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Pancreatic ductal adenocarcinomas are characterized by a complex and robust tumor microenvironment (TME) consisting of fibrotic tissue, excessive levels of hyaluronan (HA), and immune cells. We utilized quantitative multi-parametric magnetic resonance imaging (mp-MRI) methods at 14 Tesla in a genetically engineered KPC (KrasLSL-G12D/+, Trp53LSL-R172H/+, Cre) mouse model to assess the complex TME in advanced stages of tumor development. The whole tumor, excluding cystic areas, was selected as the region of interest for data analysis and subsequent statistical analysis. Pearson correlation was used for statistical inference. There was a significant correlation between tumor volume and T2 (r = −0.66), magnetization transfer ratio (MTR) (r = 0.60), apparent diffusion coefficient (ADC) (r = 0.48), and Glycosaminoglycan-chemical exchange saturation transfer (GagCEST) (r = 0.51). A subset of mice was randomly selected for histological analysis. There were positive correlations between tumor volume and fibrosis (0.92), and HA (r = 0.76); GagCEST and HA (r = 0.81); and MTR and CD31 (r = 0.48). We found a negative correlation between ADC low-b (perfusion) and Ki67 (r = −0.82). Strong correlations between mp-MRI and histology results suggest that mp-MRI can be used as a non-invasive tool to monitor the tumor microenvironment.

Background: Phimosis is narrowing of prepuce leading to non-retraction behind glans penis. Phimosis is physiological in majority of patients. Pathological phimosis gives rise to symptoms of urinary tract infection and balanoposthitis. Most of patients with phimosis are subjected to circumcision. Instead of circumcision, a conservative surgical approach preputioplasty can be done as a prepuce salvage procedure. Methods: Patients suffering from urinary tract symptoms and persistent narrowing of phimotic ring and recurrent balanoposthitis were subjected to this prepuce salvage surgery. The dorsal slit preputioplasty was performed in these patients. Results: All patients were operated under local anaesthesia in outpatient department. The mean operative time was 10 minutes. No major complication was seen in any of these patients. Oedema of prepuce, haematoma and mild inflammation was noticed in a small number of patients. But wound infection and disruption occurred in none of the patients. The wound healing was good in all the patients on two weeks follow up. On one month follow up the cosmetic results were very good as per patient satisfaction. Conclusions: Dorsal slit preputioplasty is a simple procedure to perform without special equipment, less cost and less morbidity as day surgery procedure. This technique produces salvage of prepuce thereby conserving the sensations and functions inherent to prepuce.

Background: Blunt hepatic trauma is common in abdominal injuries. In seventies different surgical procedures were evolved for operative treatment of liver injuries. In eighties the conservative treatment of liver injuries became the management of choice in hemodynamically stable patients. This study was conducted in patients of blunt hepatic trauma to assess the effectiveness of conservative treatment.to assess the effectiveness of conservative treatment. Methods: Two hundred patients with blunt hepatic trauma were included in this study. Clinical parameters, GCS and ISS were recorded in all the patients. FAST and CT scan were also done. Patients with unstable hemodynamics who responded to fluid challenge and with stable hemodynamics were included in conservative management of liver trauma. Results: In this study 200 patients were analyzed, 30 patients were operated due to unstable hemodynamics while 170 patients treated conservatively. Average numbers of blood units transfused were 2-3 units and average hospital stay was 4-7 days. The patient recovery is to the extent of 97% with a few complications only. Conclusions: The conservative treatment is safe option for blunt hepatic trauma patients in patients with stable hemodynamics. Intensive monitoring is essential as there may be failure in a few patients. The complication rate was minimum and no mortality.

To investigate how differing amounts of experiential feedback and feedback’s availability in an interactive simulation tool influences people’s decision-making against landslide risks. Feedback via simulation tools is likely to help people improve their decisions against disasters; however, currently little is known on how differing amounts of experiential feedback and feedback’s availability in simulation tools influences people’s decisions against landslides. We tested the influence of differing amounts of experiential feedback and feedback’s availability on people’s decisions against landslide risks in an Interactive Landslide Simulation (ILS) tool. In an experiment, in high-damage conditions, the probabilities of damages to life and property due to landslides were 10-times higher than those in the low-damage conditions. In feedback-present condition, experiential feedback was provided in numeric, text, and graphical formats in ILS. In feedback-absent conditions, the probabilities of damages were described; however, there was no experiential feedback present. Investments were greater in conditions where experiential feedback was present and damages were high compared to conditions where experiential feedback was absent and damages were low. Furthermore, only high-damage feedback produced learning in ILS. Experience gained in ILS enables people to improve their decision-making against landslide risks. Simulation tools seem appropriate for landslide risk communication and for performing what-if analyses.

