Only 15 cases of intraperitoneal knot formation causing intestinal obstruction to have been described. So here ABSTRACT Despite high incidence of complications, Ventriculoperitoneal shunting for hydrocephalus is the cornerstone and the most common neurosurgical procedure. Ventriculoperitoneal shunt knot causing intestinal obstruction is an extremely rare complication needing surgical intervention. A 19 years old male with history of VP shunting in infancy for hydrocephalus with no history of any revision surgery presented in emergency with pain abdomen and multiple episodes of vomiting for 2 days. X ray showed dilated bowel loops with a coiled up VP shunt in the abdomen. Exploratory laparotomy showed multiple dilated bowel loops with a loop of VP shunt around ileal segment with dense fibrotic adhesions causing obstruction. Extensive adhesiolysis was done. Procedure underwent uneventful. Patient recovered swiftly in postoperative period and is currently asymptomatic after 6 months of surgery. Improved surgery skills and shunt design have prevented much of the morbidity of VP shunting. Most of the cases reported earlier were paediatric patients with history of repetitive handling of catheter. We believe this to be the first case of intestinal obstruction by a VPS knot in an adult with no history of manipulation after primary surgery. Due to low incidence it is difficult to clinically suspect such an extremely rare complication. Therefore, an awareness of VP shunt related complications in adult is essential.

Pulmonary embolism is rare in haemophilia. Only eight cases of pulmonary embolism have been described in the literature [1]. Here, we report a case of pulmonary emboli in a patient with haemophilia. The underlying cause for pulmonary embolism in our patient was very unusual.A 34-year-old patient with severe haemophilia A presented with progressive dyspnoea at rest. Physical examination was remarkable for a loud S2, holosystolic murmur along the left sternal border increased with inspiration, and jugular venous distension. Workup included a normal chest X-ray, EKG showing T-wave inversions in leads V1-V3 (Fig. 1a) and a transthoracic echocardiogram, suggesting severe pulmonary hypertension, right ventricular dilation and tricuspid regurgitation (Fig. 1b). After worsening respiratory distress, repeat EKG suggested development of a S1Q3T3 pattern (S-wave in lead I, and Q-wave and inverted T-wave in lead III; Fig. 1c) strongly suggesting the evolution of pulmonary embolism on pre-existing pulmonary hypertension, despite concomitant auto-anticoagulation from haemophilia. Prior to intubation, the patient admitted he had been crushing, then injecting carisoprodol tablets intravenously. A CT angiogram of the chest revealed numerous micronodular opacities (Fig. 1d) compatible with pulmonary microemboli resulting from the injected medication. The patient was started on mechanical ventilation and the S1Q3T3 pattern on the EKG resolved after a few hours. He was eventually extubated and discharged to rehab on supplemental oxygen. As there was no actual thrombus and the patient improved without any particular intervention, we did not initiate anticoagulation. In the absence of bleeding, no factor was administered. The patient refused a follow-up echocardiogram.From the eight available case reports of pulmonary embolism in haemophilia, two cases occurred in patients with haemophilia A, one of whom did not have any risk factors [2] and the other was receiving Feiba and rFVIIa for inhibitors [3]. The other six patients had haemophilia B; four of them were receiving prothrombin complex concentrate [4] or FIX concentrates for surgery [5], one was receiving Feiba for inhibitors [6], and one was heterozygous for factor V Leiden and underwent hip fracture surgery [7]. Interestingly, although the (a) (b) (c) (d) Fig. 1. Electrocardiographic, echocardiographic and computed tomography scan findings in a patient with multiple pulmonary emboli. (a) shows T-wave inversions in leads V1-V3, a common finding in pulmonary embolism. (b) shows severe right ventricular dilation. (c) shows the classical S1Q3T3 pattern of pulmonary embolism after worsening respiratory distress. (d) shows numerous small emboli in the lungs.

Aims: Metastasis to axillary lymph nodes is an important prognostic factor in carcinoma breast patients, with implications on overall survival and progression-free survival. To evaluate the accuracy of pre-operative clinical palpation and USG axilla in patients with carcinoma breast, using histopathology as the gold standard. Study Design: Cross-sectional observational study. Place and Duration of Study: This was a retrospective study, carried out at Cancer Research Institute, SRHU, India, between January 2015 and December 2018. Methodology: Data was collected from Case records and Hospital Information System for patients having undergone surgery for breast cancer. Pre-treatment clinical, ultrasound axilla, and final histopathology details were recorded. Taking histopathology as the gold standard test, diagnostic accuracy of clinical palpation and ultrasound axilla was calculated. Results: 256 patients were enrolled in the study. Clinically, 70.7% of patients were T1/T2 stage, 53.9% were node-positive, on USG axilla 59% had abnormal nodes, pathologically 53.52% had nodal metastasis. The sensitivity, specificity for clinical palpation was 77.86% and 75%, for USG was 90.71% and 79.31%. Sensitivity and specificity of USG in c T1/2 was 88.64% and 80.21%; in c T3/4 94.23% and 65.22%; in c N negative 87% and 72.16%; in c N positive 91.74% and 75.86%. Conclusion: The diagnostic accuracy of clinical palpation of axilla alone was low; Ultrasound axilla had high sensitivity but low specificity across all T stages of breast tumor. The ultrasound had a high negative predictive value in clinically non-palpable nodes and a high positive predictive value in clinically palpable nodes.

Background: There has been frequent researches on liver pathologies and its variables in the world. There is no known research carried on liver in Garhwal region. Uttarakhand is one area where the hill people are more habitual of alcohol abuse and alcoholism is more endemic here. Primary objective was to correlate alcohol intake and its effect on liver function test. Secondary objectives were to screen the patients for abnormal LFTs and to observe and understand changes needed in lifestyle to reduce risk of developing liver disorders.Methods: A cross sectional observational study was conducted on patients in a medical college in north India. The participants above the age of 10 years were included for the study.Results: Out of all the 150 study participants screened, 120 (80%) were detected to have abnormal liver function tests (LFT) (65 females and 55 males). Maximum numbers of participants with abnormal LFT belong to age group of 21-30 yrs. More frequent and higher amount of alcohol consumption was found to adversely affect the liver physiology.Conclusions: The most important risk factor for liver damage is frequent consumption of alcohol in excess of 4 pegs a day for males and 2 for females (One standard drink contains 10 grams of alcohol).