Abstract Generalised weakness of the abdominal wall can lead to its failure to contain the abdominal viscera within the confines of the abdominal cavity, resulting in simultaneous hernias at different sites. We propose that this entity should be termed ‘abdominal wall failure’, and the laparoscopic approach is ideal for the management of such a condition. This report presents the case of a patient with concurrent hiatal hernia, bilateral direct inguinal hernias, bilateral femoral hernias and recurrent paraumbilical hernia, managed laparoscopically.

AIM:To evaluate thyroid nodules with sonoelastography and magnetic resonance imaging (MRI). MATERIALS AND METHODS:The study included 28 patients with 40 thyroid nodules. Clearance was obtained from the institute's ethical clearance committee. Patients with pure cystic nodules or nodules with eggshell calcification, diffuse thyroid pathology (such as Graves' disease, Hashimoto's thyroiditis, De Quervain thyroiditis, and Riedel's thyroiditis), inaccessible nodules via fine needle aspiration cytology (FNAC), or patients with a history of thyroid gland surgery were excluded from the study. Strain elastography was performed on a Phillips iU22 machine, producing qualitative color-coded strain maps (graded using the Rago 5-point system) and semiquantitative strain ratios. MRI was performed on a Phillips ACHIEVA 1.5T magnet with a head and neck coil. RESULTS:Rago scores statistically correlated (χ2 = 18.052, p < 0.001) with malignant nodules, and using the receiver operating characteristic (ROC) curve, the area under the ROC curve (AUROC) for the mean strain ratio predicting malignant outcomes was 0.88 [95% confidence interval (CI): 0.767-0.992], which was also statistically significant (p < 0.001). A cutoff of mean strain ratio ≥2.48 predicted malignant outcomes with 100% specificity. T2 signal intensity ratio (SIR) and apparent diffusion coefficient (ADC) values were not statistically significant in predicting malignant outcomes. Kinetic curves were statistically significant for Rago scores (χ2 = 11.356, p = 0.045); however, no significant difference was found in predicting malignant outcomes. CONCLUSION AND CLINICAL SIGNIFICANCE:We concluded that sonoelastography, along with grayscale ultrasound, is a useful noninvasive technique for predicting histological outcomes. However, MRI should largely be reserved as a problem-solving tool rather than a standalone imaging modality. The kinetic curves show some degree of overlap between histologically distinct diseases, and thus large-scale multicenter trials are needed for further standardization.

In the extra-peritoneal approach for inguinal hernias, pre-peritoneal space creation is one of the most crucial steps. In the absence of well-defined landmarks, it is difficult to identify the correct plane of dissection, and blind dissection can sometimes lead to peritoneal injury, resulting in loss of working space. In this article, we describe our technique of pre-peritoneal space creation by following the fatty tissue of the median umbilical ligament and fatty tissue along the rectus muscle. The data of all patients (total 84) who underwent surgery with this technique between January 2021 and May 2023 were retrieved and assessed for demographics, hernia type, and perioperative complications. Except for two peritoneal injuries, there were no other intraoperative complications.

