Racial differences in prostate cancer (PCa) outcomes in the United States may be due to differences in tumor biology and race-based differences in access and treatment. We designed a study to estimate the relative contribution of these factors on Black/White disparities in overall survival (OS) in advanced PCa.
We identified Black and White men aged ≥ 40 years with metastatic or locally advanced PCa (cN+ cM+ and/or T3/4) between 2004 and 2010 using the National Cancer Database. We employed sequential propensity score weighting procedures to generate simulated cohorts of Black and White patients with equal demographics, access to care, treatment, and tumor characteristics. Adjusted survival analyses were used to compare survival in these simulated cohorts. The changes in relative survival after each weighting procedure were used to infer the contribution of each set of variables on the excess risk of mortality in Blacks.
In total, 35,611 men met inclusion criteria, 5927 (16.77%) of whom were Black. Survival was significantly worse for Black men after adjusting for demographics and comorbidities (hazard ratio (HR) 1.27, 95%-confidence interval (95%-CI) 1.2–1.34, p < 0.001). After simulating equal access to care, there was no significant difference in survival between races (HR 1.04, 95%-CI 0.97–1.12, p = 0.276), despite worse tumor characteristics in Blacks. After simulating equal treatment and equivalent tumor characteristics, Black men had a better survival than Whites (HR 0.93, 95%-CI 0.86–1.01, p = 0.071 and HR 0.92, 95%-CI 0.84–1.00, p = 0.043, respectively). Overall, access-related variables explained 84.7% of the excess risk of death in Black men.
Our analysis of men with advanced PCa revealed worse OS among Blacks. However, when access to care, treatment, and cancer characteristics are accounted for, Black race was associated with better OS. These findings suggest that initiatives to improve access to care may represent an effective tool to reduce disparities in PCa outcomes.
At first glance, physicians’ poor understanding of death and the process of dying is baffling, since they are supposed to be custodians of health across the lifespan. Look deeper, though, and it may reflect less the attitudes of physicians themselves and more the system that nurtures them. After all, we train vigorously on how to delay the onset of death, and are judged on how well we do that, but many of us get little training on how to confront death.
Surgery. The field of medicine, that has played a pivotal role in the evolution of healthcare delivery for generations, even centuries. We have moved far from the time when breast surgery was a grotesque scene in a lecture hall to a state where dozens of operations are performed at outpatient (OPD) facilities. This change has brought with it certain limitations to the growth of the psyche of a surgeon. The tsunami of machines and technologies, which brought comfort and ease to the struggling patients, has also brought mindlessness and arrogance to the practitioners of this beautiful art. As we rely more on machines now than ever before, our approach has become, unsurprisingly, more mechanistic, and we may have lost our grip on the ambition we had when we entered our career: to help humanity. One of the most gratifying aspects of surgery is that we can actually heal a patient in real time; heal their wounds, both physical and metaphorical, with our own hands. This notion was consolidated in my mind as I volunteered at the Savar building collapse a while back, but the lessons I have learned are still very fresh. In this article, I have attempted to put my feelings and my hopes in to words, as a token to the global surgeons-in-training so they can take heed. In our classrooms, the focus on humanity has greatly reduced, and this has in turn produced surgeons who rarely follow the path of volunteerism. There is a solution to this disarray: separate the money from the art, not always, but occasionally. Surgeons have always been the beacons of volunteer activities; there is a reason Doctors Without Borders (MSF) constitutes more of surgeons than any other disciplines. With volunteerism, surgeons understand the world outside the hospital ward and gain insights into patient’s mentality and their fears at a more visceral level. The empathy we gain from such activities will eventually help us become better guardians of health when he re-enters these hospital wards.
