Background and Aims: There is a need for research into opioid sparing analgesic options. The study aimed to compare postoperative pain scores at 24 h in patients receiving preoperative magnesium–lignocaine–ketorolac (MLK) or magnesium–lignocaine (ML) with control during laparoscopic cholecystectomy. Methods: The present randomized, controlled trial enrolled 120 patients, 18–60 years, American Society of Anesthesiologists I/II, scheduled for laparoscopic cholecystectomy. Patients were randomized preinduction to either Group MLK (n = 40), magnesium 50 mg/kg + lignocaine 1.5 mg/kg + ketorolac 0.5 mg/kg in normal saline (NS), Group ML (n = 40), magnesium 50 mg/kg + lignocaine1.5 mg/kg in NS, or group saline (S) (n = 40) NS. All patients received a standard general anesthetic (GA) technique. In the postoperative period, if the Visual Analog Scale (VAS) ≥30, the patient received morphine boluses of 1 mg by intravenous (IV) PCA pump with a lockout interval of 10 min. Results: VAS at rest in group MLK was lower in group S, (P = 0.001) at 12 h postoperatively. VAS on movement in group MLK and group ML was lower as compared to group S (P < 0.001) at 24 h postoperatively. IV Morphine consumption in the first 24 h after surgery was lower in groups MLK and ML versus group S (P < 0.001). The time to first rescue analgesia was early in Group S, delayed in Group MLK and Group ML (P < 0.001). Conclusion: A preoperative IV MLK or ML resulted in lower VAS on movement score in patients undergoing laparoscopic cholecystectomy under GA at 24 h postoperatively.

ObjectivesTo determine the efficacy of quantitative shear wave elastography in differentiating benign and malignant axillary lymph nodes (ALN).MethodsExactly 127 lymph nodes from 127 patients with clinically palpable axillary swelling were examined by both B‐mode sonography and elastography from November 2022 to March 2024. Gray‐scale sonograms were evaluated based on: the short‐axis diameter, shape, hilum, maximum cortical thickness, and border of the ALN. Shear wave elastography determined the mean elasticity modulus (E‐mean) and elasticity ratio (E‐ratio). Fine needle aspiration cytology or histopathological examination was kept as the gold standard and diagnostic performance shear wave elastography was compared.ResultsThe data showed that out of 127 lymph nodes, 77 (60.6%) were benign and 50 (39.4%) were malignant based on pathological results. The E‐mean for malignant lymph nodes (mean, 73.15 kPa) was higher than that for benign lymph nodes (mean, 21.47 kPa; P < .001). The area under the receiver operating characteristic curve for E‐ratio in predicting malignant and benign lymph nodes was 0.897 (95% CI: 0.839–0.955). The E‐ratio for malignant lymph nodes was also higher (mean, 10.2) than for benign nodes (mean, 2.95; P < .001). The area under the receiver operating characteristic curve for E‐ratio in predicting malignant and benign lymph nodes was 0.816 (95% CI: 0.733–0.899).ConclusionOur results showed a significant association between tissue elasticity and pathological correlation.

Retroperitoneal fasciitis is a progressive infection involving the retroperitoneal fascial planes and deeper soft tissues, requiring prompt diagnosis. A 20-year-old man in India with a history of perianal abscess presented with fever, swelling, and severe pain in the abdomen and inguinoscrotal region. Local examination revealed extensive necrotic skin changes involving the perineum and right lumbar region, extending to the scrotum. Contrast-enhanced computed tomography demonstrated a large myocutaneous defect with extensive air foci, fat stranding, and fluid collections in the abdominal wall extending into both retroperitoneal spaces. The patient underwent emergency surgery with debridement of the perineum and right lumbar region. Vacuum-assisted closure therapy and local sump application facilitated rapid and effective wound healing, eliminating the need for reconstruction. This case illustrates successful management of a rare but severe condition.

