Hyperpigmented Macules Caused by Burrowing Bugs (Cydnidae) May Mimic More Serious Conditions.

Fully covered self-expanding metal stents (FCSEMS), unlike partially covered SEMS (PCSEMS), have been used to treat benign as well as malignant conditions. We aimed to evaluate the outcome of PCSEMS and FCSEMS in patients with both benign and malignant esophageal diseases. Data were reviewed of all patients who underwent SEMS placement for malignant or benign conditions between January 1995 and January 2012. Patients with cancer were followed for at least 3 months, until death or surgery. Patients with benign conditions had stents removed between 4 and 12 weeks. Patient demographics, location and type of lesion, stent placement and removal, clinical success, and adverse events were analyzed. A total of 252 patients (mean ± standard deviation age 68.5 ± 14 years; 171 male) received 321 SEMS (209 PCSEMS, 112 FCSEMS) for malignant (78 %) and benign (22 %) conditions. Stent placement and removal was successful in 97.6 and 95.6 % procedures. Successful relief of malignant dysphagia was noted in 140 of 167 patients (83.8 %) and control of benign fistulas, leaks, and perforations was noted in 21 of 25 patients (84 %), but only 8 of 15 patients (53 %) with recalcitrant benign strictures had effective treatment. Fifty-six patients (22.2 %) experienced at least one stent-related adverse events. Migration was frequent, occurring in 61 of 321 stent placements (19 %), and more frequently with FCSEMS than PCSEMS (37.5 vs. 9.1 %, p < 0.001). FCSEMS, benign conditions, and distal location were the variables independently associated with migration (p < 0.001, p = 0.022, and p = 0.008). Patients with PCSEMS were more likely to have tissue in- or overgrowth than FCSEMS (53.4 vs. 29.1 %, p = 0.004). Both PCSEMS and FCSEMS can be used in benign and malignant conditions; they are both effective for relieving malignant dysphagia and for closing leaks and perforations, but they seem less effective for relieving benign recalcitrant strictures. Stent migration is more common with FCSEMS, which may limit its use for the palliation of malignant dysphagia.

Su1149 COMPLICATIONS RELATED TO ESOPHAGEAL STENT (BOSTON SCIENTIFIC [WALLFLEX] VS MERIT MEDICAL ENDOTEK) USE IN BENIGN AND MALIGNANT CONDITION- A SINGLE CENTER RETROSPECTIVE REVIEW

Hyperpigmented macules on the face of young children: A series of 25 cases

The aim of this study was to review the outcomes of thyroid surgery in children operated for both benign and malignant conditions. Demography, clinical features, and surgical outcomes were noted retrospectively for operations performed during the last 23 years. Results were analyzed using Fisher exact test and Woolf (logit) method with p value < 0.05 considered as significant. In total, 61 children (43 girls and 18 boys) underwent thyroidectomy for benign (70%) and malignant (30%) conditions. Median follow-up period was 1.4 years. In the benign group, 84% children had Graves disease and 16% had other conditions. In this study, 42% children had total, 22% had near-total, 27% had subtotal, and 9% had type 2 hemithyroidectomy. In the malignant group, 50% had multiple endocrine neoplasia, 33% had papillary, 11% had follicular cancer, and 6% had B-cell lymphoma. Fifty percent children had prophylactic thyroidectomy, 44% had total thyroidectomy plus lymphadenectomy, and 6% had hemithyroidectomy. At the time of surgery, children with benign conditions were older than those with malignancy (median, 12 vs. 7.5 years). There were no incidents of postoperative bleeding or infection. Hypocalcemia was significantly more frequent in the malignant group (39 vs. 9%, p value = 0.01). The type of recurrent laryngeal nerve (RLN) injury was more serious in the benign group (one bilateral and one unilateral permanent injury) than in the malignant group (transient hoarseness in three). Overall rate of complications was higher for operations for malignancy (56 vs. 28%, p value = 0.07). In Graves disease, the subtotal thyroidectomies had a recurrence of 30% but no recurrence was seen following total or near-total thyroidectomy group (p value = 0.01). There was no recurrence in the malignant group. Children operated after 2000 were younger than those operated before 2000 (median age, 9 vs. 14 years). Malignant conditions were more common in children operated after 2000 in comparison to before 2000 (55 vs. 10%). Benign conditions are commonest indications for thyroid surgery in children but the incidence of surgery for malignant conditions is rising. Overall rate of complications, especially hypocalcemia, is higher after surgery for malignancy but all cases of permanent RLN injury were in benign group. Total or near total thyroidectomy prevents recurrence of thyrotoxicosis and is an operation of choice for Graves disease.

