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Background: Axillary lymph nodes are surrogate markers for mapping the optimal management of axilla in breast cancer, and their assessment is pivotal to management and outcome. Until now, the assessment of axillary lymph nodes largely relies upon sentinel node biopsy (dual method) or conventional lymph node dissection. The morbidity of axillary lymph node dissection, however, is well known. Sentinel node biopsy is thus considered the standard of care in a node-negative axilla. However, developing economies face the dilemmas and challenges of matching up to the high cost of gamma probe, the vagaries of its learning curve, and, often, the advanced stage of disease at which the patients present. Also, with the advent of neo-adjuvant chemotherapy, the axilla can now be downstaged to a node negative status (N0). In this setting, a targeted four-node sampling (FNS) can offer a simple, reliable, and cost-effective approach for assessment of the axilla. Material and Methods: A total of 50 patients with locally advanced breast cancer who had received neo-adjuvant chemotherapy form the nucleus of this study. In each patient, axillary mapping was done using periareolar injection of 3 mL of methylene blue dye immediately before surgery. Four blue nodes from the specified anatomical site at level-I were picked up and subjected to frozen section. The axillary dissection was subsequently completed in a conventional manner in all patients irrespective of the outcome of frozen section and the entire specimen was the sent separately for histopathological examination. The outcome of frozen section was compared and correlated with the actual histopathological assessment of entire axilla to find out the sensitivity, specificity, and false negative rates of the technique. Results: The sensitivity and specificity of FNS were found to be 89.5% and 93.3%, respectively. The negative and positive predictive values were found to be 84.6% and 100%, respectively. Conclusions: It was observed that "targeted" FNS using methylene blue dye can serve as a reliable and inexpensive alternative to other techniques for addressal of axilla even in locally advanced breast cancers. This is particularly relevant in developing economies where majority patients still present as locally advanced; and high-end facilities, such as gamma camera and isotope studies, are scarce.

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Tumors of the central nervous system (CNS) exhibiting a papillary pattern constitute a remarkably diverse group of neoplasms that can occur at virtually any site and in patients of any age. Since the first classification of nervous system tumors in 1926, formulated by Percival Bailey and Harvey Cushing based on the presumed parallels between embryologic and neoplastic cells to the World Health Organization (WHO) classification of tumors of the CNS 2007, CNS tumors have come a long way. WHO classification of tumors of the CNS 2007, lists several new entities. However, despite the advancements and the rapid progress with various classification systems in place, as a first step, brain tumors are still characterized largely by the typical patterns and their histopathological features. This pictorial essay represents the histopathology of one of these patterns comprised of various papillary tumors of the CNS, highlighting the diagnostic approach.

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Background: Infected pancreatic necrosis is associated with the risk of considerable morbidity and mortality. Preventing the development of infection in pancreatic necrosis may help reduce the poor outcomes in patients with severe acute pancreatitis (SAP). Aim : The aim of the current review was to determine the benefit of selective digestive decontamination (SDD) in improving outcomes in SAP. Materials and Methods: A systematic literature search was conducted using MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Methodology Register, Database of Abstracts of Reviews of Effects and Health Technology Assessment, until June 2011 without any restrictions. Papers reporting on experimental animal studies and clinical studies on patients with acute pancreatitis (AP) who were treated with SDD, either alone or in combination with intravenous antibiotic and antifungals in comparison with other interventions, antibiotics, or placebo, were eligible for inclusion. Outcome data collected were duration and regimen of SDD used, short- and long-term morbidity and mortality rates, length of hospital stay, incidence and rates of bacterial/fungal infection. Results: A total of 53 articles were identified from the literature search of which 10 (7 animals, 3 humans) were eligible for inclusion in this systematic review. There was only one randomized controlled trial among the human studies. Most studies used a combination of SDD and intravenous antibiotics precluding a clear interpretation of the individual benefit of SDD. Although SDD significantly reduced pancreatic infection rates, its benefit on patient survival is unclear. Conclusion: Although SDD significantly reduced pancreatic infection rates and overall survival in experimental animal models, in human studies this benefit is not clearly appreciated owing to the confounding effects of concurrently administered intravenous antibiotics. Hence, further controlled studies are needed to determine the benefit of SDD in AP in humans.

