untreated, can have debilitating consequences. A high index of suspicion should be exercised while evaluating all suspected cases of metabolic bone disorders and being the third most common endocrine disorder, the possibility of PHPT should be entertained wherever appropriate.

lt;bgt; Introduction:lt;/bgt; The COVID-19 pandemic is an exceptional situation which has rigorously affected surgical education and training worldwide. This current situation has carved innovative ways like online teaching to counter the challenges of the pandemic faced by a surgical resident. However, online teaching is not complimentary to bedside teaching which is a traditional practice. Therefore, we designed this study to assess the residents' perceptive towards online learning as a mode of education which is extensively implemented during the COVID-19 pandemic at our centre.lt;/brgt;lt;/brgt;lt;bgt; Methods:lt;/bgt; This study was a cross-sectional survey. An online Google survey was circulated among junior residents in the department of General Surgery. This survey included residents' demographic profile, effect on working hours, their perception with online teaching, and effect on their surgical training during the COVID 19 pandemic.lt;/brgt;lt;/brgt;lt;bgt;Results:lt;/bgt; A total of 95 junior residents participated in this study. Surgical training and teaching was rigorously affected according to most of them and they also believe they have lost crucial training time in their tenure as a surgical resident. A majority found the communication with the faculty during online teaching adequate; however, the main drawback of online classes was the lack of clinical exposure and practical experience. Only 4.2% preferred 100% online teaching in future.lt;/brgt;lt;/brgt;lt;bgt; Conclusion:lt;/bgt; COVID-19 pandemic has affected surgical training much more as compared to other medical fields. However, we believe online education is still a potential instrument during the COVID-19 pandemic. Online learning platforms can be used in future as a supplement to time-honoured classroom teaching and didactic lectures.

Background: Postoperative pancreatic fistula (POPF) is associated with high morbidity and mortality rates. Studies have reported internal stenting of the pancreaticojejunostomy (PJ) to reduce POPF, but it is still controversial. Aim: In this study, we compared the outcome of internal stenting across the PJ to reduce POPF following pancreaticoduodenectomy (PD) and described our technique of putting the internal stent across the PJ and in to the main pancreatic duct. Materials and methods: Fifty patients undergoing elective PD were included. Patients were divided into two groups in a randomized fashion; Group A (n = 25) without internal stenting across the PJ and Group B (n = 25) with internal stenting of the PJ. The primary endpoint was the occurrence of POPF. Results: Both groups were comparable in demographics, comorbidities, pathologies, pancreatic texture and pancreatic duct diameter. Out of 50 patients studied, a total of 23 (46.0%) patients developed postoperative pancreatic fistula. Ten (40%) in group A and 13 (52%) in group B (p = 0.156). Sixteen patients (32%) developed Grade A and 7 (14%) patients had Grade B postoperative pancreatic fistula. In group A, 6 patients developed grade A and 4 patients developed grade B postoperative pancreatic fistula. In group B, 10 patients developed grade A and 3 patients developed grade B postoperative pancreatic fistula. There was no Grade C fistula. All patients had satisfactory recovery after conservative management. Eight patients (16%) developed delayed gastric emptying [5 in group A and 3 in group B; p = 0.366]. Six patients developed a superficial surgical site infection (2 in group A and 4 in group B; p = 0.445). The length of hospital stay was comparable between the two groups. There was no mortality. Conclusion: Internal stenting of PJ does not decrease the rate of POPF after PD.