A systematic review and cost analysis of robot-assisted hysterectomy in malignant and benign conditions

Sir, Reticulate pigmentary disorders are a broad group of pigmentary disorders with significant overlap, often posing a diagnostic challenge due to variable phenotypic expression of similar gene defects. The acral reticulate pigmentary disorders described so far including reticulate acropigmentation of Kitamura, Dowling–Degos disease, and acropigmentation of Dohi are characterized by the presence of hyperpigmented macules with or without hypopigmented lesions. Here, we describe a patient presenting with only hypopigmented macules in a speckled pattern on acral sites. A 17-year-old boy presented with a 2-year history of asymptomatic hypopigmented to depigmented macules on the dorsae of hands and feet. On examination, there were multiple, small (1–3mm), well-defined hypopigmented to depigmented macules symmetrically over the dorsae of hands and feet with prominent clustering over the sides. Lesions were mostly discrete, coalescing at few places, and present over a normal background skin, thus giving a speckled appearance [Figure 1a]. There were no hyperpigmented or atrophic macules, no palmar pits or break in dermatoglyphics, and no involvement of flexures. The patient was otherwise healthy with no significant medical history. He was born of nonconsanguineous marriage with no similar history in family.Figure 1: (a) Symmetric involvement of bilateral dorsae of hands and feet in form of multiple, small (1–3-mm sized), well-defined hypopigmented macules with prominent clustering over the sides. (b) Histopathology showing macromelanosomes in melanocytes as well as in keratinocytes (H and E, ×400). (c and d) Fontana-Masson and HMB-45 staining showing similar findings (×100, ×200)Two biopsies done from the hypopigmented macules of both hands showed similar features. The number of melanocytes were normal but there were a striking number of macromelanosomes in melanocytes and keratinocytes [Figure 1b]. Fontana-Masson and HMB-45 staining showed similar findings [Figure 1c and d]. Reticulate pigmentary disorders are an evolving group of dermatoses with a recent report of unusual clinical presentation as “speckled acral hypopigmentation.”The term familial was used by authors to describe a case similar to ours where a 14-year-old girl presented with speckled hypopigmentation on the sides of hands and feet bilaterally with a strong family history of similar lesions. Histopathological evaluation in this patient showed decreased number of melanocytes.[1] Congenital symmetric acroleukopathy has been described in literature, but here depigmented macules are large and present over periungual areas.[2] Reticulate acropigmentation of Kitamura is characterized by the presence of well-defined atrophic hyperpigmented macules on the dorsum of hands and feet, palmar pits, and break in dermatoglyphics.[3] Rare cases of disseminated hypo- or depigmented macules and papules are described, but presence of only hypopigmented macules is not seen in this condition.[4] Dowling–Degos disease is characterized by the presence of hyperpigmented macules over the flexures along with comedonal papules on the back and neck.[3] Rarely, Dowling–Degos disease presenting as hypopigmented macules similar to our case has been described, but in this case lesions were widely distributed over the chest, back, axilla, upper arms, and inguinal folds and there was no clustering of lesions.[5] Acropigmentation of Dohi shows presence of both hyper and hypopigmented macules on the hands and feet, which may extend to the proximal extremities and face. Extragenital lichen sclerosus is a chronic inflammatory disorder characterized by the presence of small, porcelain white, mildly atrophic polygonal papules and plaques which commonly affects neck, shoulders, and upper portion of the trunk.[6] Confetti or guttate form of hypomelanotic macules seen in tuberous sclerosis patients present as 1–3 mm, numerous, small hypopigmented macules that typically occur symmetrically over the distal extremities. These hypopigmented macules usually develop during early childhood. Over time, these patients develop other characteristic cutaneous and systemic features of tuberous sclerosis.[7] None of the above described differential diagnosis have macromelanosomes on histopathology. Histopathological differential diagnosis of macromelanosomes include Griscelli syndrome, Chediak Higashi disease, albinism, nevus spilus, neurofibromatosis, and xeroderma pigmentosum.[89] However, our patient did not have clinical features of any of the above described histopathological differentials. Our patient has an unusual clinical presentation which does not fit into any of the well described reticulate pigmentary disorders. It may be a hitherto unknown presentation of previously described disorders or it may be a unique disorder itself. Careful study of large number of patients and genomic analysis will be required to unfold this mystery. Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

The imaging characteristics of microcalcifications in both benign and malignant breast conditions were analyzed in 48 digitized film mammograms. Each case included in this analysis had findings considered suggestive of malignancy by the radiologist, with the underlying histologic structure determined by excisional biopsy. Imaging properties of each microcalcification--such as pixel intensity, relative location, distribution, size, and local neighborhood intensities--were recorded. This information was statistically analyzed at the population level according to such selection criteria as histologic type, size of calcification, and cluster size. Distribution ranges were determined for these criteria. Statistical differences between data from benign and malignant cases show the average distance between calcifications in malignant conditions was greater than in benign conditions, and tissue region averages surrounding calcifications associated with malignant conditions were consistently higher than those for benign conditions.