INTRODUCTION:Extra-pulmonary tuberculosis occurring in the breast is a rarity. The clinical presentation is multifaceted, often mimicking malignancy and pyogenic breast abscess. Fine needle aspiration cytology (FNAC) is an essential component of the triple test in evaluating breast lumps. METHODS:The present study is a retrospective analysis of 18 cases of tubercular mastitis (TM) over two years who underwent FNAC and were found to respond to anti-tubercular therapy on follow-up. Air-dried and alcohol-fixed smears were made and stained with May Grünwald Giemsa and hematoxylin and eosin stains. Special stains: Ziehl Neelsen (ZN), Gram, and periodic-acid Schiff (PAS) were done. In cases where pus was aspirated, material was sent for microbiological culture. For the Mycobacterium culture, Lowenstein-Jensen medium slants were employed. RESULTS:All 18 cases were female in the age range of 13-59 years (mean 29.5 years). The majority were in the age bracket of 21-30 years. Frank pus was aspirated in 9 cases. Based on FNAC characteristics, cases were divided into three groups. Group I included 10, 55.6 % cases with epithelioid cell granulomas without necrosis. Group II had 6, 33.3 % cases showing epithelioid cell granulomas and necrosis, while Group III had 2, 11.1 % cases revealing caseous necrosis without any evidence of granulomas. The correlation of these groups to acid-fast bacilli (AFB) status showed AFB positivity of 100 % in group III, followed by 66.7 % in group II and 20 % in group I. Culture was positive for Mycobacterium tuberculosis in 5 cases. CONCLUSION:FNAC is a preliminary diagnostic modality which avoids unnecessary surgical intervention for tubercular mastitis. Demonstration of epithelioid cell granulomas in breast aspirates, even without AFB positivity in endemic regions for tuberculosis, calls for a therapeutic trial of anti-tubercular therapy.

BACKGROUND:Breast cancer is the most common cancer among women worldwide, with no biomarker validated for reliable early diagnosis. miRNAs have emerged as potential circulating biomarkers for several diseases. miR-27a has shown a multifaceted role in the pathogenesis of breast cancer and may be explored for its diagnostic potential. Similarly, soluble HER-2/neu may reflect the presence of tissue HER2 receptors in breast cancer. METHODS:Ninety-four patients with breast lumps (BIRADS III or above) were enrolled. Diagnosis and grading were confirmed by biopsy. Serum miRNA was extracted, and miR-27a expression was measured via RT-PCR using RNU6 as a control. sHER-2 levels were assessed using ELISA. Statistical analyses included chi-square, Mann-Whitney U, Kruskal-Wallis, and ROC curve analysis. RESULTS:MiR-27a expression was significantly higher in breast cancer patients than those with benign tumours (p < 0.0001), correlating with tumour size, grade, lymph node involvement, and metastasis (p < 0.05). ROC analysis revealed a cut-off >10.31 (AUC 0.971, sensitivity 93.0%, specificity 89.2%). sHER-2 levels were significantly elevated in tissue HER-2 positive breast cancer cases (p < 0.0001). CONCLUSION:MiR27a shows strong potential to be used as a biomarker for breast cancer diagnosis and prognosis. sHER-2 effectively differentiated between the HER-2 status of breast cancer. Larger studies with follow-up are needed for clinical validation.

Background: Malignancy of the breast is one of the most common cancers among females worldwide. Magnetic resonance mammography (MRM) is a valuable complement to conventional methods for the early diagnosis of disease, thereby providing patients with a better prognosis. The number of unnecessary biopsies and repeated excisions in cases of indeterminate breast lesions detected on conventional imaging is high. Aims: The purpose of this study was to evaluate the role of MRM in the evaluation of indeterminate breast lesions [Breast Imaging Reporting and Data System (BIRADS) 3/4] found in conventional mammography and ultrasonography (USG), taking the histopathological examination (HPE) as the gold standard. Materials and methods: A total of 38 patients with conventional radiological imaging diagnosis of indeterminate breast lesions (BIRADS 3/4) were included in this study and evaluated using contrast-enhanced MRM according to the MR-BIRADS lexicon (5th edition). Morphological characteristics of lesions were evaluated to determine the probability of malignancy. Histopathology was kept as the gold standard for comparing all the statistical parameters. Results: There were a total of 40 lesions, 35 masses, and five nonmass enhancement (NME) available for evaluation out of the 38 patients. The sensitivity of margins to detect malignancy approached 100%; however, it had a slightly lower specificity of 66.67%. Magnetic resonance imaging (MRI) showed good diagnostic performance with sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of 85, 90, 89.47, 85.71, and 87.50%, respectively. Conclusion: The MRI has been shown to be useful as a problem-solving tool in breast cancer screening, clarifying indeterminate findings and avoiding unnecessary short follow-ups and percutaneous biopsies. How to cite this article: Mishra E, Kaur N, Kaur R, et al. Role of Magnetic Resonance Mammography in the Evaluation of Indeterminate Breast Lesions. J Assoc Physicians India 2023;71(11):76-84.