Background and Aims: Modified pectoral nerve block (PEC) has been reported to have variable effects on perioperative pain in patients undergoing surgery for carcinoma breast. This randomised controlled trial was conducted to study the effect of modified PEC on postoperative pain relief in patients undergoing breast surgery. Methods: Fifty patients with carcinoma breast undergoing breast surgery were randomised to receive a modified PEC block consisting of 30 ml of ropivacaine 0.2% after induction of anaesthesia (PEC group) or no block (GA group) in this prospective randomised trial. Time to first rescue analgesia was recorded as primary outcome. Other secondary outcomes recorded were postoperative visual analogue scale (VAS) scores, number of rescue boluses and 24-h fentanyl consumption. Results: There was no significant difference in time to first rescue analgesia between the two groups, with mean difference (95% confidence interval) of 22.91 (−6.8 to 52.69) min. Amount of fentanyl required to keep pain VAS less than 3 was also comparable between the two groups, mean (standard deviation) of 42.0 μg (17.42) in GA group versus 43.24 μg (17.22) in PEC group; P = 0.830.20/25 patients required rescue analgesia in GA group as compared to 17/25 in PEC group (P = 0.334). The postoperative VAS scores were also comparable between the groups at all time intervals. Conclusion: Balanced anaesthesia supplemented with modified PEC block performed after general anaesthesia did not improve the postoperative pain in patients undergoing modified radical mastectomy.

A 43-year-old male patient, who received a deceased donor liver transplant for background ethanol-related decompensated cirrhosis, presented 7 months after transplant with mild abdominal distension and pain. On evaluation, the patient had thrombocytopenia, high serum-ascites albumin gradient ascites, and deranged liver functions. The Doppler study of the splenoportal axis showed hepatofugal flow in the recipient's portal vein, normal hepatic veins, a normal liver, splenomegaly, mild ascites, and multiple periportal collaterals. A transjugular liver biopsy and a hepatic venous pressure gradient measurement were done, which suggested mild portal tract inflammation with portal tract fibrosis with prominent portal venous thickening and normal hepatic venous pressure gradient (4 mm). However, the patient had a progressive increase in ascites and a dramatic increase in serum bilirubin level. A triple-phase computed tomography was done that showed rapid contrast flow in both the portal and hepatic arterial phase, suggesting arterialization of the portal flow with possible suspicion of a communicating arterioportal fistula. The patient underwent digital subtraction angiography, which was followed by an embolization of the arterioportal fistula. After embolization, serum bilirubin gradually decreased and ascites resolved. A repeat Doppler of the portal venous system showed established hepatopetal flow with progressively rising portal flow velocities.

Young women with breast cancer (BC) are not represented in the trials on hypofractionation. In this study we compared outcomes in young patients with BC to their older counterparts treated with hypofractionated radiotherapy (RT) in a regional cancer centre in India.Between January 1990 to December 2010, women with BC, treated with hypofractionated RT dose of 35-40 Gy/15#/3 weeks were divided into two groups, ≤ 35 years and35 years. Outcomes compared were locoregional recurrence rate (LRR), locoregional recurrence-free survival (LRRFS), disease-free survival (DFS), overall survival (OS) and toxicities. LRRFS, DFS and OS were estimated using the Kaplan-Meier method.Of total 2244 patients, 359 were ≤ 35 years of age and 1885 were35 years. Patient and disease characteristics were comparable between the two groups, except that comorbidities were significantly higher in the35 years age group, more patients aged ≤ 35 years had nodal N3 disease, received chemotherapy and RT to internal mammary nodes and more patients in the35 years group received hormonal therapy. Median follow up was 10 years (range 1-30 years). LRR and distant metastases were comparable between the two groups. However, synchronous LRR and distant metastases were significantly higher in the ≤ 35 years group 18 (5.1%) as compared to the35 years group 39 (2.1%) with p = 0.018. Estimated 10-year LRRFS, DFS and OS were 92%Young BC patients had higher LRR and distant metastases. LRRFS, DFS and toxicities were comparable between the two groups. However, OS was poorer in young BC patients with stage 2 and 3 disease.

Single complete denture opposing natural dentition is a challenging situation when the opposing natural dentition is with malaligned tipped or supra-erupted teeth. This clinical scenario further requires more attention when it is accompanied by a defect in the arch. Osteomyelitis is a serious inflammatory condition requiring necrotic removal of the bone leading to defect formation. Every minute detail needs to be recorded in such defects to further enhance the stability and retention of the prosthesis. The digital fabrication of the metal denture base is discussed in this clinical report for the rehabilitation of a completely healed edentulous maxillary arch opposing the natural dentition.