Understanding landslide risks is important for people living in hilly areas in India. A promising way of communicating landslide risks is via simulation tools, where these tools integrate both human factors (e.g., public investments to mitigate landslides) and environmental factors (e.g., spatial geology and rainfall). In this paper, we develop an interactive simulation model on landslide risks and use it to design a web-based Interactive Landslide Simulator (ILS) microworld. The ILS microworld is based on the assumption that landslides occur due to both environmental factors (spatial geology and rainfall) as well as human factors (lack of monetary investments to mitigate landslides). We run a lab-based experiment involving human participants performing in ILS and we show that the ILS performance helps improve public understanding of landslide risks. Overall, we propose ILS to be an effective tool for doing what-if analyses by policymakers and for educating public about landslide risks.

Background: Epididymal cysts are common in teenagers and young adults. They can present as unilocular or multilocular swelling. These cysts are generally present on one side but can be bilateral. Small epididymal cyst are asymptomatic but are detected on ultrasound examination of scrotum. This study was done with aim of treating epididymal cyst with different modalities based on size of the epididymal cyst.Methods: A total of 124 patients of epididymal cyst were included in this study. Scrotal ultrasonography was done in these patients. The clinical presentations of these patients were asymptomatic detected on ultrasound, orchialgia, scrotal swelling and physical examination. Based on the size of epididymal cyst patients were divided into three groups. The treatment modalities used these were natural involution, aspiration, aspiration and sclerosing agent and surgical excision.Results: The group I consisted of cyst size less than 10mm having 73 patients. The group II consisted of patients with cyst size 11-20mm having 39 patients; and group III patients were with cyst size 21-50mm having 12 patients. Natural involution was most effective treatment modality in group I and group II. Aspiration was the second was most effective. Only a few patients required aspiration and sclerosing agent. Surgical excision was done in majority of group III patients and failed aspiration in group II.Conclusions: The results of present study show that asymptomatic and small epididymal cyst can be cured by natural regression in 77.42%. The cysts 11 to 20mm are amenable to aspiration alone, only a few need repeat aspiration and instillation of a sclerosing agent. These conservative approaches save the cost. Excision should be reserved for very large cysts and in which conservative approach fails.

Background: The liver is the most common solid viscera injured in motor vehicle accidents. Advances in radiological diagnostic techniques and critical care have increasing trend towards the nonoperative management. Still operative management is needed if there is continuous bleed or haemodynamic instability. The omentum commonly known as policeman of abdomen as it reaches intra-abdominal injury site. It is known to adhere to the site of injury and seals it. It increases the vascularity and starts neoangiogenesis. This produces haemostasis and promotes wound healing.Methods: In this study 24 patients were managed by this technique of pedicled omentoplasty. These patients were in the age group of 22 to 42 years. There was male dominance, 22 patients were males (91.7%) while only 2 patients were females (8.3%). The use of omentum in packing is described here. The omentum is converted to a pedicled flap based on right omental artery by tailoring it. The active bleeding vessels can be ligated. The whole length of pedicled omentum is packed in liver cavity. Using liver sutures two or more sutures are applied for stabilization.Results: On exploration, the hepatic injury was assigned grade as per AAST liver injury scale. Out of 24 patients included in this study; two (8.33%) were grade I patients, three (12.5%) were grade II patients, nine (37.5%) were grade III patients and ten (41.67%) were grade IV patients. Patients with grade V and grade VI were dealt by perihepatic packing as damage control surgery were excluded from this study.Conclusions: Pedicled omentoplasty in blunt hepatic trauma can be used irrespective of the grade of liver injury. It should be used in combination with other procedures like debridement, segmental or unsegmental resection, control of active bleeding vessels, use of Pringles manoeuvre, selective hepatic artery ligation and even with deep mattress suturing. This helps in haemostasis, early healing and rapid recovery with minimum complications.

Background: Sacrococcygeal pilonidal sinus disease is treated better with various flaps and primary closure. This study was aimed to describe the lateral advancement flap in surgical treatment of sacrococcygeal pilonidal sinus disease in an effort to redefine the results of this technique. It is a fascio-adipo-cutaneous flap which is advanced from one buttock to opposite across the natal cleft and providing the off midline closure with cleft lift.Methods: The results of this technique were assessed in 65 patients. The technique consists of adequate excisions of sinus, tracts and surrounding inflamed tissue till depth of presacral fascia. The defect was covered with a thick lateral advancement flap and produce an off midline closure and cleft lift.Results: The sixty patients were hirsute males and five were hairless females. The maximum length and breadth covered was 7x5cm. The operative time taken was 40±10 minutes. The average hospital stay was 5 to 7 days. The surgical site infection in 4 patients and wound dehiscence occurred in one patient only. No recurrence was recorded in follow up period of one year.Conclusions: The lateral fascio-cutaneous advancement flap is gaining popularity for its ease of designing and harvesting. The short hospital stay, minimum postoperative complications, no recurrence and acceptable aesthetic results make this a uniformly acceptable technique for surgical primary closure of pilonidal sinus disease.

