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Sister Mary Joseph Nodule

Main sites of metastases for some common cance...

Main sites of metastases for some common cancer types. Primary cancers are denoted by “…cancer” and their main metastasis sites are denoted by “…metastases”. List of included entries and references is found on main image page in Commons: (Photo credit: Wikipedia)

Sister Mary Joseph Dempsey (born Julia Dempsey; 1856-1939) was the surgical assistant of William J. Mayo at St. Mary’s Hospital in Rochester, Minnesota,USA from 1890 to 1915. She drew Mayo’s attention to the phenomenon, and he published an article about it in 1928. The eponymous term Sister Mary Joseph nodule was coined in 1949 by Hamilton Bailey.

What is Sister Mary Joseph Nodule?

Sister Mary Joseph nodule or node, also called Sister Mary Joseph sign, refers to a palpable nodule bulging into the umbilicus as a result of metastasis of a malignant cancer in the pelvis or abdomen.

Etiology

1.Gastrointestinal malignancies account for about half of underlying sources (most commonly gastric cancer, colonic cancer or pancreatic cancer, mostly of the tail and body of the pancreas)

2.Gynecological cancers account for about 1 in 4 cases (primarily ovarian cancer and also uterine cancer).

3.Unknown primary tumors and rarely, urinary or respiratory tract malignancies cause umbilical metastases.

Mechanism of spread

Proposed mechanisms for the spread of cancer cells to the umbilicus include direct transperitoneal spread, via the lymphatics which run alongside the obliterated umbilical vein, hematogenous spread, or via remnant structures such as the falciform ligament, median umbilical ligament, or a remnant of the vitelline duct.

Importance of the finding

Sister Joseph nodule is associated with multiple peritoneal metastases and a poor prognosis.So once you find a Sister Mary Joseph nodule in a patient you can brace for a bad outcome.
Source:Medcosmos surgery

Cardinal Signs of Kanavel

Seen in suppurative tenosynovitis,which involves infection of the flexor tendon sheath, which is usually caused by a puncture wound to the volar aspect of the digit or palm.

Diagnosed by:Cardinal Signs of Kanavel

  • Finger held in flexion.
  • Fusiform swelling of the finger.
  • Tenderness along the tendon sheath.
  • Pain on passive extension.

The Reconstructive ladder of soft tissues

The reconstructive ladder of soft-tissue coverage begins with consideration of the simplest approach (healing by secondary intention) and culminates with the most complex (free tissue transfer)

1.Healing by secondary intention is the simplest approach but is not always feasible. Absolute contraindications include exposed vessels, nerves, tendons, viscera, or bone. Relative contraindications include a large or poorly vascularized wound with a prolonged (>3 weeks) anticipated period of healing and undesirable aesthetic consequences.

2.Primary Closure may provide the most aesthetically pleasing result, but excessive tension on the skin may cause displacement of neighboring structures (e.g., lower eyelid) or necrosis of the skin flaps.

3.Skin grafting is the most common method of large-wound closure. Skin grafts require a healthy, uninfected bed, protected from shear forces, to survive. Wound surfaces such as bare tendon, dessicated bone or cartilage, or infected tissue beds will not support skin graft survival. In addition, exposed vessels, nerves, or viscera are relative contraindications for skin grafting.

4.Local tissue transfers of skin, fascia, and muscle may be used in regions with healthy adjacent tissue. If the adjacent tissue cannot be adequately mobilized or the wound requires more bulk than is locally available, the sole use of local flaps may not be adequate.

5.Distant tissue transfers were the mainstay of difficult wound closure until the advent of free tissue transfer in the 1970s. This involves transferring healthy tissue into the wound bed while leaving it attached to its native blood supply. The pedicle is divided in a subsequent procedure. Inherent disadvantages of this technique include multiple operations, prolonged wound healing, immobilization for at least 3 weeks, and a limited choice of donor sites.

6.Free tissue transfer is the most technically demanding approach to wound closure but has several potential advantages, including single-stage wound closure, a relatively wide variety of flaps to ensure closure specifically tailored to coverage needs, and, in many cases, an aesthetically pleasing outcome.

7.Vacuum-assisted closure has altered wound management by decreasing bacterial load and accelerating granulation. Wounds may be treated adequately with vacuum-assisted closure that would not traditionally be candidates for healing by secondary intention. Furthermore, it may convert a wound that would otherwise need adjacent or free tissue transfer into a wound that needs only split-thickness skin grafting.