INTRODUCTION Currently, multimodal analgesia and adjunctive therapies are recommended for postoperative pain relief in abdominal surgeries.[1,2] Intravenous (IV) lignocaine is a better alternative for individuals hesitant or not fit to undergo interventional neuraxial and peripheral nerve blocks.[1] Perioperative IV lignocaine has several benefits, including analgesic effects, earlier return of bowel function, decreased postoperative nausea and vomiting (PONV) incidence and shorter hospital stay.[3] Serum lactate level is used as a marker of balance between demand and available oxygen, leading to an immunoinflammatory response.[4] Postoperative increased lactate levels after major elective abdominal surgery can be linked to an increased risk of postoperative complications and mortality.[4] Pain affects the levels of biochemical markers like lactate dehydrogenase (LDH). The release of inflammatory markers, tissue injury, cell necrosis and damage to tissue architecture are all associated with elevated levels of LDH.[5] The primary objective of this study was to compare the postoperative serum LDH and lactate levels in patients receiving intraoperative lignocaine versus saline during restoration of bowel surgery under general anaesthesia (GA). METHODS This randomised, controlled study was done after approval by the hospital ethics committee (GMCH/IEC/2020/446/36R, dated 16/02/2021) and registration at the Clinical Trials- Registry-India (CTRI/2021/03/032273, dated 24/03/2021, https://www.ctri.nic.in/). The patients were enroled between June 2021 and March 2022. The study complied with the Declaration of Helsinki's ethical principles, 2013 and the Good Clinical Practice. Written informed consent was taken from all participants for study participation and patient data use for research and educational purposes. Patients of the American Society of Anesthesiologists (ASA) physical status I–II were included in the present study. Patients with neurological disorders, renal or hepatic impairment, inability to understand visual analogue scale (VAS), history of substance abuse, contraindications to study drugs, chronic pain conditions, neurodegenerative or autoimmune disorders, abnormal cardiac conduction or congestive heart failure were excluded from the study. Baseline haemodynamic data were recorded in the operating room using a multichannel monitor (Aespire View; Datex-Ohmeda, Madison, WI, USA). Serum lactate was measured using a metabolite analyser (blood gas analyser; Radiometer Medical ApS Radiometer Medical Equipment Co. Ltd., Brønshøj, Denmark). LDH was measured using an automated random access chemistry analyser (Clinical Chemistry Analyser; Randox Laboratories Ltd., County Antrim, UK). Randomisation of the patients was done using a computer-generated random number table, and group allocation concealment was performed by placing the details of group allocation in an opaque sealed numbered envelope: Group lignocaine (n = 30): Patients received 1.5 mg/kg IV lignocaine 2% followed by infusion at a rate of 1.5 mg/kg/h till the end of surgery. Group normal saline (n = 30): Patients received 1.5 mg/kg IV normal saline followed by infusion at a rate of 1.5 mg/kg/h till the end of surgery. The observer (candidate) and the patient were blinded during the study. An independent anaesthesia resident who prepared the study drug did not participate in further analysis and management of the patient. A standard technique of GA using IV fentanyl 1–2 µg/kg, propofol 2–3 mg/kg, vecuronium 0.1 mg/kg, sevoflurane 1%–2% and nitrous oxide with oxygen (60:40) was followed to maintain a minimum alveolar concentration (MAC) of 1.0. Haemodynamics were kept within 20% of baseline with balanced anaesthesia, fluid and vasopressors as required. All patients received a standardised fluid therapy of 10–12 ml/kg in the first hour, followed by maintenance fluid therapy of 1.5–2 ml/kg/h.[6] Urine output was maintained at 1 ml/kg/h during the perioperative period. Residual neuromuscular blockade was reversed, and the trachea was extubated after surgery. In the postoperative period, rescue analgesia with IV tramadol 2 mg/kg was given if the patient experienced a VAS >3 with a maximum dose of 400 mg in 24 h. All patients received IV paracetamol (PCM) 1 g 6 hourly and IV diclofenac 75 mg 12 hourly for 24 h postoperatively. The primary outcome was to compare serum LDH and lactate levels before surgery (baseline), before tracheal extubation intraoperatively and postoperatively at 6 and 24 h in patients receiving intraoperative lignocaine versus saline during restoration of bowel surgery under GA. Other outcomes measured were VAS at rest and on movement – baseline, 1 h in the postoperative anaesthesia care unit (PACU), and 6, 12 and 24 h after surgery. Based on the finding that serum LDH concentration was significantly linked with increased postoperative pain [β (standardised regression coefficient) = 0.606, P < 0.001],[5] the sample size for the present study was calculated. The sample size (n) was determined using the formula n = [(Zα + Zβ)/C]2 + 3, where standard normal deviate for α = Zα = 1.96, standard normal deviate for β = Zβ = 0.84, C = 0.5* ln[(1 + r)/(1- r)] and r is the regression coefficient. Twenty-five subjects comprised our sample, with a power of 0.90 and a 95% confidence interval. It was decided to include 30 patients in each group to account for potential attrition. The primary outcomes, serum LDH and lactate values were represented as mean (standard deviation [SD]). Secondary outcomes, including demographics, haemodynamic parameters, VAS scores, rescue analgesia used, fluid intake, urine output, patient satisfaction score and arterial blood gas (ABG) parameters, were reported as mean (SD). The t-test was utilised for the calculation of pulse rate, blood pressure and respiratory rate, whereas the Mann–Whitney U-test was used for age, weight, height, body mass index (BMI), oxygen saturation, VAS score at rest and on movement, rescue analgesia, fluid intake, urine output, patient satisfaction score, serum LDH and lactate values and ABG parameters. The relationship between serum LDH and lactate values with VAS mean (SD) was analysed using the Spearman/Pearson correlation coefficient. The significance level for each two-sided statistical test was set at α = 0.05. RESULTS Demographic profile was comparable in the two groups (P > 0.05). Values of serum LDH and lactate were lower in Group lignocaine before extubation (P < 0.001) and at 6 h (P < 0.001) [Table 1].Table 1: Perioperative comparison of LDH and lactate in patients receiving intravenous lignocaine versus normal saline while undergoing bowel surgeryPostoperative VAS scores at rest [Figure 1a] and on movement [Figure 1b] were lower in Group lignocaine, with statistical significance at all intervals except at 45 min in PACU (P = 0.062). A significant