Lack of opportunities, and a limited availability of employment in the politically unstable valley of Jammu and Kashmir, in India, has permeated each section of the society, creating new problems for the ethnic minority of Kashmiris in all spheres of their lives from healthcare, to drug addiction. A novel approach is presented, where the control of economic destiny is shaped by promoting the entrepreneurial spirit of the people, so that their dependence on public sector jobs is decreased. Social entrepreneurship, in addition to creating economic benefits for the general populace of Jammu and Kashmir (J&K), would be an ideal solution for a society which has been at constant war with itself, both metaphorically and literally. In this policy article, in addition to literature review, we discuss the potential of Social Business in J&K, and present examples of market opportunities which, if explored and invested in properly, can predict a stable and self-sufficient future for Kashmir.
Tuberculosis is endemic in Bangladesh. It remains a resilient public health concern. Reports on presentation and management of intracranial tuberculoma from Bangladesh are sparse. Despite being potentially remediable, tuberculomas are still a cause of significant morbidity and mortality in developing nations. Intracranial tuberculomas can occur as solitary or multiple lesions. Multiple isolated intracranial tuberculomas are rare, and difficult to discern from brain metastases. A unique case of intracranial tuberculomas is presented, which masqueraded as brain metastases on imaging studies and was diagnosed and treated with a trial of antitubercular chemotherapy. A 43-year-old Bengali male presented to the OPD with headaches and blurring of vision for four months. He was provided symptomatic treatment at his regional hospital, which did not abate his condition and was later referred to our center when he developed severe vomiting. Routine investigations including chest radiograph were clean. CT scan showed bilateral edema in cerebral hemispheres and MRI revealed rounded signal change areas of right frontal lobe and left parietal lobe posteriorly, strongly suggestive of brain metastases. Patient declined biopsy. In view of his past history, a full course of antitubercular chemotherapy was prescribed. Following the medication, patient’s condition improved and at 24 months follow-up, there was complete resolution of the lesion.
Purpose: The purpose of the study was to compare the mean sodium and potassium levels in patients with senile cataract and age-matched normal individuals in Kashmir.
Material and Methods: The study was designed as cross sectional observational study. 200 senile cataract patients scheduled for cataract surgery in the Department of Ophthalmology and 200 individuals of the same age group without cataract were selected. Mean serum sodium and potassium levels in the senile cataract group were calculated and compared with the control group. Serum sodium and potassium levels were measured by flame photometry technique. Statistical software SPSS-16 was used and means were compared between two groups by t-test. Since the study was a non interventional one, clearance was given by the department and study abides by the guidelines laid in the declaration of Helsinksi.
Results: Mean serum sodium level in senile cataract patients and normal individuals was 139.60 ± 5.23 mEq/L and 137.15 ± 2.93 mEq/L respectively and there was statistically significant difference (p < 0.0001). Mean serum potassium level in senile cataract patients and normal individuals was 4.35 ± 0.574 mEq/L and 4.31 ± 0.45 mEq/L, and the difference was not statistically significant (p = 0.60).
Conclusion: Serum sodium level in senile cataract patient was higher as compared to the control group. This outcome might suggest that increased dietary intake of the sodium leads to higher levels of serum sodium which in turn influences the cataractogenesis in senile patients.
Intussusception in adults is rare, accounting for only 5% of all cases of intussusceptions and only 1% of bowel obstruction. Preoperative diagnosis is often difficult due to non specific symptoms and subacute nature. This case report was a per-operatively diagnosed adult colo-colic intussusception induced by a lipoma which mimicked a sigmoid polyp on colonoscopy. A 40-year-old Bengali woman was admitted with two weeks history of colicky lower abdominal pain. Ultrasound abdomen was unremarkable. Colonoscopy revealed a moderately enlarged sigmoid polyp at 25 cm from the anal verge. A midline incision laparotomy was performed only to reveal a colo-colic intussusception. The intussusception was reduced and the patient underwent a segmental resection of the involved bowel. Histological evaluation confirmed the diagnosis of lipoma of the colon. The patient however satisfactory recovery and remains well six months after surgery.
