A giant aggressive angiomyxoma of the vulva in a dwarf: a rare case report

Aggressive angiomyxoma is a rare soft tissue tumour that carries a high risk of local relapse. The tumour usually arises from the pelvic and perineal regions. We presented a case of a young girl with dwarfism, mental retardation and thyroid agenesis who presented with aggressive angiomyxoma of the vulva. As it is almost exclusively seen in women of reproductive age group, this is the first case reported in a teenage girl, to the best of our knowledge. A mentally retarded girl, aged fifteen years, presented with a large mass hanging from the vulva, with ulceration over the mass. She had short stature, anasarca, mental retardation, primary amenorrhoea, under-developed secondary sexual characters .and thyroid agenesis. Local examination revealed a pedunculated mass of 15 by 4 cm size arising from the mons pubis closely resembling a giant penis. Full hormonal and radiological work-up was done. Her condition was optimized and the mass was removed with wide excision of margins followed by cystoscopy under general anaesthesia. Histopathology and immunohistochemistry were suggestive of aggressive angiomyxoma. She has no recurrence till date. Despite its rarity, angiomyxoma should be considered in the differential diagnosis of any painless swelling located in the genitofemoral region. The principal treatment is surgical excision. Long term follow-up is needed due to its high tendency of local recurrence

On the Efficacy of Fine-Grained Traffic Splitting Protocols in Data Center Networks

Multi-rooted tree topologies are commonly used to construct high-bandwidth data center network fabrics. In these networks, switches typically rely on equal-cost multipath (ECMP) routing techniques to split traffic across multiple paths, such that packets within a flow traverse the same end-to-end path. Unfortunately, since ECMP splits traffic based on flow-granularity, it can cause load imbalance across paths resulting in poor utilization of network resources. More finegrained traffic splitting techniques are typically not preferred because they can cause packet reordering that can, according to conventional wisdom, lead to severe TCP throughput degradation. In this work, we revisit this fact in the context of regular data center topologies such as fat-tree architectures. We argue that packet-level traffic splitting, where packets of a flow are sprayed through all available paths, would lead to a better load-balanced network, which in turn leads to significantly more balanced queues and much higher throughput compared to ECMP

Congenital epidermoid cyst of penis with hypospadias: A case report

The epidermoid cysts are the most common cutaneous cysts and may develop from any parts of the human body. Primary epidermoid cyst with hypospadias in the penis is very rare. Here, we present the case of a slow growing, mobilized; non-tender frenulum of the penis mass in a 44-year-old male patient. Complete excision of the cyst was performed under spinal anesthesia. Histopathological examination confirmed the mass to be an epidermoid cyst. Care must be given during examination to rule out another entity. If thereis any indication, complete excision and hypospadias repair is the best treatment

The TCP Outcast Problem: Exposing Unfairness in Data Center Networks

In this paper, we observe that bandwidth sharing via TCP in commodity data center networks organized in multi-rooted tree topologies can lead to severe unfairness, which we term as the TCP Outcast problem, under many common traffic patterns. When many flows and a few flows arrive at two ports of a switch destined to one common output port, the small set of flows lose out on their throughput share significantly (almost by an order of magnitude sometimes). The Outcast problem occurs mainly in taildrop queues that commodity switches use. Using careful analysis, we discover that taildrop queues exhibit a phenomenon known as port blackout, where a series of packets from one port are dropped. Port blackout affects the fewer flows more significantly, as they lose more consecutive packets leading to TCP timeouts. In this paper, we show the existence of this TCP Outcast problem using a data center network testbed using real hardware under different scenarios. We then evaluate different solutions such as RED, SFQ, TCP pacing, and a new solution called equal-length routing to mitigate the Outcast problem.

Study of POSSUM Score for Risk Assessment in Patients of Perforation Peritonitis at a Tertiary Care teaching hospital

Background: Perforation peritonitis carries considerable morbidity and mortality with the unpredictable postoperative period. Continuous audit of clinical practice is an essential part of making improvements in enhancing patient care. This warrants a scoring system that predicts the post-operative outcome. POSSUM (Physiological and Operative Severity Score for the enumeration of Mortality and Morbidity) helps in predicting the post-operative morbidity and mortality in these patients. This study was done in our centre to evaluate the POSSUM score in our set of patients. Material and methods: This prospective observational study was performed in patients of perforation peritonitis admitted under the Department of General Surgery, Sri Aurobindo Medical College And Post Graduate Institute Indore (M.P.) from June 2018 to January 2020. A total of 92 patients were recruited. Data was collected from patients by their clinical history, examination, with appropriate investigations. Data were analysed using appropriate statistical tests.Results: Most common site of perforation was gastro-duodenal followed by ileal perforation. The most common surgical procedure performed was modified Graham’s patch repair. Most common complication was wound infection followed by wound dehiscence and anastomotic leak. Patients who had complications had higher mean POSSUM morbidity score .It was also observed that POSSUM mortality score was significantly higher in subjects who died.Conclusion: POSSUM scoring system is a good indicator of postoperative outcome in patients with perforation peritonitis and was applicable in our setup. It is useful in identifying high risk patients and give preferential care to them for better outcom