correlation was found between LDH and lactate with VAS at rest [Figure 2a and b] and movement [Figure 2c and d] at 6 h. Lactate and LDH at 6 h overall had a moderate positive correlation (rho = 0.54, P < 0.001) [Figure 2e].Figure 1: Postoperative comparison of (a) VAS at rest and (b) VAS on movement between Group lignocaine and Group normal saline in patients undergoing bowel surgery. Values are represented as box and whisker plots. VAS = visual analogue scale scoreFigure 2: Scatterplot depicting the correlation between (a) VAS at rest (6 h) and LDH (IU/l) (6 h) overall, with a moderate positive correlation, which was statistically significant (rho = 0.34, P = 0.008). (b) VAS at rest (6 h) and lactate (mmol/l) (6 h) overall, with a moderate positive correlation, which was statistically significant (rho = 0.44, P < 0.001). (c) VAS on movement (6 h) and LDH (IU/l) (6 h) overall, with a moderate positive correlation, which was statistically significant (rho = 0.34, P = 0.008). (d) VAS on movement (6 h) and lactate (mmol/l) (6 h) overall, with a moderate positive correlation, which was statistically significant (rho = 0.44, P < 0.001). (e) Lactate (mmol/l) (6 h) and LDH (IU/l) (6 h) overall, with moderate positive correlation, which was statistically significant (rho = 0.54, P < 0.001). Individual points represent individual cases. The blue trendline represents the general trend of correlation between the two variables. The shaded grey area represents the 95% confidence interval of this trendline. LDH = lactate dehydrogenase, VAS = visual analogue scale scoreThe consumption of IV tramadol as rescue analgesia was lower in Group lignocaine in PACU (P < 0.001) and at 12 h (P = 0.010). Patient satisfaction score mean (SD) [95% confidence interval (CI)] at 24 h was statistically superior in Group lignocaine 4.93 (0.25) [4.84–5.03] compared to Group normal saline 4.67 (0.48) [4.49–4.85] (P = 0.010). The ABG parameters were constant, comparable and within normal physiological bounds for both groups. Haemodynamics in both groups remained within the physiological range. No adverse effects were noted. DISCUSSION The novelty of the present study is that we have demonstrated that LDH and lactate levels are reduced with IV lignocaine. The scientific data supporting the same is the published literature that reports pain hypersensitivity due to acidic microenvironments with lactic acid production in anaerobic situations.[7-9] Inflammatory insult to tissues causes recruitment of neutrophils and macrophages. Increased activity of pyruvate dehydrogenase kinase (PDK) 2 and PDK4 in neutrophils and macrophages after a stimulus causes phosphorylation/inhibition of pyruvate dehydrogenase, leading to increased lactate production. This acidic microenvironment favours the recruitment of more inflammatory cells, and increases localised inflammation that causes nociceptive reactions. Increased levels of lactate and pro-algesic signals cause peripheral sensitisation of the dorsal root ganglion and central sensitisation of the spinal cord via inflammatory mediators, leading to increased pain hypersensitivity.[10,11] A strong association was found between LDH concentrations and postoperative pain. LDH as a biochemical predictor may be used to identify patients who need more potent analgesics for aggressive pain management following surgery.[5] The analgesic effect of IV lignocaine can be understood via the peripheral and central nervous systems. IV lignocaine decreases the influx of macrophages and neutrophils at the site of inflammation, thereby suppressing the rise in levels of proinflammatory cytokines and decreasing the formation of lactate, leading to adequate pain relief.[12,13] Lignocaine suppresses the activity of neural glial cells, causing reduced pain hypersensitivity and release of inflammatory mediators.[14] This mechanism can probably explain the novelty of the present study as it demonstrates lower LDH and lactate with lower pain scores in patients receiving IV lignocaine infusion during restoration of bowel continuity surgery. There were a few limitations in the present study. The present study was a single-centre study and included only patients with ASA physical status I and II. The entropy measurement was not included in the present study. Multicentric studies or studies with larger sample sizes will be desired to fill the knowledge gaps. CONCLUSION The postoperative serum LDH and lactate levels were lower in patients receiving intraoperative IV lignocaine compared to normal saline in patients undergoing bowel surgery. Study data availability De-identified data may be requested with reasonable justification from the authors (email to the corresponding author) and shall be shared after approval as per the authors' institution policy. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Objectives:Phaeohyphomycosis refers to infections caused by phaeoid/dematiaceous or darkly pigmented fungi. This study was undertaken to further increase our knowledge about the incidence of phaeohyphomycosis and its causative agents. Materials and Methods:The present study was conducted over a period of one and a half years (January 2018-June 2019) on specimens received from patients with varied clinical manifestations ranging from superficial infections, subcutaneous cysts, pneumonia, brain abscess to a disseminated infection. These specimens were processed in the Department of Microbiology for potassium hydroxide (KOH) examination and culture and in Pathology for cytology/histopathological examination (HPE). All specimens positive on direct examination for dark grey, brown or black fungi were included in the study. Results:A total of 20 specimens were confirmed as phaeohyphomycosis. Most of the patients belonged to the age group of 41 to 50 years. Male: Female ratio was 2.3:1. Trauma was the most common risk factor. Spectra of the isolated fungal pathogens comprised of Bipolaris species, Exophiala species, Curvularia geniculata, Phialemonium species, Daldinia eschscholtzii, Hypoxylon anthochroum, Phaeoacremonium species, Leptosphaerulina australis, Medicopsis romeroi, Lasiodiplodia theobromae, Eutypella species, Chaetomium globosum, Alternaria species, Cladophialophora bantiana and 2 unidentified dematiaceous fungi. Recovery from phaeohyphomycosis was seen in 12 patients, 7 were lost to follow up and one patient succumbed to the illness. Conclusion:Infections caused by phaeoid fungi can no longer be viewed as rare. In fact, phaeohyphomycosis can have myriad of presentations spanning from mild cutaneous infections to fatal brain disease. Therefore, a high index of clinical suspicion is needed to diagnose such infections. The primary treatment modality remains surgical removal of the lesion in cutaneous or subcutaneous infections however disseminated disease with a guarded prognosis requires aggressive management.

