Carcinoma of unknown primary site (CUP) is a heterogeneous group of cancers defined by the presence of metastatic disease with no identifiable primary tumor at presentation. We undertook this study to assess the utility of immunohistochemistry (IHC) for the determination of primary tumor site in adenocarcinomas. This retrospective study included 51 cases with a morphological diagnosis of metastatic adenocarcinoma with unknown primary. Basic IHC panel that included cytokeratin 7 (CK-7), cytokeratin 20 (CK-20), pan-cytokeratin (pan-CK), thyroid transcription factor-1 (TTF-1), and caudal type homebox 2 (CDX-2) was used. Additional extended panel with specific IHC markers was used in cases where the primary could not be determined using the basic panel. The male-to-female ratio was 1.4:1 with mean age of 50 years. The most common metastatic site was lymph node followed by liver. A conclusive diagnosis using IHC was achieved in 30 cases (58.82%). Specific diagnosis could be made in 8 cases (16%) using basic IHC panel. Extended panel yielded specific diagnosis in additional 22 cases (43.13%). Primary site could not be determined using even both the panels in 21 cases (41.18%). The panels for identification of the primary need to be flexible depending on the site of metastasis, age/sex of the patient, and detailed history, which may determine sensitivity and specificity of primary detection.

Introduction: End-stage renal disease (ESRD) patients consider hemodialysis (HD) to be an invasive and time-consuming procedure. The total success of HD depends not only on the medical parameters, but also on the patients’ satisfaction with life (SwL). The purpose of this study was to evaluate ESRD patients’ self-reported SwL and compare it with patient-related and dialysis-related factors. Materials and methods: Fifty-nine patients [average age = 63.3 (standard deviation, SD = 12.3), 19 women (32.2%)] were evaluated in the survey. Both the present and expected 5-year SwL scores were evaluated according to the Cantril ladder (CL). Findings: The relations between the present and expected 5-year CL-SwL scores and gender, education, fulfillment of medical recommendations, months on dialysis, type of vascular access, urea reduction ratio (URR), and ultrafiltration (UF) were excluded. The results indicated highly positive relationships between high expected 5-year CL-SwL scores and being in a relationship, having a kidney graft performed in the past, and willingness to have a kidney graft performed in the future. The group of ESRD patients who were not in a relationship, did not undergo kidney grafts in the past, did not want to undergo a kidney graft in the future, and the eldest patients expected their SwL in 5 years to be significantly lower. Practical implications: Cantril ladder is a useful tool for SwL measurements among ESRD patients. The ESRD patients who expected their SwL in 5 years to be significantly lower (who were not in a relationship, did not undergo a kidney graft, did not desire a kidney graft, and the eldest patients) must be provided with psychological support. Originality: This article fills the gap in the ESRD patients’ quality of life assessment. The self-reported present SwL was evaluated along with expected 5-year SwL.

Introduction: Fine needle aspiration cytology (FNAC) plays a vital role in diagnosing thyroid lesions. However, follicularpatterned lesions need to be evaluated meticulously due to markedly overlapping cytomorphological features. Aim: To study the role of FNAC in follicular-patterned lesions of thyroid. Materials and methods: A retrospective and prospective study of 50 cases in which thyroid FNAC showed follicular-patterned lesions along with histopathological correlation wherever available was done over a period of 3 years (January 2013– December 2015). Results: Out of 50 cases of follicular-patterned lesions, 44 cases were reported as adenomatous goiter (AG), 3 cases each of follicular neoplasm (FN), and follicular variant of papillary thyroid carcinoma (FVPTC) on FNAC. Out of total 24 cases available for histopathological correlation, 5 cases (20.83%) showed discordance and the possible causes for the discordance were analyzed. The diagnostic accuracy, sensitivity, specificity, positive predictive value, and negative predictive value were 83.3, 42.9, 100, 100, and 81.0% respectively. Conclusion: Diagnosing follicular-patterned lesions on FNAC is challenging and will remain a “gray zone” for all cytopathologists. Scrupulous and thorough examination of all cytological smears should be done for predominant follicular pattern along with cytomorphological and background details to differentiate follicular-patterned thyroid lesions in order to minimize falsenegative diagnosis on FNAC.

Teaching hospitals are the apex body of Indian hospital system and are expected to lead from the front in offering quality health care services in a safe environment by qualified and skilled staff. In this study, we conducted a reality check on some teaching hospitals in Maharashtra to assess gaps between declared policies and actual results achieved. We studied three parameters, i.e., human resource management (HRM), quality and safety, and communication and patient relations through three indicators, viz., policies, practices, and services from the Joint Commission International Accreditation (JCIA) standards in concurrence with National Accreditation Board for Hospitals (NABH). A total of 11 teaching hospitals were selected randomly across Maharashtra. The requisite data for the study were collected through personal interview from medical superintendents, employees, and patients. The responses were coded as: 10 (full compliance), 5 (partial compliance), and 0 (no compliance) as per NABH evaluation criteria. The study shows that while teaching hospitals are maintaining most of the policies, they are poor in translating the standards into practices and services. Teaching hospitals need to lay greater emphasis on continuous training and development of their employees that should be focused on improving quality of patient care as per global standards as far as possible.