Early management of mesenteric cyst prevents catastrophes: A single centre analysis of 17 cases

<b>Background:</b> Mesenteric cysts are rare intra-abdominal masses in the paediatric age group with varied presentation, ranging from an asymptomatic mass to acute abdomen. This study reviews our experience in the diagnosis and treatment of 17 mesenteric cysts in our centre, with especial reference to acute abdominal symptoms. <b>Patients and Methods:</b> Seventeen patients (age less than 10 years) with mesenteric cysts were managed in our hospital. The age ranged from 15 days to 10 years. Patients were admitted with acute or chronic symptoms. They were evaluated with complete history, clinical examination, blood investigations and radiological investigations (x-ray abdomen erect, ultrasound abdomen (USG) and computed tomography (CT) scan in selected cases) to reach a provisional diagnosis. The diagnosis was proven on laparotomy and histologically confirmed. <b>Results:</b> The main presenting symptoms were abdominal pain or lump. The most common mode of presentation was acute small intestinal obstruction. USG was not conclusive in all. Abdominal CT scan with intravenous contrast was diagnostic in nine patients. Five patients had volvulus on exploration. Cysts were located in small intestinal mesentery in 14 cases and three were in the sigmoid mesentery. Seven patients had complete excision, intestinal resection was required in four and marsupialisation with cauterisation of margins was done in six patients. Histologically, all were lymphangiomatous mesenteric cysts. <b>Conclusion:</b> The diagnosis of mesenteric cysts should be kept in mind in any patient presenting with acute abdominal symptoms. Small bowel volvulus with mesenteric cyst constituted a significant number in children with acute abdominal symptoms. Early diagnosis and treatment yields excellent outcome

Intussusception in a premature neonate: A rare and often misdiagnosed clinical entity

Intussusception is a very rare cause of intestinal obstruction in neonates. It is of extremely rare occurrence among premature neonates. We present a case of 11-day-old premature neonate who presented with abdominal distension, intolerance to feeds, vomiting, significant bilious aspirate and bleeding per rectum. The initial diagnosis of necrotizing enterocolitis (NEC) led to a delay in the diagnosis. On exploratory laparotomy, it turned out to be a case of ileo-colic intussusception with Meckel′s diverticulum as a lead point. This site of intussusception (ileo-colic) and presence of a lead point among premature neonate is of exceedingly rare occurrence and very few such cases have been reported. In this article, the published work about clinical features and management on intussusceptions in premature neonates has been reviewed. The authors intend to highlight the difficulty in distinguishing the NEC and intussusception. Subtle clinical and radiological features which can help in differentiating the two conditions have been emphasized. This can avoid the delay in diagnosis and management which can prove critical. High index of suspicion with timely intervention is the key for optimizing outcome. A diagnosis of intussusception should always be considered in any preterm infant with suspected NEC

Minimal access surgery in newborns and small infants; five years experience

Aims and Objectives: The aim of this study was to assess and present the outcome (initial experience and lessons learnt) of minimally invasive surgery for various indications in neonates and small infants (< 5 kg) at a single medical centre. Materials and Methods: A retrospective analysis was performed on 65 patients (age day 2 to 10 months) managed with minimal access surgery (MAS) for various indications, between 2005 and 2010. We analyzed demographic information, procedures, complications, outcomes, and follow-up and overall feasibility of the procedure. Results: No serious complications except one death in congenital diaphragmatic hernia (CDH) (due to other comorbidities) occurred. Intra operative hypercarbia and hypoxia were observed more frequently in thoracoscopic procedures. Intra operative hypothermia was not common and was well tolerated. Conversion to open procedure (n = 5), post operative ileus (n = 3), port site infection (n = 5) were other complications. Conclusion: MAS in neonates and small infants is a technically demanding but a feasible choice available. Some prior experience in older children is required for safe and effective outcome. Good quality optics, video equipments and instruments are required for safe and effective procedure. Intra operative measurement of oxygen saturation and temperature, and diligent post operative ICU care are mandatory for safe and successful outcome

Making the hidden visible: Economic valuation of tiger reserves in India

Tiger reserves in India not only support more than half of the global tiger population and are cornerstones of biodiversity conservation, they also provide a wide range of economic, social and cultural benefits in the form of ecosystem services. Ignorance of such values influences public policies, including decisions involving investments and allocation of funding, that may impact their protection status with serious implications on human well-being. Through economic valuation of ecosystem services from 6 tiger reserves in India, we demonstrate that enhanced investment in these tiger reserves is economically rational. The flow benefits from selected tiger reserves range from US$769 ha−1 year−1 to US$2923 ha−1 year−1. The usefulness of such information for developing incentive-based mechanisms and informing zoning and management of tiger reserves at the landscape level is also discussed