It has been argued that hysterectomy has a negative impact on female sexual functioning, possibly as the result of a multifactorial interplay of postsurgical changes in pelvic anatomy, hormonal influences, and psychological factors. Most hysterectomies are performed for benign gynecologic conditions, and most studies of posthysterectomy female sexuality have been done on women who have had hysterectomies for benign conditions. We are finding that as attitudes toward the use of hysterectomies evolve (ie, the increased use of hysterectomies for malignant and benign conditions), the focus on hysterectomy’s potential impact on sexual functioning also evolves. Increasing attention is being directed to the sexual impact on patients who have hysterectomies for malignant conditions. This review focuses on hysterectomy for both benign and malignant conditions. We use supporting evidence to highlight the similarities and differences in outcomes.

Pseudohyperkalaemia is defined as a rise in serum potassium with concomitantly normal plasma potassium. The case of long undiagnosed pseudohyperkalaemia in an 84-year-old lady with thrombocytosis post splenectomy is presented. Presenting a historical perspective and the multifactorial aetiology of pseudohyperkalaemia the author underlines the importance of detecting apparent hyperkalaemia by testing the plasma potassium. Awareness of the possible causes of pseudohyperkalaemia increases the likelihood of it being detected earlier thereby decreasing the risk of harming the patient. Unnecessary treatment and investigation of pseudohyperkalaemia can cause harm to the patient in the form of undesired side effects, unnecessary investigations and concerns, and potentially dangerous iatrogenically induced cardiac arrhythmias.

BackgroundIn our institutions, there are two types of stents used: the Boston Scientific Wallflex (Marlborough, Massachusetts) and Merit Medical Endotek (South Jordan, Utah). So we performed this retrospective study to compare complication rates in various esophageal disorders to improve our quality of care.MethodsCharts were reviewed to capture gender, indications of stent placement, stent length/diameter, age of the patient at the time of stent placement, length of hospital stay, physicians performing a procedure, and complications within 90 days of stent placement.ResultsA total of 67 patients (71.6% male) underwent stent placement (WallFlex 49.3% and Merit 50.8%) for malignant (68.7%) mainly esophageal obstruction by primary esophageal cancer (89.1%) and benign causes (31.3%) mainly esophageal leak (66.7%). Merit and WallFlex used in malignant conditions were 82.4% and 54.6%, respectively, and in benign conditions, they were 17.7% and 45.5%, respectively. The mean age at which endoscopy was performed was 64. Complications post Merit and WallFlex placement were 79.4% and 60.6%, respectively. Complications with malignant and benign conditions were 73.9% and 61.9%, respectively. Complications with 19, 18, and 23 mm diameters were 75.0%, 66.7%, and 69.4%, respectively. Complications with 120, 150, 100, 15, 12, 10 mm stent lengths were 84.6%, 58.3%, 58.8%, 80.0%, 75.0%, and 33.3%, respectively.ConclusionOur study showed that the Merit stent was mainly used, and the major indication of stent placement was a malignant condition. Major complications were seen when the reason for stent placement was a malignant condition, the diameter was 19 mm, the length was 120 mm, and the use of the Merit stent.

BackgroundEndobronchial ultrasound-guided trans-bronchial needle aspiration (EBUS-TBNA) is minimally invasive technique used for diagnosis and/or staging of benign and malignant pulmonary and non-pulmonary disease. Previous studies have established the utility of EBUS-TBNA in narrowly defined indications and populations. In this pragmatic ‘real world’ study we have analysed the use of EBUS-TBNA for a variety of clinical presentations and its clinical application in conjunction with other invasive investigations.MethodsAll EBUS-TBNA procedures performed at Sir Charles Gardiner Hospital in 2012–2014 were reviewed retrospectively, using relevant hospital databases.ResultsA total of 327 patients underwent 337 EBUS-TBNA procedures. EBUS-TBNA procedures were used to diagnose a wide spectrum of benign and malignant conditions. The main application was in the diagnosis and staging of malignant conditions (70.6%), and in the diagnosis of benign conditions such as sarcoidosis 40 (12.2%), and silicoanthracosis 17 (5.2%). EBUS-TBNA was sufficient to diagnose and stage the disease as a single stand-alone invasive procedure in 191 (59.2%) patients. EBUS-TBNA was the final invasive procedure undertaken in 283 (87.6%) patients. Only 13.3% of non small cell lung cancer (NSCLC) patients who had EBUS-TBNA as a first investigation required multiple procedures compared to 51.1% of all NSCLC patients undergoing EBUS-TBNA. Overall sensitivity, specificity, NPV and diagnostic accuracy for EBUS-TBNA were 89.7, 100, 85.1 and 89.9%, respectively and three minor complications (0.9%) occurred as a result of the procedure.ConclusionsEBUS-TBNA was undertaken for a wide variety of clinical conditions. Good diagnostic accuracy and safety profiles were demonstrated for the procedure, supporting its application as a first line investigation in the diagnosis and/or staging of a range of malignant and benign conditions. Our study was unique in its documentation of the use of EBUS-TBNA in a real-world setting in conjunction with other invasive modalities. EBUS-TBNA was utilised as a stand alone invasive procedure in more than half of the patients. Importantly, in NSCLC, when EBUS-TBNA was performed as primary diagnostic and staging investigation, less patients underwent subsequent invasive procedures.