OBJECTIVE:Morphological indicators of chromosomal instability (CI), including multipolar mitoses, chromatin bridges (CB), strings, nuclear buds (NB), micronuclei (MN), and deoxyribonucleic acid (DNA) ploidy analysis help in prognostication of breast carcinoma. The present study was done to evaluate CI in breast carcinoma and correlate with DNA ploidy and tumor grade. STUDY DESIGN:Fifty cases of carcinoma breast diagnosed by fine-needle aspiration cytology were included. Robinson's grading method was used on smears to grade breast carcinoma. To assess the morphological features of CI, the best May-Grünwald Giemsa stained smear was chosen. At least 1,000 epithelial cells on oil immersion magnification (×100 objective) were counted. DNA ploidy on the aspirates was done by flow cytometry. RESULTS:All the patients were female, diagnosed as infiltrating ductal carcinoma on cytology. Eight tumors were grade I, 32 were grade II, and 10 were grade III. MN was seen in 48 cases, NB in 45, and CB in 12 cases. Mean MN, NB, and CB scores in aneuploid (24) cases were 9.96 ± 8.42, 5.29 ± 4.71, and 1.08 ± 1.84 while 6.19 ± 6.67, 1.92 ± 1.79, and 0.11 ± 0.33 were seen in diploid (26) cases. Statistically significant positive correlation was observed between CI and DNA ploidy. CONCLUSIONS:Morphological evaluation of CI by light microscopy on routinely stained breast aspirates is feasible, although a meticulous search is required. Cytomorphological features of CI and ploidy have a positive correlation with increasing tumor grade.

Introduction: Chondroid syringoma also known as benign mixed tumor of the skin presents as a slow growing, painless dermal/subcutaneous nodule. The cytological features of this entity have been rarely described, and are limited to a few case reports. The present study emphasizes on the cytological features of chondroid syringoma on fine needle aspiration (FNA). Materials and Methods: A retrospective analysis of all cases of chondroid syringoma diagnosed/missed on fine needle aspiration (FNA) with subsequent histopathologic confirmation over a period of five years (2011-2015) was undertaken. FNA was done using a 23 gauge needle fitted to a 10 mL syringe mounted on Franzen’s handle. Chondroid syringoma was diagnosed on cytology in 3 cases of which 2 were confined to head and neck region while 1 was in axilla. One case was misdiagnosed as fibroadenoma with secondary myxoid change on cytology. Results: Case 1 was a 57-year-old man with a nodule in left axilla. Case 2 was a 52-year-old woman who presented with a nodule on tip of the nose. Case 3 was a 46-year-old man with nodule on upper lip. Case 4 was a 38-year-old lady with lump breast. FNA smears were cellular in all the cases and showed clusters of cells embedded in chondromyxoid stroma. Cells were round to oval with bland nuclear features and moderate amount of cytoplasm. Plentiful of chondromyxoid material was seen in the background. No cytological atypia/mitosis/necrosis was seen. Conclusions: Chondroid syringoma can undoubtedly be diagnosed on FNA. Cytologic smears are reminiscent of pleomorphic adenoma of salivary gland. Rarity of this adnexal tumor may be responsible for the diagnosis being missed on evaluation of aspirates.