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Foreign bodies in maxillary sinus, whatever their origin or nature, are unusual. However unilateral unexplained chronic rhinosinusitis should arouse clinical suscipicion. The diagnosis is based on radiological findings. The range of such foreign bodies is wide; those of dental origin such as tooth roots, burs, dental impression material, root-filling materials, dental implants, and needles take precedence over all others, but rarely, they may relate to blast injuries and penetrating objects. This special report highlights the unusual case of a pressure cooker nozzle lodged in maxillary sinus of a 28-year-old female who suffered a facial injury caused by explosion of a pressure cooker at home. The acuteness of the event and the flight of the foreign body were such that neither the casualty felt the ingress of foreign body nor was the diagnosis entertained by the surgeon who first examined her. Each blast injury therefore must be thoroughly evaluated for such possibility. While a radiological examination can clinch the diagnosis, treatment lies in endoscopic or surgical foreign body removal, with Caldwell luc procedure being a preferred technique.

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Background: Metabolic bone disease of prematurity due to reduced bone mineralization is mostly described in infants of less than 1500 g. Although various guidelines recommend calcium and phosphate supplementation for low birth weight (LBW) newborns less than 1500 g and on exclusive breast feeding but there are no guidelines for those weighing above 1500 g and on exclusive breast feeding. Moreover, there is insufficient data on incidence of rickets and serum biochemical status in these babies of birth weight more than 1500g and on unsupplemented breast feeding and among term growth retarded babies. Objectives: To determine the incidence of rickets and changes in biochemical profile including serum calcium, phosphate, and alkaline phosphatase in preterm appropriate for gestational age (PTAGA) and term small for date (TSFD) babies with birth weight between 1500 and 2000 g and on unsupplemented breast feeding. Materials and Methods: It is an observational cohort study done at a tertiary care centre in northern India over a period of one year, including LBW babies between 1500 and 2000 g and on unsupplemented breast feeds. In group I, 116 PTAGA babies with birth weight 1500-2000g and on unsupplemented breast feeds were enrolled and 100 PTAGA babies completed follow up till 6 months. In group II 124 TSFD babies with birth weight 1500-2000 g and on unsupplemented breast feeds were enrolled and 100 TSFD babies completed follow up till 6 months. Biochemical parameters were done at baseline (before discharge) and were followed-up for a period of 6 months. Radiological assessment was done if clinical features of rickets appeared or serum biochemistry was suggestive of rickets. Results: Both groups, of babies, developed progressive decrease in serum calcium and phosphate levels, which was statistically significant as shown by time trend. Serum alkaline phosphatase showed significant increase from baseline in both the groups. Fourteen out of 200 (7%) babies developed radiological rickets at end of 3 months, which increased to 34/200 (17%) at end of 6 months. Serum alkaline phosphatase showed most consistent correlation with occurrence of rickets. Conclusion: LBW babies 1500-2000 g and on exclusive breast feeding are at significant risk of developing metabolic bone disease including rickets and need extra supplementation with calcium and phosphate besides Vitamin D.

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A variety of supportive ventilatory, feeding and circulatory devices are employed in the management of critically sick patients. The hardware ranges from endotracheal, tracheostomy and chest tubes, nasogastric and nasoenteric feeding tubes, to central venous lines, umbilical venous and arterial catheters, pacers and automatic implantable cardioverter defibrillators, intraaortic balloon pumps and ventricular assist devices. The accurate positioning of this hardware is critical to the well being of a patient. However, these devices may not be positioned appropriately. Faults may occur at the time of their insertion, or the hardware may get dislodged while in use. A portable chest radiograph can be extremely useful in identifying such mishaps. This pictorial review captures some of the critical scenarios which must be known to radiologists and the treating intensivists.

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Oral care is critical from the stand point of systemic health. No health preventive strategy is complete without taking into cognizance the significance of subgingival microbiota in causation of a number of systemic conditions. Clinical studies and etiopathogenetic models substantiate a distinct connect between chronic periodontitis and a host of cardiovascular, respiratory, endocrine, musculoskeletal, and reproductive system pathologies. A potent source of contagion, subgingival microbiota associated with periodontitis may act as a significant risk factor in atherosclerotic coronary disease, carotid atheromas, chronic obstructive pulmonary disease, rheumatoid arthritis, systemic osteoporosis, diabetes mellitus, premature labor and birth of preterm babies, head and neck squamous cell carcinomas, and a myriad of other conditions.