Necrotizing enterocolitis is one of the most common and worrying diseases in neonates, commonly shown in premature neonates, and is associated with significant mortality and morbidity. Necrotizing enterocolitis is characterized by intestinal mucosal injury that can progress to transmural bowel necrosis, and radiologically it can present with either pneumatosis intestinalis or portal venous gas. It is postulated to develop in an immunocompromised host in the setting of bacterial colonization, usually after administration of non-breast milk feed. Cow's milk allergy association with necrotizing enterocolitis has not been well determined, and the pathophysiology is still not clear. Necrotizing enterocolitis is very rare following living donor liver transplant. In our case, a 6-year-old boy who was doing well in the postoperative period had sudden worsening of general condition after he was started on milk feed. On evaluation and reexploration, he was diagnosed with necrotizing enterocolitis and later succumbed to death.

Cleft lip and palate is a congenital anomaly resulting in functional, esthetic and psychological disharmony of the patient. In infants, parents face a major problem in feeding them because of oro-nasal communication prior to any surgical intervention. In this article, various designs of passive feeding plates have been described to meet the nutritional demands of the infants. In young children, active feeding plates help in improving functioning along with the naso alveolar moulding.

BACKGROUND Primary hyperparathyroidism (PHPT) results in reduction of bone mineral density (BMD) and an increased risk of pathological fractures. Curative surgery does improve BMD; however, the magnitude of rise and predictive factors are highly variable amongst the hitherto available studies. OBJECTIVES To quantify the magnitude of improvement in BMD after curative surgery in patients with symptomatic PHPT and dissect out the possible clinical and biochemical parameters predicting the BMD rise. METHODS We conducted a retrospective study of symptomatic PHPT patients undergoing surgery between August 2016 and July 2018. Patients achieving biochemical cure with pre- and post-operative (at least 1 year after surgery) dual-energy X-ray absorptiometry scans performed were included in the study. RESULTS After exclusion, 63 patients were included in the study (M:F = 2:5; mean age = 44.8 years). At a median interval of 15 months, the median per cent change in BMD (ΔBMD) at lumbar spine (LS), total hip (TH), femoral neck (FN) and one-third distal radius (forearm) was 6.5%, 7.0%, 8.1% and 6.9%, respectively. Following multiple linear regression analysis, baseline BMD was found to inversely predict ΔBMD at LS, TH and forearm. Pre-operative iPTH positively predicted ΔBMD at LS and FN. Interestingly, 82.5% of the patients had a gain in body weight following curative surgery and change in body weight emerged as a significant positive predictor of ΔBMD at all sites. CONCLUSIONS Curative surgery improves BMD at all sites in patients with symptomatic PHPT. Weight gain following surgery can be used as a positive clinical predictor of BMD rise.

Background Gallstone disease (GSD) and nonalcoholic fatty liver disease (NAFLD) are connected with a high prevalence in the general population and they share common risk factors for their occurrence. Limited literature with inconsistent results is available, suggesting a potential association between these lifestyle-induced diseases. Liver biopsy is the gold standard for diagnosing NAFLD. The aim of this study was (1) to identify the prevalence of asymptomatic NAFLD or NASH in liver biopsy; (2) to identify the association of hypercholesterolemia with NAFLD in patients undergoing laparoscopic cholecystectomy (LC). Methods This is a prospective observational study conducted on patients who underwent LC for symptomatic gallstones in the Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India, from 1st July 2013 to 31st December 2014. All included patients had ultrasonography (USG) and the following parameters tested: serum triglycerides (TG), cholesterol, low density lipoprotein cholesterol (LDL-C), and high-density lipoprotein cholesterol (HDL-C). A wedge liver biopsy was obtained from free edge of the right liver lobe during LC and all biopsy specimens were analyzed by a single pathologist. Results Among 101 patients included in the study, dyslipidemia was present in 49.50%. There was no association between NAFLD and serum cholesterol, TG or LDL-C (P, 0.428, 0.848, 0.371 respectively). NAFLD was confirmed in liver biopsy in 21.8% of patients but none had fibrosis or cirrhosis on biopsy. No complications were observed following liver biopsy. Conclusions Liver biopsy during LC gives an opportunity to diagnose the disease at an early and reversible stage. It is feasible, safe and cost effective.