ANZ Journal of SurgeryVolume 91, Issue 6 p. E415-E416 IMAGES FOR SURGEONS Rectal duplication cyst: a rare surgical case in a child Ravinder Kaur MBBS, MD, Department of Radiodiagnosis, Government Medical College and Hospital, Chandigarh, India Contribution: Conceptualization, ​Investigation, VisualizationSearch for more papers by this authorUsha Dalal MBBS, MS, Department of General Surgery, Government Medical College and Hospital, Chandigarh, India Contribution: Formal analysis, ​Investigation, Supervision, Validation, Writing - original draftSearch for more papers by this authorArshpreet Kaur MBBS, MD, orcid.org/0000-0001-6997-2711 Department of Radiodiagnosis, Government Medical College and Hospital, Chandigarh, India Contribution: Data curation, Methodology, Resources, Visualization, Writing - original draft, Writing - review & editingSearch for more papers by this author Ravinder Kaur MBBS, MD, Department of Radiodiagnosis, Government Medical College and Hospital, Chandigarh, India Contribution: Conceptualization, ​Investigation, VisualizationSearch for more papers by this authorUsha Dalal MBBS, MS, Department of General Surgery, Government Medical College and Hospital, Chandigarh, India Contribution: Formal analysis, ​Investigation, Supervision, Validation, Writing - original draftSearch for more papers by this authorArshpreet Kaur MBBS, MD, orcid.org/0000-0001-6997-2711 Department of Radiodiagnosis, Government Medical College and Hospital, Chandigarh, India Contribution: Data curation, Methodology, Resources, Visualization, Writing - original draft, Writing - review & editingSearch for more papers by this author First published: 23 November 2020 https://doi.org/10.1111/ans.16460 Read the full textAboutPDF ToolsRequest permissionExport citationAdd to favoritesTrack citation ShareShare Give accessShare full text accessShare full-text accessPlease review our Terms and Conditions of Use and check box below to share full-text version of article.I have read and accept the Wiley Online Library Terms and Conditions of UseShareable LinkUse the link below to share a full-text version of this article with your friends and colleagues. Learn more.Copy URL Share a linkShare onEmailFacebookTwitterLinked InRedditWechat No abstract is available for this article. Volume91, Issue6June 2021Pages E415-E416 RelatedInformation

Background: Primary mediastinal masses are uncommon lesions encountered in clinical practice and the source of origin of these masses can be an enigma for the clinicians. These masses can be neoplastic, congenital, or inflammatory in nature. The data regarding their true incidence and the clinicopathological profile they present with is scarce due to their rarity. The clinical manifestations of these masses are usually nonspecific and protean. A standardized diagnostic workup is essential for their early detection and proper management. We retrospectively analyzed the clinicopathological profile of 29 cases of mediastinal masses diagnosed and operated in the department of General Surgery at a tertiary care hospital over a period of 11 years (2008-2019). Aims and objectives: The study aims to assess the clinical profile of adult patients with primary mediastinal masses that presented to General Surgery department at Government Medical College and Hospital, Chandigarh (India). Study design: This was a retrospective, descriptive and cross-sectional study of 11 years in which 29 patients of primary mediastinal masses with a definitive pathologic diagnosis after surgical resection were included. Detailed clinical profile, radiological and pathological findings along with their management outcome was noted. Results: Maximum numbers of cases were symptomatic at presentation and presented with non-specific symptoms. Maximum numbers of cases were found to be in the 3rd decade of life. Anterior mediastinal masses are encountered more frequent as compared to middle and posterior compartments. Male to female ratio was almost equivalent and benign tumor predominated in this study. Diagnostic workup included thorough radiological assessment using Chest X-Ray and Contrast Enhanced CT scan (CECT). FNAC and/or biopsy were performed as and when required. Final histopathological analysis after surgical resection revealed 6 cases of thymoma, 6 cases of teratoma, 5 cases of neurofibroma, 3 cases of retrosternal goitre, 2 benign epithelial cyst, 2 schwannoma, 1 case each of bronchogenic cyst, ganglioneuroma and chylo-lymphatic cyst. Conclusion: Majority of the patients of primary mediastinal masses present with non-specific chest pain and/or symptoms of compression at the time of their first visit to the hospital. Early detection is the key for prompt surgical intervention to reduce the overall morbidity associated with these masses.

Recognition of oesophageal injury is often delayed due to its protean manifestations. Principles of management are: control of sepsis and contamination by diversion and/or drainage, nutrition, broad spectrum antibiotics and restoration of continuity. Age, general condition of the patient, aetiology, the anatomical location and size of perforation, early versus delayed presentation, clinical condition of the patient, underlying oesophageal disease and other associated co-morbid medical conditions are important determinants of the outcome. Primary repair is the gold standard treatment in early hours. Drainage and diversion are required when perforation is not localised and in late and unstable cases. Endoscopic stenting with drainage may be useful in selected cases. Oesophagectomy is required in extensive damage, stricture or carcinoma. We retrospectively analyzed the data of nine patients of oesophageal injuries managed in a tertiary care hospital from 2009 to 2019. Various causes of oesophageal injury were; spontaneous perforation in 3 cases, foreign bodies in 3 cases (one each of razor blade, coin, denture), blunt trauma chest in one case, iatrogenic injury in 2 cases (one during cervical spine fixation and another due to endoscopic dilatation of corrosive oesophageal stricture). Mainstay of the treatment was: nutritional support, control of sepsis with antibiotics and drainage and/or diversion with early or delayed repair of the rent. Transhiatal esophagectomy was done in one patient. Out of eight patients who survived, oesophageal injury was diagnosed within 24 hours in only one case; however, in seven patients it was diagnosed after 24 hours. One case of delayed presentation died due to uncontrolled sepsis and multi-organ failure.