Background: Clostridium sporogenes is reported rarely in literature. Reports from the skin and soft tissue infections are even less, more so in immunocompetent patients. Case Presentation: Two skin and soft tissue infections with C. sporogenes in immunocompetent patients have been presented in this study. One of the cases was following an electrical burn wound, and the other was following a bedsore. Both patients expired despite antibacterial treatment and debridement. Discussion and Conclusion: C. sporogenes had usually been reported after trauma particularly after penetrating and deep wound infection. More attention should be given to these patients so that the infection can be treated and diagnosed early in suspected anaerobic infections like Clostridium species.

Background: Complete mesocolic excision with central vascular ligation for colonic cancers improves overall survival. To achieve better short term and oncological results, different laparoscopic techniques have been described for right-sided colonic cancers. Laparoscopic right hemicolectomy by the Initial Retrocolic Endoscopic Tunnel Approach (IRETA) is proposed to be easy and offer desired oncological resection; we present our results with IRETA. Patients and Methods: The data of all patients who underwent right hemicolectomy by IRETA for colonic cancer between January 2019 and March 2020 were retrospectively analysed for demographics, clinical features, oncological completeness of resected specimen, complications, hospital stay, morbidity and mortality. Results: A total of eight patients (05 males and 03 females) were identified. The mean operating time was 190 ± 32.40 minutes. Margins of all resected specimens were free of tumour except for one in which retro-peritoneal circumferential resection margin was positive. On average 13.75 ± 2.63 lymph nodes were retrieved. Except for wound infection in one patient, no other morbidity was seen. Conclusion: Laparoscopic radical right hemicolectomy by IRETA is safe and gives desired oncological results.