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Study design forms a core component of research, mainly determined by the study objectives, and it in turn further decides the type of statistical analyses to be carried out. Observational studies are devoid of the investigator's control over assignment of a subject to the treated or control group, in contrast to interventional studies Even though randomized controlled trials are seen as the best study design, evidence shows that properly conducted observational studies give similar results, and is relevant in medical research where ethics and feasibility concerns assume great significance. Observational studies point out towards possible causal associations, are less resource intensive than trials and have a better external validity. This review article discusses various types of observational study designs such as case reports, cross sectional, cohort, case-control and nested case-control studies with real literature examples.

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Notwithstanding the unfulfilled quest for immortality, man's endeavor to outdo organ failure and prolong life has been a journey bejeweled with hues of ingenuity. This exciting odyssey has been marked with chimerical events and miracles in the olden times, and, in the more recent, by triumphs of technical and cognitive advances in organ preservation, surgical skill, immunology, management of infectious diseases, and multidisciplinary innovative approaches, which have collated to fructify the realm of tissue and organ transplantation. The remarkable evolution-colored with serendipitous discoveries, tragic accidents, abandoned paths, and incidents that have produced ethical and legal predicaments-stems from a confluence of cultural, legal, and political acceptance of the need to facilitate organ donation, procurement, and allocation. This serial narrative, punctuated with historic pictures, captures some of the major milestones in the saga of transplant medicine.

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Although corruption in health care reflects the ills of the society in general, some key areas to be focused upon are as follows: procurement processes; the so-called 'speed money'; theft, pilferage and malpractices; and staff recruitment. Each organization needs to devise its own mechanisms for transparency and accountability in procurements. A two-bid system of technical and price bid, asking for users' list, demonstration, or onsite visits to ascertain the functioning of equipments, 'Publish What You Pay' type of initiative, participation of users as in Rogi Kalyan Samitis, anticorruption networks are some of the tools to address corruption in hospital procurement. The menace of informal payments or speed money can be addressed by encouraging and facilitating users' feedback, involving hospital neighborhoods in anticorruption squads and having CCTV surveillance in key areas. Theft, pilferage, and malpractice siphons off goods and services meant for the ailing. Administrative vigilance and strict handling of the instances reported may serve as a deterrent. Having a labor law professional or a trustworthy NGO on the panel may help reduce corruption, especially seen in the case of contractual jobs. Phenomenon of corruption is difficult to capture in a single definition or measure. Sincere, intense, and sustained anticorruption measures have to be adopted and pursued by health care facilities top-down as well as bottom-up, providers as well as users, ex ante as well as post facto. All anticorruption measures have a use-by-date to them. Innovations would be required. Key ingredient would be sincerity of the management.

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Introduction: A large number of drugs may interfere with hair cycle and produce diffuse hair loss (DHL). This needs to be identified, as it may lead to poor compliance with the drug regimen. Material and Methods: History of drug intake in the recent past was taken from 255 females presenting with DHL. Sixty-seven patients (26.2%) revealed a history of drug intake. Out of these, a detailed history about nature and duration of drugs was taken from 57 patients (22.3%) who had a history of drug intake preceding the onset of DHL or had a history of aggravation in preexisting hair loss following drug intake. Results: Duration of DHL ranged from 1 month to 5 years with a mean duration of 9.8±13.1 months. The mean duration of drug intake was 49.1±80.8 months. History of intake of 100 suspected drugs was available, most common group being antihypertensives (23%), followed by hormones (12%), nonsteroidal antiinflammatory drugs (11%), antidiabetic (8%), oral contraceptive pills (6%), antitubercular treatment (5%), tricyclic antidepressants (4%), and vitamin supplements (4%). Among individual drugs, thyroxine (10%) was the most commonly implicated agent followed by amlodipine (5%), Amitriptyline (4%), atorvastatin, aspirin, metformin, ibuprofen, and vitamin B complex (3% each). Conclusions: Drugs should be suspected as a cause of DHL in females and a detailed history about the nature and duration of drug intake should be taken in such patients.

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Breast can be the seat of a number of benign and malignant pathologies. Even though digital mammography - with or without correlative ultrasonography - is still largely the mainstay of breast imaging, the newer technique of magnetic resonance mammography has come of age. Capable of capturing wide and varied morphology of diverse breast lesions, it can contribute in a major way to the diagnosis and management of some patients. Characteristic magnetic resonance mammography features can help obviate the need of a biopsy in lesions like hamartomas, and benign virginal hyperplasia, whereas in conditions like invasive lobular carcinoma and Paget's disease, it can make a significant difference to the surgical plan. This pictorial kaleidoscope presents the imaging and histopathology characteristics of many usual and unusual breast lesions.

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