INTRODUCTION: Phyllodes tumors are rare fibroepithelial tumors which constitute less than 1% of all known breast neoplasms. The importance of recognizing these tumors lies in the need to differentiate them from fibroadenomas and other benign breast lesions to avoid inappropriate surgical management. We report a case of large phyllodes tumor which caused rupture of the breast and presented as an external fungating breast mass, a presentation which is exceedingly rare.
CASE PRESENTATION: A 32-year-old female presented with a 1-year history of a mass in her right breast and eruption of the mass through the skin for the last 3 months. On physical examination, an ulcerated, irregular, and nodular mass measuring 9 × 8 cms was found hanging in the lower and outer quadrant of the right breast. Ultrasonography revealed an exophytic mass with heterogeneous echotexture and vascularity. Under general anesthesia, the tumor was excised. The resected specimen was 9.5 × 8.5 × 4.5 cm in size and the tumor was not invasive to the surrounding tissues. Histological examination confirmed a benign case of Phyllodes tumor.
CONCLUSION: Clinicians should be aware of the myriad ways in which Phyllodes can present. A rapidly growing breast mass in a female should raise strong suspicion for Phyllodes. It is necessary to differentiate it from fibroadenomas to avoid inappropriate surgical management which may lead to local recurrence.
Adrenocortical tumors (ACTs) causing Cushing's syndrome are extremely rare in children and adolescents. Bilateral macronodular adrenocortical disease which is a component of the McCune-Albright syndrome is the most common cause of endogenous Cushing's syndrome. We report the case of a boy with Cushing's syndrome who presented with obesity and growth retardation. The child was hypertensive. The biochemical evaluation revealed that his serum cortisol levels were 25.80 μg/dL, with a concomitant plasma ACTH level of 10.0 pg/mL and nonsuppressed serum cortisol on high-dose dexamethasone suppression test (HDDST) to be 20.38 μg/dL. Computed tomography of the abdomen demonstrated a 8 × 6 × 5 cm left adrenal mass with internal calcifications. Following preoperative stabilization, laparotomy was carried out which revealed a lobulated left adrenal mass with intact capsule weighing 120 grams. Histopathological examination revealed a benign cortical neoplastic lesion, suggestive of adrenal adenoma; composed of large polygonal cells with centrally placed nuclei and prominent nucleoli without capsular and vascular invasion. On the seventh postoperative day, cortisol levels were within normal range indicating biochemical remission of Cushing's syndrome. On followup after three months, the patient showed significant clinical improvement and had lost moderate amount of weight and adrenal imaging was found to be normal.
INTRODUCTION: Adrenal myelolipoma is a rare tumor that is benign in nature, usually asymptomatic, unilateral, and nonsecreting. It is composed of variable mixture of mature adipose tissue and hematopoietic elements and develops within the adrenal gland. With the widespread use of cross-sectional imaging modalities such as ultrasonography and computed tomography, the incidental detection of these tumors is increasing in frequency.
CASE PRESENTATION: We report a case of adrenal myelolipoma in a 63-year-old Kashmiri male, who presented with pain in the right upper abdomen. Physical examination was unremarkable. Ultrasound abdomen showed the presence of a hyperechoic mass in the right suprarenal region with undefined margins. Contrast-enhanced computed tomography (CECT) scan of abdomen revealed a well-defined, round lesion in the right suprarenal region with heterogeneous attenuation suggesting the possibility of myelolipoma. The patient was subjected to right adrenalectomy and his postoperative course was uneventful. The histopathological evaluation of the mass confirmed the initial diagnosis of adrenal myelolipoma.
CONCLUSION: Although mostly discovered as an "incidentaloma", the diagnosis of adrenal myelolipoma warrants thorough diagnostic study. Imaging techniques such as ultrasonography and CT scans as well as biochemical studies are useful for indicating the best treatment taking into account the size of the mass and possible hormone production. Surgical resection is advocated through extraperitoneal approach as it minimizes postoperative complications and leads to quicker recovery.