Fine‐needle aspiration cytology (FNAC) forms one of the first‐line investigations in the evaluation of tumors in modern era. Its role in diagnosing soft tissue tumors (STT) has been well established. However, the morphological overlap and biological heterogeneity of STT pose a morphological diagnostic challenge.

The members of the family Pseudomonadaceae have been reorganised under various groups, each with several species and are known as opportunistic pathogens. Pseudomonas mendocina (P.mendocina) formerly known as CDC group Vb-2, belongs to stutzeri group (group II) and was first discovered in 1970 in Mendoza. The present case report is about an overwhelming leg ulcer in an asthmatic and diabetic 53-year-old, Indian farmer following a fall due to a multi-drug resistant strain of P.mendocina without any systemic spread due to timely intervention. Authors emphasise that P. mendocina may be an important emerging pseudomonad or alternatively an under-diagnosed pathogen in immunocompromised patients exposed to soil. The multidrug resistant nature of this organism is alarming and it may become a threat to people with weakened immune systems.

Background: Circulating tumor cells (CTCs) are cells present in the blood stream that are antigenically or genetically similar to a specific tumor type and are markers of tumor diagnosis, prognosis, residual disease and metastasis. The ever-increasing burden of breast cancer globally warrants the incorporation of this all-inclusive marker in the diagnostic repertoire using the simplest of techniques. Aims: To identify CTCs in peripheral blood by cell block (CB) technique in cases of breast cancer diagnosed on fine-needle aspiration (FNA) or core needle biopsy (CNB) and to correlate their presence with nodal metastasis. Material and Methods: This study was conducted in the Department of Pathology, at a tertiary care hospital. Peripheral blood samples from a total of 30 cases of primary breast carcinoma diagnosed on FNA or CNB without prior neoadjuvant chemotherapy were analyzed using the CB technique. Results: The age ranged between 29-74 years with the most common presenting complaint being a palpable, single, unilateral breast lump. CTCs were detected in 2 (6.7%) cases with a <5 cell cluster with both the cases being grade I breast carcinomas and also displaying nodal metastasis.