Source:Washington manual of Surgery

Why do people undergoing surgery develop transient diabetes

English: Diagram shows insulin release from th...

English: Diagram shows insulin release from the Pancreas and how this lowers blood sugar leves. (Photo credit: Wikipedia)

 

During our training period in surgical wards in the medical college, we encounter a lot of accident cases, non healing ulcers, necrotizing fascitis etc. Most of these people have one thing in common, increased blood sugar levels. One thing to note is that,these people were having completely normal or near normal values before they met with an accident or developed the disease.Naturally the question which springs up in our mind is:why does this happen?

 

Why do blood sugar values rise in injuries and infections?

In severe injury(including surgeries) and infections,plasma insulin concentrations initially fall as a result of sympathetic inhibition of pancreatic beta cells,but may rise to supra physiological levels after several days.A state of insulin resistance may persist for several weeks.There is increased breakdown of glycogen,lipid and muscle protein yielding amino acid precursors for glucose production.This increased hepatic glucose production cannot be inhibited by administering glucose or with physiological insulin concentrations.When combined with impaired insulin mediated glucose storage in skeletal muscle due to insulin resistance, this leads to a tendency to marked hyperglycemia and diabetes like state.

X ray KUB showing Left VUJ calculus

X-ray KUB showing Left vesico ureteric junction calculus.

Left VUJ calculus

Left VUJ calculus

Hodgkins lymphoma classification

There are five subtypes of Hodgkins lymphoma, they are distinguished by their morphology immunophenotype and clinical features.This classification of Hodgkins Lymphoma helps in determining the treatment and provides a rough idea regarding prognosis.

1.Nodular sclerosis

  1. Frequent lacunar cells and occassional Reid Sternberg(RS)cells.
  2. RS cells,CD15+,CD30+,EBV-ve
  3. Stage 1 and 2 diseases most common,frequent mediastinal involvement,affects young adults

2.Mixed cellularity

  1. Frequent mononuclear and diagnostic RS cells
  2. RS cells,CD15+,CD30+,70%EBV+ve.
  3. Biphasic incidence,M>F,>50%present with stage 3 or 4 disease.

3.Lymphocyte rich

  1. Frequent mononuclear and diagnostic RS cells
  2. RS cells,CD15+,CD30+,40%EBV+ve
  3. Uncommon,M>F,seen in older adults.

4.Lymphocyte depletion

  1. Reticular variant,frequent RS cells.
  2. RS cells,CD15+,CD30+,EBV+ve
  3. Uncommon,Older males affected,Advanced disease.

5.Lymphocyte predominance

  1. Lymphocytic Histiocytic(L&H)variant or Popcorn cell variant,reactive Bcells seen.
  2. RS cells,CD15-ve,CD30-ve,CD20+ve,CD45+ve,EBV-ve.
  3. Uncommon,Young males,mediastinal involvement.

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Life of a PG aspirant

When I got MBBS, I thought it would be the beginning of a new life, a life filled with happiness. I thought treating patients will bring joy not only by relieving their suffering but also by bringing peace to my mind.As years progressed expectations were there but life was lacking. When I passed MBBS, next big task awaited me, the medical PG entrance. I decided to study, but it was a bit too late and inadequate. I was so immersed in stock trading, blogging, watching football matches, there was very little time to study. I thought it was enough because I had never studied so much in my life! But it was too little, but I couldn’t help it, I needed rest I wanted happiness.

Friends told me ” If you work hard for one year, you will pass through and everything will be just fine. When I see the life of a PG student, I am horror struck. So what I endured was too little, what lays ahead of me is something which I thought would never happen to me. It is inevitable in the life of any doctor, to endure the hardships. Many say, you will reap the benefits in the end. I ask myself, where is the end? Passing MBBS is just the beginning, trying for PG is the next part. If I get a PG, will it be the end? I don’t think so, superspeciality entrance awaits!

I wanted to draw a line, where I could stop and rest. There is no such line in my field of vision, an year has to pass before any line can be drawn. That’s how a PG Aspirant( PG worker) has to live, no rest, no happiness, just days and nights spent among piles of books.

But I do find happiness, by bathing, sleeping and eating from different shops! Sometimes I love this life. I think it is better not to worry too much about future. I will do my part and await for a wonderful result, meanwhile I will be blogging and posting what I learn on this blog.

I can see many young doctors who are in the same fix as I am in, visiting this blog.So I expect some comments from you guys, so that we can strengthen each other on the way forward.

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