Intraductal papillary mucinous neoplasm (IPMN) of the pancreas is one of the two entities which come under the realm of non-inflammatory cystic lesions of the pancreas, the other one being mucinous cystic neoplasm. The clinco-pathological features of intraductal papillary mucinous neoplasm of the pancreas are unique. The patient had a long history of symptoms suggestive of chronic pancreatitis. Endoscopic retrograde cholangiopancreatography revealed dilatation of the main duct, ultrasonography showed cystic dilatation interpreted as pseudocyts. Current thinking suggests that at best IPMN represents a premalignant condition and, as such, surgical intervention is recommended. The aim should be to resect all gross disease while attempting to achieve a negative surgical margin, which in the majority of cases can be achieved by a partial or subtotal pancreatectomy, which was performed on the patient. Histologically, they demonstrate a spectrum of cellular atypia ranging from minimal mucinous hyperplasia to frank invasive carcinoma. Although the neoplasms are less aggressive as a group than conventional pancreatic ductal adenocarcinoma, patients with IPMNs may pursue a deadly course, even in the absence of identifiable invasive carcinoma thus emphasizing the importance of recognizing IPMNs and initiating optimal modalities of treatment.
Introduction. Hashimoto’s thyroiditis is a common form of chronic autoimmune thyroid disease (AITD) and often coexists with other autoimmune diseases, but Hashimoto’s thyroiditis associated with an autosomal dominant neurofibromatosis type 1 is exceedingly rare. Case Presentation. A 30-year-old Bengali woman presented to the OPD with complaints of aching pain and tingling sensation in her hands and feet. Physical examination revealed dysmorphic facies, nodular swelling in the neck, cafe-au-lait spots, and neurofibromas covering the entire surface of her body. Her thyroid hormones were within normal limits. Thyroid ultrasound revealed a cystic area in the left lobe of the gland, and ultrasound-guided fine needle aspiration cytology revealed lymphocytic infiltration of the gland, suggesting Hashimoto’s thyroiditis. High levels of autoimmune antibodies such as antithyroglobulin and antimicrosomal antibodies confirmed the diagnosis. Conclusion. When encountered with a patient of Neurofibromatosis type 1, a physician should be careful about the possibility of a concomitant autoimmune disease. Clinical presentation of neurofibromatosis and Noonan syndrome often overlaps and recent studies have implicated a mutation in NF1 gene in the etiology of NFNS. More extensive reports and further investigations of such patients having combination of neurofibromatosis type 1 and autoimmune thyroiditis will certainly provide better understanding of this link in the near future.
The clinical entity 'Wandering spleen' is an uncommon presentation and it is more often diagnosed in children than in adults, mostly women of reproductive age. Here is a case of a young woman who presented with generalized weakness and fever, and a painless mobile lump in her central abdomen. The laboratory evaluation revealed a haemolytic state and Haemoglobin electrophoresis showed β-Thalassemia trait (Hb A2 5.1%). Ultrasonography and Computerized Tomography (CT) scan confirmed that the mass is spleen and spleen is not present in its normal anatomical location. Abdominal CT described a well-defined, homogenous pediculated mass with echo texture comparable to spleen. Radioisotope scanning could be used as an alternative for confirmation of diagnosis of this rare condition, but was not done in our case. Colour Doppler sonography of the splenic circulation revealed no infarction and intact splenic vasculature. Wandering spleen should be considered in the differential diagnosis of idiopathic abdominal or pelvic lumps. The authoritative opinion for the treatment of such a case is splenectomy or splenopexy especially in children and here, in this case splenectomy was done.
A myoepithelial hamartoma is a very uncommon submucosal tumor of the stomach. In an atypical presentation in our case, it mimicked the clinical presentation of a gastrointestinal stromal tumor. To the best of our knowledge, it is the first case of a hamartoma of the stomach reported from Bangladesh and one of few cases described in the literature.