Background: Peptic perforation is an emergency and requires urgent surgical treatment. Many modalities of treatment are available ranging from conservative treatment to laparoscopic repair. There is no consensus on treatment of perforated pylorodudenal ulcer which can be treated with conservative treatment, simple closure of ulcer, closure of ulcer with free omentum, closure of perforation with use of pedicled omentum, definitive treatment with truncal vagotomy and drainage procedures or parietal cell vagotomy. However best treatment is still to be decided.Methods: This study was conducted in department of surgery 60 patients presenting with peptic perforation in last three years. All patients with duodenal perforation in first part (D1) were included in the study. Pyloric perforations, multiple perforations, traumatic perforations and severe co-morbid condition were excluded from study. A pedicled omentum was used in the repair of duodenal perforation. Immediate and late postoperative complications were recorded. The patients were followed for three months.Results: Out of 60 cases there were 50 male patients and 10 female patients. The majority of male patients were in the middle age group between 35 to 45 years of age and the female patients were of older age group between 40 to 65 years of age. These patients presented with history of acute pain abdomen in the epigastric region. All the patients underwent modified Graham’s patch repair. In postoperative period, two patients had burst abdomen on fourth postoperative day. Biliary fistula formation occurred in 2 patients. Wound infection occurred in 4 patients and the hospital stay was 5 to 9 days. There was no mortality recorded in this series.Conclusions: In summary, the surgery for perforated peptic ulcer should use modified Graham’s repair using pedicled omentum giving excellent results in terms of healing, morbidity and mortality.

Background: There are so many subtitles for difficult laproscopic cholecystectomy. Stone in the neck of gall bladder constitutes one of the entities. Wall echo complex is an ultrasound terminology used for cholelithiasis. It has three layers, first the pericholecystic fat between gallbladder and liver. Second layer consists of gall bladder wall. The third layer consists of echogenic stone itself. Wall echo complex is one of the entities which constitute difficult laproscopic cholecystectomy. Wall echo complex in the neck of the gall bladder is particularly difficult gall bladder where the conversion rates are high.Methods: The study was conducted in Department of Surgery. Standard four port cholecystectomy was done in 50 patients. Wall echo complex in all these patients was reported by ultrasonologist. Difficulties in operating wall echo complex cholelithiasis consisted of dissection of neck of gall bladder due to adhesions and a sleeve of fat covering the calot’s triangle. The difficulty of wall echo cholelithiasis was managed by opening the neck of gall bladder and evacuating the stones into a separate latex bag. By this procedure the difficult wall echo cholelithiasis was managed in all cases. Ligaclips were used for ligation of cystic duct, cystic artery and pericholecystic veins.Results: The evacuation of stones from the neck of gall bladder led to an easy cholecystectomy in 46 patients while the four patients had conversion to open cholecystectomy.Conclusions: Wall echo complex although an ultrasonologists entity but is a difficult gall bladder for laproscopic cholecystectomy.

We construct a stress p53-Mdm2-p300-HDAC1 regulatory network that is activated and stabilised by two regulatory proteins, p300 and HDAC1. Different activation levels of [Formula: see text] observed due to these regulators during stress condition have been investigated using a deterministic as well as a stochastic approach to understand how the cell responds during stress conditions. We found that these regulators help in adjusting p53 to different conditions as identified by various oscillatory states, namely fixed point oscillations, damped oscillations and sustain oscillations. On assessing the impact of p300 on p53-Mdm2 network we identified three states: first stabilised or normal condition where the impact of p300 is negligible, second an interim region where p53 is activated due to interaction between p53 and p300, and finally the third regime where excess of p300 leads to cell stress condition. Similarly evaluation of HDAC1 on our model led to identification of the above three distinct states. Also we observe that noise in stochastic cellular system helps to reach each oscillatory state quicker than those in deterministic case. The constructed model validated different experimental findings qualitatively.

Background: Phimosis is non-retractile foreskin or prepuce over the glans. This is due flimsy adhesions between glans and prepuce. The two types of phimosis, physiological and pathological must be differentiated. The phimosis can be treated by conservative methods by application of topical steroid cream. The objective of this study was to evaluate the efficacy of nonsurgical separation and topical clobetasol propionate 0.05% cream therapy in treatment of phimosis. Methods: This study was done on 62 patients presenting with symptoms of phimosis were included in the study. The clinical examination prepuce and penis was done. The patients were classified according to Kirkiros classification. In this classification of phimosis, 5 grades have been ascribed according to the retractibility of prepuce. Results: Out of total 62 patients, the complete response was obtained in 55 (80.71%), partial response in 5 (8.06%) and no response in 2 (3.23%) patients. In patients with partial response the topical clobetasol therapy, the treatment was repeated for another 4 weeks. The phimotic ring disappeared in all the patients after 4 or 8 weeks of topical clobetasol propionate 0.05% cream application. The surgical therapy either circumcision or preputioplasty should be done only in selected cases. Conclusions: This study concludes that nonsurgical separation and topical clobetasol cream therapy is quite effective for treatment of phimosis.