In India, Apophysomyces species complex is the second common agent of mucormycosis mainly affecting immunocompetent hosts unlike other Mucorales. It is frequently involved in causing necrotizing cutaneous infections. The present two-year study was planned to investigate the causative role of Apophysomyces spp. in cutaneous necrotizing infections. The tissue samples were processed using standard techniques and in five out of 65 patients, Apophysomyces variabilis was the etiological agent. Diabetes mellitus and trauma were common risk factors and despite appropriate treatment only one patient could be survived. Apophysomyces variabilis is emerging as agent of necrotizing infections which invariably result in poor patient outcomes.

BACKGROUND:The use of fine-needle aspiration (FNA) as a primary tool in the diagnosis of breast carcinoma provides opportunity for early proliferative characterization of the tumor. This study was undertaken to assess DNA ploidy and S-phase (SPF) fraction by flow cytometry in fine needle aspirates of patients with breast cancer.METHOD:Fifty patients of breast cancer diagnosed on fine needle aspiration cytology (FNAC) and who subsequently underwent either mastectomy or lumpectomy were included. Material obtained by FNAC was subjected to DNA ploidy and SPF analysis. Immunohistochemical estimation of Ki-67 was done on histopathology sections. The proliferation markers (SPF and Ki-67) were compared with each other and with the histopathologic parameters.RESULTS:On DNA flow cytometry, 27 (54%) cases were aneuploid and 23 (46%) cases were diploid. The median SPF was 12.43% and 4.03% in aneuploid and diploid tumors respectively. Median Ki-67 among aneuploid tumors was 28.6% compared to 8.7% among diploid tumors. Aneuploid tumors were significantly associated with higher values of SPF and Ki-67, with Kappa 0.437 and agreement of 72%. Diploid tumors showed lower values of SPF and Ki-67, with Kappa 0.455 and agreement of 72.7%. Correlation among SPF and Ki-67 was highly significant with Kappa value 0.446, P value of .002 and agreement of 72.3%.CONCLUSION:DNA ploidy and proliferative activity by flow cytometric SPF estimation on fine needle aspirates from breast cancer can provide valuable prognostic and predictive information at the time of diagnosis in patients with breast cancer. This might help in selection of appropriate treatment modality.

Necrotizing soft tissue infections (NSTI) are frequently encountered, with a high mortality despite advances in health care. Patients presenting with NSTI were prospectively followed up in an attempt to identify factors that were significantly associated with mortality. There were a total of 86 patients [65 males (75.6%) and 21 females (24.4%)] with an overall mortality of 33.7% (29 patients). The average age was 50.37 years and trauma was the commonest aetiology (34 patients, 66.7%). The average duration of symptoms prior to presentation was 10.56 days; the lower limb was most commonly involved (62 patients, 72.09%). Fifty nine patients had comorbidities (commonest being diabetes mellitus in 41). Age above 50 years, symptoms for more than 8.5 days, involved surface area more than 15.5%, of the total body surface, on-admission pulse rate more than 99 beats/minute, systolic blood pressure less than 103 mm Hg, Glasgow scale less than 12, need for inotropes, low hemoglobin, high leukocyte counts, uraemia, deranged coagulation, low serum albumin, and high levels of lactic acid were significant for mortality. On multivariate analysis, only age above 50 years, presence of acidosis and low serum albumin significantly affected survival. NSTI carry high mortality. The identification of potential risk factors associated with mortality might help in guiding and optimizing the management of patients who present with NSTI.

Transhiatal esophagectomy (THE) with cervical esophagogastric anastomosis is done for esophageal carcinoma and various benign lesions of the esophagus. Cervical anastomotic (CA) leak following THE is a serious complication that adds significantly to morbidity. As these leaks usually manifest in neck, local wound care is one of the essential components to manage such leaks. This study aims to evaluate the effect of negative pressure therapy (NPT) on healing of cervical wound following CA leaks. The record of all patients, who underwent THE for benign or malignant lesion of the esophagus from 2012 to 2019, was retrospectively analyzed. Of all the patients who had CA leak, patients with type II CA leak were only included for further analysis. The outcome of the patients who received NPT for wound care was compared with those who received simple wound dressings in terms of time to oral feed, hospital stay, mortality, and dysphagia at 6 months. Seventy-two patients were thus identified and 18 (25%) had an anastomotic leak. Patients with type II leaks (n = 16) were successfully managed by conservative approach. NPT for wound care in these patients was associated with significant reduction in hospital stay and early resumption of oral intake (p < 0.05) as compared with simple wound dressings. Conservative approach is effective for management of CA leaks. NPT for wound care significantly reduces associated morbidity.