We describe the case of a 35-year-old Bengali man with recurrent epigastric pain and occasional vomiting with radiographic findings of a gut mass. An upper gastrointestinal endoscopy revealed a healed duodenal ulcer, deformed ‘D’ bulb and a submucosal swelling in his antrum. Ultrasonography and a contrast-enhanced computed tomography scan confirmed the presence of a well-defined, oval gut mass in his upper abdomen, compressing his duodenum. The mass had a mixed density and was considered to probably be a gastrointestinal stromal tumor. Ultrasonography-guided fine needle aspiration cytology was inconclusive. After resection at laparotomy, a histopathological examination revealed a myoepithelial hamartoma. These tumors are characterized by hypertrophic smooth muscle bands surrounding varied epithelial elements, which may be arranged in diverse patterns such as simple glandular structure, Brunner’s gland, pancreatic ducts and sometimes pancreatic acini. This case report is complemented by a literature review relating to the atypical presentation.
Gut masses need to be investigated thoroughly and the possibility of rare tumors should not be excluded. Although the recommended treatment for such lesions is limited resection, radical procedures such as a pancreaticoduodenectomy are often performed when the lesion occurs in the periampullary area because of preoperative misdiagnosis as a carcinoma. Therefore, it is essential for clinicians to maintain current knowledge of the lesion to avoid inaccurate diagnosis and prevent unnecessary surgery.
Introduction: Breast cancer is the most common malignancy of women in Kashmir. This study was conductedwith the objective of assessing hormone receptor positivity and its correlation with age at diagnosis, tumor size,histological grade and lymph node metastasis. Materials and Methods: 132 newly diagnosed cases of invasivebreast cancer diagnosed at the Department of Pathology, SKIMS, Srinagar, J&K, were included after excludingbiopsies, in-situ lesions and recurrence cases. Results: Mean age of the patients was 48.2 years, 59.1% being≤50 years of age. Mean duration of symptoms was 6.32 months. Most lesions (65.1%) were 2-5 cm and 16.7%were ≥5.0 cm in greatest dimension. The predominant (80.3%) morphology was IDC-NOS. The majority of thecases presented as grade II (52.1%) lesions and lymph node involvement was present in 65.2%. ER and PRwere positive in 66.3% and 63.4% cases, respectively, increasing with rising age. High grade lesions and largersize tumors were more likely to be ER and PR negative. No correlation was found between ER/PR status andlymph node metastasis. Conclusions: ER and PR expression in breast cancers in the current study was found tobe higher than studies done in India/Asia but lower than studies conducted in the West, even on Indian/Asianimmigrants. Markedly lower receptor expression in Indian/Asian studies is likely due to preanalytic variables,thresholds for positivity, and interpretation criteria. American Society of Clinical Oncology/College of AmericanPathologists Guideline Recommendations for Immunohistochemical Testing of Estrogen and ProgesteroneReceptors in Breast Cancer are strongly advocated for standardization of receptor evaluation and for clinicalmanagement of breast cancer patients to provide best therapeutic options.
Introduction. Circumcision is a common procedure carried out around the world. Due to religious reasons, it is routinely done in Bangladesh, by both traditional as well as medically trained circumcisers. Complications include excessive bleeding, loss of foreskin, infection, and injury to the glans penis. Myiasis complicating male circumcision appears to be very rare. Case Presentation. In 2010, a 10-year-old boy presented to the OPD of Dhaka Medical College Hospital with severe pain in his penile region following circumcision 7-days after. The procedure was carried out by a traditional circumciser using unsterilized instruments and dressing material. After examination, unhealthy granulation tissue was seen and maggots started coming out from the site of infestation, indicating presence of more maggots underneath the skin. An emergency operation was carried out to remove the maggots and reconstruction was carried out at the plastic surgery department. Conclusion. There is scarcity of literature regarding complications following circumcision in developing countries. Most dangerous complications are a result of procedure carried out by traditional circumcisers who are inadequately trained. Incidence of such complications can be prevented by establishing a link between the formal and informal sections of healthcare to improve the safety of the procedure.