Introduction: The liver is one of two most frequent abdominal parenchymal organs involved in trauma. Liver injury (LI) remains an important cause of trauma-related mortality. It is often accompanied by trauma to the other organs. Materials, methods and results: During 9 years in the Provincial Trauma Center, out of 10,191 hospitalized patients, there were 1,702 trauma-related hospitalizations and 393 multiorgan traumas; 217 patients underwent surgery due to multiorgan trauma and coexisting LI. The most frequent coinvolved organs were spleen (83.9%), colon (33.6%), kidney (18.9%), small intestine (18.9%), pancreas (17.5%), gallbladder (16.6%), diaphragm (15.7%), and ileocecal valve (12.9%), with 33.2% of rib fractures and 31.3% of pneumothorax and pneumohemothorax. Grade of liver trauma was assessed according to American Association for the Surgery of Trauma—Organ Injury Scale (AAST-OIS). Fifty-two liver injuries (24,9%) were classified as AAST-OIS grade I, 54 (24.9%) as grade II, 46 (21.2%) as grade III, 41 (18.4%) as grade IV, and 25 (11.5%) as grade V. Patients received laparotomy (n = 205, 94.5%) or thoracolaparotomy (n = 12, 5.5%). Liver injuries were managed with electrocoagulation (n = 64, 29.5%), parenchymal sutures (n = 87, 40.1%), resectional debridement (n = 12, 5.5%), and perihepatic packing (n = 54, 24.9%). Predominance of males and young patients with a mean age of 36 corresponds to accident statistics. Among patients receiving surgery, 88.9% had blunt trauma, with a high predominance of motor vehicle accidents. Conclusion: Liver injuries predominantly follow a blunt abdominal injury. Despite good results of nonoperative management in hemodynamically stable patients with blunt trauma, surgery is still required due to complexity and seriousness of multiorgan injuries. Complex liver injuries require surgery in a well-equipped and active trauma center, since the mortality rate of surgical management of major liver injuries remains high.

Research has demonstrated clear benefits of student engagement both in terms of student performance and for academic institutions. Policy guidelines from a variety of sources have advocated for student engagement on a variety of levels. Academic Support Program Inspiring Renaissance Educators (ASPIRE)-to-Excellence initiative represents a means for medical schools to gain recognition of their achievements in this area. We continually see examples of positive initiatives through our work with AMEE, an international association for medical education and the Essential Skills in Medical Education course for students (ESME-Student). We hope to encourage further debate and sharing of experiences to promote student engagement.

Self-medication is on the rise in India. This is due to various reasons that are connected to the environment, demographic factors, changing consumer lifestyles, government policies, and strategies of the pharmaceutical industry. There has been a significant increase in the number of over-the-counter (OTC) products introduced in the health care market in India. On the regulatory front, the government is trying to consider legal recognition to the OTC category of drugs which currently do not have any legal recognition. Over-the-counter drugs in India can be advertised in media unlike some categories of the prescriptiononly drugs which are totally prohibited. The OTC drugs require a sales license except some drugs in Schedule K, which are categorized as household remedies. However, Ayurvedic drugs in India do not require a sales license and therefore, can be sold freely. It is expected that the regulatory policies would undergo changes initiated by the government in the near future.

Pancreatic dermoid cyst is a rare clinical entity. We report the case of a 26-year-old female who presented with epigastric pain and weight loss for 1 month duration. Ultrasonography and computed tomography (CT) showed large solid cystic mass in the tail of pancreas. At surgery, the entire mass was excised. Histopathologic report revealed it to be a dermoid cyst.

Introduction: Wilson's disease (WD) is rare, but it commonly presents with a variety of psychiatric symptoms. Case report: A 31-year-old male presented with depression as the earliest manifestation. The depressive symptoms showed limited response to conventional antidepressants and electroconvulsive therapy in spite of compliance. Gradually, the patient showed neurological symptoms like motor slowing, speech disturbances, and abnormal movements which gave a clue toward organic etiology. Laboratory and neuroimaging findings along with ophthalmological examination helped in confirmation of diagnosis of WD. Introduction of the chelating agent penicillamine led to improvement in nonpsychiatric as well as psychiatric symptoms. Conclusion: Psychiatric manifestations are common in WD. Depression was the earliest manifestation in our patient, which was not responding to usual treatment. Workup for organicity helped to diagnose WD and patient's depressive symptoms responded to chelating therapy.

A 25-year-old woman, gravida 2, para 1 reported with history of 27 weeks pregnancy with pain abdomen and bleeding per vaginum (PV) of 2 days duration. She had undergone lower segment cesarean section (LSCS), done 3 years back during previous pregnancy. On examination, patient had pallor, tachycardia, and hypotension. The uterus was corresponding to the period of gestation. There was tenderness over left side of uterus and fetal heart sounds were absent. Per speculum examination revealed amniotic fluid leak mixed with blood. Ultrasonography (USG) findings were suggestive of moderate hemoperitoneum. Uterine rupture at the site of the previous LSCS scar was suspected. Patient was taken for emergency laparotomy. Intraoperative, previous cesarean scar was intact with the fetus inside the uterine cavity. There was left cornual implantation of placenta with a rent of about 4 cm. The placenta was protruding outside the uterus at left cornual end. Per-operative diagnosis of placenta percreta leading to uterine rupture was made. Obstetric hysterectomy was performed. The diagnosis of placenta percreta was confirmed later by histopathological examination.

Cerebral venous sinus thrombosis (CVST) is an uncommon but important cause of stroke in young women. Subarachnoid hemorrhage (SAH) secondary to CVST is a rare presentation. We present a case of 40-year-old female who presented with hemicranial headache. Magnetic resonant imaging (MRI) showed CVST along with SAH and venous infarcts. The patient improved on anticoagulant therapy. This report highlights the value of early diagnosis of CVST through neuroimaging and the importance of immediate anticoagulation as a part of patient management.