Background: Postoperative pancreatic fistula (POPF) or leak from pancreaticojejunostomy (PJ) is one of the most common complications after pancreaticoduodenectomy (PD), with an incidence of 5%–30%. Various techniques have been advocated to bring down the incidence of POPF, but there is still none that can be called the “gold standard”. Peng's binding PJ (BPJ) was proposed as a good method of performing PJ with low fistula rates; we present our results with BPJ. Methods: The data of all patients who underwent PD with BPJ between January 2016 and March 2018 were retrospectively analyzed for demographics, clinical features, type of procedure performed, complications (especially POPF), hospital stay, morbidity, and mortality. Results: A total of 24 patients (18 males and 6 females) were identified. The mean age at the diagnosis was 65.5 ± 6.4 years. Majority of the patients had ampullary carcinoma (62.5%). The most common postoperative complication was delayed gastric emptying seen in 10 patients, whereas only 2 (8.33%) had POPF and there was one mortality. Conclusion: BPJ is safe and is associated with a low incidence of POPF.

Objective:Phaeohyphomycosis caused by phaeoid fungi is a type of mycosis emerging worldwide which causes a wide variety of clinical manifestations.Study Design:A retrospective analysis of 11 cases diagnosed with fungal inflammation on cytology over a period of 6 years (2013-2018) was done along with culture/histopathologic confirmation.Results:Of the total of 11 cases, 9 cases presented with subcutaneous swellings and 1 case each with brain and lung lesions. The age range was 30-83 years (mean: 53.6); 8 patients were male and 3 were female. Cytologic smears showed fungal profiles with septate tortuous hyphae, as well as swollen and narrow, yeast-like swellings with an irregular breadth of the hyphae in all cases. The fungal profiles were visualized on a Masson-Fontana stain. The background showed inflammatory cells, giant cells, and necrosis in variable proportions. Five cases were diagnosed as phaeohyphomycosis on cytology, whereas 3 cases were misdiagnosed as aspergillus and 2 as candida. In 1 case, typing of the fungus was not done. Histopathology was available in 5 cases, and in all these a diagnosis of phaeohyphomycosis was reached. Ten of the 11 cases had confirmation on fungal culture.Conclusions:Phaeoid fungi are rarely seen in routine cytologic practice. Careful evaluation of cytologic smears and an awareness of the characteristic morphologic features of phaeohyphomycosis are helpful in arriving at a correct diagnosis. Fine needle aspiration cytology provides a rapid diagnosis, enabling prompt therapy.

PURPOSE:The aim is to study the clinical profile and outcome of patients presenting with diabetic foot infections (DFI). METHODS:This was a prospective study recruiting patients >18 years of age, with DFI. All patients underwent a detailed history and clinical examination. Patients were classified as per the International Working Group on the Diabetic Foot -IDSA classification. The patients were followed up every month for 3 months. Clinical outcome was studied regarding the rate of amputations, readmissions, and mortality. RESULTS:There were 65 patients with a mean age of 58.49 ± 11.04 years with male predilection (83.08%). Mean duration of diabetes mellitus was 12.03 ± 6.96 years. Ulcer (92.31%) and discharge (72.31%) were the most common presenting complaints. Monomicrobial growth was present in 36 patients (55.38%). Majority of isolates were Gram-negative (71.43%). The most common isolates were Escherichia coli and Staphylococcus aureus (28.57% each). Mild, moderate, and severe DFI was present in 40%, 47.69%, and 12.31% of patients, respectively. Severe DFI was associated with poor ulcer healing (P = 0.02) and higher number of major amputations (P < 0.001). Minor amputations were most commonly associated with moderate and severe DFI. Severe DFI had the highest number of readmissions (P = 0.04). Patients undergoing minor amputations had a significant association with area of ulcer (P < 0.001). CONCLUSION:This study shows the predominance of monomicrobial growth and Gram-negative organisms in diabetic foot patients. With increase in the severity of DFI, there was increased rate of hospital readmissions, amputations (major and minor), and mortality. Dimensions of ulcer may have a bearing on rate of minor amputations.