Background: Proseal LMA (PLMA) has been used for airway maintenance during laparoscopic cholecystectomy. However, there is limited data regarding the effects of pneumoperitoneum, particularly on pulmonary mechanics. Objective of the present study was to evaluate and compare the use of PLMA with a cuffed endotracheal tube (ETT) with regard to changes in pulmonary mechanics, haemodynamic variables, degree of gastric inflation, ease of device insertion and possible adverse events in patients undergoing laparoscopic cholecystectomy. Methods: After written informed consent and institutional ethics committee approval, we enrolled one hundred patients (ASA physical status1/2), 18-60 years of age who were scheduled to undergo laparoscopic cholecystectomy under general anesthesia (GA). Patients were randomly allocated to one of the two groups of 50 each. Group 1: cuffed endotracheal tube and Group 2: ProSeal LMA. Patients as well as the surgeons were blinded to the airway device used. Insertion parameters, haemodynamic and ventilatory parameters (compliance, resistance and peak/plateau airway pressure) were measured at different time intervals before, during and after pneumoperitoneum. Results: Statistically significant (p< 0.05) but clinically insignificant difference was found in time taken for device insertion in the two groups (21.8 ± 5.9 s group I & 25.4 ± 5.7 s group II). Insertion of orogastric tube was easier and less number of attempts was required with PLMA. Hemodynamic parameters like heart rate, systolic, diastolic and mean blood pressures increased after the ETT insertion while there was a decrease/no change after PLMA insertion. There was a significant decline in the pulmonary compliance in Group 2, which was more pronounced after pneumoperitoneum. During pneumoperitoneum, higher peak and plateau airway pressures were noted in PLMA group than in ETT group. After desufflation these parameters returned to near pre-insufflation levels. There was no episode of arterial desaturation or end tidal carbon dioxide changes in either group. Conclusion: Our results indicate that in the PLMA group, the degree of changes in pulmonary mechanics caused by the pneumoperitoneum were significant however there was no incidence of arterial desaturation, or gastric regurgitation. Due to better hemodynamic stability with PLMA, it may even be better alternative than ETT in hypertensive/cardiac patients. Hence PLMA is a satisfactory airway device for laparoscopic cholecystectomy under GA, but further studies are required regarding its safety in patients with decreased pulmonary compliance like morbid obesity or obstructive pulmonary disease.

Background and Aims: Sevoflurane is an excellent but expensive anesthetic agent for laparoscopic cholecystectomy. To decrease sevoflurane consumption during surgery adjuvants like dexmedetomidine may be used. Dexmedetomidine is a recently introduced drug which alleviates the stress response of surgery, produces sedation and analgesia. We aimed to evaluate sevoflurane sparing effect of dexmedetomidine in patients undergoing laparoscopic cholecystectomy under entropy-guided general anesthesia (GA). Material and Methods: In this prospective randomized control study, 100 American Society of Anesthesiologists physical status I–II adult surgical patients scheduled to undergo laparoscopic cholecystectomy were enrolled. Patients were randomly divided into two groups (n = 50). In dexmedetomidine group, patients received intravenous (IV) dexmedetomidine 0.5 μg/kg over 10 min before induction followed by 0.5 μg/kg/h infusion while in control group, patients received the same volume of normal saline. Results: Sevoflurane consumption was 41% lower in dexmedetomidine group as compared to control group (7.1 [1.6] vs. 12.1 [1.9] ml, P<0.001). A 40% reduction was observed in induction dose of propofol (83.0 [19.1] vs. 127.6 [24.8] mg, P<0.001). Mean Riker sedation-agitation score, visual analog score for pain and Aldrete's score were significantly lower in dexmedetomidine group as compared to control group. None of the patients experienced any significant side effects. Conclusion: A 41% reduction in sevoflurane consumption was observed in patients receiving IV dexmedetomidine as an adjuvant in patients undergoing laparoscopic cholecystectomy under GA.