Objectives: With blue and green light only, narrow band imaging (NBI) allows better visualization of mucosal micro-vascular architecture. Intra-epithelial papillary capillary loops (IPCL) is a classification of vascular patterns based on previous esophageal NBI studies. The aims of the study were to: (1) Study the normal micro-vascular anatomy of the larynx by means of NBI. (2) Better understand the clinical applications of NBI in laryngeal lesions. (3) Assess the relative advantages and disadvantages of NBI versus white light imaging in the larynx. (4) Assess the relevance of previously described IPCL classification in laryngeal pathologies. Methods: A prospective comparative study including patients who arrived for laryngeal examination at an ENT referral center in 2013. White light images and NBI were compared in each patient to assess relative advantages of each modality. Micro-vascular architecture was described by IPCL classification. Results: A total of 110 patients were included and underwent video-stroboscopy, flexible distal-chip endoscopy, and NBI of the larynx. Thirty-two patients had a normal larynx, 54 had benign conditions, and 24 had malignant lesions. Distinct characteristics of vascular patterns were visualized by NBI in normal tissues, as well as a wide spectrum of benign and malignant conditions. In several patients with malignant and premalignant conditions, NBI revealed more extended disease than what was observed by white light imaging. Conclusions: Using NBI along with white light imaging, while understanding the unique microvascular fingerprint of each laryngeal pathologic condition, can assist the physician in differential diagnosis. In specific conditions, including malignant and premalignant lesions, NBI can bring better assessment of lesions’ size and extension.

Raman Spectroscopic Analysis Identifies Testicular Microlithiasis as Intratubular Hydroxyapatite

CA 19-9 is a tumour marker which has been used widely in patients with pancreatic adenocarcinoma. Elevated levels are associated with advanced disease at presentation and disease progression during follow-up. CA19-9 levels may also be elevated in a variety of other malignant and benign conditions. This study examined the significance and implications of elevated CA19-9 levels. An analysis of all CA19-9 measurements performed over a 4 yr period was undertaken and 204 patients with elevated CA19-9 levels were identified. One hundred and thirty patients (63.7 per cent) had malignant conditions and 74 (36.3 per cent) had benign conditions or no definite cause was found. There was a significant correlation between CA19-9 levels and CEA (r = 0.3137; P < 0.001) as well as alkaline phosphatase, ALT, AST, bilirubin, gamma glutamyl transpeptidase and lactate dehydrogenase. CA19-9 levels were significantly lower in patients with benign pathology than those with malignant pathology. Similar differences were observed for CEA. CA19-9 levels were in fact highest in patients with pancreatic carcinoma (P < 0.05) while no significant differences were observed for CEA. In conclusion CA19-9 may be elevated in both benign as well as malignant conditions and interpretation of CA19-9 results must be made in light of the clinical condition of the patient.

Background: Masturbation is not uncommon in younger children. Due to variable presentation in early childhood often leads to misdiagnosis and may result in unnecessary investigation and treatment. Materials &amp; Method: This retrospective case study was conducted at outpatient department of Rehabilitation and Neurology unit of Dr.M R Khan Shishu Hospital and Institute of Child Health between 2013-2019. Result: Among 40 patients, majority (90%) had age of onset within 36 months of age. Mean and median age were 27.45 months and 25.5 months respectively, the range was between 4 months to 84 months. Male: female was 1:1.2. Most of the children came from urban area (85%) and from single family (77.5%). All 40 children shared common features like stereotype movement with variable duration, no alteration of consciousness, cessation with distraction when attempted, remained responsive during the events, their neurological examination was normal and no abnormalities were detected in laboratory studies. Thirty- three (82.5%) children did this behaviour on prone position. Thirty-one (77.5%) children had vocalization. Duration of episode was 5-10 min in 19(47.5%) children. Frequency of masturbation was up to 5 times per day in 30(75%) children. Twenty-two (55%) children did this behaviour when remained unnoticed. Antiepileptic drug was given to 14(35%) children but had no clinical improvement. Home video recordings were available in 18(43.9%) children. Conclusion: Early diagnosis from the knowledge of clinical manifestations helps to minimize unnecessary laboratory investigations and use of drugs. BANGLADESH J CHILD HEALTH 2022; VOL 46 (2) : 71-75