AIMS: Diabetic foot ulcer is a dreaded complication of diabetes. Diabetic foot ulcer patients are often infected with multidrug resistant organism (MDRO) due to chronic course of the wound, inappropriate antibiotics treatment, frequent hospital admission, neuropathy, nephropathy, and peripheral vascular disease. MATERIALS AND METHODS: This prospective study was conducted in our 750 bedded hospital for a period of 6 months. The present study was undertaken to isolate various MDRO methicillin resistant Staphylococcus aureus; Gram-negative bacteria producing enzymes such as extended spectrum beta-lactamases (ESBL), Amp C, Carbapenamases; Pseudomonas and Acinetobacter species producing metallo-beta-lactamases (MBL). In addition we attempted to identify risk factors for association of diabetic foot ulcer and MDRO. RESULTS: A total of 149 bacterial isolates were identified. Of the total isolates 73.2% were Gram-negative and remaining 26.8% were Gram-positive bacteria. Among Enterobacteriaceae 59% were ESBL producers and 48% were Amp C producers. In addition, 41.5% of the isolates produced both ESBL and Amp C and 13.4% were carbapenem resistant Enterobacteriaceae. Among 20 Pseudomonas and Acinetobacter isolates, 5 were MBL producers (25%). Furthermore, in the study, 56% of patients with diabetic foot ulcer harbored MDRO. The risk of multidrug-resistant infection is significantly more in patients having diabetes duration >20 years and size of ulcer more than 4 cm(2). CONCLUSION: The detection of MDRO in patients of diabetic foot ulcer changes the treatment strategies limits the antimicrobial options and causes higher complications among them.

Background: Majority of poorly functioning kidney (PFK) due to primary ureteropelvic junction obstructions (UPJO) in young adult have potential to recover after an attempted percutaneous nephrostomy (PCN). The split renal function measured by nuclear renal scan may not be sufficient enough to predict recovery of such kidney. Therefore, this study was undertaken to determine the functional recovery and potential salvageability of PFK due UPJO. Objective of the study was to evaluate safety and efficacy of PCN in adult patients with severe hydronephrosis due to PUJO.Methods: A total of 25 (10 male and 15 female) young adult patients of severe hydronephrosis due to PUJO and SRF<20% underwent PCN procedures. Only, those who had significant improvement in their SRF ≥10% and developed PCN output ≥400 ml/day underwent Anderson-Hyenas pyeloplasty and rest underwent nephrectomy.Results: Both male and female young patients had significantly improvement after 6 weeks of PCN, their mean pre-PCN SRF changed from 16.30% and 12.27% to became 28.10±08.41% and 18.53±09.89%, respectively. Those with age <30 years improved most with ≥10% increase in the mean SRF and in 72% patients average PCN output increased from 279.80±93.90 ml/day to 445.20±160.341 ml/day at 6 weeks period. Overall, the patients with average PCN output ≥400 ml/day had a mean improvement of 10.33±05.48% in SRF. However, 5(20%) developed haematuria, 8% fever, 16% displaced PCN tip with no major puncture site bleed.Conclusions: The trial of PCN before definite surgery in young adult patients with poorly functioning kidney due to UPJO not only predicts renal renal function recovery but also prevent unwarranted renal loss.